Rosewalk Village At Lafayette
Inspection history, citations, penalties and survey trends for this long-term care facility in Lafayette, Indiana.
- Location
- 1903 Union St, Lafayette, Indiana 47904
- CMS Provider Number
- 155121
- Inspections on file
- 26
- Latest survey
- March 3, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Rosewalk Village At Lafayette during CMS and state inspections, most recent first.
A resident with multiple chronic conditions, including type 2 DM with neuropathy and chronic bilateral knee pain, was found with a medicine cup containing a pill left on the bedside table. Staff, including the DON and ADON, confirmed there was no MD order, assessment, or care plan authorizing self-administration, and facility policy required staff to observe medication consumption and obtain an order for any self-administered meds. Multiple RNs stated that meds should not be left at bedside without such an order, indicating that the unattended pill at the bedside occurred in violation of facility policy and physician orders.
A resident with dementia, hypotension, and risk for fluid imbalance had a physician’s order for daily midodrine 5 mg with instructions to hold the dose if systolic blood pressure (SBP) exceeded 130. Review of the MAR showed the medication was administered multiple times when SBP readings were above the ordered hold parameter, and there was no indication the doses were held. An LPN and the DON stated that medications with hold parameters should not be given when vital signs are outside those parameters, and that held doses should be documented on the MAR, while the ADON noted there was no specific policy on medication parameters beyond a general medication administration policy requiring appropriate measures such as obtaining vital signs.
Surveyors found that employee food and drinks were improperly stored in the kitchen, expired food was present, and cardboard boxes were stored on the floor in both the walk-in freezer and food preparation areas. Interviews with the ED and DM confirmed these practices were not allowed and did not comply with facility policy, which requires food to be stored above the floor and in a manner that prevents contamination.
The facility did not hold timely care plan meetings with residents and their representatives as required, resulting in missed quarterly reviews for several residents with complex medical and psychiatric conditions. In each case, care plan meetings were not conducted in alignment with MDS assessment schedules, and staff confirmed the omissions.
A resident was prescribed new psychotropic medications and received new mental health diagnoses, but the facility did not complete an updated PASARR Level I assessment as required by policy. Interviews with the Executive Director and Social Service Director confirmed the oversight, despite facility policies mandating PASARR updates with significant changes in mental or physical status.
A dependent resident with severe cognitive impairment and incontinence was not provided timely incontinence care, resulting in the resident being observed in the dining room with a strong odor of urine and feces, soiled clothing, and bowel movement on his hand. Staff interviews confirmed that care was not provided according to the required two-hour schedule, and a family member reported repeated instances of the resident having dried feces on his hands during meals.
A resident with diabetes and chronic kidney disease received insulin doses despite blood glucose readings below the physician-ordered hold parameter. Nursing staff confirmed that insulin should have been withheld in these cases, but the facility lacked a specific policy on following such hold parameters at the time.
A resident with type 2 diabetes mellitus did not receive proper insulin management as per physician's orders. Insulin was administered despite blood sugar levels being below the specified threshold, and the hypoglycemic protocol was not followed when blood sugar levels dropped below 60 mg/dL. The facility failed to notify the physician promptly, contrary to their policies.
A resident with multiple health conditions experienced significant weight loss, but the facility failed to notify the physician in a timely manner. Despite a care plan directive, the physician was informed 10 days after a 13% weight loss was noted. The facility's policy requires prompt notification of significant weight changes, which was not followed.
A facility failed to properly label OTC medications on a medication cart, affecting two residents. The medications, including aspirin and turmeric, lacked labels, instructions, and physician names, despite existing physician orders. The DON and facility pharmacist were initially unable to confirm labeling regulations, but later clarified requirements for proper identification.
Medication Left at Bedside Without Self-Administration Order
Penalty
Summary
Surveyors observed that a clear plastic medicine cup containing a white oblong pill was left on a resident's bedside table, and the DON later removed it, stating it should not have been left there. The resident's clinical record showed diagnoses including type 2 diabetes mellitus with diabetic neuropathy, chronic pain, bilateral knee pain, abnormal posture, and muscle weakness. The record contained a physician's order for hydrocodone-acetaminophen 7.5/325 mg every four hours and a pain management care plan directing staff to administer medications as ordered. However, there was no physician's order, self-medication administration assessment, or care plan authorizing the resident to self-administer medications. Multiple staff interviews confirmed that medications were not to be left at the bedside unless there was an order for self-administration and that staff were required to observe residents consuming all medications before leaving the room. The ADON, DON, and several RNs each stated that the resident did not have an order to self-administer medications and that the pill cup should not have been left in the room. Facility policies on General Dose Preparation and Medication Administration required staff to observe residents' consumption of medications, and the Self-Administration of Medications policy required a physician order specifying a resident's ability to self-administer medications. The presence of the unattended pill at the bedside without the required order or assessment constituted the deficiency.
Failure to Follow Blood Pressure Hold Parameters for Midodrine
Penalty
Summary
The deficiency involves the facility’s failure to follow a physician’s order for holding a blood pressure medication according to specified parameters for one resident. The resident had multiple diagnoses, including Alzheimer’s disease, vascular dementia with psychotic disturbance, psychotic disorder with delusions, adjustment disorder with anxiety, muscle weakness, and hypotension, and was care planned as being at risk for fluid imbalance due to blood pressure issues, with an intervention to administer medications as ordered. A physician’s order directed that 5 mg of midodrine be given every morning and held if the systolic blood pressure (SBP) was greater than 130. Review of the Medication Administration Records over several months showed that midodrine was administered despite SBP readings above the ordered hold parameter on multiple occasions: SBP 155 and 135 in December, SBP 138 and 137 in January, and SBP 153 in February. Interviews with an LPN and the DON confirmed that medications with hold parameters should be withheld when vital signs fall outside those parameters, and that held medications should be documented with initials in parentheses on the MAR. The ADON reported there was no specific facility policy addressing medication parameters, while the general medication administration policy required staff to take necessary measures, including obtaining vital signs, prior to administration.
Deficient Food Storage and Handling Practices in Kitchen
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's kitchen related to food storage and handling. Employee lunches were found stored in brown plastic grocery sacks inside the reach-in refrigerator, and two half-empty clear plastic water bottles were stored on a shelf in the food preparation area. Additionally, a large clear container of diced ham with a use-by date that had passed was found in the food preparation refrigerator. Cardboard boxes, including one containing a bag of frozen blueberries and others stacked on top, were stored directly on the floor of the walk-in freezer, and four empty cardboard boxes were found on the floor under the food preparation sink. Interviews with the Executive Director and Dietary Manager confirmed that employees were not permitted to store personal food or drinks in the kitchen, and that food and cardboard boxes should not be stored on the floor. The facility's policy on food storage requires that food be stored at least six inches above the floor and in a manner that prevents contamination, with all items clearly labeled and dated. These observed practices were not in compliance with the facility's stated policies and professional standards for food safety.
Failure to Conduct Timely Care Plan Meetings with Residents and Representatives
Penalty
Summary
The facility failed to ensure that care plan meetings were held with residents and their representatives in a timely manner for four residents. For one resident with multiple diagnoses including Parkinson's disease, dementia, and diabetes, there was no care plan meeting held during the second quarter between two documented meetings. Another resident with chronic conditions such as COPD, diabetes, and end stage renal disease did not have a care plan meeting for the fourth quarter between two documented meetings. In both cases, facility staff confirmed that the required meetings were not conducted during the specified periods. Additionally, a resident with Alzheimer's disease and other psychiatric and medical conditions did not have a care plan meeting during the second quarter, despite an MDS assessment being completed. The family was invited to a meeting but did not attend, and the facility did not reschedule or conduct the meeting. Another resident with respiratory failure, dementia, and other chronic illnesses did not have a care plan review meeting during the third quarter, even though an MDS assessment was completed. Facility policy required care plan reviews and revisions by the interdisciplinary team following each MDS assessment, but this was not followed for these residents.
Failure to Update PASARR After New Psychotropic Medications and Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that a preadmission screening and resident review (PASARR) was updated when a resident was prescribed new psychotropic medications and received new mental health diagnoses. The resident's clinical record showed diagnoses of anxiety disorder and depressive disorder. The initial PASARR, completed prior to these changes, indicated no mental health diagnoses or medications. Subsequently, the resident was prescribed sertraline, an antidepressant, and clonazepam, an antianxiety medication, but no new PASARR Level I was completed after these changes. Interviews with the Executive Director and Social Service Director confirmed that a new PASARR Level I assessment was not conducted when the resident's mental health status and medication regimen changed. Facility policy requires PASARR assessments to be updated with significant changes in mental or physical status, and the policy on psychotropic management emphasizes the importance of assessment and person-centered intervention when such medications are prescribed. The failure to update the PASARR assessment was contrary to these policies.
Failure to Provide Timely Incontinence and Hygiene Care
Penalty
Summary
A dependent resident with severe cognitive impairment and multiple psychiatric diagnoses was not provided timely incontinence care. During an observation, the resident was found in the dining room sitting in a wheelchair, leaning to one side, with a strong odor of urine and bowel movement. The resident's sweatpants were partially pulled down, and there was visible bowel movement on his right hand. Staff confirmed that the resident had last been checked and changed at 10:00 a.m., despite facility policy and care plans requiring checks and changes every two hours. At the time of observation, it had been over three hours since the last care was provided. Interviews with staff and a family member revealed that the resident was frequently found with dried bowel movement on his hands during mealtimes, and staff did not consistently clean his hands before meals. The resident's care plans indicated a need for assistance with all activities of daily living, including toileting and hygiene, and required staff to check and change the resident every two hours. Facility policy and CNA job descriptions also outlined the expectation for prompt and regular incontinence care, which was not followed in this instance.
Failure to Hold Insulin Doses per Physician Order
Penalty
Summary
The facility failed to ensure that insulin doses were withheld when blood glucose readings were below the physician-ordered hold parameter for a resident with type 2 diabetes mellitus, diabetic nephropathy, and chronic kidney disease. The physician's order specified that 35 units of Fiasp FlexTouch U-100 Insulin should be administered three times daily, but included instructions to hold the dose if the blood sugar was below 130. Despite this, the Medication Administration Records showed that insulin was administered multiple times when the resident's blood sugar was below the specified threshold. Interviews with nursing staff confirmed that insulin should have been held according to the order, and the facility did not have a specific policy regarding insulin administration or adherence to physician-ordered hold parameters at the time of the incidents. The facility's general medication administration policy referenced the 'right dose' but did not address the specific issue of holding medications based on blood sugar readings.
Failure to Follow Insulin and Hypoglycemic Protocols
Penalty
Summary
The facility failed to adhere to physician's orders regarding insulin administration and hypoglycemic protocol for a resident with type 2 diabetes mellitus. The resident had specific orders to hold insulin if blood sugar levels were below 110 mg/dL. However, insulin was administered on multiple occasions when the resident's blood sugar was below this threshold, including readings of 109 mg/dL, 83 mg/dL, and 95 mg/dL. The Assistant Director of Nursing indicated that nurses should be aware of when to hold medication by checking the Medication Administration Record, but this was not followed. Additionally, the facility did not follow the hypoglycemic protocol or notify the physician in a timely manner when the resident's blood sugar fell below 60 mg/dL. On two occasions, the resident's blood sugar was recorded at 56 mg/dL and 58 mg/dL, but there was no immediate recheck or notification to the physician as required. The Director of Nursing stated that the protocol was to administer juice and recheck the blood sugar in 15 minutes, which was not done. The facility's policies required prompt documentation and communication of such conditions to the attending physician, which was not adhered to in this case.
Failure to Timely Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to notify the physician about a significant weight loss in a timely manner for a resident with multiple health conditions, including end-stage renal disease, chronic heart failure, and a below-the-knee amputation. The resident's care plan required notifying the medical doctor or family of significant weight changes. The resident experienced a 9% weight loss over 36 days, which was attributed to the amputation, and the physician was notified. However, a subsequent weight loss of 13% from August to October was not communicated to the physician until 10 days after the significant change was noted. The resident's weight log showed fluctuations and refusals to be weighed, with a notable drop from 198 pounds in August to 171 pounds in October. Despite the care plan's directive, the physician was not informed of the significant weight loss until late October, as confirmed by the Director of Nursing. The facility's policy on resident weight monitoring, last reviewed in July, mandates notifying the physician of unplanned significant weight changes, which was not adhered to in this case.
Improper Labeling of OTC Medications
Penalty
Summary
The facility failed to ensure that over-the-counter (OTC) medications were properly labeled with directions for use and the physician's name on one of the medication carts reviewed. During an observation of medication storage, several bottles of OTC medications, including aspirin and turmeric capsules for two residents, were found without proper labeling. The bottles were either unopened or opened, with the residents' names handwritten on them, but lacked labels, instructions for use, and the physician's name. The clinical records for the residents involved indicated that there were physician's orders for the medications found on the cart. However, the facility's Director of Nursing (DON) and the facility pharmacist were unable to confirm the specific regulations for labeling OTC medications in a long-term care setting. An email from the facility pharmacist later confirmed that OTC medications should be identified with the resident's name, physician's name, expiration date, drug name, and strength. The facility's policy on medication storage and expiration, revised earlier in the year, also emphasized the need for proper labeling and storage of medications.
Latest citations in Indiana
Surveyors observed that dietary staff repeatedly worked in kitchen and meal service areas with uncovered facial hair, despite facility policy and state sanitation requirements mandating effective hair restraints. Two dietary aides with short beards or mustaches were seen walking through food preparation areas, taking food temperatures, handling food, and plating meals at steamtables in dining rooms without any facial hair coverings, while the current policy required all hair, including facial hair, to be restrained to prevent contamination.
The facility failed to consistently provide and document required bed-hold policy notices when several residents were transferred to the hospital. In multiple cases, residents with dementia, psychotic disorders, COPD, chronic respiratory failure, altered mental status, and cerebral infarction were sent out for acute changes in condition, and while transfer notes reflected physician and family notifications, they lacked documentation that the bed-hold policy was discussed with the resident or responsible party. Notices of Transfer or Discharge often indicated a copy of the bed-hold policy was sent with the resident, but the records did not show signed and dated acknowledgment by the resident or appropriate representative, including in situations where a resident had moderate cognitive impairment, short-term memory issues, or a documented need for a proxy and a financial POA authorizing an agent for health care decisions.
Surveyors found that the facility failed to provide trauma‑informed and culturally competent care by not incorporating two residents’ extensive trauma histories and specific behavioral triggers into their care plans. One resident with documented homelessness, polysubstance abuse, severe accidents with multiple fractures, viral encephalitis with coma, physical and sexual abuse, loss of family contact, and a past suicide attempt had multiple behavior‑focused care plans that referenced identifying triggers but listed none and did not mention their physical, sexual, medical, or psychosocial trauma. Another resident with TBI from being struck by a truck, an 11‑month coma, long‑term state hospital residence, alleged shooting of a parent, and diagnoses including intermittent explosive disorder and borderline personality disorder had a PASRR identifying a specific trigger and notes of inappropriate sexual behavior, yet their care plans omitted these traumatic events, the identified trigger, and the sexual behavior. Staff interviews confirmed that residents were screened for trauma, but the trauma histories and triggers were not reflected in the individualized plans of care.
A resident with schizophrenia, post‑stroke hemiparesis, and mild cognitive impairment expressed feeling down and wanting to kill himself, but staff did not document asking about a specific plan, did not notify the physician or psychiatric NP as expected, and did not develop or update a care plan addressing depression or suicidal ideation. The SSD documented offering support and initiating 15‑minute checks once, but there was no further follow‑up or documentation of interventions after subsequent suicidal statements made in a care plan meeting with the resident’s father. The DON and Administrator reported that facility policy requires immediate notification of key staff, assessment for a plan and means of self‑harm, and thorough documentation, which were not carried out or reflected in the medical record for this resident.
A resident with schizophrenia, post-stroke hemiparesis, and mild cognitive impairment verbalized suicidal ideation, but the care plan did not address depression or suicidal thoughts, and required assessments and services were not accurately or timely documented. An SSD note recorded the resident saying he wanted to kill himself and referenced 15‑minute checks and a care plan update, yet the active care plan lacked depression/suicidal ideation interventions. Multiple late-entry Social Services notes were later added, describing follow-up visits and the resident denying suicidal ideation, but the SSD later reported she did not typically ask about a suicide plan and did not personally provide individual follow-up visits as described. These practices conflicted with the facility’s policy requiring factual, first-hand, and timely documentation of assessments and services.
A resident was observed with an Albuterol inhaler on an overbed table and later reported keeping the inhaler in a nightstand drawer, with no staff present during these observations. Record review showed the resident had no cognitive impairment on the admission MDS but lacked any documented self-medication administration assessment. The DON acknowledged that the required assessment had not been completed, despite facility policy requiring staff and the practitioner to evaluate each resident’s mental and physical abilities before allowing self-administration of medications.
Surveyors found that the facility submitted inaccurate direct care staffing data to CMS through the PBJ system over multiple days in a quarter. CASPER reports showed apparent gaps in 24-hour licensed nurse coverage, low weekend staffing, and a 1-star staffing rating, while internal staffing sheets documented that licensed nurses were present and the facility was fully staffed on those days. The Administrator reported that the discrepancies were due to PBJ data entry errors, despite a facility policy requiring all PBJ entries to be accurate, auditable, and verifiable against payroll, invoices, or contracts.
Surveyors found that the facility did not provide or document required written transfer/discharge notices and bed-hold policy information for four residents who were sent to the hospital, including individuals with conditions such as dementia, CHF, chronic respiratory failure, and CKD. In each case, progress notes showed that the resident was transferred for acute issues, but the clinical records lacked evidence that written notices were given to the residents or their representatives, and in one case lacked documentation that required information was sent to the receiving provider. Facility leadership, including the ADON, DON, and Administrator, acknowledged that the records did not contain the required documentation, despite a written policy requiring such notices and information exchange.
A resident with Alzheimer’s disease and depression, previously on an antidepressant, exhibited intermittent refusals of medications and care, occasional yelling at staff, and reports of unusual perceptions, such as believing men were in or near her room. Nursing notes over several months documented these refusals and complaints but did not show that the behaviors were evaluated or recorded as dangerous, non-redirectable, or causing significant distress, nor did they document specific non-pharmacological interventions attempted or their outcomes. Despite this, a psychiatric NP later added new diagnoses of schizoaffective disorder, borderline personality disorder, and delusional disorder and ordered an antipsychotic (Seroquel) without a comprehensive evaluation in the record to support these diagnoses. The facility’s psychotropic medication policy, which requires identification and documentation of target behaviors, use of nonpharmacological interventions, and ongoing behavior monitoring, was not followed for this resident.
The facility failed to keep PASARR Level I screenings accurate and current for three residents when new mental health diagnoses and psychoactive medications were initiated. One resident’s PASARR omitted a PTSD diagnosis and an added antidepressant, despite documentation of PTSD on the MDS and care plan and a physician order for Pristiq. Another resident’s PASARR listed only depression and dementia, even after additional diagnoses such as borderline personality disorder, delusional disorder, and schizoaffective disorder were added and an antipsychotic (quetiapine) was ordered, with the MDS later reflecting psychotic disorder, schizophrenia, and depression with antipsychotic and antidepressant use. A third resident’s PASARR did not include a depression diagnosis or newly ordered escitalopram and lorazepam, although the admission MDS documented depression with antianxiety and antidepressant use. These omissions occurred despite facility policy requiring a new Level I review after significant mental status changes, including new mental health diagnoses or new psychotropic medications.
Uncovered Facial Hair During Food Preparation and Meal Service
Penalty
Summary
The deficiency involves the facility’s failure to ensure that food was served in a sanitary and safe manner in accordance with professional standards and facility policy during multiple kitchen and meal service observations. During an initial kitchen observation, two dietary aides were seen walking through the kitchen food preparation area with uncovered facial hair. One aide had facial hair above and below the lip and along the jaw line, approximately one-fourth inch in length, and the other had a mustache of similar length; neither used any facial hair covering. These observations occurred while staff were present in the kitchen area where food was stored and prepared. During subsequent observations on the same day, the same two dietary aides were again observed with uncovered facial hair while directly involved in meal preparation and service. One aide walked through the kitchen while the noon meal was being prepared and placed into a transport cart for service in the south dining room, and later was observed plating the noon meal at the steamtable in that dining room, still without a facial hair covering. The other aide walked through the kitchen while the noon meal was being prepared and placed into the steamtable for the north dining room, took food temperatures, assisted with plating meals at the steamtable, and retrieved food items and supplies from the kitchen, all while having an uncovered mustache approximately one-fourth inch in length. The Dietary Manager stated that staff hair was to be covered when in the kitchen and during meal service, and the facility’s written policy and the cited Indiana Food Establishment Sanitation Requirements both required effective hair restraints, including for facial hair, to prevent contamination of food, equipment, and utensils.
Failure to Provide and Document Bed-Hold Policy at Time of Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure that required bed-hold policy information was provided and documented for four residents transferred to the hospital. For a resident with dementia, psychotic disorder, and autistic disorder who had a BIMS score of 0 indicating severe cognitive impairment, progress notes documented physician notification and guardian notification when the resident was sent to the hospital, but there was no documentation that the bed-hold policy was provided to the responsible party. A Notice of Transfer or Discharge later indicated a copy of the bed-hold policy was sent with the resident. Another resident with COPD and chronic respiratory failure, cognitively intact with a BIMS score of 13, experienced a decline in condition and was transferred to the hospital by ambulance; progress notes documented family notification but did not document any discussion of the bed-hold policy, although a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident. A third resident with altered mental status and cerebral infarction, with a BIMS score of 10 indicating moderate cognitive impairment and documented short-term memory impairment, experienced changes in condition and was transferred to the hospital. Progress notes stated the resident was their own responsible party and that no other notification was completed, and transfer documentation did not include the bed-hold policy, although an untimed Notice of Transfer or Discharge indicated a copy of the bed-hold policy was signed by the resident. A financial power of attorney document in the record showed the resident had designated an agent to act in consent or refusal of health care. For a fourth resident with dementia and osteomyelitis, transfer documentation and a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident, and the transfer form noted the resident required a proxy for decision making. The facility’s policy required that at the time of transfer to a hospital, written notice specifying the duration of the bed-hold policy and information on return to the next available bed be provided, and that a signed and dated copy of the bed-hold notice given to the resident or representative be kept in the resident file, which was not consistently documented for these residents.
Failure to Integrate Trauma Histories and Behavioral Triggers Into Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to identify and incorporate residents’ trauma histories and specific behavioral triggers into their care plans, despite documented histories of significant trauma and behavioral health issues. For one resident, extensive social service and progress notes documented homelessness, polysubstance abuse, major depressive and anxiety disorders, chronic pain, a history of severe car accidents with multiple fractures, viral encephalitis resulting in a three‑month coma, loss of child custody, multiple divorces, physical abuse by a spouse, the death of a fiancé who was struck by a car while in a wheelchair, lack of family contact, and a past suicide attempt by Valium overdose. Additional documentation noted a history of rape by a brother at age eight and prior placement under direct supervision and 15‑minute checks related to suicidal ideation. Despite these documented traumatic events and behavioral health concerns, the resident’s care plans did not identify a history of physical trauma, sexual trauma, homelessness, substance abuse, medical trauma, or attempted suicide. For this same resident, the MDS showed no cognitive deficit and identified behaviors such as verbal aggression and rejection of care, along with diagnoses including seizure disorder, depression, chronic pain syndrome, homelessness, and anxiety disorder. Multiple care plans addressed behaviors such as drug‑seeking, pretending to have seizures for attention or medication, making false allegations, verbal aggression when unable to smoke, and a desire for intimate relationships with consenting male residents. These care plans referenced goals such as effective coping skills, seeking staff support, and compliance with the smoking policy, and they called for identification and reduction of behavioral triggers. However, none of these care plans actually listed any specific triggers. The care plan addressing the resident’s right to consensual intimate relationships focused on assessment and education regarding consent but did not integrate the resident’s extensive trauma history. Staff interviews indicated the resident had displayed sexual behaviors since admission, including an incident where the resident expressed anger at another resident for not buying a soda after engaging in sexual acts. A second resident with a documented history of traumatic brain injury (TBI), dementia, seizure disorder, borderline personality disorder, anxiety, intermittent explosive disorder, tobacco use, and other behavioral/emotional disorders was also affected by the same deficiency. Social history and progress notes documented that this resident sustained a TBI after being hit by a semi‑truck while riding a bicycle at age 18, resulting in an 11‑month coma, followed by 13 years in a state hospital and subsequent residence in a group home. Additional documentation indicated the resident allegedly shot their father at age 26 after being sworn at and had a PASRR identifying TBI, intermittent explosive disorder, and borderline personality disorder, with a specific trigger of hearing the name of the current U.S. President. Progress notes also described inappropriate sexual behavior toward staff, including touching themselves intimately during personal care and refusing to stop when redirected. Despite this, the resident’s care plans, which addressed explosive disorder and history of altercations, risk for decreased psychosocial well‑being, and refusal to bathe or shower, did not list any specific behavioral triggers, did not reference the traumatic events such as being hit by a truck or shooting their father, and did not document the inappropriate sexual behavior. The Administrator and Social Service Director acknowledged that residents were to be screened for trauma and that trauma responses and PTSD should be added to care plans, but the specific trauma histories and triggers for these two residents were not incorporated into their plans of care.
Failure to Assess and Care Plan for Resident Suicidal Ideation
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess, investigate, and care plan for a resident’s suicidal ideation in accordance with its own policy and staff expectations. The resident had diagnoses including schizophrenia, cerebral edema, and hemiparesis/hemiplegia following a cerebral infarction, and a current MDS showed mild cognitive impairment (BIMS score 12). A progress note documented that the resident told the Social Services Director (SSD) he was feeling down and wanted to kill himself; the SSD offered assistance, activities, and initiated 15‑minute checks, and the note stated the care plan was updated. However, the note did not indicate that the SSD asked whether the resident had a plan to kill himself, and there were no additional notes regarding suicidal ideation or follow‑up. Review of the current care plan showed no problem, goal, or interventions addressing depression or suicidal ideation, and progress notes over the following month contained no documentation of physician notification related to the suicidal statement. Further record and interview evidence showed that the care plan conference summary did not document interventions for suicidal ideation, and the SSD acknowledged she did not normally ask residents expressing suicidal ideation if they had a plan. The SSD reported that the resident had admission paperwork mentioning suicidal ideation related to depression after a stroke and that the resident again vocalized suicidal ideation during a care plan meeting with his father, after which emotional support was offered and the father took the resident out on a leave of absence; no further visits or follow‑up were done. The DON stated that, upon notification of suicidal verbalization, staff should assess the resident, ask if there is a plan, remove potential means of self‑harm, immediately notify the psychiatric NP, and document the occurrence, and that a detailed progress note and updated care plan were expected but not present for this resident. The Administrator similarly stated that staff should ask about a plan, document interventions, notify the physician and family, and update the care plan, and indicated the resident should have had a care plan addressing depression with suicidal ideation. The facility’s written policy required immediate notification of the DON, SSD, and physician, an interview including asking about a plan and assessing mood and means for self‑harm, and thorough documentation of mood, behavior, and all actions taken, which were not reflected in the resident’s record.
Incomplete and Inaccurate Documentation of Suicidal Ideation and Follow-Up
Penalty
Summary
The facility failed to ensure accurate, complete, and timely documentation of assessments and services for a resident who verbalized suicidal ideation. Resident 6, who had schizophrenia, cerebral edema, and right-sided hemiparesis/hemiplegia following a cerebral infarction, had a BIMS score of 12 indicating mild cognitive impairment. The resident’s admission paperwork mentioned suicidal ideation related to depression after a stroke, and a Social Services note on 3/11/2026 documented that the resident was feeling down and said he wanted to kill himself. The Social Services Director (SSD) documented that she talked with the resident, coordinated with Activities, advised the resident to contact SSD or nursing if he wanted to talk, and that the resident was scheduled for 15-minute checks and the care plan was updated. However, the current care plan initiated on 2/26/2026 did not address depression or suicidal ideation. Multiple Social Services progress notes were later entered as late entries in April, with effective dates in March, stating that the resident had no plan and no longer had suicidal ideation, that he felt much better after 1:1 time, and that he continued his daily routine and therapy. These late entries described follow-up visits and reassessments of suicidal ideation on several consecutive days, but in interviews the SSD stated she did not normally ask residents about having a plan when they verbalized suicidal ideation and did not recall any other occurrences beyond the initial event. She further indicated she did not personally provide individual follow-up visits with this resident regarding suicidal ideation, despite the late-entry notes describing such visits. The DON acknowledged that late entries had been added to address concern about suicidal verbalization, and the Administrator stated that upon suicidal statements staff should ask about a plan, notify the physician and family, and update the care plan, and that this resident should have had a care plan addressing depression with suicidal ideation. The facility’s documentation policy required factual, first-hand, timely documentation, which was not followed in this case.
Failure to Complete Required Self-Administration Assessment for Inhaler Kept at Bedside
Penalty
Summary
Surveyors identified that a resident was allowed to keep and access an Albuterol inhaler without the facility completing the required self-administration medication assessment. During an initial tour, the resident was observed sitting in a wheelchair with a handheld Albuterol inhaler on the overbed table and no staff present in the room or hallway. On a subsequent observation, the resident again was in a wheelchair and reported that the Albuterol inhaler was stored in the top drawer of the nightstand, where it was found. Review of the clinical record showed an admission MDS indicating no cognitive impairment, but there was no documentation of a self-medication administration assessment. In an interview, the DON confirmed that the resident did not have the required self-medication assessment, despite the facility’s policy stating that staff and the practitioner must assess each resident’s mental and physical abilities to determine whether self-administering medications is clinically appropriate. This failure to complete and document a self-administration medication assessment for a resident who had an Albuterol inhaler kept at bedside constituted noncompliance with the facility’s own policy and with 410 IAC 16.2-3.1-11(a).
Inaccurate PBJ Staffing Data Submission to CMS
Penalty
Summary
The deficiency involves the facility’s failure to electronically submit complete and accurate direct care staffing information to CMS through the Payroll-Based Journal (PBJ) system for 22 days in a fiscal quarter. A CASPER report review on 4/6/26 showed that, according to PBJ data, the facility did not have licensed nursing coverage 24 hours per day on multiple specific dates across three months, had low weekend staffing, and held a 1-star staffing rating. However, review of the facility’s internal staffing sheets for that quarter indicated the facility was fully staffed and had licensed nurse coverage on all of the dates in question. During an interview, the Administrator stated that the PBJ information must have contained data entry errors, as she had verified licensed staff coverage on the timesheets. The facility’s PBJ policy in effect stated that all staffing data entered into the PBJ system would be auditable and verifiable through payroll, invoices, or contracts, but the submitted PBJ data did not accurately reflect the facility’s actual licensed nurse staffing as documented on internal records. No specific residents or clinical conditions were mentioned in the report, and the deficiency centers solely on inaccurate staffing data submission rather than direct resident care events.
Failure to Provide and Document Required Transfer/Discharge and Bed-Hold Notices
Penalty
Summary
The deficiency involves the facility’s failure to provide and document required written notices of transfer/discharge and bed-hold policies, as well as required information to receiving providers, for four residents who were transferred or discharged to the hospital. For a resident with generalized anxiety disorder, major depressive disorder, and dementia, progress notes showed that the resident was sent to the hospital via 911 for chest pain, lower back pain, and shortness of breath and later returned to the facility, but the clinical record lacked documentation that a written Notice of Transfer/Discharge and the bed-hold policy were provided to the resident or representative, and lacked documentation that required information was conveyed to the receiving facility. The ADON and the Administrator both confirmed there was no documentation that these written notices were provided. For a resident with congestive heart failure and muscle weakness who was sent to the emergency room for painful urination and bloody urine, the clinical record lacked documentation that a Notice of Transfer/Discharge or bed-hold policy was given to the resident or representative, which the DON confirmed. Another resident with chronic respiratory failure and diabetes was discharged to the hospital for respiratory failure, and a resident with chronic kidney disease and dementia was discharged to the hospital, but in both cases there was no documentation that a written notice of transfer/discharge or bed-hold policy was provided to the residents or their representatives. Review of the facility’s Transfer and Discharge policy, dated 1/15/26, showed that the policy required the facility to provide written transfer/discharge notices and bed-hold information to residents and representatives and to provide specified information to receiving providers, but the records for these four residents did not contain the required documentation.
Failure to Document Target Behaviors and Non-Pharmacological Interventions Before Initiating Antipsychotic
Penalty
Summary
The deficiency involves the facility’s failure to document how a resident’s behaviors presented danger or distress to self or others, and failure to document non-pharmacological interventions attempted prior to initiating an antipsychotic medication. Resident 6 had documented diagnoses of Alzheimer’s disease, depression, and severe cognitive impairment, and was receiving sertraline for depression. A PASSAR identified only depression and dementia, and the admission MDS listed Alzheimer’s disease and depression as active diagnoses. Over several months, nursing progress notes documented that the resident intermittently reported unusual perceptions, such as believing there were men causing trouble, a man in her room, or a man wanting to marry her and yelling through the walls, but there was no documentation that these episodes caused danger to the resident or others or that they resulted in unmanageable distress. From late April through mid-July, nursing notes primarily described the resident’s frequent refusals of evening and morning medications, blood sugar checks, blood pressure checks, insulin administration, hygiene care, and showers. Staff documented that the resident sometimes yelled at staff, said “Get out!”, was visibly upset by a room move, was leery of staff and asked to see name badges, and became upset about a pillow under her head until it was removed, after which she calmed down. The notes also recorded instances where the resident believed housekeeping had not cleaned her room or that she had not received medications when she had. However, there were no progress notes or assessments indicating that these behaviors were evaluated as dangerous, non-redirectable, or causing significant distress or functional impairment, and no detailed behavior monitoring logs were present as required by facility policy. On a psychiatric NP visit for initial psychotropic medication management, new mental health diagnoses of schizoaffective disorder, borderline personality disorder, and delusional disorder were added, and Seroquel 25 mg, an antipsychotic, was ordered. The clinical record did not contain a comprehensive evaluation to support these new diagnoses, and there was no documentation of target behaviors meeting the facility’s policy criteria for psychotropic use, such as behaviors representing danger to self or others, causing distress and impairment in functional abilities, or clearly attributable to psychosis or mania. The resident’s representative reported that the resident had no prior history of mental health disorders or psychiatric hospitalization and was unaware of the new diagnoses. The facility’s own psychotropic medication policy required identification and documentation of specific target behaviors, use and documentation of nonpharmacological interventions, and ongoing monitoring of behaviors and interventions, which were not reflected in the record for this resident.
Failure to Update PASARR Screens for New Mental Health Diagnoses and Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that Preadmission Screening and Resident Review (PASARR) Level I screenings were accurate and updated when new mental health diagnoses and psychoactive medications were initiated for multiple residents. For one resident with dementia, anxiety, depression, and post-traumatic stress disorder (PTSD), the PASARR completed on admission listed anxiety, depression, and dementia with sertraline and quetiapine, but did not include the PTSD diagnosis or the antidepressant Pristiq, despite the admission MDS and care plan documenting PTSD and a subsequent physician’s order for Pristiq. For another resident with Alzheimer’s disease, borderline personality disorder, delusional disorder, schizoaffective disorder, and depression, the PASARR only reflected depression and dementia with sertraline, even though additional mental health diagnoses were added later and an antipsychotic (quetiapine) was ordered for borderline personality disorder, and the quarterly MDS documented psychotic disorder, schizophrenia, and depression with antipsychotic and antidepressant use. A third resident had diagnoses including Alzheimer’s disease, depression, anxiety disorder, irritability and anger, and nonrheumatic aortic valve stenosis. The PASARR for this resident listed dementia and anxiety with Risperdal but omitted the diagnosis of depression and the medications escitalopram and lorazepam, although physician’s orders were in place for escitalopram for depression and lorazepam for anxiety, and the admission MDS documented depression with antianxiety and antidepressant use. Interviews with the Assistant Director of Nursing confirmed that new Level I PASARR screens should have been completed when new mental health diagnoses and psychoactive medications were added, and that the PASARR for one resident, completed prior to arrival, should have included all mental health diagnoses and medications. The facility’s own policy required notification of the state mental health authority within 14 days after a significant change in mental condition and specified that a new Level I screen is required for new mental health diagnoses or newly prescribed psychotropic medications, which was not followed in these cases.
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