Robin Run Health Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Indianapolis, Indiana.
- Location
- 6370 Robin Run W, Indianapolis, Indiana 46268
- CMS Provider Number
- 155505
- Inspections on file
- 29
- Latest survey
- December 23, 2025
- Citations (last 12 mo.)
- 29
Citation history
Health deficiencies cited at Robin Run Health Center during CMS and state inspections, most recent first.
A resident with hypertension and type 2 diabetes was admitted without a documented code status order in their chart, despite hospital records and the resident's verbal confirmation indicating a full code preference. An LPN was aware of the resident's wishes and had prepared a POST form for the family, but did not obtain the necessary documentation during the family's visit, resulting in noncompliance with facility policy on advanced directives.
Surveyors found that the facility did not update care plans for three residents after incidents such as bruising, an allegation of sexual abuse, and injury following suctioning. Despite changes in condition and new events, care plans were not revised as required by facility policy.
Staff failed to initiate and document appropriate care for a newly admitted resident with complex needs, including missing orders for catheter and oxygen use, lack of adherence to dietary recommendations, and incomplete documentation. Another resident with CHF and edema was not properly monitored for weight changes as ordered by the physician, with significant weight gain not reported. These deficiencies reflect failures in following physician orders and providing individualized care.
A resident with a pressure ulcer and indwelling catheter, who was under Enhanced Barrier Precautions, did not have appropriate signage or a PPE cart at the room. Multiple staff members provided care while only wearing gloves, without gowns, contrary to EBP requirements. The facility's infection control policy did not address EBP, and staff interviews revealed inconsistent understanding of required precautions.
The facility did not ensure the timely return of personal funds to multiple residents after discharge, with several individuals not reimbursed within the required 30-day period. Funds owed ranged from small to substantial amounts, and the issue persisted for months in some cases. The process for managing and refunding resident money, handled by a third-party system and overseen by the BOM, did not comply with facility policy or regulatory timelines.
Four residents dependent on staff for ADL assistance did not receive scheduled showers, with some going over a month without bathing. Observations noted strong urine odors and unkempt appearances, and documentation failed to show completed showers or refusals. Care plans did not address bathing preferences or refusals, and facility policy requirements for documentation and supervisor notification were not met.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, as identified by surveyors through observation and record review.
A resident with pressure ulcers did not consistently receive required interventions to promote healing, and preventive measures for at-risk residents were not adequately implemented, including lapses in repositioning, skin assessments, and use of pressure-relieving devices.
Two residents did not receive respiratory care in line with professional standards when QMAs administered nebulizer treatments, left residents unattended, and failed to assess or monitor respiratory status before, during, or after treatments. Facility records lacked care plans and documentation of required assessments, and staff were unclear about QMA scope of practice regarding nebulizer administration.
A resident with a history of falls and multiple diagnoses, including Alzheimer's and pancreatic cancer, experienced a fall resulting in a hip fracture. Despite being in obvious pain, the resident only received routine pain medication, as staff awaited hospice arrival. The hospice nurse arrived hours later, and the family eventually decided to transport the resident to a hospital. The facility's pain management policy was not effectively followed, leading to inadequate pain relief for the resident.
A facility failed to ensure proper supervision and care for a resident with a history of falls, leading to a fall in the shower room and multiple fractures. The care plan did not reflect the need for two-person assistance, and post-fall procedures were not followed. Additionally, cleaning chemicals were not stored securely, allowing a resident on the memory care unit to access a poisonous substance. The resident's record lacked documentation of physician notification or follow-up care for the potential ingestion.
The facility failed to comply with its food storage and temperature logging policies. In the main kitchen, several food items were found without proper labeling of arrival or expiration dates. Additionally, the facility did not maintain complete temperature logs for its refrigerators and freezers across multiple locations, missing entries for both opening and closing temperatures on various dates. These deficiencies indicate a lack of compliance with the facility's policies on food safety standards.
The facility failed to conduct a significant change MDS assessment for two residents admitted to hospice. One resident with pancreatic cancer and Alzheimer's, and another with dementia, did not receive the required assessment within 14 days of hospice admission, as confirmed by the MDS Coordinator.
The facility inaccurately coded the MDS for three residents, leading to deficiencies in their assessments. A resident with schizoaffective disorder and another with paranoid schizophrenia had Level II assessments completed, but their MDS inaccurately indicated they did not require them. Another resident admitted with hospice services had an MDS that failed to reflect her hospice status. Attempts to interview the MDS coordinator were unsuccessful.
A resident with a history of falls and medical conditions such as myocardial infarction and hypertension was admitted to the facility without a documented fall care plan. Despite the facility's policy requiring a comprehensive care plan, no interventions were documented to address the resident's fall risk. The DON confirmed the absence of the care plan, citing the resident's short stay as a factor.
The facility failed to provide comprehensive nutritional assessments and services for two residents. One resident, at risk for malnutrition, consistently left meals untouched without timely alternative options, and lacked a comprehensive care plan. Another resident, unable to consume oral nutrition, experienced significant weight loss due to a disconnected feeding pump, with no adjustments made to the feeding plan. Facility policies on care planning and nutritional services were not followed, leading to deficiencies in care.
The facility failed to reconcile medications upon discharge for two residents, leading to a deficiency in pharmaceutical services. One resident, with a history of myocardial infarction and other conditions, was discharged without a record of medication reconciliation for twelve medications. Another resident, who passed away, also had five medications not reconciled. The facility's policy on discharge medications was not followed.
A facility failed to label a vial of tuberculin serum with the date it was opened, as observed in the medication room. The DON confirmed that the serum should be dated and refrigerated when not in use. The facility's policy requires labels to include necessary information such as the drug's name, strength, lot number, expiration date, and cautionary statements.
The facility failed to document insulin administration and blood sugar levels for two residents, leading to a deficiency in maintaining accurate medical records. One resident with type 2 diabetes and other health issues had multiple instances of undocumented insulin administration. Another resident with similar conditions also experienced omissions in documenting insulin and blood sugar levels. The DON acknowledged the omissions, attributing them to staff forgetting to document after administering medication.
The facility failed to ensure dietary staff covered facial hair during food preparation, maintained clean and sanitary conditions in the kitchen and pantry, and stored food at proper temperatures. Observations revealed kitchen staff without beard covers, a dirty pantry refrigerator at 54°F, and an opened, undated gallon of milk left out. Confidential interviews indicated issues with snack availability and improper storage of personal food in the resident refrigerator.
The facility failed to care for a resident in a manner that preserved his dignity and rights. Despite the family's request and the care plan agreement to have the resident out of bed daily, observations showed that the resident remained in bed for several days, not dressed appropriately, and not participating in activities. Staff interviews revealed inconsistencies in the care provided, and the resident expressed a preference to be out of bed daily.
The facility failed to ensure call lights were within reach for three dependent residents, leading to a deficiency. Despite staff passing by, call lights were observed unplugged or out of reach for residents with severe impairments and a history of falls, contrary to their care plans and facility policy.
The facility failed to address resident grievances regarding missing clothing and hearing aids for multiple residents. Interviews revealed frequent issues with missing laundry and a lack of response from management. Grievance logs did not document these concerns, and staff were unaware of the grievance process.
The facility failed to provide personalized activities for two residents, one dependent and one with dementia. Despite care plans and family requests, the residents were often left in bed or alone without meaningful engagement. Staff inconsistencies and lack of alternative hearing devices further hindered their participation in activities.
The facility failed to ensure fall follow-up and care plan updates for two residents. One resident had several falls with no documented root causes or follow-up assessments, and another resident experienced a witnessed fall with no 72-hour follow-up or care plan. Staff interviews revealed inconsistent adherence to fall follow-up procedures.
The facility failed to properly elevate the head of the bed for a resident with a g-tube and a history of aspiration pneumonia. Observations showed the resident lying on his back with the HOB elevated less than 30 degrees while tube feeding was infusing, and the feeding bags were not labeled as required. Despite family complaints, the issue remained unresolved.
The facility failed to post the Ombudsman's contact information, affecting all 44 residents and their representatives. Staff interviews and observations revealed that the information was missing, and the facility had no specific policy for posting it.
Failure to Document Resident Code Status Upon Admission
Penalty
Summary
The facility failed to ensure that a newly admitted resident had a documented code status order in their medical record. Record review showed that the resident, who had diagnoses including hypertension and type 2 diabetes and was their own responsible party, did not have a code status order in their chart. Hospital records indicated the resident was a full code during their hospital stay, and the resident verbally confirmed their wish to be a full code and to have all interventions in place. However, this preference was not formally documented in the facility's records. An LPN acknowledged awareness of the resident's full code status from hospital records and stated that a POST form was prepared for the resident's family to complete. Although the family visited the facility, the LPN did not have time to have them fill out the necessary paperwork during their visit. Facility policy requires inquiry about advanced directives prior to or upon admission and assessment of decision-making capacity, but these steps were not completed as required, resulting in the absence of a documented code status for the resident.
Failure to Update Care Plans After Incidents and Allegations
Penalty
Summary
The facility failed to update or revise care plans for three residents following significant incidents or allegations, as required by policy. For one resident, visible bruising over the bridge of the nose and both eyes was observed, but the care plan was not updated to reflect this new condition, despite the resident's history of wandering, falls, and anticoagulant therapy. Another resident made an allegation of sexual abuse, which led to an investigation and subsequent treatment for a urinary tract infection, but the care plan was not revised to address the new allegation or related behavioral changes. A third resident was noted to have bruising on the right jawline after being suctioned, yet there was no care plan addressing this injury. These deficiencies were identified through observation, record review, and interviews. The facility's policy requires ongoing assessment and revision of care plans as residents' conditions change, but this was not followed in the cases reviewed. The lack of timely care plan updates after incidents or allegations was confirmed by the administrator during the survey.
Failure to Provide Resident-Specific Care and Follow Physician Orders
Penalty
Summary
The facility failed to provide resident-specific care and follow physician orders for two residents, resulting in deficiencies related to quality of care. For one newly admitted resident with diagnoses including dysphagia, functional quadriplegia, and weakness, staff did not initiate appropriate care or document necessary orders for critical aspects such as catheter use, catheter care, oxygen use, respiratory care, and code status. Observations revealed the resident was left in discomfort, unable to access their call light or television, and was not provided with their personal clothing or dentures. Staff were unaware of the resident's needs and failed to follow hospital speech therapy recommendations regarding diet and liquid consistency, resulting in the resident receiving inappropriate meal trays with thin liquids despite a recommendation for thickened liquids. Documentation in the resident's medical record was inconsistent and incomplete, with conflicting information about the resident's catheter size, oxygen use, and level of independence with oral care. Staff interviews revealed a lack of awareness regarding the resident's care needs and orders, with some staff admitting to confusion due to multiple admissions and others not realizing required standing orders were missing. The admitting nurse did not enter necessary orders for the resident's indwelling catheter, oxygen, or code status, and this was not corrected by subsequent shifts. The facility's policies required complete and accurate documentation and timely initiation of care plans and orders, which were not followed in this case. For another resident with congestive heart failure and edema, the facility failed to follow physician orders for daily weight monitoring and notification of significant weight gain. The resident experienced a weight increase of over 6 pounds in 24 hours, but there was no documentation that the physician was notified as required. Additionally, a weight was omitted on a subsequent date, further indicating a lack of adherence to monitoring protocols. These failures demonstrate lapses in following physician orders and ensuring quality of care for residents with complex medical needs.
Failure to Implement Enhanced Barrier Precautions and Infection Control Practices
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices for a resident who was under Enhanced Barrier Precautions (EBP). Observations revealed that the resident, who had a pressure ulcer on the coccyx and an indwelling urinary catheter, did not have an EBP sign posted on or around her door during multiple checks. Staff members, including a CNA, a physical therapy assistant, a QMA, and an RN, were observed providing care to the resident while only wearing gloves, without donning gowns as required for high-contact care under EBP. Additionally, there was no PPE cart located next to the resident's room, and the resident's catheter bag was observed lying on the ground next to the bed. Interviews with staff indicated a lack of consistent understanding regarding the reasons for EBP and the required PPE. The infection prevention nurse confirmed that both gloves and gowns should be worn for high-contact care, but this was not followed in practice. Review of the facility's infection control policy showed that EBP was not addressed, and no other relevant policy was provided. These failures resulted in the facility not maintaining proper infection control practices for the resident on EBP.
Failure to Timely Return Resident Personal Funds After Discharge
Penalty
Summary
The facility failed to maintain a system for the proper management and timely return of resident personal funds for 8 out of 11 residents reviewed. Anonymous concerns were raised during the survey process regarding mismanagement of residents' personal money by management. Record review revealed that several residents had not been reimbursed their personal funds within 30 days of discharge, with some cases dating back several months. Specific amounts owed to discharged residents ranged from $16.18 to $7,480.00, and in some instances, the non-return of funds dated back to residents who had left the facility as early as December 2023. Interviews with the Business Office Manager (BOM) indicated that resident funds were managed by a third-party system at the corporate office, with the BOM responsible for daily census updates and submitting refund requests after resident discharge. Despite the facility's policy requiring the return of personal funds and a final accounting within 30 days of discharge, eviction, or death, this process was not followed for multiple residents. The deficiency was identified through both interviews and record reviews, confirming that the facility did not adhere to its own policy or regulatory requirements regarding the timely conveyance of resident funds.
Failure to Provide Scheduled Bathing and Showering Assistance
Penalty
Summary
The facility failed to provide necessary assistance with bathing and showering for four residents who were dependent on staff for activities of daily living. Observations and interviews revealed that these residents had not received showers as scheduled, with some going over a month without a shower. For example, one resident reported receiving only one shower since admission several weeks prior, and another was last documented as having a shower nearly a month before the survey. In multiple cases, there were strong urine odors present in residents' rooms, and residents appeared disheveled or unkempt. Documentation in the Point of Care system showed missed scheduled showers, and there was no evidence that residents had refused care or that their preferences or refusals were addressed in their care plans. Record reviews confirmed the lack of documentation for completed showers or refusals, and the facility's own policy required detailed documentation of bathing, including refusals and interventions taken. The policy also required notification of supervisors if a resident refused a shower, but there was no documentation to support that this process was followed. The deficiency was identified through observation, interview, and review of both electronic and handwritten records, which consistently showed a lack of compliance with scheduled bathing and documentation requirements for the affected residents.
Failure to Follow Physician Orders and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. This deficiency was identified through surveyor observation and review of records, which showed that care provided did not align with the documented orders or the expressed wishes and goals of the resident. Specific details regarding the resident’s medical history and condition at the time of the deficiency were not provided in the report.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through surveyor observations and documentation review, which indicated that residents with existing pressure ulcers did not consistently receive the necessary interventions to promote healing. Additionally, preventive strategies to protect residents at risk for developing pressure ulcers were not adequately carried out, as evidenced by lapses in repositioning, skin assessments, and use of pressure-relieving devices.
Failure to Provide Safe and Appropriate Respiratory Care During Nebulizer Treatments
Penalty
Summary
The facility failed to provide respiratory care in accordance with professional standards for two residents who required nebulizer treatments. During a medication administration observation, a Qualified Medication Aide (QMA) prepared and administered a nebulizer treatment to a resident, left the resident unattended, and did not assess the resident's respiratory status before or after the treatment. The resident was not monitored during the treatment, and there was no documentation of respiratory assessments or monitoring by a licensed professional. Additionally, the facility's records for both residents lacked care plans related to their respiratory conditions and did not include interventions for nebulized treatments. Review of medication administration records showed that the majority of nebulizer treatments were administered by QMAs, despite state guidelines prohibiting QMAs from administering nebulizer treatments. Interviews with staff revealed confusion regarding the scope of practice for QMAs, with some staff unaware of the restrictions. The facility did not have a policy outlining the QMA scope of practice, and the job description and competency evaluations for QMAs did not address nebulizer treatments. The facility's own policy required licensed staff to assess and monitor residents during nebulizer treatments, but this was not followed.
Failure to Manage Pain for Resident After Fall
Penalty
Summary
The facility failed to manage pain for a resident, identified as Resident B, who had a history of falls and was experiencing pain related to a fall that resulted in a fracture of her left hip. Resident B had multiple diagnoses, including osteoarthritis, pancreatic cancer, Alzheimer's disease, and major depressive disorder. Her care plan indicated she was at risk for falls due to confusion, dementia, and impaired safety awareness. Despite these risks, Resident B attempted to self-ambulate and fell while trying to self-toilet, resulting in a head laceration and a fractured femur. Following the fall, Resident B was found with a bruise and cut on her head, and she was in obvious pain, crying out and wincing. Although she had orders for pain medications, including tramadol and acetaminophen, she was only administered her routine doses at 8:30 a.m. The nursing staff, including RN 7, did not administer additional pain medication despite recognizing her pain, as they were waiting for hospice to arrive. The hospice nurse did not arrive until around 12:30 p.m., and by that time, the family had decided to transport Resident B to a hospital for further evaluation and treatment. The facility's policy on pain management emphasizes the importance of alleviating pain based on clinical assessment and treatment goals. However, the staff failed to provide timely pain relief for Resident B after her fall, as evidenced by the delay in administering additional pain medication and the reliance on hospice for pain management. The Executive Director was unaware of the hospice nurse's order for pain medication, indicating a lack of communication and coordination in managing Resident B's pain effectively.
Deficiencies in Resident Supervision and Chemical Storage
Penalty
Summary
The facility failed to ensure that a resident with a history of fall-related fractures was transferred with two staff persons as per the care plan, leading to a fall in the shower room. This incident resulted in the resident sustaining fractures of two left ribs, the spine, and the sacrum. The resident's care plan did not reflect the need for extensive assistance of two persons for transfers, and post-fall procedures were not followed, as there was no documentation of the fall, root cause analysis, or follow-up assessments in the resident's record. Additionally, the facility failed to store cleaning chemicals securely, allowing a resident on the secured memory care unit to access and potentially ingest a poisonous substance. The resident was observed with a bottle of Faboloso cleaner, and although staff did not witness the resident ingesting the cleaner, poison control was contacted. The resident's record lacked documentation of physician notification, follow-up orders, or a care plan addressing the ingestion of a poisonous chemical. The report highlights deficiencies in both the supervision and care of residents, as well as the storage and management of hazardous materials. These failures resulted in significant risks to resident safety and well-being, as evidenced by the incidents involving falls and potential chemical ingestion.
Food Storage and Temperature Logging Deficiencies
Penalty
Summary
The facility failed to adhere to its food storage and temperature logging policies, as observed during a survey. In the main kitchen, several food items, including fresh herbs, pepperoni, whipped cream, and feta cheese, were found without proper labeling of arrival or expiration dates. Additionally, the walk-in freezer contained undated items such as crumbled sausage, impossible burgers, and a lemon meringue pie. These observations indicate a lack of compliance with the facility's policy that requires all foods stored in the refrigerator or freezer to be covered, labeled, and dated. Furthermore, the facility did not maintain complete temperature logs for its refrigerators and freezers across multiple locations, including the main kitchen, satellite kitchenette, and Memory Care pantry. The logs were missing entries for both opening and closing temperatures on various dates throughout August. This failure to document temperatures as per the facility's policy, which mandates monthly tracking sheets for all refrigerators and freezers, suggests a systemic issue in monitoring and ensuring food safety standards.
Failure to Conduct Significant Change MDS Assessment for Hospice Admissions
Penalty
Summary
The facility failed to conduct a Minimum Data Set (MDS) significant change assessment for three residents who experienced a change in condition due to hospice admission. Resident 14 was admitted to hospice on June 22, 2024, but a significant change MDS assessment was not completed following this admission. Resident 14's medical history included malignant neoplasm of the pancreas, Alzheimer's disease, and a history of breast cancer. Despite the hospice and cancer care plans indicating her terminal prognosis and hospice status, the required MDS assessment was not performed. Similarly, Resident 49, residing in a secured memory care unit with dementia, was admitted to hospice on March 15, 2024. However, no significant change MDS assessment was initiated following his hospice admission. The MDS Coordinator confirmed that the facility's protocol required a significant change assessment when a resident was admitted to hospice. According to the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, a significant change MDS must be completed within 14 days of hospice election, which was not adhered to in these cases.
Inaccurate MDS Coding for Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for three residents, leading to deficiencies in their assessments. Resident 11, diagnosed with schizoaffective disorder, diabetes mellitus type 2, anxiety disorder, and chronic kidney disease, had a Level II assessment completed in October 2021 due to her mental health condition. However, her MDS inaccurately indicated that she did not require a Level II assessment. Similarly, Resident 1, with diagnoses including paranoid schizophrenia, major depression, heart failure, insomnia, and unspecified dementia, had a Level II assessment completed in January 2024, but her MDS also incorrectly stated that she did not require it. Additionally, Resident 211, who was admitted with hospice services and had diagnoses such as hypertension, anxiety, diabetes mellitus, and degenerative disease of the nervous system, had an MDS that failed to reflect her hospice status. Attempts to interview the MDS coordinator were unsuccessful, and the facility's policy on resident assessments, provided by the Administrator, mandates the use of the MDS form as per federal and state regulations.
Failure to Implement Fall Care Plan for Resident
Penalty
Summary
The facility failed to implement a fall care plan for a resident with a history of falls. During a record review, it was found that Resident 60, who had been admitted with diagnoses including myocardial infarction, hypertension, and vitamin D deficiency, did not have a documented care plan addressing his risk for falls. Despite his history of falls, there were no interventions documented to prevent future falls. The Director of Nursing confirmed the absence of a fall care plan during an interview, noting that the resident had only been at the facility for a short time. The facility's policy requires the interdisciplinary team to develop and implement a comprehensive, person-centered care plan for each resident, which was not adhered to in this case.
Deficiencies in Nutritional Care and Assessment
Penalty
Summary
The facility failed to ensure comprehensive nutritional assessments and services for Resident 43, who was at risk for malnutrition and had a history of poor food intake. Observations revealed that Resident 43 consistently left meals untouched, and alternative food options were not offered in a timely manner. Despite being identified as a picky eater and having difficulty expressing preferences due to dementia, the facility did not develop a comprehensive nutritional care plan or notify the dietician of the resident's poor intake. The resident's weight decreased over time, and her nutritional assessment was overdue. Resident 53, who was unable to consume oral nutrition due to dysphagia, experienced significant weight loss over a four-month period. The resident had a prescribed feeding regimen via a gastrostomy tube, but observations showed that the feeding pump was disconnected for three hours, contrary to the physician's orders. The Assistant Director of Nursing was unaware of the weight loss, and the Registered Dietician did not adjust the feeding plan despite the resident's weight loss, citing a recent slight weight gain. The facility's policies on care planning and nutritional services were not adhered to, as evidenced by the lack of timely assessments and interventions for both residents. The interdisciplinary team failed to effectively monitor and address the nutritional needs and weight changes of the residents, leading to deficiencies in providing adequate nutrition and care.
Failure to Reconcile Medications Upon Discharge
Penalty
Summary
The facility failed to reconcile medications upon discharge for two residents, leading to a deficiency in pharmaceutical services. Resident 60, who had a history of myocardial infarction, hypertension, type 2 diabetes mellitus, and other conditions, was discharged to home without a record of medication reconciliation. The medications not reconciled included aspirin, atorvastatin, Crestor, and several others, totaling twelve different medications. This lack of reconciliation was identified during a record review conducted on August 20, 2024. Similarly, Resident 58, who had diagnoses including the presence of an artificial hip, chronic kidney disease, and osteoporosis, passed away without a record of medication reconciliation. The medications not reconciled for this resident included aspirin, Miralax, paroxetine sodium, and others, totaling five medications. The Director of Nursing indicated that all available information regarding the residents' discharge medications was provided, but the facility's policy on discharge medications, which requires a complete medication disposition record, was not followed.
Failure to Label Tuberculin Serum Appropriately
Penalty
Summary
The facility failed to appropriately label tuberculin serum in the medication room, as observed during a survey. On the specified date, a vial of tuberculin serum was found at the north nurse's station without a date indicating when it was opened. This observation was made in the presence of the Assistant Director of Nursing (ADON). During a subsequent interview, the Director of Nursing (DON) confirmed that tuberculin serum should be dated upon opening and stored in the refrigerator when not in use. The facility's policy, dated April 2019, requires that labels for stock medications include necessary information such as the name and strength of the drug, lot or control number, expiration date, and appropriate accessory and cautionary statements and directions for use.
Failure to Document Insulin Administration and Blood Sugar Levels
Penalty
Summary
The facility failed to document the administration of insulin and blood sugar levels for two residents, leading to a deficiency in maintaining accurate medical records. Resident 20, who had diagnoses including hypertension, type 2 diabetes mellitus, unspecified dementia, and chronic kidney disease, had multiple instances where insulin administration was not documented on the Medication Administration Record (MAR). The omissions occurred at various times, including before meals and at bedtime, despite having a care plan that required monitoring and documenting the effectiveness of diabetes medication. Similarly, Resident 11, diagnosed with schizoaffective disorder, muscle weakness, type 2 diabetes mellitus, and difficulty walking, also experienced multiple omissions in documenting insulin administration and blood sugar levels on the MAR. The resident's care plan included goals to prevent complications related to diabetes, yet the documentation was incomplete on several occasions. The Director of Nursing acknowledged the omissions, attributing them to staff forgetting to document after administering the medication, despite a policy requiring immediate documentation post-administration.
Failure to Maintain Sanitary Conditions and Proper Food Storage
Penalty
Summary
The facility failed to ensure dietary staff covered facial hair during food preparation, maintained clean and sanitary conditions in the kitchen, pantry, and pantry refrigerator, and stored food at proper temperatures. During an observation, two kitchen staff members with full beards were seen prepping raw chicken without beard covers. The kitchen floors had a buildup of grease, debris, and trash. The pantry refrigerator was found to be at 54 degrees Fahrenheit, with food debris and dried liquid substances inside, and a broken rubber seal on the door. Additionally, an opened, undated gallon of milk was left out without a lid on a utility cart in the hallway. Confidential interviews revealed that the pantry on the unit was frequently filthy and smelled, and that extra food was immediately thrown away after meal trays were passed, leaving residents without the option for more food. Snacks were not consistently offered outside of mealtimes, especially for diabetic residents, and nursing staff did not have access to juice off-hours in case of a diabetic emergency. The Director of Dietary confirmed ongoing issues with nursing staff storing their food in the resident refrigerator and acknowledged that dietary staff were responsible for cleaning the pantry refrigerator. The Administrator observed that staff members were not supposed to store personal food among resident food and that resident food should have been discarded due to the refrigerator not being cool enough. The facility's policies on sanitization and food preparation were provided, indicating that food service areas should be maintained in a clean and sanitary manner and that food and nutrition services staff should wear hair restraints. No policy regarding resident snacks was obtained during the survey process.
Failure to Preserve Resident's Dignity and Rights
Penalty
Summary
The facility failed to care for Resident K in a manner that preserved his dignity and rights. Despite the family's request and the care plan agreement to have Resident K out of bed daily from around 11:00 a.m. to 3:00 p.m., observations showed that the resident remained in bed for several days. On multiple occasions, Resident K was found lying in bed, wearing only a hospital gown, and not participating in any activities. The resident expressed a preference to be out of bed daily and mentioned that it had been three days since he was last gotten up. Staff interviews revealed inconsistencies in the care provided, with some staff unable to explain why the resident had not been out of bed as scheduled. Resident K's medical history includes hemiplegia, hemiparesis on the left non-dominant side, and dysphagia. The resident enjoyed attending social events, bingo, movies, exercise, and art, and his family had provided thermal clothing to keep him warm. Despite these preferences and the care plan interventions, the resident was repeatedly observed in bed, not dressed appropriately, and not engaged in activities. The Nurse Practitioner also confirmed that she had not seen Resident K out of bed in the past week, noting that he enjoyed social interactions and cared about his appearance.
Failure to Ensure Call Lights Within Reach
Penalty
Summary
The facility failed to ensure call lights were within reach for three dependent residents, leading to a deficiency. Resident M was observed multiple times with her call light unplugged and out of reach while sitting in a wheelchair. Despite staff members, including CNAs, an RN, and the DON, passing by her room, none addressed the issue. Resident M's medical history includes severe vision impairment, moderate cognitive impairment, and a need for extensive assistance with mobility and transfers. Her care plan specifically required that her call light be within reach to prevent falls and ensure timely assistance. Resident P was found lying in bed with her call light tucked under her shoulder and out of sight. Although capable of using the call light, she was unable to transfer or ambulate independently. Her medical history includes severe vision impairment, severe cognitive impairment, and a history of falls. Her care plan also emphasized the importance of having the call light within reach to prevent falls and ensure prompt assistance. Resident Q was observed sitting in a wheelchair with her call light under the bedding and out of reach. She indicated that she would use the call light to call for assistance but was unable to locate it. Resident Q's medical history includes hemiplegia, hemiparesis, and dementia, and she is totally dependent on assistance for mobility and transfers. Her care plan required that the call light be within reach to prevent falls and ensure timely assistance. The facility's policy on answering call lights, which mandates that call lights be plugged in and within easy reach, was not followed in these instances.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to address resident grievances regarding missing clothing and hearing aids for multiple residents. Confidential interviews revealed that patient laundry was frequently missing, and there were multiple complaints by family members about the missing clothes. Concerns about resident care and the quality of care were reported to the nursing staff and receptionist, but there was no response from management. Grievance logs from January to April 2024 indicated only a few documented concerns, none of which related to the missing clothing or hearing aids. Resident C's record lacked documentation of clothing or missing clothing, and there was no inventory of personal effects completed. Resident J's family reported multiple missing items, including hearing aids and clothing, but no grievance forms were filled out, and the items were not found or replaced. Resident Q's family also reported missing clothing, but there was no documentation in the grievance logs, and the inventory list was outdated. Interviews with staff revealed a lack of knowledge about the grievance process and the location of grievance forms. The Social Services Director (SSD) acknowledged the problem with staff not filling out grievance forms and indicated there was no current process in place for handling grievances. The facility's grievance policy was provided, but it was not being followed, as evidenced by the lack of documentation and follow-up on reported grievances.
Failure to Provide Personalized Activities for Residents
Penalty
Summary
The facility failed to provide personalized activities to a dependent resident, Resident K, who was incapable of self-initiated activities. Despite the family's request for the resident to be out of bed daily from around 11:00 a.m. to 3:00 p.m. to attend activities, observations showed that Resident K was frequently left in bed, often in a hospital gown, and not engaged in any activities. Staff interviews revealed inconsistencies in getting the resident out of bed, with some staff unable to explain why the resident had not been up during the day shift. The resident's care plan indicated a need for support in activity participation, but this was not consistently provided, as evidenced by multiple observations of the resident lying in bed without engagement in activities over several days. Resident J, who had dementia, also did not receive consistent activity engagement. The resident had moved from a secured memory care unit to a room in the health center due to the busy atmosphere of the former. Despite the resident's need for hearing aids, which were lost, no alternative hearing devices were provided, making it difficult for her to engage in activities or hear the TV without disturbing others. Observations showed Resident J often sitting alone, either in her room or in the hallway, without meaningful engagement. The resident's record lacked documentation of care plans for activity preferences or personal preferences for care. Interviews with staff, including the Director of Life Enrichment, revealed that while activity calendars and participation tracking were in place, they were not effectively implemented for Residents K and J. The facility's documentation did not provide specific details on the activities attended by the residents or their level of engagement. This lack of personalized activity planning and execution led to the residents not receiving the cognitive, social, and emotional stimulation they needed, as outlined in their care plans.
Failure to Ensure Fall Follow-Up and Care Plan Updates
Penalty
Summary
The facility failed to ensure fall follow-up was completed for two residents, Resident C and Resident K, who were reviewed for falls. Resident C had several falls due to muscle weakness and cognitive impairment, but the facility did not document root causes, follow-up assessments, or care plan updates for incidents on 3/9/24 and 3/13/24. Additionally, there was a discrepancy in the reported location of a fall that led to hospitalization on 4/11/24, and the resident was not listed on the fall tracking log during her admission period. Resident K, who had hemiplegia and dysphagia, experienced a witnessed fall on 3/1/24. The facility did not document 72-hour follow-up assessments, family notifications, or a fall care plan. Observations on 4/24/24 revealed the resident lying in bed with a fall mat on the floor, but no care plan was found despite a high fall risk score. Interviews with staff indicated that proper fall follow-up procedures, including head-to-toe assessments, vital signs, and neuro checks for unwitnessed falls, were not consistently followed. The facility's policy on managing falls, dated March 2018, was not adequately implemented, leading to deficiencies in fall prevention and follow-up care for the residents involved.
Failure to Properly Elevate Head of Bed for Resident with G-Tube
Penalty
Summary
The facility failed to properly elevate the head of the bed (HOB) for a resident receiving nutrients via a gastroscopy tube (g-tube) who had a known history of aspiration pneumonia. Multiple observations revealed that the resident was frequently lying on his back with the HOB elevated less than 30 degrees while the tube feeding formula was infusing at 70 ml/hr. Additionally, the bags of tube feeding formula and water were not labeled with the date, time, nurse's name, or physician's order, as required by the facility's policy. Despite the family member's concerns and complaints to the facility management, the issue remained unresolved, posing a risk to the resident's health. The resident's medical record indicated diagnoses including a history of pneumonitis due to inhalation of food and vomit, hemiplegia, hemiparesis, dysphagia, and gastro-esophageal reflux disorder (GERD). Physician's orders and the care plan specified that the HOB should be elevated 30-45 degrees during feeding and at least one hour post-feeding. However, observations on multiple occasions showed non-compliance with these orders. The facility's policy on enteral feedings also emphasized the importance of preventing aspiration by elevating the HOB at least 30 degrees during and after tube feeding, which was not adhered to in this case.
Failure to Post Ombudsman Contact Information
Penalty
Summary
The facility failed to publicly post the name, address, and telephone number of the area Ombudsman, affecting all 44 residents and their representatives. During a confidential interview, a resident expressed a desire for regular visits from the Ombudsman but noted the absence of posted contact information. Observations on 4/25/24 confirmed that there was no Ombudsman contact information posted at the front entrance or common areas of the health center. Interviews with staff, including a Registered Nurse, the Assistant Director of Nursing, the Director of Nursing, and the receptionist, revealed that none of them knew where the Ombudsman information was posted. The receptionist mentioned that the information had been in a frame that broke and was subsequently misplaced. The Administrator acknowledged that the signs had been stolen and indicated plans to make new ones. Further observations on 4/25/24 showed the receptionist retrieving the broken frame that had previously contained the Ombudsman contact information. On 4/29/24, the Administrator confirmed that the facility had no specific policy regarding the posting of Ombudsman information. This lack of posted information and the absence of a policy directly contributed to the deficiency, leaving residents and their representatives without easy access to the Ombudsman’s contact details.
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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