Rosewalk Village
Inspection history, citations, penalties and survey trends for this long-term care facility in Indianapolis, Indiana.
- Location
- 1302 N Lesley Ave, Indianapolis, Indiana 46219
- CMS Provider Number
- 155329
- Inspections on file
- 32
- Latest survey
- March 6, 2026
- Citations (last 12 mo.)
- 10 (1 serious)
Citation history
Health deficiencies cited at Rosewalk Village during CMS and state inspections, most recent first.
A resident with severe dementia and a known risk for elopement exited the facility unsupervised while wearing a wanderguard device that failed to trigger an alarm. The resident was found in the community with multiple injuries and required hospital treatment. Staff did not document when the resident was discovered missing, and interviews indicated that no alarm was heard at the time of the incident. The exit door involved was found to have incomplete wanderguard coverage due to only one antenna being installed.
The facility failed to dispose of expired food items in a timely manner, affecting all 98 residents receiving food from the kitchen. Expired items were found in both dry storage and the walk-in refrigerator, and pies were improperly stored uncovered. The Dietary Manager acknowledged the oversight, which violated the facility's food storage policy.
The facility failed to maintain infection control by not ensuring hand hygiene before donning gloves during medication administration for several residents and not using PPE for a resident requiring enhanced barrier precautions. An LPN did not perform hand hygiene before a blood glucose check, another LPN failed to do so before administering medications, and a Unit Manager handled medication with bare hands. Additionally, CNAs did not use gowns and gloves for a resident with a dialysis port, despite care plan requirements.
A resident with diabetes was nearly administered insulin lispro despite a blood sugar reading below the physician's prescribed threshold. An LPN was observed preparing to give 12 units of insulin lispro when the resident's blood sugar was 122 mg/dL, contrary to the order to hold insulin if below 150 mg/dL. The LPN acknowledged the error, highlighting a significant medication administration oversight.
A resident with multiple health conditions, including hemiplegia, was found to have her call light out of reach, despite needing it for assistance. Observations confirmed the call light was inaccessible, and the DON acknowledged the lack of a specific policy on call light accessibility, relying instead on general standards of care.
The facility failed to ensure that arbitration agreements were properly explained and signed by the appropriate representatives for two residents with cognitive impairments. One resident signed without a legal representative despite being incapacitated, and another signed without the physical presence of her POA, who only gave verbal consent.
The facility failed to respect the dignity and rights of three residents during interactions with an LPN. A resident with heart disease reported rude behavior and gestures from the LPN, while another with heart failure described the LPN as pushy and demanding. A third resident with quadriplegia recounted an argument involving inappropriate language. The facility's policy on resident rights was not upheld.
A resident with multiple health conditions did not receive adequate assistance with ADLs, including regular hair shampooing and mobilization to a wheelchair. Despite being scheduled for showers, the resident reported not having received a full bed bath or hair wash in over a week, and her wheelchair was missing for several days. Staff interviews revealed inconsistencies in care, and the facility lacked a specific ADL policy, relying on general standards of care.
A resident with contractures did not receive the recommended splint application as advised by therapy staff. Despite being aware of the need for a splint, the resident reported that staff never applied it. Observations confirmed the absence of the splint, and the clinical record lacked orders or care plans for splint application, indicating a failure in care coordination.
The facility did not update the daily nurse staffing information, affecting all 98 residents. Observations showed outdated postings, and interviews revealed that the night shift nurse forgot to update the information. The facility's policy requires daily updates, but oversight occurred, especially on weekends.
Failure to Prevent Elopement and Ensure Resident Safety
Penalty
Summary
A resident with diagnoses of vascular dementia and Alzheimer's dementia, who was identified as being at risk for elopement, exited the facility unsupervised while wearing a wanderguard device. The resident was able to leave through the G-hall exit door without staff knowledge, and the wanderguard alarm did not sound as expected. The resident was later found by a member of the community approximately 0.6 miles from the facility, having sustained multiple injuries including a laceration and hematoma to the forehead, periorbital edema, abrasions to the left knee and shoulder, and skin tears to the left hand. The resident was transported to the hospital for treatment of these injuries. Review of the resident's clinical record showed that the care plan included interventions for elopement risk, such as securing facility exits and using a wanderguard device, with orders to check the device for placement and function. Despite these interventions, there was no documentation in the electronic health record indicating when staff noticed the resident was missing, when a code silver was called, or when the search for the resident began. Additionally, there were no nursing progress notes documented from the time of the last elopement assessment until after the resident returned from the hospital, and no indication that the resident had any of the documented injuries prior to the elopement. Interviews with staff revealed that no one heard the wanderguard alarm sound at the time of the elopement, and the facility later discovered that the G-hall exit door had only one antenna, providing incomplete coverage for the double doors. The door company confirmed that the system was not providing full coverage and required an additional antenna for proper operation. The facility's policy required staff to know the location of residents under their care and to take appropriate action if a resident was missing, but these procedures were not effectively implemented in this incident.
Removal Plan
- Completed elopement risk assessments on all residents
- Conducted elopement drills with staff
- Educated all staff on the elopement procedure and high-risk behaviors
- Installed a second antenna on the G-hall double door exit
- Ensured proper operation of the elopement prevention system
- Increased the range of the elopement prevention system
- Changed door codes to prevent unauthorized exits
Expired Food Items Found in Facility's Kitchen
Penalty
Summary
The facility failed to ensure that expired food items were disposed of in a timely manner, which had the potential to affect all 98 residents receiving food from the kitchen. During an inspection of the dry storage area, several expired food items were found, including graham cracker crumbs, sugar-free Jell-O, pork-flavored gravy mix, cream soup base, brownie mix, cake mix, streusel topping, chocolate chips, assorted Jell-O, vanilla pudding, corn starch, peanut butter, rainbow sprinkles, oatmeal, and thickener. These items were identified as expired by the Culinary Aide, who explained the labeling system for delivery and expiration dates. In addition to the dry storage issues, the walk-in refrigerator contained expired items such as pre-made peanut butter and jelly sandwiches, green peppers, shredded lettuce, lettuce, shredded cheese, and English cucumbers. Furthermore, pies stored in the refrigerator were not covered, contrary to the facility's food storage policy. The Dietary Manager acknowledged that expired items should have been removed and disposed of properly and that the pies should have been covered. The facility's food storage policy, which was revised, mandates that food should be covered, labeled, and dated appropriately, with opened food not exceeding the manufacturer's use-by date.
Infection Control Deficiencies in Hand Hygiene and PPE Usage
Penalty
Summary
The facility failed to maintain proper infection control practices, as evidenced by several observed deficiencies in hand hygiene and personal protective equipment (PPE) usage. For Resident 20, an LPN did not perform hand hygiene before donning gloves to conduct a blood glucose check. Similarly, for Resident 12, another LPN failed to perform hand hygiene before donning gloves to administer a nasal spray and oral medications. Additionally, the Unit Manager was observed handling medication with bare hands without performing hand hygiene before administering Tylenol to Resident 24. Furthermore, the facility did not adhere to enhanced barrier precautions for Resident 2, who required such measures due to renal disease and the presence of a dialysis port and gastrostomy tube. Certified Nurse Aides were observed preparing the resident for dialysis without donning the required gown and gloves, despite the care plan indicating the necessity for enhanced barrier precautions. These observations highlight lapses in following the facility's hand hygiene and PPE policies, as outlined by the Director of Nursing.
Insulin Administration Error Due to Non-Adherence to Physician's Order
Penalty
Summary
The facility failed to adhere to a physician's order regarding insulin administration for a resident diagnosed with diabetes. The resident's care plan, dated October 21, 2024, highlighted the risk of adverse effects from hyperglycemia or hypoglycemia due to glucose-lowering medication. The physician's order, dated December 30, 2024, specified that insulin lispro should be held if the resident's blood sugar was below 150 mg/dL. However, during a random observation on March 9, 2025, an LPN was preparing to administer 12 units of insulin lispro to the resident despite a blood sugar reading of 122 mg/dL, which was below the threshold set by the physician's order. The LPN, upon reviewing the Medication Administration Record, acknowledged the oversight and confirmed that the insulin should have been held. This incident was documented during an interview with the LPN, who admitted the error. The facility's Medication Administration Skills Competency, last revised in July 2023, emphasizes the importance of adhering to the five rights of medication administration, which includes administering the right dose at the right time. The failure to follow the physician's order resulted in a significant medication error, as the insulin was nearly administered contrary to the prescribed parameters.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a call light was within reach for a resident, identified as Resident G, who was reviewed for call light accessibility. Resident G's clinical record indicated multiple diagnoses, including anemia, cancer, heart failure, diabetes, hemiplegia caused by a stroke, and depression. The resident was cognitively intact but had impairment of her right upper extremity and required an interpreter for communication. During an observation, it was noted that the call light cord was attached to the wall mount and was hanging near the ground, out of sight and reach of the resident. Resident G confirmed that she sometimes did not have access to her call light, although she knew how to use it when available. Further observations revealed that the call light remained out of reach throughout the day. The Director of Nursing (DON) was interviewed and initially believed the call light was within reach, but upon testing, Resident G was unable to access it without assistance. The DON later acknowledged that there was no specific policy on call lights, and the facility followed general standards of care. This deficiency highlights the facility's failure to accommodate the resident's needs by ensuring the call light was accessible, as required by their own standards.
Failure to Ensure Proper Signing of Arbitration Agreements
Penalty
Summary
The facility failed to ensure that a binding arbitration agreement was properly explained and signed by the appropriate resident representatives for two residents. Resident 42, who was admitted with severe cognitive impairment and later deemed incapacitated, signed an arbitration agreement without the involvement of a legal representative. Despite having a temporary guardian appointed, the agreement was signed by Resident 42, who was unable to fully comprehend the document, as indicated by Admission Staff 3, who had to explain the agreement multiple times. Similarly, Resident 88, who was also cognitively impaired, signed an arbitration agreement without the physical presence of her power of attorney (POA), her daughter. Admission Staff 3 contacted the POA over the phone, who verbally consented to the signing, but did not sign the document herself. The facility had the option for electronic signing, but it was not utilized. These actions led to the deficiency as the facility did not ensure the agreements were properly explained and signed by the appropriate representatives.
Failure to Respect Resident Dignity and Rights
Penalty
Summary
The facility failed to ensure the dignity and respect of three residents, identified as Residents J, K, and L, during interactions with a Licensed Practical Nurse (LPN 22). Resident K, who was cognitively intact and diagnosed with heart disease, reported that LPN 22 was rude and disrespectful during an interaction involving the changing of her oxygen humidifier. The resident described an incident where LPN 22 made rude statements and gestures, including sticking up his middle finger. Although the incident was reported to the Executive Director (ED), Resident K did not receive an apology from LPN 22, who no longer worked at the facility. Resident J, also cognitively intact and diagnosed with heart failure, reported that LPN 22 was pushy and demanding, often waking him up at night to perform tasks such as taking a sip of water. Despite Resident J's requests for LPN 22 to be removed from his care, the LPN continued to be disrespectful. Resident J expressed that LPN 22's behavior was too forceful and made him uncomfortable. Resident L, diagnosed with quadriplegia and cognitively intact, recounted an argument with LPN 22 where the LPN used inappropriate language and rushed through care without listening to the resident's concerns. Resident L reported the incident to the Director of Nursing (DON) and the ED, describing LPN 22 as disrespectful. The facility's resident rights policy emphasizes the importance of treating residents with dignity and respect, which was not upheld in these interactions.
Deficiency in ADL Assistance for Resident
Penalty
Summary
The facility failed to provide adequate care and assistance with activities of daily living (ADLs) for Resident G, who was unable to perform these tasks independently. Resident G, who has a medical history including anemia, cancer, heart failure, diabetes, hemiplegia from a stroke, and depression, was observed in her room with oily, stringy, and tangled hair, indicating she had not received a shower or hair shampooing in 10-12 days. Despite being scheduled for showers twice a week, the resident reported not having received a full bed bath or hair wash recently, and her wheelchair was missing from her room for several days, preventing her from being mobilized as needed. Interviews with facility staff revealed inconsistencies in the care provided to Resident G. LPN 10 confirmed that the resident's showers were scheduled for specific days, but the resident had not been assisted to her wheelchair for some time. The Assistant Director of Nursing Services (ADNS) and the Director of Nursing (DON) were unaware of the wheelchair's location, which was later found and returned to the resident's room. The Occupational Therapist (OT) and Speech Therapist (ST) had evaluated the resident for wheelchair use, noting a decline in her mobility and the need for a larger wheelchair, but the nursing staff had not been actively facilitating her transfers. The care plan for Resident G indicated she required assistance with ADLs due to impaired mobility and a history of stroke, with a goal of maintaining her cleanliness and grooming. However, the facility's failure to adhere to this plan resulted in the resident not receiving the necessary care. The DON acknowledged the lack of a specific policy on ADLs, relying instead on general standards of care, which contributed to the oversight in Resident G's care.
Failure to Apply Recommended Splints for Resident with Contractures
Penalty
Summary
The facility failed to ensure that a resident with contractures received the recommended splint application as advised by therapy staff. Resident B, who has a history of hemiplegia and hemiparesis following a stroke, as well as multiple contractures and muscle wasting, was observed without the necessary splint on multiple occasions. Despite being cognitively intact and aware of the need for a splint, Resident B reported that the staff never applied it. The clinical record lacked any physician orders or care plans related to the application of splints, indicating a gap in the coordination and implementation of care. The therapy staff had recommended the use of a grip hand splint and an elbow extension splint to prevent the progression of contractures, and an in-service was conducted to ensure nursing staff understood the proper application of these splints. However, observations and interviews revealed that the splints were not being applied as needed. The facility's policy on the Restorative Nursing Program, which includes splint or brace assistance, was not followed, as evidenced by the absence of a resident-centered care plan with specific interventions for maintaining or improving function.
Failure to Post Current Nurse Staffing Information
Penalty
Summary
The facility failed to ensure the daily posting of current nurse staffing information, which had the potential to affect all 98 residents residing in the facility. Observations on multiple occasions revealed that the staffing information posted was outdated, showing the date of 3/07/25 instead of the current date. Interviews with the Nurse Schedule Coordinator (NSC) and the Executive Director (ED) revealed that the NSC prepares the staffing sheets daily and leaves them for the night shift nurse to post the following morning. However, the night shift nurse forgot to update the posting, resulting in outdated information being displayed. The facility's policy requires that staffing information be posted at the beginning of each shift, including details such as the facility name, current date, resident census, and the number of hours worked by registered nurses, licensed practical nurses, and certified nurse aides. Despite this policy, the failure to update the staffing information was attributed to oversight by the night shift nurse, particularly on weekends when the NSC might not be present to ensure compliance.
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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