Rensselaer Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Rensselaer, Indiana.
- Location
- 1309 E Grace St, Rensselaer, Indiana 47978
- CMS Provider Number
- 155287
- Inspections on file
- 34
- Latest survey
- March 6, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Rensselaer Care Center during CMS and state inspections, most recent first.
A resident with Alzheimer’s disease received multiple doses of PRN lorazepam for anxiety and agitation over an extended period without documentation that non-pharmacologic interventions were attempted beforehand, despite a care plan and behavioral health policy requiring such measures. On many occasions, there was no record of the specific behaviors present at the time of administration on the MAR, behavior sheets, or progress notes, and when behaviors such as yelling, agitation, and inappropriate comments were noted, there was still no evidence of attempted interventions prior to giving the medication. Staff later reported increased behaviors after the PRN order expired and indicated the resident had been receiving lorazepam routinely before meals, leading a psychiatric NP to order scheduled lorazepam BID without documented behavioral justification in the record for the period immediately preceding the change.
A resident with a history of stroke, moderately impaired cognition, and a care plan requiring staff assistance with ADLs was scheduled to receive showers twice weekly in the evening. Review of records showed no signed shower forms or completed bathing tasks on multiple scheduled shower days over several months. A nurse interview confirmed that no additional documentation could be found to show the resident received bathing on those missed dates.
The facility did not follow its policy requiring annual staff training on abuse, neglect, exploitation, and resident rights. Record review showed that an LPN and a CNA, each employed for more than four months, had not completed abuse or resident rights training since their hire dates. The Business Office Manager confirmed they had no such training during the following year, while the Corporate Regional Manager stated that this training was required yearly. The current facility policy specified that all staff must receive training on abuse and abuse prevention, which was not implemented for these employees.
The facility did not obtain food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards.
Multiple residents reported not receiving meal choices or having their dietary preferences honored, with staff failing to post menus or assist with meal selections as required. One resident with diabetes and other health conditions was repeatedly served unwanted foods, and her preferences were not reflected on her dietary card, contrary to facility policy.
A resident reported concerns about cold food, and during a subsequent meal observation, a supper tray was served with BBQ chicken, mashed potatoes, and spinach at temperatures below the facility's required minimum of 135°F. The dietary aide noted the steam table had been turned off shortly before the tray was tested, resulting in food that was not served at an appetizing or safe temperature. This deficiency had the potential to affect 71 residents on regular diets.
The facility did not honor a resident's right to voice grievances without discrimination or reprisal and failed to establish a grievance policy or make prompt efforts to resolve complaints.
A resident with paraplegia, diabetes, and two stage four pressure ulcers did not consistently receive physician-ordered wound care treatments. Multiple missed applications of prescribed wound care products were documented in the TAR, and the resident and family reported several days when treatments were not completed as scheduled. The facility's policies required adherence to physician's orders for wound care, but these were not followed in this case.
A resident with severe cognitive impairment and multiple medical conditions did not receive proper monitoring during a nebulizer treatment. The LPN left the resident unattended, resulting in the resident not wearing the nebulizer mask during the treatment, contrary to facility policy requiring staff to remain with the patient until the treatment was complete.
An agency LPN inaccurately documented completion of a prescribed wound treatment for a resident with stage four pressure ulcers, despite the treatment not being performed. The resident, who was cognitively intact, reported the omission, which was confirmed by another LPN and the treatment was subsequently completed by the night shift.
Three agency LPNs did not have their medication administration competency and understanding of medication management completed or signed off on the required checklist, as mandated by facility policy for all staff, including contracted personnel.
A resident with cognitive impairments was found with a medication cup containing multiple pills, which he intended to self-administer without the necessary physician's orders or assessments. The facility's DON was unaware of any self-administration, and the required interdisciplinary team assessment was not conducted.
A facility failed to maintain a resident's ADL functions as care planned, specifically in assisting with walking. The resident, with multiple health conditions, was observed in a wheelchair, and his daughter reported a lack of staff assistance with walking. The care plan required staff to assist the resident in walking twice daily, but records showed this occurred only five times in 30 days. Interviews revealed unclear responsibility for implementing therapy recommendations, contributing to the deficiency.
A facility failed to provide necessary care for three residents: one resident received an incorrect dosage of Eliquis post-procedure, another had a bandage applied without an order, and a third was observed without prescribed compression stockings. The LPN was unsure of the medication order source, and the DON confirmed the lack of proper documentation for the bandage and compression stockings.
A resident with paraplegia and other conditions did not receive recommended range of motion (ROM) exercises as outlined in a Physical Therapy Discharge Summary. Despite being cognitively intact and requiring substantial assistance, the facility did not implement the restorative ROM program. The Occupational Therapist and Director of Nursing indicated a lack of clarity and responsibility in executing therapy recommendations, with no specific restorative nursing program in place.
A facility failed to monitor the nutritional intake of a resident with a history of weight loss, resulting in significant weight reduction. Despite being on a regular diet with supplements, the resident's meal consumption was inconsistently documented, with several meals missing from the log. The DON acknowledged the missing documentation, suggesting frequent meal refusals by the resident, but provided no further information.
The facility failed to provide necessary respiratory care and treatments for residents with respiratory infections and oxygen therapy needs. A resident with COVID-19 did not receive prescribed medications, and two residents received incorrect oxygen flow rates, contrary to physician orders. These discrepancies were confirmed by staff interviews, indicating a failure to adhere to prescribed treatments.
The facility failed to provide ground meat as ordered for six residents on a memory care unit, resulting in a cognitively impaired resident's death due to aspiration of food. The dietary staff did not send the required ground meat or dietary cards, and the nursing staff did not alert them about the missing items.
A cognitively-impaired resident with a history of food stuffing was not adequately supervised during meals, leading to her death from aspiration of unchewed food. The resident wandered in and out of the dining room, taking food from other residents' plates, and was later found unresponsive with sausage obstructing her airway. Despite resuscitation efforts, the resident could not be revived.
Failure to Attempt and Document Non-Pharmacologic Interventions Before PRN and Scheduled Lorazepam Use
Penalty
Summary
The deficiency involves the facility’s failure to ensure that non-pharmacological interventions were attempted and documented prior to administering PRN lorazepam for anxiety and agitation, and before converting it to a scheduled medication, for a resident with Alzheimer’s disease. The resident had multiple PRN lorazepam orders beginning in early December, with doses administered on numerous dates in December and January for behaviors such as yelling, agitation, and inappropriate comments. Nursing progress notes occasionally described behaviors like yelling in the dining room or at other residents, but consistently lacked documentation that any non-pharmacological interventions were attempted before giving the medication, despite a behavioral health policy stating that pharmacologic interventions should only be used when non-pharmacologic measures are ineffective or clinically indicated. On several dates when lorazepam was administered, there was no documentation at all on the MAR, behavior sheets, or progress notes describing what behaviors the resident was exhibiting at the time of administration. Even when behaviors were described, such as yelling at staff and residents or becoming aggressive after medication, there was still no indication that staff tried interventions like redirection, removal from the situation, or environmental modification before administering the PRN medication. The resident’s care plan, initiated in early January, identified physical aggressiveness, poor impulse control, and a history of physical altercations with other residents, and included interventions such as assessing and anticipating needs, using physical and verbal cues to alleviate anxiety, and documenting behaviors and attempted interventions. However, the documentation reviewed did not show that these care-planned interventions were implemented prior to medication use. Later, staff reported to a psychiatric NP that the resident’s behaviors had increased after the PRN lorazepam order expired, and that the resident had been receiving lorazepam routinely in the morning and evening prior to meals. Based on this report and discussion with the DON and Social Service Director, the NP ordered lorazepam 0.5 mg twice daily on a routine basis for generalized anxiety disorder. There was no documentation in the progress notes or MAR of behaviors between the end of the last PRN order and the start of the scheduled lorazepam, aside from behavior monitoring entries on a few dates in early February that showed both effective and ineffective non-pharmacological interventions. During interview, the DON acknowledged that there had been no interventions documented prior to lorazepam administration before early February, and the Administrator could not provide a facility policy specific to PRN medication administration, only the behavioral health policy requiring non-pharmacologic measures first.
Failure to Provide Scheduled Twice-Weekly Bathing for a Dependent Resident
Penalty
Summary
The facility failed to ensure that a resident who required assistance with activities of daily living received bathing or showers at least twice weekly as care planned. Record review for Resident J, who had a diagnosis including stroke, a care plan revised on 10/2/25 indicating a need for staff assistance with ADLs, and a Quarterly MDS dated 2/7/26 showing maximum assistance required for bathing and moderately impaired cognition, showed that scheduled showers were to occur on Wednesday and Saturday evenings. However, there were no signed shower forms or tasks indicating that bathing occurred on multiple scheduled days, specifically 12/17/25; 1/7/26, 1/17/26, and 1/21/26; and 2/4/26, 2/18/26, and 2/25/26. During interview, the Wound Nurse confirmed that no additional shower forms could be found to show the resident was bathed on those dates. This deficiency was cited under 410 IAC 16.2-3.1-38(a)(3) and 16.2-3.1-38(b)(2) and relates to Intake 2733197.
Failure to Provide Required Annual Abuse and Resident Rights Training to Staff
Penalty
Summary
The facility failed to implement its abuse policy and procedure requiring annual training on abuse, neglect, exploitation, and resident rights for staff who had been employed more than four months. Record review on 3/6/26 showed that an LPN who started on 4/12/24 and a CNA who started on 7/11/24 had not completed abuse training or resident rights training since their start dates in 2024. During interview, the Business Office Manager confirmed that these two staff members had no abuse or resident rights training in 2025, and the Corporate Regional Manager stated that such training was required to be completed yearly. A facility policy dated 5/6/25, identified by the Administrator as current, indicated the facility would maintain an effective training program for all staff that included, at a minimum, training on abuse and abuse prevention, which was not followed for these two staff members.
Failure to Follow Food Procurement and Handling Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events are provided in the report.
Failure to Honor Resident Meal Preferences and Dietary Needs
Penalty
Summary
The facility failed to provide residents with meal choices and did not honor their dietary preferences, as evidenced by interviews and record reviews involving nine residents. Resident Council meeting notes and a grievance form indicated that residents were not receiving requested meals, and the issue was not addressed by facility leadership. Residents reported that menus were not posted in a timely manner, making it difficult to make meal selections, and that CNAs were no longer assisting residents in filling out their meal orders for the following day. As a result, residents were often served whatever was on the menu without consideration for their preferences. One resident with diabetes, paraplegia, and stage four pressure ulcers reported consistently receiving meals high in carbohydrates and being served scrambled eggs despite a documented preference for fried eggs. The resident's dietary card did not reflect her dislike for scrambled eggs, and her care plan indicated a need for dietary interventions. The facility's food preference policy required that allergies, dislikes, and special requests be addressed prior to meal service, but this was not followed, resulting in residents not receiving meals according to their preferences and needs.
Failure to Serve Hot Foods at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to serve a supper meal at an appetizing and safe temperature, as required by its food temperature policy. During an observation, a test tray of BBQ chicken, mashed potatoes, and spinach was served with temperatures below the minimum standard of 135°F: the chicken measured 133.6°F, the mashed potatoes 126.2°F, and the spinach 90.3°F. The chicken and mashed potatoes were warm to taste, while the spinach was cold. This issue was identified after a resident had previously voiced a grievance about cold food, which was documented and marked as resolved. The dietary aide reported that the steam table had been shut off for about two minutes prior to the sample tray being received. The deficiency had the potential to affect 71 residents on a regular diet with regular textured foods. No further information was provided by the administrator at the time of the sample tray testing, and the facility's policy required hot foods to be held at a minimum of 135°F.
Failure to Honor Resident Grievance Rights
Penalty
Summary
The facility failed to honor the resident's right to voice grievances without discrimination or reprisal. Additionally, the facility did not establish a grievance policy or make prompt efforts to resolve grievances as required. This deficiency was identified based on the facility's lack of appropriate procedures and actions to address resident complaints in a timely and non-retaliatory manner.
Failure to Complete Physician-Ordered Pressure Ulcer Treatments
Penalty
Summary
The facility failed to ensure that pressure ulcer treatments were completed as ordered by the physician for a resident with significant medical conditions, including paraplegia, diabetes mellitus, and two stage four pressure ulcers on the sacrum and right ischium. Record review and interviews revealed that there were multiple instances where prescribed wound care treatments were not administered as scheduled. Specifically, the resident and a family member reported missed treatments on several days, including a missed evening shift treatment that was only completed after being reported to the night shift nurse. Review of the Treatment Administration Record (TAR) showed several missed applications of wound care products such as zinc oxide, collagen, hydroferablue, betamethasone valerate, calcium alginate, and BNZ cream, with specific dates and times documented where treatments were not completed as ordered. The care plan for the resident indicated that pressure ulcer treatments were to be completed as ordered, and physician's orders detailed specific wound care regimens for both the sacrum and right ischium. Despite these orders, the TAR documented multiple missed treatments across different shifts and dates. The facility's own pressure ulcer and wound care policies required that physician's orders for wound care be followed, but these were not adhered to in this case. The Director of Nursing was informed of the missed treatments, but no additional information was provided at the time of the survey.
Failure to Monitor and Administer Nebulizer Treatment as Required
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including COPD, dementia, and hemiplegia, did not receive safe and appropriate respiratory care during a nebulizer treatment. During observation, the resident was found lying in bed with the nebulizer running, but the mask was not on the resident and was instead lying next to him, disconnected from the medication cup. The LPN was notified and assisted the resident in putting the mask back on, but then left the room to administer medications to another resident. When the LPN returned, the resident was again not wearing the mask, which was lying next to him, and the treatment was completed at that time. The resident's medical record indicated severe cognitive impairment and a need for substantial to maximum assistance with activities of daily living. The care plan required oxygen therapy, and physician orders specified nebulizer treatments four times daily. The facility's policy, based on the Lippincott procedure and an approved addendum, required staff to remain with the patient and continue the treatment until the nebulizer began to sputter. The LPN reported that she typically set a timer and monitored the resident via video, acknowledging the resident's tendency to remove the mask due to confusion and impulsivity. The failure to remain with the resident during the treatment and ensure the mask was worn as required led to the deficiency.
Inaccurate Documentation of Wound Care by Agency LPN
Penalty
Summary
A deficiency occurred when an agency LPN documented that a prescribed wound treatment for a resident with paraplegia, diabetes mellitus, and two stage four pressure ulcers had been completed, when in fact the treatment was not performed. The resident, who was cognitively intact, reported that the evening shift did not complete the treatment on her pressure areas, despite the Treatment Administration Record showing the LPN's initials indicating completion. The resident informed the night shift nurse, who confirmed the treatment had not been done and subsequently completed it. Record review showed physician orders for specific wound care, including the application of BNZ cream and various wound dressings to the sacral area, to be performed twice daily. During interviews, it was confirmed by another agency LPN that the treatment had not been completed as documented, and the lapse was not communicated during shift report. The Director of Nursing stated that the agency LPN responsible would not return to work at the facility.
Deficiency in Contracted Staff Medication Administration Training
Penalty
Summary
The facility failed to ensure that contracted agency staff completed required training and competency checks for medication administration. Record review showed that three agency LPNs did not have their medication pass competency and understanding of medication management completed and signed off on the Agency Competency Checklist. The facility's current policy, which includes contracted staff in its training requirements, specifies that all staff must be trained and demonstrate competency in relevant areas. During an interview, the Administrator confirmed that the checklist should have been signed off and no additional information was provided.
Failure to Ensure Proper Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident had the necessary physician's orders and assessments to self-administer medications. During a random observation, a resident was found with a medication cup containing multiple pills, which he intended to take. The resident indicated that the nurse had left the medications in his room that morning. Upon reviewing the resident's records, it was noted that there were no assessments or physician's orders authorizing the resident to self-administer medications. The resident in question had a history of cognitive communication deficit, age-related cognitive decline, and type 2 diabetes mellitus. The resident's care plan indicated a moderately impaired cognitive status, requiring cues and reminders from staff. Despite this, the facility's Director of Nursing was unaware of any self-administration by the resident and confirmed the absence of necessary assessments or orders. The facility's policy requires an interdisciplinary team assessment to determine the safety and appropriateness of self-administration, which was not conducted in this case.
Failure to Maintain Resident's ADL Functions
Penalty
Summary
The facility failed to maintain a resident's ability to perform activities of daily living (ADLs) as care planned, specifically in relation to walking. Resident 70, who has diagnoses including acute and chronic respiratory failure, cerebral ischemia, and acute kidney failure, was observed in a wheelchair with a rollator walker present in his room. His daughter reported that staff were not assisting him with walking as they previously did. The resident's care plan, dated August 14, 2024, indicated a walking program that required staff to assist him in walking with his rollator walker twice daily, 6-7 days a week. However, the Point of Care (POC) tasks showed that the resident was only walked on five occasions over a 30-day period, with the remaining days marked as the activity did not occur. Interviews with facility staff revealed a lack of clarity and responsibility regarding the implementation of therapy recommendations. The Occupational Therapist mentioned that therapy recommendations were made to nursing staff upon discharge, but there was no clear assignment of responsibility for carrying out these recommendations. The Director of Nursing confirmed that therapy recommendations were included in the POC tasks for CNAs to complete, but there was no specific restorative nursing program in place. This lack of documentation and follow-through on the resident's walking program contributed to the deficiency in maintaining the resident's ADL functions.
Deficiencies in Medication Management and Skin Care
Penalty
Summary
The facility failed to provide necessary care and services for Resident B, who was cognitively intact and required assistance for mobility and transfers. The resident was prescribed Eliquis, an anticoagulant, to be taken twice daily for a chronic pulmonary embolism. However, after a medical procedure, the medication was incorrectly resumed at a reduced frequency of once daily, despite hospital discharge instructions to resume the original dosage. The LPN involved was unsure of the source of the incorrect order, and the Nurse Practitioner confirmed that no changes were made to the medication list. Resident D, who was cognitively impaired and dependent on staff for activities of daily living, had a skin tear on the left forearm. Although there was an order to monitor the area for redness and drainage, there was no order for a bandage, yet a white bandage was observed on the resident's forearm. The Director of Nursing confirmed the absence of an order for a dressing, indicating a lack of proper documentation and adherence to treatment protocols. Resident C, who had chronic kidney disease, heart failure, and stasis dermatitis, was observed without compression stockings on multiple occasions, despite a physician's order to wear them during the day. The resident's legs were swollen and red, and there was no documentation for a bandage on the right lower leg. The Director of Nursing noted that the resident was independent and sometimes removed the stockings, but the nursing staff failed to document their status accurately. This lack of documentation and adherence to care plans contributed to the deficiency in care for Resident C.
Failure to Implement Therapy Recommendations for ROM
Penalty
Summary
The facility failed to maintain a resident's range of motion (ROM) as per therapy recommendations. Resident 21, who has diagnoses including paraplegia, diabetes mellitus, and spinal stenosis, was observed seated in a recliner with her legs elevated. She reported that she used to receive ROM exercises from the staff, but these had not been performed recently. The resident's record indicated she was cognitively intact and required substantial to maximum assistance for bed mobility, and was dependent for transfers and toileting. However, she had not received restorative nursing services as recommended. A Physical Therapy Discharge Summary from February 2024 outlined a restorative ROM program with specific interventions, but these were not implemented. The Occupational Therapist confirmed that therapy recommendations were made to the nursing staff upon discharge, but there was uncertainty about who was responsible for executing them. The Director of Nursing indicated that therapy recommendations were included in the point of care tasks for CNAs, but there was no specific restorative nursing program in place. A review of records back to February 2024 showed no evidence of the implementation of the therapy recommendations for ROM.
Failure to Monitor Nutritional Intake for Resident with Weight Loss
Penalty
Summary
The facility failed to adequately monitor the nutritional intake of a resident with a history of weight loss. The resident, who was cognitively intact and required only setup help for eating, had diagnoses including multiple sclerosis, protein-calorie malnutrition, and adult failure to thrive. Despite being on a regular diet with additional supplements, the resident experienced significant weight loss, dropping from 88 pounds to 78 pounds over several months. The care plan noted the resident's risk for weight fluctuations due to variable meal intakes and refusals of nutritional supplements. The deficiency was further highlighted by the lack of documentation in the meal consumption log for several meals across different days. The Director of Nursing acknowledged the missing documentation and suggested that the resident might have refused those meals, as she often did. However, there was no further information provided to account for the missing records, indicating a lapse in monitoring and documentation of the resident's nutritional intake, which is crucial for managing her health condition.
Failure to Provide Appropriate Respiratory Care and Oxygen Therapy
Penalty
Summary
The facility failed to provide necessary respiratory care and treatments for residents with respiratory infections and oxygen therapy needs. Resident 70, diagnosed with COVID-19, acute and chronic respiratory failure, cerebral ischemia, and acute kidney failure, did not receive prescribed medications such as Vitamin C, Zinc, Mucinex, Duonebs, and oxygen. These medications were ordered on 1/31/25 but were not entered into the Physician's Orders or documented in the Medication Administration Record for January and February 2025. Additionally, the facility did not maintain correct oxygen flow rates for two residents. Resident 10, with chronic obstructive pulmonary disease, heart failure, and dementia, was observed receiving oxygen at 2.5 liters per minute, contrary to the prescribed 2 liters. Similarly, Resident 65, with a history of stroke, chronic obstructive pulmonary disease, and asthma, was observed receiving oxygen at 1 liter per minute instead of the prescribed 3 liters during napping and nighttime. These discrepancies were confirmed by staff interviews, indicating a failure to adhere to physician orders for oxygen therapy.
Failure to Provide Mechanically Altered Diets as Ordered
Penalty
Summary
The facility failed to ensure that ground meat was provided in accordance with physician orders and did not provide specialized dietary instructions to nursing staff for six residents on a memory care unit. This resulted in a cognitively impaired resident with a history of food stuffing ingesting regular meat, leading to airway blockage and the resident's death. The resident had an order for a diet with ground meat, but the dietary staff did not send the ground meat or dietary cards for the evening meal. The staff served the resident Polish sausage cut into pieces, which led to the resident becoming unresponsive and ultimately passing away due to aspiration of food. The incident report indicated that the resident was found unresponsive with sausage in her mouth and airway after the evening meal. Despite attempts to revive the resident using the Heimlich Maneuver and CPR, the resident was pronounced deceased by EMS. The coroner confirmed the cause of death as aspiration of food. The facility's dietary manager admitted that the dietary staff forgot to send the ground meat and meal tickets, and the nursing staff did not alert the dietary staff about the missing items. Further review revealed that five other residents on the memory care unit had physician orders for mechanically altered diets with ground meat, but their care plans did not include these dietary instructions. During a meal observation, another resident was served breaded shrimp that was not mechanically altered, contrary to the physician's order. The facility's policies required that meals be verified to match the prescribed diet, but these procedures were not followed, leading to the deficiencies observed.
Removal Plan
- The facility assessed all residents for their current diet orders.
- Audits to residents' care plans and dietary tray cards were completed.
- Any discrepancies were corrected.
- Nursing staff were in-serviced regarding checking resident tray cards when setting up resident trays and removing trays when residents were done eating.
- Dietary staff were in-serviced on preparing diet consistencies and sending tray cards to the units.
Failure to Supervise Cognitively-Impaired Resident During Meals
Penalty
Summary
The facility failed to ensure adequate supervision for a cognitively-impaired resident with a history of food stuffing, leading to the resident's death. The resident, who was on the Memory Care Unit, had a care plan that required supervision during meals due to her tendency to stuff food into her mouth without chewing. However, during the evening meal, the staff did not adequately supervise the resident, allowing her to ingest and aspirate a large amount of unchewed food, specifically sausage, which led to her becoming unresponsive and ultimately passing away despite resuscitation efforts by the staff and EMS. The incident report and subsequent interviews revealed that the resident was wandering in and out of the dining room during the meal and was observed trying to take food from other residents' plates. The staff present in the dining room did not have a clear view of the entire area and failed to monitor the resident effectively. The resident was later found unresponsive in her room with sausage obstructing her airway. Despite attempts to clear the airway and perform CPR, the resident could not be revived and was pronounced dead by EMS. The coroner confirmed the cause of death as aspiration of food. The resident's medical records indicated a history of dementia and psychotic disorder with delusions, and she had a documented behavior of rapidly consuming food without chewing. Despite this, the care plan did not include specific interventions for her behavior of taking food from other residents' plates. The dietary staff also failed to provide the required ground meat for the resident's meal, and the nursing staff did not follow up to ensure the dietary instructions were met. This lack of supervision and failure to adhere to dietary requirements directly contributed to the resident's death.
Removal Plan
- The facility assessed all residents for the need of additional supervision and implemented at-risk interventions.
- Reviewed residents in need of additional supervision for appropriate care and interventions, and updated care plans.
- Inserviced nursing staff regarding supervision and safety during meals.
Latest citations in Indiana
Surveyors observed that dietary staff repeatedly worked in kitchen and meal service areas with uncovered facial hair, despite facility policy and state sanitation requirements mandating effective hair restraints. Two dietary aides with short beards or mustaches were seen walking through food preparation areas, taking food temperatures, handling food, and plating meals at steamtables in dining rooms without any facial hair coverings, while the current policy required all hair, including facial hair, to be restrained to prevent contamination.
The facility failed to consistently provide and document required bed-hold policy notices when several residents were transferred to the hospital. In multiple cases, residents with dementia, psychotic disorders, COPD, chronic respiratory failure, altered mental status, and cerebral infarction were sent out for acute changes in condition, and while transfer notes reflected physician and family notifications, they lacked documentation that the bed-hold policy was discussed with the resident or responsible party. Notices of Transfer or Discharge often indicated a copy of the bed-hold policy was sent with the resident, but the records did not show signed and dated acknowledgment by the resident or appropriate representative, including in situations where a resident had moderate cognitive impairment, short-term memory issues, or a documented need for a proxy and a financial POA authorizing an agent for health care decisions.
Surveyors found that the facility failed to provide trauma‑informed and culturally competent care by not incorporating two residents’ extensive trauma histories and specific behavioral triggers into their care plans. One resident with documented homelessness, polysubstance abuse, severe accidents with multiple fractures, viral encephalitis with coma, physical and sexual abuse, loss of family contact, and a past suicide attempt had multiple behavior‑focused care plans that referenced identifying triggers but listed none and did not mention their physical, sexual, medical, or psychosocial trauma. Another resident with TBI from being struck by a truck, an 11‑month coma, long‑term state hospital residence, alleged shooting of a parent, and diagnoses including intermittent explosive disorder and borderline personality disorder had a PASRR identifying a specific trigger and notes of inappropriate sexual behavior, yet their care plans omitted these traumatic events, the identified trigger, and the sexual behavior. Staff interviews confirmed that residents were screened for trauma, but the trauma histories and triggers were not reflected in the individualized plans of care.
A resident with schizophrenia, post‑stroke hemiparesis, and mild cognitive impairment expressed feeling down and wanting to kill himself, but staff did not document asking about a specific plan, did not notify the physician or psychiatric NP as expected, and did not develop or update a care plan addressing depression or suicidal ideation. The SSD documented offering support and initiating 15‑minute checks once, but there was no further follow‑up or documentation of interventions after subsequent suicidal statements made in a care plan meeting with the resident’s father. The DON and Administrator reported that facility policy requires immediate notification of key staff, assessment for a plan and means of self‑harm, and thorough documentation, which were not carried out or reflected in the medical record for this resident.
A resident with schizophrenia, post-stroke hemiparesis, and mild cognitive impairment verbalized suicidal ideation, but the care plan did not address depression or suicidal thoughts, and required assessments and services were not accurately or timely documented. An SSD note recorded the resident saying he wanted to kill himself and referenced 15‑minute checks and a care plan update, yet the active care plan lacked depression/suicidal ideation interventions. Multiple late-entry Social Services notes were later added, describing follow-up visits and the resident denying suicidal ideation, but the SSD later reported she did not typically ask about a suicide plan and did not personally provide individual follow-up visits as described. These practices conflicted with the facility’s policy requiring factual, first-hand, and timely documentation of assessments and services.
A resident was observed with an Albuterol inhaler on an overbed table and later reported keeping the inhaler in a nightstand drawer, with no staff present during these observations. Record review showed the resident had no cognitive impairment on the admission MDS but lacked any documented self-medication administration assessment. The DON acknowledged that the required assessment had not been completed, despite facility policy requiring staff and the practitioner to evaluate each resident’s mental and physical abilities before allowing self-administration of medications.
Surveyors found that the facility submitted inaccurate direct care staffing data to CMS through the PBJ system over multiple days in a quarter. CASPER reports showed apparent gaps in 24-hour licensed nurse coverage, low weekend staffing, and a 1-star staffing rating, while internal staffing sheets documented that licensed nurses were present and the facility was fully staffed on those days. The Administrator reported that the discrepancies were due to PBJ data entry errors, despite a facility policy requiring all PBJ entries to be accurate, auditable, and verifiable against payroll, invoices, or contracts.
Surveyors found that the facility did not provide or document required written transfer/discharge notices and bed-hold policy information for four residents who were sent to the hospital, including individuals with conditions such as dementia, CHF, chronic respiratory failure, and CKD. In each case, progress notes showed that the resident was transferred for acute issues, but the clinical records lacked evidence that written notices were given to the residents or their representatives, and in one case lacked documentation that required information was sent to the receiving provider. Facility leadership, including the ADON, DON, and Administrator, acknowledged that the records did not contain the required documentation, despite a written policy requiring such notices and information exchange.
The facility failed to ensure timely electronic transmission of MDS assessment data to CMS for a resident. Record review showed an annual MDS that was more than 120 days overdue for submission. The MDS coordinator reported that two care area assessments on the annual MDS had remained incomplete until just before surveyor review, at which time the MDS was finished and submitted. The Administrator acknowledged there was no facility policy in place governing MDS transmissions.
Surveyors found that MDS assessments were inaccurately coded for two residents. One resident with a prior Level II PASARR for serious mental illness was incorrectly coded on the Annual MDS as not having a serious mental illness or related condition. Another resident with generalized anxiety disorder, major depressive disorder, and dementia, who was receiving Lorazepam for anxiety, was not coded with an active anxiety disorder diagnosis on the Quarterly MDS, despite active orders documented on the MAR. The MDS coordinator acknowledged both coding errors, and leadership reported there was no facility-specific MDS policy, relying instead on the RAI manual.
Uncovered Facial Hair During Food Preparation and Meal Service
Penalty
Summary
The deficiency involves the facility’s failure to ensure that food was served in a sanitary and safe manner in accordance with professional standards and facility policy during multiple kitchen and meal service observations. During an initial kitchen observation, two dietary aides were seen walking through the kitchen food preparation area with uncovered facial hair. One aide had facial hair above and below the lip and along the jaw line, approximately one-fourth inch in length, and the other had a mustache of similar length; neither used any facial hair covering. These observations occurred while staff were present in the kitchen area where food was stored and prepared. During subsequent observations on the same day, the same two dietary aides were again observed with uncovered facial hair while directly involved in meal preparation and service. One aide walked through the kitchen while the noon meal was being prepared and placed into a transport cart for service in the south dining room, and later was observed plating the noon meal at the steamtable in that dining room, still without a facial hair covering. The other aide walked through the kitchen while the noon meal was being prepared and placed into the steamtable for the north dining room, took food temperatures, assisted with plating meals at the steamtable, and retrieved food items and supplies from the kitchen, all while having an uncovered mustache approximately one-fourth inch in length. The Dietary Manager stated that staff hair was to be covered when in the kitchen and during meal service, and the facility’s written policy and the cited Indiana Food Establishment Sanitation Requirements both required effective hair restraints, including for facial hair, to prevent contamination of food, equipment, and utensils.
Failure to Provide and Document Bed-Hold Policy at Time of Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure that required bed-hold policy information was provided and documented for four residents transferred to the hospital. For a resident with dementia, psychotic disorder, and autistic disorder who had a BIMS score of 0 indicating severe cognitive impairment, progress notes documented physician notification and guardian notification when the resident was sent to the hospital, but there was no documentation that the bed-hold policy was provided to the responsible party. A Notice of Transfer or Discharge later indicated a copy of the bed-hold policy was sent with the resident. Another resident with COPD and chronic respiratory failure, cognitively intact with a BIMS score of 13, experienced a decline in condition and was transferred to the hospital by ambulance; progress notes documented family notification but did not document any discussion of the bed-hold policy, although a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident. A third resident with altered mental status and cerebral infarction, with a BIMS score of 10 indicating moderate cognitive impairment and documented short-term memory impairment, experienced changes in condition and was transferred to the hospital. Progress notes stated the resident was their own responsible party and that no other notification was completed, and transfer documentation did not include the bed-hold policy, although an untimed Notice of Transfer or Discharge indicated a copy of the bed-hold policy was signed by the resident. A financial power of attorney document in the record showed the resident had designated an agent to act in consent or refusal of health care. For a fourth resident with dementia and osteomyelitis, transfer documentation and a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident, and the transfer form noted the resident required a proxy for decision making. The facility’s policy required that at the time of transfer to a hospital, written notice specifying the duration of the bed-hold policy and information on return to the next available bed be provided, and that a signed and dated copy of the bed-hold notice given to the resident or representative be kept in the resident file, which was not consistently documented for these residents.
Failure to Integrate Trauma Histories and Behavioral Triggers Into Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to identify and incorporate residents’ trauma histories and specific behavioral triggers into their care plans, despite documented histories of significant trauma and behavioral health issues. For one resident, extensive social service and progress notes documented homelessness, polysubstance abuse, major depressive and anxiety disorders, chronic pain, a history of severe car accidents with multiple fractures, viral encephalitis resulting in a three‑month coma, loss of child custody, multiple divorces, physical abuse by a spouse, the death of a fiancé who was struck by a car while in a wheelchair, lack of family contact, and a past suicide attempt by Valium overdose. Additional documentation noted a history of rape by a brother at age eight and prior placement under direct supervision and 15‑minute checks related to suicidal ideation. Despite these documented traumatic events and behavioral health concerns, the resident’s care plans did not identify a history of physical trauma, sexual trauma, homelessness, substance abuse, medical trauma, or attempted suicide. For this same resident, the MDS showed no cognitive deficit and identified behaviors such as verbal aggression and rejection of care, along with diagnoses including seizure disorder, depression, chronic pain syndrome, homelessness, and anxiety disorder. Multiple care plans addressed behaviors such as drug‑seeking, pretending to have seizures for attention or medication, making false allegations, verbal aggression when unable to smoke, and a desire for intimate relationships with consenting male residents. These care plans referenced goals such as effective coping skills, seeking staff support, and compliance with the smoking policy, and they called for identification and reduction of behavioral triggers. However, none of these care plans actually listed any specific triggers. The care plan addressing the resident’s right to consensual intimate relationships focused on assessment and education regarding consent but did not integrate the resident’s extensive trauma history. Staff interviews indicated the resident had displayed sexual behaviors since admission, including an incident where the resident expressed anger at another resident for not buying a soda after engaging in sexual acts. A second resident with a documented history of traumatic brain injury (TBI), dementia, seizure disorder, borderline personality disorder, anxiety, intermittent explosive disorder, tobacco use, and other behavioral/emotional disorders was also affected by the same deficiency. Social history and progress notes documented that this resident sustained a TBI after being hit by a semi‑truck while riding a bicycle at age 18, resulting in an 11‑month coma, followed by 13 years in a state hospital and subsequent residence in a group home. Additional documentation indicated the resident allegedly shot their father at age 26 after being sworn at and had a PASRR identifying TBI, intermittent explosive disorder, and borderline personality disorder, with a specific trigger of hearing the name of the current U.S. President. Progress notes also described inappropriate sexual behavior toward staff, including touching themselves intimately during personal care and refusing to stop when redirected. Despite this, the resident’s care plans, which addressed explosive disorder and history of altercations, risk for decreased psychosocial well‑being, and refusal to bathe or shower, did not list any specific behavioral triggers, did not reference the traumatic events such as being hit by a truck or shooting their father, and did not document the inappropriate sexual behavior. The Administrator and Social Service Director acknowledged that residents were to be screened for trauma and that trauma responses and PTSD should be added to care plans, but the specific trauma histories and triggers for these two residents were not incorporated into their plans of care.
Failure to Assess and Care Plan for Resident Suicidal Ideation
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess, investigate, and care plan for a resident’s suicidal ideation in accordance with its own policy and staff expectations. The resident had diagnoses including schizophrenia, cerebral edema, and hemiparesis/hemiplegia following a cerebral infarction, and a current MDS showed mild cognitive impairment (BIMS score 12). A progress note documented that the resident told the Social Services Director (SSD) he was feeling down and wanted to kill himself; the SSD offered assistance, activities, and initiated 15‑minute checks, and the note stated the care plan was updated. However, the note did not indicate that the SSD asked whether the resident had a plan to kill himself, and there were no additional notes regarding suicidal ideation or follow‑up. Review of the current care plan showed no problem, goal, or interventions addressing depression or suicidal ideation, and progress notes over the following month contained no documentation of physician notification related to the suicidal statement. Further record and interview evidence showed that the care plan conference summary did not document interventions for suicidal ideation, and the SSD acknowledged she did not normally ask residents expressing suicidal ideation if they had a plan. The SSD reported that the resident had admission paperwork mentioning suicidal ideation related to depression after a stroke and that the resident again vocalized suicidal ideation during a care plan meeting with his father, after which emotional support was offered and the father took the resident out on a leave of absence; no further visits or follow‑up were done. The DON stated that, upon notification of suicidal verbalization, staff should assess the resident, ask if there is a plan, remove potential means of self‑harm, immediately notify the psychiatric NP, and document the occurrence, and that a detailed progress note and updated care plan were expected but not present for this resident. The Administrator similarly stated that staff should ask about a plan, document interventions, notify the physician and family, and update the care plan, and indicated the resident should have had a care plan addressing depression with suicidal ideation. The facility’s written policy required immediate notification of the DON, SSD, and physician, an interview including asking about a plan and assessing mood and means for self‑harm, and thorough documentation of mood, behavior, and all actions taken, which were not reflected in the resident’s record.
Incomplete and Inaccurate Documentation of Suicidal Ideation and Follow-Up
Penalty
Summary
The facility failed to ensure accurate, complete, and timely documentation of assessments and services for a resident who verbalized suicidal ideation. Resident 6, who had schizophrenia, cerebral edema, and right-sided hemiparesis/hemiplegia following a cerebral infarction, had a BIMS score of 12 indicating mild cognitive impairment. The resident’s admission paperwork mentioned suicidal ideation related to depression after a stroke, and a Social Services note on 3/11/2026 documented that the resident was feeling down and said he wanted to kill himself. The Social Services Director (SSD) documented that she talked with the resident, coordinated with Activities, advised the resident to contact SSD or nursing if he wanted to talk, and that the resident was scheduled for 15-minute checks and the care plan was updated. However, the current care plan initiated on 2/26/2026 did not address depression or suicidal ideation. Multiple Social Services progress notes were later entered as late entries in April, with effective dates in March, stating that the resident had no plan and no longer had suicidal ideation, that he felt much better after 1:1 time, and that he continued his daily routine and therapy. These late entries described follow-up visits and reassessments of suicidal ideation on several consecutive days, but in interviews the SSD stated she did not normally ask residents about having a plan when they verbalized suicidal ideation and did not recall any other occurrences beyond the initial event. She further indicated she did not personally provide individual follow-up visits with this resident regarding suicidal ideation, despite the late-entry notes describing such visits. The DON acknowledged that late entries had been added to address concern about suicidal verbalization, and the Administrator stated that upon suicidal statements staff should ask about a plan, notify the physician and family, and update the care plan, and that this resident should have had a care plan addressing depression with suicidal ideation. The facility’s documentation policy required factual, first-hand, timely documentation, which was not followed in this case.
Failure to Complete Required Self-Administration Assessment for Inhaler Kept at Bedside
Penalty
Summary
Surveyors identified that a resident was allowed to keep and access an Albuterol inhaler without the facility completing the required self-administration medication assessment. During an initial tour, the resident was observed sitting in a wheelchair with a handheld Albuterol inhaler on the overbed table and no staff present in the room or hallway. On a subsequent observation, the resident again was in a wheelchair and reported that the Albuterol inhaler was stored in the top drawer of the nightstand, where it was found. Review of the clinical record showed an admission MDS indicating no cognitive impairment, but there was no documentation of a self-medication administration assessment. In an interview, the DON confirmed that the resident did not have the required self-medication assessment, despite the facility’s policy stating that staff and the practitioner must assess each resident’s mental and physical abilities to determine whether self-administering medications is clinically appropriate. This failure to complete and document a self-administration medication assessment for a resident who had an Albuterol inhaler kept at bedside constituted noncompliance with the facility’s own policy and with 410 IAC 16.2-3.1-11(a).
Inaccurate PBJ Staffing Data Submission to CMS
Penalty
Summary
The deficiency involves the facility’s failure to electronically submit complete and accurate direct care staffing information to CMS through the Payroll-Based Journal (PBJ) system for 22 days in a fiscal quarter. A CASPER report review on 4/6/26 showed that, according to PBJ data, the facility did not have licensed nursing coverage 24 hours per day on multiple specific dates across three months, had low weekend staffing, and held a 1-star staffing rating. However, review of the facility’s internal staffing sheets for that quarter indicated the facility was fully staffed and had licensed nurse coverage on all of the dates in question. During an interview, the Administrator stated that the PBJ information must have contained data entry errors, as she had verified licensed staff coverage on the timesheets. The facility’s PBJ policy in effect stated that all staffing data entered into the PBJ system would be auditable and verifiable through payroll, invoices, or contracts, but the submitted PBJ data did not accurately reflect the facility’s actual licensed nurse staffing as documented on internal records. No specific residents or clinical conditions were mentioned in the report, and the deficiency centers solely on inaccurate staffing data submission rather than direct resident care events.
Failure to Provide and Document Required Transfer/Discharge and Bed-Hold Notices
Penalty
Summary
The deficiency involves the facility’s failure to provide and document required written notices of transfer/discharge and bed-hold policies, as well as required information to receiving providers, for four residents who were transferred or discharged to the hospital. For a resident with generalized anxiety disorder, major depressive disorder, and dementia, progress notes showed that the resident was sent to the hospital via 911 for chest pain, lower back pain, and shortness of breath and later returned to the facility, but the clinical record lacked documentation that a written Notice of Transfer/Discharge and the bed-hold policy were provided to the resident or representative, and lacked documentation that required information was conveyed to the receiving facility. The ADON and the Administrator both confirmed there was no documentation that these written notices were provided. For a resident with congestive heart failure and muscle weakness who was sent to the emergency room for painful urination and bloody urine, the clinical record lacked documentation that a Notice of Transfer/Discharge or bed-hold policy was given to the resident or representative, which the DON confirmed. Another resident with chronic respiratory failure and diabetes was discharged to the hospital for respiratory failure, and a resident with chronic kidney disease and dementia was discharged to the hospital, but in both cases there was no documentation that a written notice of transfer/discharge or bed-hold policy was provided to the residents or their representatives. Review of the facility’s Transfer and Discharge policy, dated 1/15/26, showed that the policy required the facility to provide written transfer/discharge notices and bed-hold information to residents and representatives and to provide specified information to receiving providers, but the records for these four residents did not contain the required documentation.
Failure to Timely Transmit MDS Assessment Data to CMS
Penalty
Summary
The facility failed to ensure timely electronic transmission of MDS (Minimum Data Set) assessment data to the CMS system for one resident. Review of the clinical record for Resident 36 on 4/9/26 showed an annual MDS assessment dated 2/23/26 that was more than 120 days overdue for submission to CMS. During an interview on 4/10/26 at 11:22 a.m., the MDS coordinator stated she still had two care area assessments left to complete on the annual MDS assessment and that she had just finished them and submitted the MDS to CMS, indicating the assessment had not been completed and transmitted within the required timeframe. In a separate interview on 4/10/26 at 12:05 p.m., the Administrator reported that the facility did not have a policy regarding MDS transmissions, further demonstrating the lack of an established process to ensure that MDS data were encoded and transmitted to the State and CMS within the required time limits.
Inaccurate MDS Coding for Mental Health and PASARR Status
Penalty
Summary
The deficiency involves the facility’s failure to ensure that MDS assessments accurately reflected residents’ clinical status for two residents. For one resident with diagnoses including bipolar disorder and anxiety, the Annual MDS dated 3/11/26 indicated the resident was not considered by the state Level II PASARR process to have a serious mental illness or intellectual disability/related condition, despite a Level II PASARR having been completed on 3/31/23. This discrepancy was identified through record review and confirmed in an interview with the MDS coordinator, who acknowledged that the MDS assessment did not accurately reflect the existing Level II PASARR information. For another resident with generalized anxiety disorder, major depressive disorder, and dementia, the Quarterly MDS dated 3/30/26 did not code anxiety as an active diagnosis. However, review of the MAR showed active orders as of 2/27/26 for Lorazepam, prescribed for generalized anxiety disorder, and the RAI manual specifies that active diagnoses should be identified using sources such as medication sheets and physician orders during the 7-day look-back period. In an interview, the MDS coordinator confirmed that the resident did have an active anxiety disorder diagnosis and that the MDS should have been coded “yes” for anxiety disorder but was incorrectly coded “no.” The Administrator and MDS coordinator also stated the facility did not have an MDS policy and relied on the RAI manual for completing assessments.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
