Ripley Crossing
Inspection history, citations, penalties and survey trends for this long-term care facility in Milan, Indiana.
- Location
- 1200 Whitlatch Way, Milan, Indiana 47031
- CMS Provider Number
- 155730
- Inspections on file
- 35
- Latest survey
- December 16, 2025
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Ripley Crossing during CMS and state inspections, most recent first.
A resident with a history of falls and multiple medical conditions was being pushed in a wheelchair by an LPN without foot pedals attached, contrary to facility policy. As the wheelchair was pushed over a rug, the resident's feet dropped to the floor, causing a forward fall that resulted in facial fractures and a severe nosebleed requiring hospitalization and further interventions.
A registered nurse failed to follow infection control protocols during wound care for a resident with a malignant breast wound and a heel wound. After picking up soiled gauze from the floor, the nurse did not remove gloves or perform hand hygiene before continuing with wound cleaning and dressing changes, contrary to facility policy. This lapse was observed and confirmed by staff interview.
The facility failed to maintain safe water temperatures in residents' bathrooms, with temperatures exceeding federal guidelines. Observations showed water temperatures as high as 128 degrees Fahrenheit, causing discomfort to residents. The Maintenance Director acknowledged the issue and attempted to adjust the water heaters, but there was no specific policy in place regarding water temperatures.
The facility failed to accurately complete MDS assessments for three residents. One resident's assessment incorrectly indicated no terminal diagnosis despite receiving Hospice care. Another resident's assessment inaccurately documented a GDR of antipsychotic medications that did not occur. A third resident's assessment was incomplete, missing evaluations for cognitive patterns and mood. These deficiencies highlight lapses in the facility's assessment processes.
A facility failed to adequately monitor a dialysis access site for a resident with an AV shunt, who received dialysis three times a week. The resident's shunt was not assessed on non-dialysis days, despite a physician's order to check it every shift. The order was not included in the EMAR/ETAR, leading to a lack of documentation and routine assessment. The DON acknowledged the oversight, which resulted in non-compliance with the facility's policy and the physician's order.
A facility failed to treat a resident with dignity and respect, as observed when a CNA spoke disrespectfully to a resident with severe cognitive impairment. The resident, who has dementia, reported that some staff were mean to her. The facility's policy emphasizes treating residents with dignity, which was not adhered to in this instance.
An RN at the facility misappropriated medications for three residents, including Norco and Percocet, by signing out the drugs on days they were not scheduled to work. The electronic medication administration records did not match the signed-out medications, indicating the medications were not administered as prescribed. The residents involved had varying levels of cognitive impairment, and the facility's policy on identifying misappropriation events was not effectively implemented.
A resident with severe cognitive impairment fell from a shower bed due to inadequate safety checks and improper handling by a CNA, resulting in fatal injuries. The facility failed to ensure the shower bed was inspected for safety, and the CNA did not follow the care plan requiring two staff members for repositioning. The maintenance director had altered the shower bed without following manufacturer's instructions, contributing to the accident.
The facility failed to maintain safe shower beds, leading to a resident's fall from a bed on Wing 3. The bed lacked weight limit markers and had inadequate railings. Maintenance checks were insufficient, focusing only on wheel function and pin presence, not structural integrity. A similar bed on Wing 4 had a weight capacity sticker but shared maintenance issues. The facility's policy required regular maintenance, but records were incomplete, and staff training did not emphasize structural inspections.
Two residents, both cognitively intact, experienced verbal and emotional abuse by a CNA who yelled at one resident for assisting her roommate. The incident, which upset both residents, was not reported immediately despite facility policies requiring prompt reporting and investigation of abuse allegations. The CNA continued to work following the incident, highlighting a deficiency in the facility's protection of residents from abuse.
The facility failed to report an allegation of abuse involving two residents in a timely manner. CNA 5 spoke loudly to a resident, causing distress, but CNA 3 did not report the incident. LPN 2 heard the commotion but only reported it at the end of her shift. The incident was not documented or reported to the Administrator or SSD until discovered later, violating the facility's policy on immediate reporting of abuse allegations.
Failure to Use Wheelchair Foot Pedals Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when staff failed to follow appropriate safety measures while assisting a resident in a wheelchair, resulting in the resident falling and sustaining significant injuries. Specifically, a nurse was pushing the resident in his wheelchair to the front lobby for a dialysis appointment without attaching the foot pedals. As the wheelchair was pushed over a rug, the resident's feet fell to the floor, causing him to fall forward out of the wheelchair and sustain facial trauma, including a nasal and septal fracture, and a severe nosebleed. The resident required hospitalization, where he experienced complications such as recurrent bleeding, the need for nasal packing, limb restraints due to agitation, and a blood transfusion for anemia. The resident had a documented history of falls and was at risk due to weakness from chronic obstructive pulmonary disease and end stage renal disease requiring hemodialysis. The care plan in place prior to the incident included assistance with transfers but did not specify the use of foot pedals when staff propelled the wheelchair. Facility policy required foot pedals to be in place when residents could not self-propel, but this was not followed. Interviews with staff confirmed that foot pedals were not used during the incident, and that facility policy and best practices were not adhered to at the time of the fall.
Failure to Follow Infection Control Protocols During Wound Care
Penalty
Summary
A deficiency occurred when a registered nurse failed to follow infection control guidelines during a wound dressing change for a resident with a malignant neoplasm of the right breast and other significant medical conditions. During the procedure, the nurse performed hand hygiene and donned appropriate personal protective equipment before starting, but when a piece of saturated gauze fell to the floor, the nurse picked it up and discarded it without removing gloves or performing hand hygiene. The nurse then proceeded to clean the resident's wound and apply a new dressing, and subsequently performed a second dressing change on the resident's right foot, again without performing hand hygiene between the two dressing changes or after handling the soiled gauze from the floor. Facility policy required staff to avoid unnecessary touching of environmental surfaces, perform hand hygiene after removing soiled dressings, and don new gloves before continuing with wound care. The nurse's actions were inconsistent with these policies, as confirmed by both observation and staff interview. The resident involved was severely cognitively impaired and had a history of refusing treatment for the breast wound, which was prone to flare-ups and bleeding. The failure to adhere to infection control protocols was directly observed and documented during the survey.
Facility Fails to Maintain Safe Water Temperatures
Penalty
Summary
The facility failed to maintain safe water temperatures in residents' bathrooms, as required by federal guidelines, which specify a range between 100 and 120 degrees Fahrenheit. During observations and interviews, it was found that the water temperatures in 10 out of 11 residents' bathrooms exceeded this range, with temperatures recorded as high as 128 degrees Fahrenheit. Residents reported that the water was too hot to keep a hand under without discomfort, although no burns were reported. The Maintenance Director acknowledged the issue, noting that he attempted to keep water temperatures at 120 degrees and tested them monthly, but sometimes recorded temperatures as high as 125 degrees. Further investigation revealed that the water temperature logs for the facility showed consistent readings above the recommended range, with temperatures between 111 and 114 degrees Fahrenheit across different halls in the months of August, September, and October. The Maintenance Director indicated that he had recently acquired a new thermometer and adjusted the water heaters to lower the temperature. However, there was no existing policy related to water temperatures, and the facility claimed to follow federal guidelines. The Administrator confirmed the absence of a specific policy on water temperatures.
Inaccurate MDS Assessments for Three Residents
Penalty
Summary
The facility failed to accurately complete Minimum Data Set (MDS) assessments for three residents. For Resident 5, the MDS assessment incorrectly indicated that the resident did not have a terminal diagnosis, despite receiving Hospice care for a terminal condition. The MDS Coordinator acknowledged the error, noting that the information was obtained from the resident's paper chart. Resident 57's MDS assessment inaccurately documented a gradual dose reduction (GDR) of antipsychotic medications, which had not occurred. The Social Service Director (SSD) was uncertain why the documentation reflected a GDR, and the MDS Coordinator confirmed the absence of a facility policy on MDS assessments, relying instead on the Resident Assessment Instrument (RAI) manual. For Resident 61, the MDS assessment was incomplete, missing evaluations for sections C (Cognitive Patterns) and D (Mood). The MDS Coordinator was unaware of the omission, and the SSD, responsible for these sections, could not explain why they were not completed. Progress notes indicated the resident expressed feelings of sadness due to family visitation issues. These deficiencies highlight lapses in the facility's assessment processes, leading to inaccurate or incomplete resident evaluations.
Failure to Monitor Dialysis Access Site
Penalty
Summary
The facility failed to adequately monitor a dialysis access site for a resident who received dialysis treatments. The resident, who was moderately cognitively impaired and diagnosed with End Stage Renal Disease, diabetes, and heart failure, had an arteriovenous (AV) shunt in his left arm for dialysis. Although the nurses applied numbing cream before the resident went out for dialysis, they did not assess the shunt on non-dialysis days. The facility's policy required the dialysis access site to be checked every shift for patency by auscultating for a bruit and palpating for a thrill, but this was not consistently done. The physician's order to assess the dialysis shunt every shift was not included in the resident's Electronic Medication Administration Record/Electronic Treatment Administration Record (EMAR/ETAR), leading to a lack of documentation and routine assessment on non-dialysis days. The Director of Nursing acknowledged that the nurses likely did not assess the shunt every shift because the order was not visible in the EMAR/ETAR. This oversight resulted in the facility not adhering to its policy and the physician's order, potentially compromising the resident's care.
Failure to Ensure Resident Dignity and Respect
Penalty
Summary
The facility failed to ensure that a resident was treated with respect and dignity, as observed during an incident involving a Certified Nurse Aide (CNA) and Resident F. During an observation, the CNA was heard speaking disrespectfully to Resident F, stating, "I'm not dealing with people telling me to shut up. Well then someone else can deal with you then!" before exiting the room. The CNA returned shortly after noticing she was being observed and began asking the resident about her clothing preferences for the day. Resident F, who was noted to have severe cognitive impairment due to non-Alzheimer's dementia, expressed during an interview that some staff members were mean to her, although she could not recall their names. The resident's clinical record indicated she had short-term memory issues but was otherwise alert and communicated regularly with her family. The facility's policy on dignity, which was reviewed, emphasized that residents should be treated with dignity and respect at all times, highlighting a failure in adherence to this policy.
Misappropriation of Medications by RN
Penalty
Summary
The facility failed to prevent the misappropriation of medications for three residents. Resident B, who was cognitively intact, had a physician's order for Norco to be administered as needed for pain. However, records showed that RN 2 signed out the medication on a day they were not scheduled to work, and the medication was not administered according to the electronic medication administration record. Resident B confirmed that she had not taken the medication recently due to its side effects. Similarly, Resident D, who was severely cognitively impaired, had a physician's order for Percocet for breakthrough pain. RN 2 signed out the medication on a day they were not scheduled, and the medication was administered by another nurse according to the records. Resident E, who was moderately cognitively impaired, had a physician's order for Norco to be administered as needed for pain. RN 2 signed out the medication on multiple occasions, but the electronic medication administration record showed that the medication was not administered on those days. The facility's policy on abuse and neglect indicated that they would identify events that may constitute misappropriation of property, but the misappropriation occurred nonetheless.
Failure to Ensure Shower Bed Safety Leads to Resident's Fatal Fall
Penalty
Summary
The facility failed to ensure the safety of a resident during a shower, leading to a severe accident. The incident involved a shower bed that was not comprehensively inspected for safety or function by the maintenance staff or the CNA prior to its use. The resident, who was severely cognitively impaired and dependent on staff for various activities, was being showered by a CNA who did not follow proper procedure guidelines. The CNA attempted to reposition the resident on the shower bed alone, contrary to the care plan that required two staff members for such tasks. During this process, the side rail of the shower bed gave way, resulting in the resident falling and sustaining serious injuries, including a subdural hematoma, a fracture of the left humerus, and a facial laceration. The resident's medical history included conditions such as stroke, hemiplegia, hypertension, renal insufficiency, diabetes, dementia, seizure disorder, anxiety, and depression. The resident required extensive assistance for bed mobility and was dependent on staff for bathing and showering. Despite these needs, the CNA was the only staff member present during the shower, and the shower bed was not properly checked for safety, as evidenced by the mechanical failure of the side rail. The maintenance director had previously altered the shower bed by replacing pipes and putting it back into service without following the manufacturer's instructions for safety checks. Interviews with staff revealed that the maintenance director did not conduct routine checks on the shower beds, and there was a lack of documented safety inspections. The CNA involved in the incident was terminated, and it was noted that the maintenance director had replaced parts of the shower bed with materials not specified by the manufacturer. The facility's policies and procedures for accident prevention and resident supervision were not adequately followed, contributing to the incident that resulted in the resident's death.
Removal Plan
- The altered shower bed was taken out of service.
- The Maintenance Director received education to never alter medical equipment and to replace parts with the manufacturer's instructions.
- All residents who required the use of the shower bed were identified and the assignment sheet and care plan were updated.
- All staff were educated on the correct use, safety inspection, safety features of the bed and all safety measures to be taken related to the shower bed.
Failure to Maintain Safe Shower Beds
Penalty
Summary
The facility failed to ensure that resident care equipment, specifically shower beds, was in safe operating condition. On Wing 3, a shower bed was involved in an incident where a resident, referred to as Resident B, fell out of the bed during use. The bed, made of PVC pipes, lacked identifying markers for weight limits and had railings that were only six inches high. The Maintenance Director noted that the pins holding the railings in place were often lost, and there were no documented routine checks on the beds. After the incident, it was discovered that one of the pins was missing, and the bed was taken out of service for inspection. However, the inspection did not reveal any problems, and the bed was returned to service. On Wing 4, a similar shower bed was observed, which had a sticker indicating a 500-pound weight capacity. The Maintenance Director had recently replaced the pins and plastic strips holding them in place. During an interview, Maintenance Staff 5 revealed that a cap was missing from one of the stationary corners of the Wing 3 shower bed, and the PVC was broken, which compromised the bed's integrity. The maintenance staff did not perform routine checks on the shower beds, only ensuring that the wheels were functional. The Maintenance Director admitted to replacing the pipes with heavier ones after the incident but was unsure of the beds' age or original specifications. The facility's Preventative Maintenance Program policy required the Maintenance Director to maintain a schedule of maintenance services to ensure equipment safety, following manufacturers' guidelines. However, the Maintenance Checklist documentation only showed checks from May to July 2024, with no records of checks before May. Staff training included checking for the presence of pins but did not emphasize inspecting the structure for cracks or loose pieces. The manufacturer's operation instructions highlighted the importance of keeping rails up and checking for fractures, which were not consistently followed.
Failure to Protect Residents from Verbal and Emotional Abuse
Penalty
Summary
The facility failed to ensure residents were free from verbal and emotional abuse, as evidenced by an incident involving two residents, identified as Residents D and B. Resident D, who was cognitively intact and diagnosed with Parkinson's disease and hypertension, reported being mistreated by a CNA. The incident occurred when Resident D was assisting her roommate, Resident B, with her blankets. CNA 5 entered the room, mistakenly believing Resident D was trying to transfer Resident B into bed, and yelled at her to return to her side of the room. This confrontation upset both residents, with Resident B becoming teary-eyed. The incident was corroborated by a progress note from an LPN and interviews with the residents and another CNA. Resident B, also cognitively intact and diagnosed with stroke, diabetes, anxiety, and depression, confirmed the account of the incident. She stated that CNA 5 yelled at Resident D, which upset her. Both residents indicated that CNA 5 had a history of yelling in the facility, although they had not reported it previously. CNA 3, who was present during the incident, confirmed the events and noted that CNA 5's voice was louder than normal. Despite witnessing the incident, CNA 3 did not report it to the nurse on duty, as she was preoccupied with other tasks. The facility's policy on abuse, neglect, and exploitation requires immediate investigation and reporting of any allegations or suspicions of abuse. However, the incident was not reported immediately, and CNA 5 continued to work the rest of the shift and the following day. The facility's administrator confirmed that staff are trained on abuse and neglect upon hire and annually, and that signs are posted throughout the facility to encourage reporting. Despite these measures, the incident involving CNA 5 was not addressed in a timely manner, leading to a deficiency in protecting residents from verbal and emotional abuse.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to ensure timely reporting of an allegation of abuse involving two residents, identified as Residents D and B. On the evening of May 18, CNA 3 and CNA 5 were assisting Resident B when CNA 5 began speaking loudly to Resident D, who was holding onto Resident B's wheelchair. CNA 5 instructed Resident D to move to her side of the room, and when Resident D responded, CNA 5's voice grew louder, causing Resident B to become teary-eyed. CNA 3 intervened by removing CNA 5 from the room but did not report the incident to the nurse on duty. CNA 5 continued to work the rest of the shift and the following day without the incident being reported. LPN 2, who was on duty, heard yelling from the direction of the residents' room and found Resident B in bed and Resident D on her own bed, with both CNAs absent from the room. Resident D expressed that CNA 5 accused her of trying to help Resident B walk, and she felt the CNAs were rude. LPN 2 attempted to calm the situation and reported the incident to the oncoming nurse at the end of her shift. The incident was not documented in the residents' records, and the Administrator or SSD were not notified until the SSD discovered the incident in the progress notes on May 20. The facility's policy requires immediate reporting of abuse allegations to the Administrator, state agency, and other required agencies within specific timeframes. However, the incident was not reported within the required timeframe, and the staff involved were not immediately educated on the importance of reporting abuse. The failure to report the incident promptly led to a delay in addressing the situation and ensuring the residents' safety.
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.
A resident with Alzheimer’s disease and depression, previously on an antidepressant, exhibited intermittent refusals of medications and care, occasional yelling at staff, and reports of unusual perceptions, such as believing men were in or near her room. Nursing notes over several months documented these refusals and complaints but did not show that the behaviors were evaluated or recorded as dangerous, non-redirectable, or causing significant distress, nor did they document specific non-pharmacological interventions attempted or their outcomes. Despite this, a psychiatric NP later added new diagnoses of schizoaffective disorder, borderline personality disorder, and delusional disorder and ordered an antipsychotic (Seroquel) without a comprehensive evaluation in the record to support these diagnoses. The facility’s psychotropic medication policy, which requires identification and documentation of target behaviors, use of nonpharmacological interventions, and ongoing behavior monitoring, was not followed for this resident.
The facility failed to keep PASARR Level I screenings accurate and current for three residents when new mental health diagnoses and psychoactive medications were initiated. One resident’s PASARR omitted a PTSD diagnosis and an added antidepressant, despite documentation of PTSD on the MDS and care plan and a physician order for Pristiq. Another resident’s PASARR listed only depression and dementia, even after additional diagnoses such as borderline personality disorder, delusional disorder, and schizoaffective disorder were added and an antipsychotic (quetiapine) was ordered, with the MDS later reflecting psychotic disorder, schizophrenia, and depression with antipsychotic and antidepressant use. A third resident’s PASARR did not include a depression diagnosis or newly ordered escitalopram and lorazepam, although the admission MDS documented depression with antianxiety and antidepressant use. These omissions occurred despite facility policy requiring a new Level I review after significant mental status changes, including new mental health diagnoses or new psychotropic medications.
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 Document Target Behaviors and Non-Pharmacological Interventions Before Initiating Antipsychotic
Penalty
Summary
The deficiency involves the facility’s failure to document how a resident’s behaviors presented danger or distress to self or others, and failure to document non-pharmacological interventions attempted prior to initiating an antipsychotic medication. Resident 6 had documented diagnoses of Alzheimer’s disease, depression, and severe cognitive impairment, and was receiving sertraline for depression. A PASSAR identified only depression and dementia, and the admission MDS listed Alzheimer’s disease and depression as active diagnoses. Over several months, nursing progress notes documented that the resident intermittently reported unusual perceptions, such as believing there were men causing trouble, a man in her room, or a man wanting to marry her and yelling through the walls, but there was no documentation that these episodes caused danger to the resident or others or that they resulted in unmanageable distress. From late April through mid-July, nursing notes primarily described the resident’s frequent refusals of evening and morning medications, blood sugar checks, blood pressure checks, insulin administration, hygiene care, and showers. Staff documented that the resident sometimes yelled at staff, said “Get out!”, was visibly upset by a room move, was leery of staff and asked to see name badges, and became upset about a pillow under her head until it was removed, after which she calmed down. The notes also recorded instances where the resident believed housekeeping had not cleaned her room or that she had not received medications when she had. However, there were no progress notes or assessments indicating that these behaviors were evaluated as dangerous, non-redirectable, or causing significant distress or functional impairment, and no detailed behavior monitoring logs were present as required by facility policy. On a psychiatric NP visit for initial psychotropic medication management, new mental health diagnoses of schizoaffective disorder, borderline personality disorder, and delusional disorder were added, and Seroquel 25 mg, an antipsychotic, was ordered. The clinical record did not contain a comprehensive evaluation to support these new diagnoses, and there was no documentation of target behaviors meeting the facility’s policy criteria for psychotropic use, such as behaviors representing danger to self or others, causing distress and impairment in functional abilities, or clearly attributable to psychosis or mania. The resident’s representative reported that the resident had no prior history of mental health disorders or psychiatric hospitalization and was unaware of the new diagnoses. The facility’s own psychotropic medication policy required identification and documentation of specific target behaviors, use and documentation of nonpharmacological interventions, and ongoing monitoring of behaviors and interventions, which were not reflected in the record for this resident.
Failure to Update PASARR Screens for New Mental Health Diagnoses and Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that Preadmission Screening and Resident Review (PASARR) Level I screenings were accurate and updated when new mental health diagnoses and psychoactive medications were initiated for multiple residents. For one resident with dementia, anxiety, depression, and post-traumatic stress disorder (PTSD), the PASARR completed on admission listed anxiety, depression, and dementia with sertraline and quetiapine, but did not include the PTSD diagnosis or the antidepressant Pristiq, despite the admission MDS and care plan documenting PTSD and a subsequent physician’s order for Pristiq. For another resident with Alzheimer’s disease, borderline personality disorder, delusional disorder, schizoaffective disorder, and depression, the PASARR only reflected depression and dementia with sertraline, even though additional mental health diagnoses were added later and an antipsychotic (quetiapine) was ordered for borderline personality disorder, and the quarterly MDS documented psychotic disorder, schizophrenia, and depression with antipsychotic and antidepressant use. A third resident had diagnoses including Alzheimer’s disease, depression, anxiety disorder, irritability and anger, and nonrheumatic aortic valve stenosis. The PASARR for this resident listed dementia and anxiety with Risperdal but omitted the diagnosis of depression and the medications escitalopram and lorazepam, although physician’s orders were in place for escitalopram for depression and lorazepam for anxiety, and the admission MDS documented depression with antianxiety and antidepressant use. Interviews with the Assistant Director of Nursing confirmed that new Level I PASARR screens should have been completed when new mental health diagnoses and psychoactive medications were added, and that the PASARR for one resident, completed prior to arrival, should have included all mental health diagnoses and medications. The facility’s own policy required notification of the state mental health authority within 14 days after a significant change in mental condition and specified that a new Level I screen is required for new mental health diagnoses or newly prescribed psychotropic medications, which was not followed in these cases.
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.
