Riverside Village
Inspection history, citations, penalties and survey trends for this long-term care facility in Elkhart, Indiana.
- Location
- 1400 W Franklin St, Elkhart, Indiana 46516
- CMS Provider Number
- 155695
- Inspections on file
- 29
- Latest survey
- February 24, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Riverside Village during CMS and state inspections, most recent first.
The facility failed to ensure residents could file grievances anonymously as required by its own grievance policy. During a Resident Council meeting, multiple residents reported that grievance forms were kept behind the nursing station and could only be obtained by asking staff, preventing anonymous submission. In an interview and observation, the Executive Director confirmed that grievance forms were stored behind the nurse’s station, were not directly accessible to residents, and were not present in the wall-mounted holder at the station. This practice affected all residents in the facility and conflicted with the written policy stating that residents, representatives, and families may submit grievances anonymously.
Surveyors found unsanitary food storage and equipment conditions in the kitchen, including mildew on a freezer seal, expired concentrated beef broth base that had not been discarded, unlabeled house-made shakes in the freezer, and grease buildup on the side of the stovetop and oven, all contrary to facility policies on food storage and kitchen cleanliness. During a lunch meal observation in the main dining hall, a CNA repeatedly handled cups by touching the rims and even placing fingers inside a coffee cup before pouring and serving beverages to a resident, in violation of the facility’s policy requiring avoidance of contact with food-contact surfaces on drinkware and dishes.
A resident with dementia and multiple comorbidities, who required partial assistance with bathing and had a care plan specifying twice-weekly showers, was repeatedly observed with greasy, unkempt hair. Review of EMR and shower sheets over about a month showed inconsistent provision of showers, limited documented attempts after refusals, and weeks in which the resident was only offered or received one shower despite the schedule. Nursing notes lacked documentation of shower refusals, and staff interviews confirmed that expected re-approach and nurse notification procedures were not reflected in the record. Leadership reported there was no facility policy governing ADL provision, including showers and baths.
A resident with chronic CHF, receiving a daily diuretic, had a physician’s order for daily weights and provider notification for a weight gain of 3 lbs in one day or 5 lbs in one week. Documentation showed the resident’s weight increased by 3.1 lbs in one day, but the physician was not notified as required by the order. During interview, the DON acknowledged the physician should have been notified and reported that the facility did not have a specific policy on following physician orders, relying instead on standards of practice.
A resident with Alzheimer’s disease, dementia, anxiety, and schizophrenia was repeatedly observed with a strong urine odor in her room and in common areas, wearing the same ill-fitting, increasingly soiled clothing over several days, and hoarding paper towels without staff intervention. Records showed she had moderate cognitive impairment, occasional incontinence, and needed assistance with toileting and hygiene, yet her care plans, while listing multiple behavioral concerns and refusals of care, lacked individualized behavioral interventions. The resident’s guardian reported longstanding poor hygiene behaviors and stated the facility was not addressing them or communicating about behavioral health. Facility staff, including an LPN, a social services staff member, and the psychiatric NP, indicated that behaviors and refusals were not consistently documented or reported, and the NP was not advised of issues that might require intervention. No behavioral health program policy was provided when requested.
A resident with multiple chronic conditions, including dementia and psychosis, was started on Divalproex and received it continuously for several months while also receiving antianxiety, antidepressant, anticonvulsant, and hypnotic medications. The care plan identified risk for adverse effects from anticonvulsant use and called for labs as ordered, and a physician ordered a one-time ammonia and valproic acid level. However, this lab order was discontinued without the tests ever being completed, and no valproic acid or ammonia levels were obtained or followed up, despite facility policy requiring tracking and investigation of outstanding labs. This failure to perform and track ordered lab monitoring for the anticonvulsant regimen resulted in a deficiency related to unnecessary medications.
A resident with a history of chronic pain and recent injury was not properly assessed or treated for pain upon admission, despite physician orders for as-needed pain medication. During evening care, the resident experienced severe pain, which was not addressed by staff through assessment or medication, resulting in the resident calling 911 and leaving the facility for hospital care.
The facility did not obtain or complete required discharge documentation for several residents, including missing physician orders for discharge, incomplete discharge summaries lacking key clinical and personal information, and failure to provide or document discharge medications as required by policy. These deficiencies affected residents with complex medical needs and were confirmed through record review and staff interviews.
The facility failed to store food safely in the kitchen, potentially affecting 70 residents. An observation revealed open and unsealed bags of frozen peas and mixed vegetables in the reach-in freezer. The Culinary Nutrition Manager confirmed that these bags should have been sealed after use.
A CNA failed to follow infection control practices by not wearing gloves or a gown while changing bed linens for a resident in an Enhanced Barrier Precautions (EBP) room. The CNA was unaware of the resident's EBP status, despite signage indicating the need for precautions due to the resident's chronic wounds and risk of MDRO colonization.
The facility failed to document and notify the transfer of two residents to the hospital. A resident with mild cognitive impairment was hospitalized without a completed transfer/discharge assessment. Another resident with dementia and anxiety disorder was transferred to a psychiatric hospital without the necessary transfer forms. Staff interviews confirmed the lack of required documentation, which was against the facility's policy.
The facility failed to provide bed hold policies to two residents during hospital transfers. One resident with mild cognitive impairment did not receive the policy before hospitalization, and another with dementia and anxiety disorder lacked documentation of the policy during a psychiatric hospital transfer. Staff interviews confirmed the omission, despite facility policies requiring the provision of bed hold policies at the time of transfer.
The facility failed to provide timely ADL care for three dependent residents, including nail care, shaving, and repositioning. A resident with multiple health issues had long, dirty nails despite requests for trimming. Another resident, with hemiparesis, was not shaved by staff and had to rely on a roommate. A third resident, with impaired mobility, was not repositioned as required. The facility lacked specific ADL policies, relying on checklists without frequency guidelines.
A facility failed to timely address pharmacy recommendations for a resident's medication regimen, which included multiple medications for conditions such as anxiety and repeated falls. Despite pharmacy reviews in August and September recommending a decrease in gabapentin due to fall risk, the physician did not address these until October, determining gabapentin was unrelated to falls. The DON confirmed that recommendations should be addressed within 30 days, as per facility policy.
A resident with multiple diagnoses did not receive prescribed medications on several occasions due to unavailability. The facility failed to notify the physician about the missed administrations, as required by their policy. The Director of Nursing and Regional Nurse Consultant acknowledged the oversight, which led to the deficiency.
A resident with multiple diagnoses did not receive prescribed medications on several occasions due to unavailability and lack of timely administration. The facility's policy required obtaining medications from the emergency supply or arranging immediate delivery, but this was not followed. The MAR noted the unavailability of drugs, and the Director of Nursing acknowledged the issue, highlighting a failure in adhering to the 'five rights' of medication administration.
A resident with multiple diagnoses did not receive prescribed medications, Caplyta and Pregabalin, on several occasions due to unavailability. The facility failed to follow its policy on medication shortages, which required notifying the physician and seeking alternative instructions. The Director of Nursing confirmed the order was sent timely, but the medication did not arrive immediately.
Failure to Provide Anonymous Access to Grievance Forms
Penalty
Summary
The facility failed to honor residents’ right to file grievances anonymously by not making grievance forms readily and independently accessible to residents. During a Resident Council meeting, all 12 residents present reported that grievance forms were kept behind the nursing station and that they had to ask staff to obtain a form, which prevented them from submitting grievances anonymously. In a subsequent observation and interview, the Executive Director confirmed that grievance forms were located behind the nurse’s station and were not available for residents to access without staff assistance, and also noted that there were no forms present in the plastic wall hanger behind the nurse’s station at that time. This practice conflicted with the facility’s written “Resident Concerns and Grievances” policy, which states that residents, representatives, and family members have the right to file grievances orally or in writing, to file grievances anonymously, and that grievances can be submitted anonymously with anonymity maintained by the Grievance Official throughout the resolution process. As a result, for all 65 residents in the facility, grievance forms were not readily available in a manner that allowed anonymous submission, and residents were required to request forms from staff, contrary to the facility’s stated policy and residents’ rights to file grievances without fear of reprisal or discrimination.
Unsanitary Kitchen Conditions and Improper Handling of Drinkware During Meal Service
Penalty
Summary
Surveyors identified that the facility failed to maintain sanitary conditions in the kitchen and main dining hall. During a kitchen tour with the Dietary Manager, a two-door upright freezer was observed with a thick black substance on the rubber seal and adjacent stainless steel, which the Dietary Manager identified as mildew. In the walk-in cooler, a container of concentrated beef broth base was found with a best-by date of 12/2025, and the Dietary Manager acknowledged it should have been discarded in January. The freezer also contained four house-made shakes that were unlabeled and undated, contrary to facility policy requiring opened and prepared foods to be labeled and dated. Additionally, a large area of dark brown substance, identified by the Dietary Manager as grease, was observed on the side of the stovetop and oven, indicating that kitchen equipment was not kept clean as required by the facility’s kitchen cleanliness policy. During a lunch meal observation in the main dining hall, a CNA was seen handling drinkware in a manner that did not prevent contamination of food contact surfaces. The CNA cupped her hand over a plastic cup of water, touching the rim where a resident would drink, and similarly placed her fingers on the drinking area of a coffee cup before serving it to the same resident. She also put her fingers inside a resident’s coffee cup before pouring coffee and again placed her hands on the rim of another cup of water while serving it. These actions conflicted with the facility’s meal service and distribution policy, which requires utensils, cups, glasses, and dishes to be handled in a way that avoids touching any food contact surface. The Dietary Manager later confirmed that the correct method of serving drinks is to hold the bottom of the cup and keep fingers away from the drinking surface.
Failure to Provide and Document Scheduled Showers and ADL Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident received showers and ADL care as planned and documented. Surveyors repeatedly observed the resident in the Memory Care unit with greasy, unkempt, and disheveled hair over several days. Review of the clinical record showed the resident had multiple significant diagnoses, including Alzheimer’s disease, paranoid schizophrenia, diabetes mellitus, severe protein-calorie malnutrition, vascular dementia, and other conditions. A recent MDS indicated the resident had both short- and long-term memory problems, moderately impaired cognitive skills for daily decision-making, and required partial assistance with bathing and showering. The care plan documented that the resident refused showers and required staff to explain tasks in detail, allow time to process, and continue to encourage care as tolerated. The care plan also specified assistance with ADLs, including offering showers twice weekly in the morning or early afternoon per the resident’s preference. Review of the EMR and shower sheets for a one-month period showed inconsistent provision and documentation of showers and shower attempts. The records showed a shower on one date in late January, a single documented refusal with no further attempts that week, and another shower at the end of January. In early February, there was one documented refusal with no further attempts that week, followed by three documented attempts on another date, a shower on a mid-February date, and three documented refusals on a later date. Nursing notes did not contain documentation of the resident’s refusals to shower during the review period. Interviews with staff indicated that the expectation was to attempt showers up to three times, then notify the nurse so the refusal could be documented in the EMR, but there was no explanation for why the resident was only offered or received one shower in certain weeks and why nursing notes lacked refusal documentation. The Regional Director of Clinical Services stated the facility did not have a policy for providing ADLs, including showers and baths.
Failure to Notify Physician of Significant Weight Gain for Resident With CHF
Penalty
Summary
The deficiency involves the facility’s failure to follow a physician’s order to notify the provider of a specified weight gain for a resident with chronic congestive heart failure (CHF). Record review showed that the resident, who was receiving a daily diuretic for CHF per a Quarterly MDS dated 1/12/2026, had a physician’s order dated 1/14/2026 to be weighed daily and for the physician to be called for a gain of 3 pounds in one day or 5 pounds in one week. The MAR documented that the resident’s weight was 197 pounds on 2/8/2026 and 200.1 pounds on 2/9/2026, reflecting a 3.1-pound gain in one day. Despite this documented weight increase meeting the threshold in the physician’s order, the MAR indicated that the physician was not notified of the 3.1-pound gain. In an interview, the DON confirmed that the physician should have been notified of the weight gain and stated that the facility did not have a policy regarding following physician orders, indicating they followed standards of practice instead.
Failure to Provide Individualized Behavioral Health Interventions and Hygiene Care
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary behavioral health care and services, including individualized behavioral interventions, for a resident with significant behavioral-emotional issues. Surveyors repeatedly observed the resident and her room with a very strong odor of urine on multiple days and at various times, including in her room and in the dining room. The resident was also observed hoarding paper towels from a dispenser in the dining room, folding them, and placing them under her arm while staff present did not intervene. Over several days, the resident was seen wearing the same ill-fitting, oversized clothing that dragged on the ground, hung off her buttocks, and became visibly stained, with a strong urine odor detectable from several feet away. Record review showed the resident had diagnoses including Alzheimer’s disease, dementia, generalized anxiety, and schizophrenia, with a recent MDS indicating moderate cognitive impairment, occasional bladder incontinence, and a need for assistance or supervision with toileting, personal hygiene, dressing, and showering. A nurse practitioner note documented that the resident was co-managed with psychiatry, was not taking medications for schizophrenia, and was receiving supportive care only due to non-compliance related to psychosis. The resident’s care plans listed multiple behavioral concerns such as difficulty adjusting to changes, self-hitting while talking to imaginary persons, refusing showers and facial hair trimming, rummaging through others’ belongings, refusing assessments, refusing to wear incontinence briefs and using textured bath towels instead, carrying plastic bags with belongings, and episodes of verbal and combative agitation. However, the care plans lacked personalized interventions specifically aimed at preventing or managing these behavioral issues. Interviews further demonstrated a lack of coordinated behavioral health intervention and documentation. The resident’s guardian reported that the resident would not use the toilet, instead stacking towels under herself to urinate on, and stated that the facility allowed these behaviors to continue without doing anything for her situation or discussing her behavioral health. The guardian also reported not being contacted by the psychiatric NP about the resident’s behavioral issues and being told that nothing could be done because the resident would not take medication. The floating SSD acknowledged that refusals to change clothing and shower should have been charted as behaviors and became tearful after noting the strong urine odor in the resident’s room. Nursing staff stated they tried different staff and times to approach the resident but acknowledged that care plan interventions were not specific to her needs. The psychiatric NP reported not being informed of behavioral complaints, refusals of care, or documented behaviors, and the Executive Director stated that the resident had rights, had refused clothing changes, and was content and at baseline. When requested, the facility did not provide a behavioral health program policy prior to survey exit.
Failure to Complete Required Lab Monitoring for Anticonvulsant Therapy
Penalty
Summary
Surveyors identified a deficiency related to failure to ensure a resident’s drug regimen was free from unnecessary drugs by not completing required blood monitoring for an anticonvulsant medication. The resident had multiple diagnoses including dementia, psychosis, anxiety, anemia, atherosclerotic heart disease, severe protein-calorie malnutrition, spondylosis, hypertension, dysphagia, hydronephrosis, hypotension, obstructive and reflux uropathy, and atrophy of the kidney. A quarterly MDS assessment documented that the resident was receiving antianxiety, antidepressant, anticonvulsant, and hypnotic medications. The care plan, initiated in mid-November, identified the resident as being at risk for adverse side effects related to anticonvulsant/antiseizure medication use, with interventions that included obtaining labs as ordered. Physician’s orders showed that Divalproex (Depakote) 125 mg, two capsules twice daily, was started in mid-November, and MARs for November, December, January, and February showed the resident received this medication continuously from mid-November through late February. A physician’s order dated in mid-November directed a one-time blood draw for ammonia and valproic acid levels, but this lab order was discontinued later in November without the tests ever being completed. During interviews, the DON acknowledged that the valproic acid level was intended to be drawn and that no lab results could be found in the chart. The DON further stated that the lab order had been discontinued later in November after being ordered earlier that month. The Regional Director of Clinical Services confirmed that the resident had not had any valproic acid or ammonia levels monitored at all while receiving Divalproex. The facility’s policy on lab and radiology tracking, provided by the DON, required confirmation that each ordered lab was obtained and that any labs not resulted as expected be investigated, but the ordered monitoring labs for this resident were not completed or followed up, leading to the cited deficiency.
Failure to Assess and Manage Resident Pain Leading to Hospital Transfer
Penalty
Summary
A resident with a complex medical history, including left shoulder and arm pain, multiple sclerosis, spastic hemiplegia, polyneuropathy, and chronic pain, was admitted to the facility following a recent hospital stay for similar complaints. Upon admission, the resident reported new onset pain, and physician orders included as-needed oxycodone-acetaminophen for pain management. However, there was no documentation of further pain assessments or administration of pain medication on the day of admission, despite the resident's ongoing pain. Later that evening, during routine care, the resident expressed significant pain when repositioned by CNAs, who then returned her to a more comfortable position. The resident subsequently called 911 due to unresolved pain and left the facility against medical advice. Interviews with staff revealed that pain assessments were not conducted as required, and pain medication was not offered or administered, even though the resident was visibly in distress. The facility's pain management policy required pain assessment upon admission and during medication administration, but these procedures were not followed in this case.
Failure to Ensure Complete and Proper Discharge Documentation and Orders
Penalty
Summary
The facility failed to ensure proper discharge documentation and procedures for five out of six residents reviewed for transfer or discharge. In multiple cases, residents were discharged without a physician's order authorizing the discharge, as required by facility policy. For example, several residents with complex medical histories, including conditions such as cerebral palsy, diabetes, hypertension, and heart failure, were discharged home without the necessary physician documentation. Interviews with the Regional Director of Clinical Services confirmed that physician orders should have been present for each discharge but were missing in these cases. Additionally, the discharge summaries and clinical narratives for these residents were incomplete or missing critical information. Key sections such as transportation arrangements, customary routines, continence status, cognitive patterns, dental and nutritional status, vision, pressure ulcer/injury status, mood and behavior patterns, activity pursuits, psychosocial well-being, and physical functioning were left blank in the electronic records. In some instances, the discharge medication lists were not included, and the summaries lacked signatures from the residents or their representatives. The facility's own policies required that these sections be completed using information from the most recent Minimum Data Set (MDS) assessment, but this was not consistently done. Furthermore, there were failures in the handling of medications at discharge. In at least one case, medications that should have been sent home with the resident were instead returned to the pharmacy, contrary to physician orders. The facility's policies stipulated that a reconciliation of discharge orders and medications should be completed, and that a physician's order must specify if medications are to be sent with the resident. These steps were not followed, resulting in incomplete or missing discharge instructions and medication lists for the affected residents.
Improper Food Storage in Kitchen
Penalty
Summary
The facility failed to store food in a safe and sanitary manner in the kitchen, which had the potential to affect 70 of 71 residents who consumed food prepared there. During an observation of the kitchen, an open and unsealed bag of frozen peas and an open and unsealed bag of frozen mixed vegetables were found in the reach-in freezer. The Culinary Nutrition Manager, during an interview, acknowledged that the bags of opened, frozen food should have been sealed after use.
Infection Control Breach in EBP Room
Penalty
Summary
The facility failed to ensure proper infection control practices were followed for a staff member providing high contact care in an Enhanced Barrier Precautions (EBP) room. During an observation, a CNA was seen changing bed linens for a resident in isolation without wearing gloves or a gown, which are required under EBP. The CNA was unaware of the resident's EBP status, as she had not noticed the sign indicating the precautions on the resident's door. The resident in question had a history of type 2 diabetes with a foot ulcer and was at risk for colonization with a Multi-drug Resistant Organism (MDRO) due to chronic wounds. The care plan for the resident, initiated months prior, specified the need for EBP, including the use of gowns and gloves during high contact care activities. The facility's policy on EBP, provided by the Regional Nurse, also outlined these requirements, indicating a failure in adherence to established protocols.
Failure to Document and Notify Resident Transfers
Penalty
Summary
The facility failed to provide proper documentation and notification for the transfer of two residents to the hospital. Resident 21, who had mild cognitive impairment, was hospitalized but the facility did not complete the required transfer/discharge assessment. Interviews with staff revealed that the necessary paperwork was not filled out prior to the resident's transfer, and the transfer/discharge assessment was not found in the resident's chart. The Infection Prevention Nurse confirmed that the assessment was not completed, which was against the facility's protocol. Similarly, for Resident 48, who had diagnoses including unspecified dementia and generalized anxiety disorder, the facility did not document the transfer to a psychiatric hospital for evaluation and treatment. The required hospital transfer forms were missing from the electronic medical record. An LPN confirmed that the necessary transfer paperwork was not completed, which should have included an emergency transfer observation, CCD, and bed hold policy. The facility's policy, revised in 2019, mandates that these documents be attached to the resident's medical record during a transfer, but this was not adhered to in these cases.
Failure to Provide Bed Hold Policies During Hospital Transfers
Penalty
Summary
The facility failed to provide bed hold policies to residents or their representatives at the time of hospital transfer, as required. This deficiency was identified for two residents. Resident 21, who had mild cognitive impairment, was hospitalized and did not recall receiving any paperwork, including the bed hold policy, prior to her transfer. Interviews with facility staff revealed that the bed hold policy should have been included in the paperwork sent with the resident, but it was not found in the resident's records. Similarly, for Resident 48, who had diagnoses including unspecified dementia and generalized anxiety disorder, there was no documentation of the bed hold policy being provided at the time of transfer to a psychiatric hospital. Staff interviews confirmed that the necessary transfer paperwork, which should have included the bed hold policy, was not completed. The facility's policies, as provided by the Regional Nurse, indicated that the bed hold policy should be given to residents at the time of hospital transfer, but this was not adhered to in these cases.
Deficiencies in ADL Care for Dependent Residents
Penalty
Summary
The facility failed to provide timely Activities of Daily Living (ADLs) care for three dependent residents, specifically in the areas of nail care, shaving, and turning and repositioning. Resident 15, who is blind and has multiple diagnoses including Parkinson's disease and congestive heart failure, was observed with long, dirty fingernails despite requesting assistance multiple times. His care plan indicated he required assistance with ADLs, but his requests for nail trimming were not fulfilled, leading to a scab under his eye from scratching himself. Resident 38, who has conditions such as radiculopathy and hemiparesis, expressed dissatisfaction with his facial hair and long fingernails, having requested assistance multiple times without receiving it. Despite his care plan indicating a need for assistance with grooming and hygiene, he was not shaved by staff and had to rely on his roommate for help. The Executive Director acknowledged the oversight but was unaware that staff had not provided the requested care. Resident 14, with a history of cerebrovascular diseases and impaired mobility, was observed lying supine in bed with a wedge cushion next to him, indicating a lack of adherence to his care plan, which required turning and repositioning every two hours to prevent skin breakdown. Interviews with CNAs revealed inconsistencies in care practices, and the facility lacked specific policies for providing ADLs to dependent residents, relying instead on checklists that did not specify the frequency of care tasks.
Delayed Response to Pharmacy Recommendations for Medication Review
Penalty
Summary
The facility failed to address pharmacy recommendations in a timely manner for a resident reviewed for unnecessary medications. The resident, who had diagnoses including generalized anxiety, radiculopathy, hemiparesis/hemiplegia, and repeated falls, was taking multiple medications such as buspirone, diazepam, trazodone, fluoxetine, and gabapentin. A pharmacy review conducted in August and September 2024 recommended decreasing the gabapentin dose due to the potential increased risk for falls. However, these recommendations were not addressed by the physician until October 2024, when the physician decided that the gabapentin was unrelated to the falls. During an interview, the Director of Nursing (DON) indicated that pharmacy recommendations should be addressed when received or at least within 30 days. The facility's current policy, dated October 2018, also stated that pharmacy recommendations should be reviewed with follow-up to the physician within 30 days of receipt. The delay in addressing the pharmacy's recommendations for the resident's medication regimen led to the deficiency noted in the report.
Failure to Notify Physician of Missed Medication Administrations
Penalty
Summary
The facility failed to notify the physician of multiple missed medication administrations for a resident diagnosed with Bipolar II disorder, borderline personality, anxiety, obsessive-compulsive disorder, and chronic low back pain. The resident had prescribed medications including Baclophen, Caplyta, and Pregabalin, which were not administered on several occasions due to unavailability. The Medication Administration Record (MAR) indicated that Baclophen was missed on specific dates and times, with no nursing comments explaining the omissions. Caplyta and Pregabalin were also not administered on multiple occasions, with nursing comments noting the unavailability of the drugs. The Director of Nursing acknowledged that the physician should have been notified when medications were not available for administration, and the MAR should have reflected the reasons for non-administration. The facility's policy on medication shortages required the nurse to obtain medications from the Emergency Medication Supply or contact the attending physician for new orders if an emergency delivery was unavailable. However, these steps were not followed, leading to the deficiency. The Regional Nurse Consultant confirmed that the physician should have been informed about the missed medication administrations.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure that a resident received medications as ordered by the physician. Resident C, who had diagnoses including Bipolar II disorder, borderline personality, anxiety, obsessive-compulsive disorder, and chronic low back pain, did not receive prescribed medications on multiple occasions. The medications in question were Baclophen, Caplyta, and Pregabalin, which were not administered at various times between June 10 and July 2, 2024. The Medication Administration Record (MAR) indicated that Baclophen was missed on several dates and times without any nursing comments explaining the omissions. Caplyta and Pregabalin were also not administered on specific dates, with the MAR noting that the drugs were unavailable. The facility's policy on medication shortages required staff to obtain medications from the emergency supply or arrange for immediate delivery if necessary. However, the Director of Nursing and the Regional Nurse Consultant acknowledged that the facility did not have Caplyta in the emergency supply and that the physician should have been notified when medications were unavailable. The pharmacy's Proof of Delivery statement confirmed that the medications were shipped and received by the facility, but there was a delay in administration. The failure to administer medications as prescribed violated the standard nursing practice of the 'five rights' of medication administration, which includes administering medications at the right time as intended by the prescriber.
Failure to Provide Timely Medication Administration
Penalty
Summary
The facility failed to ensure that a resident received their prescribed medications in a timely manner, resulting in multiple missed doses. Resident C, who had diagnoses including Bipolar II disorder, borderline personality, anxiety, obsessive-compulsive disorder, and chronic low back pain, did not receive their prescribed Caplyta and Pregabalin medications on several occasions. The Medication Administration Record (MAR) indicated that the medications were unavailable, and the facility did not have Caplyta in their emergency medication supply. The Director of Nursing confirmed that the order for Caplyta was sent to the pharmacy in a timely manner, but the medication did not arrive immediately. The facility's policy required staff to notify the physician if medications were unavailable and to seek alternative instructions, which was not done in this case. The Regional Nurse Consultant also noted that the physician should have been notified when the resident did not receive medications as ordered. The facility's policy on medication shortages was not followed, leading to the deficiency.
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.
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