Sage Bluff Health & Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Fort Wayne, Indiana.
- Location
- 4180 Sage Bluff Crossing, Fort Wayne, Indiana 46804
- CMS Provider Number
- 155827
- Inspections on file
- 41
- Latest survey
- January 21, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Sage Bluff Health & Rehab Center during CMS and state inspections, most recent first.
The facility failed to maintain adequate hot water and to consistently monitor dish machine temperatures needed for kitchen sanitation, affecting meals prepared for most residents. A dietary staff member responsible for dishwashing reported ongoing hot water problems, used stove‑boiled water mixed with cold water for washing and sanitizing dishes, and did not measure final water temperatures or receive clear guidance for water heater failures. Review of dish machine temperature logs showed multiple missing entries despite policy requiring readings at each meal. The ADM and Dietary Manager confirmed there was no corporate policy for handling hot water failures, acknowledged that staff relied on improvised methods such as heating water on the stove or capturing hot water from the dish machine, and could not explain the missing log entries. The Maintenance Director reported that the water heater serving the kitchen and laundry had malfunctioned for months, required replacement per a contractor, and was awaiting corporate action, while existing policies required specific water temperatures and frequent monitoring that were not consistently followed.
A resident with a history of falls and multiple medical conditions sustained a wrist fracture after falling during an outside appointment where no staff accompanied her, despite a care plan intervention requiring staff accompaniment. The resident was again sent to a follow-up appointment without staff present, and facility staff interviews revealed a lack of communication and awareness regarding the need for supervision during appointments.
A resident was subjected to condescending and verbally abusive remarks by a QMA, including being called a liar and refused assistance with personal care. The resident expressed fear for her safety, was observed crying, and ultimately left the facility against medical advice. Witnesses, including another resident and staff, confirmed the QMA's threatening behavior and refusal to help, which resulted in the resident injuring herself while dressing.
A resident with a stage 4 sacral pressure ulcer, fully dependent on staff for mobility, did not receive daily wound care as ordered on two consecutive days. The resident, who was cognitively intact and admitted for wound care, reported missed dressing changes, and facility records confirmed the omission despite clear physician orders and facility policy.
A resident with cognitive impairment and dependence on renal dialysis eloped from the facility and was found outside after a door alarm was triggered. The resident was assisted back inside, but the incident was not reported to the state health department until two days later, violating the facility's policy of reporting within 24 hours.
A facility failed to attempt non-pharmacological interventions before administering PRN pain medication to a resident with dementia and other conditions. Despite having a care plan and a policy requiring such interventions, the facility did not document any attempts before administering medication on multiple occasions. The DON confirmed that the lack of documentation indicated non-compliance with the policy.
A resident with multiple health issues, including dependence on renal dialysis, experienced incomplete communication between the nursing home and dialysis center. Documentation showed repeated failures to fill out necessary sections of communication forms by both parties, affecting the resident's care. The facility's policy required thorough communication, which was not followed.
A resident with dementia and depression repeatedly grabbed another nonverbal resident's wrist and thigh without staff intervention or documentation. The behavior was not recognized as problematic, and the affected resident, who had mobility and skin integrity issues, was unable to move away independently. The facility's behavior management policy was not followed, contributing to the deficiency.
A resident with severe cognitive impairment was physically abused by a staff member during repositioning in a wheelchair. The staff member retaliated after being struck by the resident, violating the facility's abuse policy. The incident was not reported immediately, highlighting a deficiency in the facility's care practices.
A resident with severe cognitive impairment and a history of trauma was involved in an altercation with staff during repositioning, resulting in the resident being struck by a staff member. The incident was not reported immediately by the witnessing staff, leading to a delay in notifying authorities.
A facility failed to provide trauma-informed care for a resident with a history of trauma and abuse, as the care plan lacked specific triggers and approaches to prevent re-traumatization. The resident's guardian expressed concerns about safety and visitor restrictions, which were not adequately communicated to staff. Nursing staff were unaware of the resident's specific needs, and the facility lacked a specific policy for trauma-informed care.
Failure to Maintain Hot Water and Monitor Dish Machine Temperatures for Kitchen Sanitation
Penalty
Summary
The deficiency involves the facility’s failure to maintain appropriate hot water temperatures and to consistently monitor dish machine temperatures needed for kitchen sanitation, affecting meals prepared for 45 of 47 residents. A dietary staff member responsible for dishwashing reported that he was supposed to complete the dishwasher temperature log at each meal but was unsure how to determine the readings and did not know why the log was not current. He stated that water at the hand sink was usually only cool and that the dish sinks had cold water due to a water heater problem that had been ongoing for several months. To compensate, he boiled water on the stove and poured it into the sink, mixing it with cold water for washing and sanitizing dishes and preparing sanitizer water for wiping surfaces, but he did not measure the final water temperature and had not been given clear policy guidance on how to proceed during a water heater failure. Record review of the High Temperature Dish Machine log showed multiple missing wash and rinse temperature entries across numerous meal times, despite policy requiring temperatures to be recorded at breakfast, noon, and evening meals. The Assistant Dietary Manager stated there was no corporate policy on handling hot water failure, confirmed that water heater problems had persisted for about seven months, and acknowledged that staff heated water on the stove for soaking and sanitizing because the sinks did not provide sufficiently hot water, while also being unaware of any concrete plan to resolve the hot water issue or the reason for missing log entries. The Dietary Manager similarly reported there was no company policy for water temperature failure and described an informal practice of using a pot placed in the dish machine to capture hot water for sinks, while stating that dish machine temperatures should be logged with the first load each morning. The Maintenance Director reported that the water heater serving the kitchen and laundry had been replaced and then began malfunctioning months later, that a contractor had recommended replacement, and that quotes had been submitted to corporate without a replacement date established. Existing written policies required verification and frequent monitoring of dish machine temperatures and specified minimum temperatures for manual dishwashing and sanitizer preparation, which were not consistently followed under the prolonged hot water failure.
Failure to Implement Fall Prevention Interventions During Resident Appointments
Penalty
Summary
A deficiency occurred when the facility failed to ensure that fall interventions were followed for a resident identified as being at risk for falls. The resident, who had diagnoses including congestive heart disease, muscle weakness, and post-traumatic stress disorder, returned from an outside appointment and reported to staff that she had fallen in the bathroom during the appointment, resulting in an open and closed distal fracture of her left wrist. Although the care plan, updated after the incident, specified that staff were to accompany the resident to all outside appointments, documentation and interviews confirmed that this intervention was not implemented for a subsequent appointment. Specifically, the resident was transported to a follow-up appointment by the Maintenance Director without any staff accompanying her, contrary to the care plan intervention. Interviews with facility staff, including the Administrator, Maintenance Director, and LPNs, revealed a lack of communication and awareness regarding the requirement for staff accompaniment. The Maintenance Director stated he was not notified that the resident required accompaniment until after the second appointment had already occurred. The facility's fall prevention policy required that new interventions be implemented and care plans updated to prevent further falls, but the intervention to accompany the resident was not followed.
Verbal Abuse and Intimidation by QMA Toward Resident
Penalty
Summary
A resident reported experiencing condescending and verbally abusive remarks from a Qualified Medical Assistant (QMA). The resident stated she overheard the QMA accuse her of lying and expressed fear of retaliation if she reported the behavior. Documentation included a written statement from the QMA describing the resident as someone who complains frequently and tells stories, as well as an incident where the QMA allegedly pulled a curtain aggressively in the resident's room. The resident expressed fear for her safety and indicated she might call the police after contacting her daughter. Following these events, the resident left the facility against medical advice due to fear after allegations of verbal abuse, and a report was made to adult protective services. Multiple staff and another resident corroborated the account, stating they witnessed the QMA loudly calling the resident a liar, refusing to assist her with personal care, and behaving in a threatening manner. The resident was observed crying and visibly distressed, and another resident confirmed the QMA's refusal to help and the resident's subsequent injury while attempting to dress herself. Facility policy defines verbal abuse as the use of disparaging or derogatory language within hearing distance of residents, regardless of their ability to comprehend, and includes intimidation or actions causing mental anguish.
Failure to Provide Ordered Pressure Ulcer Care
Penalty
Summary
A deficiency was identified when a resident with a stage 4 sacral pressure ulcer, who was completely dependent on caregivers for mobility, did not receive wound care as ordered. The resident, who was cognitively intact and residing at the facility specifically for wound care, reported not receiving wound care on a specified Friday, with the last dressing change occurring a week prior. Review of physician orders indicated that the wound was to be cleansed and packed daily and as needed, but documentation on the medication administration record confirmed that wound care was not completed on two consecutive days. Facility policy required dressings to be changed according to orders unless specific indications for removal were present.
Failure to Timely Report Resident Elopement
Penalty
Summary
The facility failed to report an elopement incident involving Resident 199 in a timely manner. Resident 199, who has a cognitive communication deficit, muscle weakness, and is dependent on renal dialysis, was found outside the facility on the sidewalk after the 200 hall door alarm was triggered. The resident, who has a BIMS score of 10 indicating moderate impairment, stated he was attempting to find his sister. Staff immediately assisted the resident back into the facility, provided snacks, and placed him in a visible area. However, the incident was not reported to the Indiana State Department of Health until two days later, contrary to the facility's policy requiring incidents to be reported within 24 hours.
Failure to Attempt Non-Pharmacological Interventions Before PRN Pain Medication
Penalty
Summary
The facility failed to ensure that non-pharmacological interventions were attempted before administering PRN pain medication to a resident diagnosed with unspecified dementia and mild psychotic disturbance. The resident had a physician's order for Percocet to be administered for severe pain, but there were no orders indicating that non-pharmacological interventions should be attempted first. The care plan for the resident, which was last edited in October 2024, did not include personalized non-pharmacological interventions, despite the resident's diagnoses of colon cancer and fibromyalgia. The Medication Administration Record showed multiple instances in August, September, and October 2024 where PRN pain medication was administered without documentation of attempted non-pharmacological interventions. The Director of Nursing confirmed that staff are required to attempt and document non-pharmacological interventions, but acknowledged that if there is no documentation, it indicates that these attempts were not made. The facility's Pain Management policy, dated August 2024, mandates that non-pharmacological interventions be attempted prior to administering PRN pain medications, but this was not adhered to in the case of the resident.
Incomplete Communication with Dialysis Center for Resident
Penalty
Summary
The facility failed to ensure proper communication with the dialysis center for a resident who required dialysis services. The resident, who had diagnoses including dependence on renal dialysis, hepatic encephalopathy, kidney failure, cirrhosis of the liver, and general weakness, had specific orders for dialysis on certain days, a renal diet, and regular checks of their fistula. However, the communication between the nursing home and the dialysis center was incomplete on multiple occasions, as evidenced by the review of the dialysis communication book. The documentation revealed numerous instances where sections of the communication forms were left blank by both the nursing home and the dialysis center. For example, the nursing home failed to complete sections related to the resident's mental status, significant alerts, dietary needs, and whether the dialysis chair was cleaned. Similarly, the dialysis center often did not fill out sections regarding fluid removal, discharge times, weights, vital signs, and other critical information. This lack of thorough documentation persisted over several dates, indicating a pattern of incomplete communication. In an interview, the Director of Nursing and the Regional Nurse Consultant acknowledged that the forms should have been fully completed. They also noted that when the dialysis center did not return completed forms, the facility should have contacted the center to request the missing information and documented this request in the resident's chart. The facility's policy on hemodialysis care emphasized the importance of communication between the dialysis provider and facility staff before and after each treatment, which was not adhered to in this case.
Failure to Manage Resident Behaviors
Penalty
Summary
The facility failed to manage behaviors for a resident diagnosed with dementia and depression, who displayed inappropriate physical interactions with another resident. During observations, the resident was seen grabbing the wrist and inner thigh of another resident multiple times without intervention from staff. The behavior was not documented, and staff did not initially recognize it as a behavior requiring management. The resident claimed to be assisting the other resident with mobility, showing pride in perceived progress, while the other resident, who was mainly nonverbal and unable to move independently, did not consent to the physical contact. The affected resident, who was nonverbal and had limited mobility, was unable to move away from the situation independently. The resident's care plan included issues with mobility and skin integrity, but there was no documentation of the bruising observed on the resident's wrist, which was attributed to a blood test conducted weeks prior. The staff's failure to document and address the behavior as a potential issue contributed to the deficiency. Interviews with the Director of Nursing and the Regional Nurse Consultant revealed that the behavior was overlooked as harmless handholding, and no behavior tracking was in place for the resident displaying the behavior. The facility's policy on behavior management required assessment and tracking of behaviors impacting residents' quality of life, which was not followed in this case.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse by staff, as evidenced by an incident involving Resident Q. The incident occurred when Employee 5, while assisting in repositioning Resident Q in her wheelchair, was struck in the face by the resident. In response, Employee 5 retaliated by slapping Resident Q on the cheek. This action was witnessed by Employee 2, who did not report the incident immediately, leading to a delay in addressing the abuse. Resident Q, who has diagnoses including brain damage due to trauma, major depressive disorder, and dependence on a wheelchair, was assessed to have severely impaired cognition. Despite her cognitive impairments, she was noted to have no behaviors, moods, or signs of delirium prior to the incident. Her care plan included interventions for managing behaviors such as striking others during care, which were not effectively implemented during the incident. The facility's policy mandates immediate reporting of abuse, which was not adhered to by Employee 2, who only reported the incident later in the evening. This delay in reporting and the subsequent failure to protect Resident Q from abuse constituted a deficiency in the facility's care practices.
Delayed Reporting of Resident Abuse Incident
Penalty
Summary
The facility failed to report timely physical abuse of a resident, identified as Resident Q, who was involved in an altercation with a staff member. On the morning of the incident, Resident Q, who had diagnoses including brain damage due to trauma and major depressive disorder, was being repositioned in her wheelchair by three employees. During this process, Resident Q became combative and struck one of the employees, Employee 5, in the face. In response, Employee 5 retaliated by striking Resident Q in the face with an open hand. Despite witnessing the incident, Employees 2 and 3 did not report the abuse immediately. Employee 2 later reported the incident to the Administrator after leaving the facility that evening. Resident Q's medical history included severely impaired cognition and dependence on staff for most activities of daily living. The resident's care plan noted behaviors such as striking others during care and a history of trauma and abuse. Despite these considerations, the staff involved did not adhere to the facility's policy requiring immediate reporting of abuse. The incident was eventually reported to the Indiana Department of Health, but not until later that evening, indicating a delay in the reporting process.
Failure to Provide Trauma-Informed Care for Resident with History of Abuse
Penalty
Summary
The facility failed to provide trauma-informed care for Resident Q, who has a history of trauma and abuse, resulting in a deficiency. Resident Q's care plan did not identify specific triggers or implement resident-specific approaches to prevent re-traumatization. The care plan included general interventions such as administering medications, allowing the resident to vent feelings, and attempting to reduce stressors, but lacked detailed strategies to address her past trauma. Additionally, the care plan did not include measures to ensure the resident's safety from potential abusers, despite the guardian's concerns and instructions regarding visitor restrictions. Interviews with the resident's guardian and nursing staff revealed gaps in communication and awareness of the resident's needs. The guardian expressed concerns about the resident's safety, citing an incident where a family member not on the approved visitor list was allowed into the facility without notification. Furthermore, the guardian reported an incident where a staff member allegedly hit the resident, which was not communicated to her promptly. Nursing staff were unaware of the resident's specific triggers and visitor restrictions, indicating a lack of training or information dissemination regarding trauma-informed care. The facility's Director of Nursing acknowledged the absence of a specific policy for trauma-informed care, relying instead on a general social services policy.
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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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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