Springhurst Health Campus
Inspection history, citations, penalties and survey trends for this long-term care facility in Greenfield, Indiana.
- Location
- 628 N Meridian Rd, Greenfield, Indiana 46140
- CMS Provider Number
- 155767
- Inspections on file
- 21
- Latest survey
- March 23, 2026
- Citations (last 12 mo.)
- 17 (1 serious)
Citation history
Health deficiencies cited at Springhurst Health Campus during CMS and state inspections, most recent first.
A resident with type 2 DM, dementia, and other acute conditions was admitted from the hospital with discharge orders for Lantus insulin twice daily and BG monitoring before meals. Multiple staff, including the DHS, MDS staff, an NP, and nurses, reviewed the discharge paperwork but failed to identify and transcribe the DM diagnosis and insulin/BG monitoring orders into the EHR at admission. The omission was discovered days later during a care planning meeting when a family member asked about BG levels, by which time the resident had received only one insulin injection and had persistently elevated BG readings, along with diminished cognition and lethargy, leading to transfer and admission to a hospital where uncontrolled DM and altered mental status were documented.
The facility did not maintain adequate nursing staff, leading to delays in ADL care, skin care treatments, and incontinence care. Residents and family members reported long wait times for assistance, and staff described frequent shortages, missed care tasks, and unresponsive management. Documentation and Resident Council minutes confirmed ongoing concerns about short staffing and its impact on resident dignity and care.
Several dependent residents did not receive timely assistance with ADLs, including shaving and toileting. One resident was not helped with shaving for over a week despite his preferences, while another waited over two weeks for shaving assistance despite repeated requests. Two residents experienced long waits for toileting help, resulting in incontinence and embarrassment. Staff interviews confirmed challenges in meeting residents' ADL needs.
A resident with dementia, orthostatic hypotension, and muscle weakness was observed multiple times without access to a call light while in a wheelchair. The resident, who was cognitively intact and dependent on staff for toileting and transfers, reported being unable to contact staff for help and experiencing anxiety about call light accessibility. Facility policy and the resident's care plan required the call light to be within reach, but this was not consistently ensured by staff.
A resident with dementia had a Quarterly MDS assessment completed, but the facility did not transmit the assessment data to the State within the required 14-day period. The delay was attributed to MDS staff being busy with end-of-month tasks, resulting in the assessment being sent more than three weeks after the assessment reference date.
A resident with an indwelling urinary catheter and a history of UTI and neurogenic bladder was observed on multiple occasions with catheter drainage bag and tubing in contact with the floor, contrary to the care plan and facility policy. The resident reported that the bag frequently drags on the floor and has become caught under the wheelchair wheel.
A resident who returned from the hospital with acute blood loss anemia was administered aspirin despite discharge instructions to discontinue the medication. The error occurred because previous medication orders were not discontinued in the electronic system, and the required admission checklist and order review process by two nurses was not properly followed.
Two residents experienced a lack of dignity and respect: one was subjected to a staff member's negative comment about their bowel care, and another reported feeling unimportant due to long delays in call light response and insufficient staffing, with staff often stating they were too busy or alone on the floor.
Two residents with dementia were involved in an incident where one was found touching the other inappropriately while the latter was not fully clothed. The staff member who witnessed the event informed an RN, but the required immediate reporting to the ED and state authorities did not occur. Key details were not communicated to management, and the incident was not reported to the state as required by policy.
Two residents with severe cognitive impairment were found in a private room, with one resident inappropriately touching the other, who was not fully clothed. The incident was witnessed by a CRCA, but the full details were not accurately reported to management or documented in the medical record. The facility failed to initiate a thorough investigation, did not interview the witness, and did not report the incident as required by policy.
Three residents did not receive care as ordered, including missed wound and skin treatments due to staff time constraints, and a resident experienced a repeat allergic reaction to Bactrim after the allergy was not timely documented or communicated, despite prior discussion with family and staff.
The facility failed to promote resident dignity by instructing a resident to use an incontinence brief instead of a bedpan and allowing a staff member to curse within hearing distance of another resident. The incidents involved a resident with severe cognitive impairment and behavioral issues, and another resident with a medical history of depression and an ostomy.
The facility failed to provide scheduled showers for two residents. One resident, with multiple diagnoses, did not receive showers twice a week as planned, and another mildly cognitively impaired resident only received four showers in two months. The facility's policy required bathing at least twice a week.
Failure to Transcribe Hospital Diabetes Orders Resulting in Missed Insulin Therapy
Penalty
Summary
The deficiency involves the facility’s failure to correctly transcribe and enter a hospital’s discharge orders for a newly admitted resident with type 2 diabetes into the facility’s electronic health record. The resident was admitted for a short-term rehab stay with diagnoses including type 2 diabetes, acute upper respiratory infection, unspecified dementia, weakness, dehydration, and hydrocephalus. The hospital discharge orders dated 2-6-26 specified that the resident had type 2 diabetes and was to receive glargine (Lantus) 16 units subcutaneously twice daily, with blood glucose (BG) monitoring before meals or three times daily. These diabetes-related orders, including the diagnosis and insulin regimen, were not transcribed into the facility’s electronic health record at admission and were not entered until 2-12-26. Multiple facility staff, including the Director of Health Services (DHS), MDS staff, a Nurse Practitioner, and two nurses, reviewed the hospital discharge paperwork and entered orders into the electronic health record but failed to identify and transcribe the diabetes diagnosis and associated insulin and BG monitoring orders. The DHS later explained that the initial page of the hospital discharge summary did not specifically mention the diabetes diagnosis, which was located further into the document, and that staff did not locate this information during the initial review. The omission was discovered on 2-11-26 during an initial care planning meeting when a family member inquired about the resident’s BG levels, prompting a more thorough review of the hospital discharge documents. During the period when the diabetes diagnosis and insulin orders were not in place, the resident did not receive the ordered long-acting insulin for five days and had only one insulin injection documented since admission. The resident’s BG levels during this time were significantly elevated, with readings including 399, 451, 496, 316, 360, 356, 422, and 354. The resident, who was already severely cognitively impaired per the 5-day MDS assessment, experienced diminished cognitive levels and lethargy and was ultimately sent to the local hospital at the family’s request. Hospital records from that subsequent admission documented altered mental status possibly related to dehydration, infection, or diabetic ketoacidosis, and identified the resident’s diabetes as uncontrolled at that time.
Removal Plan
- notification of the physician and the responsible party of the identified issues
- obtaining updated physician orders
- implementing the orders
- educating the licensed nursing staff on the facility's policies related to transcribing physician orders and diagnoses from the discharging entity into the facility's electronic health record
- initiated an audit system to ensure residents had accurately transcribed admission orders and diagnoses correctly documented into the facility's electronic health record system
Failure to Provide Sufficient Nursing Staff Resulting in Delayed and Missed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, resulting in delays in activities of daily living (ADL) care, skin care treatments, and incontinence care, as well as negatively impacting residents' dignity. Multiple residents and family members reported long wait times for assistance after pressing call lights, with some residents waiting up to 45 minutes for help with toileting, leading to incontinence accidents and emotional distress. Staff interviews confirmed that there were frequent staffing shortages, with only one Certified Resident Care Assistant (CRCA) often assigned to a hall, making it difficult to complete scheduled showers, skin care, and other essential care tasks in a timely manner. Staff members, including RNs, LPNs, and CRCAs, described an ongoing pattern of inadequate staffing, with frequent call-offs and management being unresponsive to urgent staffing needs. On one occasion, there was a documented 40-minute period when no nurse was present in the building, and staff had to rely on a nurse who had already worked a 16-hour shift and was attempting to leave. Staff reported being unable to complete required documentation, such as admission and skin assessments, and were sometimes instructed by management to backdate records to cover missed care. Resident Council meeting minutes over several months consistently reflected concerns about short staffing, delayed medications, and missed showers. The deficiency was further substantiated by time sheet reviews and interviews with the facility scheduler, who confirmed ongoing issues with filling shifts and the impact on resident care. The lack of adequate staffing led to missed or delayed care, falsification of shower records, and increased resident behaviors due to unmet needs. The survey cited related deficiencies in ADL care, quality of care, and resident dignity, with specific examples of residents not receiving timely shaving, skin care treatments, and respectful incontinence care.
Failure to Provide Timely ADL Assistance and Shaving for Dependent Residents
Penalty
Summary
The facility failed to provide timely and adequate assistance with activities of daily living (ADL) for several dependent residents, specifically in the areas of shaving and toileting. One resident, who preferred to maintain a goatee, was not assisted with shaving the rest of his face for over a week, despite his care plan specifying shaving on shower days and as needed. He reported that only one care assistant occasionally helped him, but often did not have time. Another resident, who required partial assistance with personal hygiene, was not shaved for over two weeks despite repeated requests, and only received assistance after persistent asking. His roommate confirmed that he had not been shaved since admission, despite being able to make his needs known and having a care plan that included shaving on shower days or as requested. Two other residents experienced significant delays in receiving toileting assistance, resulting in episodes of incontinence. One resident, who was usually continent but required substantial assistance due to mobility limitations, reported waiting up to 45 minutes for help after activating her call light, leading to incontinent accidents in bed. She described feeling anxious and embarrassed as a result. Another resident, also cognitively intact and dependent on staff for toileting, reported that her call light was not answered promptly, causing her to be incontinent and remain in a wet bed, which she found embarrassing and unnecessary. Staff interviews corroborated these findings, with a Certified Resident Care Assistant stating she was unable to complete bathing and ADL needs for residents on her assigned hall. The administrator confirmed that nursing staff were responsible for ensuring residents were shaved. The deficiencies were identified through observation, resident and staff interviews, and record review, and were associated with multiple complaints.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
A deficiency was identified when a resident was repeatedly observed without access to their call light while seated in a wheelchair in the middle of their room. On two separate occasions, the call light was found on the floor or on the opposite side of the bed, out of the resident's reach. The resident reported being unable to contact staff for assistance during the day and expressed anxiety at night due to uncertainty about call light accessibility, sometimes having to yell for help. During one observation, the resident needed to use the restroom but could not summon assistance due to the inaccessible call light. The resident's clinical record indicated diagnoses of dementia, orthostatic hypotension, and muscle weakness, with a recent BIMS evaluation showing cognitive intactness. The MDS assessment documented the resident's dependence on staff for toileting and transfers, and the care plan included an intervention to keep the call light within reach due to fall risk. Facility policy also required staff to ensure call lights were accessible to residents. An RN confirmed that it was the responsibility of any staff member entering the room to ensure the call light was within reach.
Failure to Timely Transmit Quarterly MDS Assessment
Penalty
Summary
The facility failed to timely transmit a Quarterly Minimum Data Set (MDS) assessment for one resident diagnosed with dementia. The resident's clinical record showed that a Quarterly MDS assessment with an assessment reference date (ARD) was completed, but the transmission of this assessment to the State occurred significantly later than required. Specifically, the assessment was completed, but not transmitted within the 14-day window as outlined in the RAI Manual. According to MDS Support staff, the delay was due to being occupied with end-of-month activities, resulting in the assessment being transmitted more than three weeks after the ARD.
Failure to Maintain Catheter Bag and Tubing Off the Floor
Penalty
Summary
The facility failed to ensure that a resident's indwelling urinary catheter drainage bag and tubing were kept off the floor, as required by facility policy and the resident's care plan. Resident E, who had diagnoses including urinary tract infection and neurogenic bladder, was observed on two separate occasions with his catheter drainage bag and tubing in contact with the floor while seated in his wheelchair. The resident reported that his catheter bag often drags on the floor and has previously become caught under his wheelchair wheel. The care plan specifically directed staff to ensure the catheter did not touch the floor, and the facility's urinary catheter care policy also required that catheter tubing and drainage bags be kept off the floor.
Failure to Discontinue Medication per Hospital Discharge Orders
Penalty
Summary
A deficiency occurred when the facility failed to follow hospital discharge orders for a resident who had recently returned from the hospital with a diagnosis of acute blood loss anemia. The hospital discharge summary specifically instructed discontinuation of aspirin 81 mg daily, but the Medication Administration Record showed that the resident received aspirin after readmission. The resident, who was cognitively intact, reported being told that all blood thinners would be held for a while following her hospitalization for blood loss. The Director of Health Services confirmed that the resident's previous medication orders were not discontinued in the computer system when she was transferred to the hospital, resulting in all prior orders reappearing on her MAR upon readmission. Although facility policy required an admission checklist and review of new or discontinued orders by two nurses, this process was not followed, leading to the administration of a medication that should have been discontinued. The resident's care plans identified risks related to bleeding and anemia, with interventions to administer medications as ordered, but these were not adhered to in this instance.
Failure to Promote Resident Dignity and Respect
Penalty
Summary
The facility failed to promote and maintain resident dignity for two residents. For one resident with Parkinson's disease and bowel issues, a family member reported that a Certified Resident Care Assistant (CRCA) made a disrespectful comment about the resident's condition in his presence, describing the situation as 'gross.' The family filed a grievance, but the grievance log only documented concerns about missing supplies and dietary needs, not the staff's comment. Interviews with facility leadership revealed inconsistent recollections about the incident, with no documentation of the alleged disrespectful behavior, though a verbal warning was later issued to the CRCA for customer service concerns. The lack of clear documentation and follow-up on the dignity-related incident contributed to the deficiency. Another resident, who was cognitively intact and required significant assistance with activities of daily living, reported that insufficient staffing during night and early morning shifts led to long wait times for call lights to be answered, sometimes up to an hour. The resident expressed feeling unimportant and forgotten due to these delays and reported that staff often responded by saying they were too busy or the only CNA on the floor. This lack of timely assistance and communication failed to support the resident's dignity and emotional well-being.
Failure to Immediately Report Alleged Abuse and Notify Authorities
Penalty
Summary
The facility failed to immediately report an allegation of abuse involving two residents with dementia, both of whom were assessed as severely cognitively impaired and unable to give consent. On the evening in question, a Certified Resident Care Assistant (CRCA) discovered one resident in another resident's room, with one resident touching the other's breast and thigh while the latter was not wearing pants. The CRCA separated the residents and informed the on-duty Registered Nurse (RN), but did not escalate the report to the Executive Director (ED) as required by facility policy, citing the ED's unavailability and a history of not answering calls. The RN, upon being informed, contacted the Assistant Director of Health Services (ADHS) but did not notify the ED or the Indiana Department of Health (IDOH). The ADHS, in turn, contacted corporate leadership but did not initiate a formal report to the state or conduct a thorough investigation, as she was not fully informed of the details of the incident, including the fact that one resident was not wearing pants and was being touched inappropriately. The Director of Health Services (DHS) and other members of the interdisciplinary team were also unaware of the full extent of the incident, as the CRCA was not interviewed and her account was not documented in detail. Facility policy required immediate reporting of suspected abuse to the ED and state authorities, but this process was not followed. The incident was not reported to the IDOH as a reportable event, and no internal investigation was initiated to gather statements or clarify the events from all involved staff. The lack of timely and complete reporting, as well as the failure to follow up with the primary witness, resulted in a deficiency related to the facility's abuse reporting procedures.
Failure to Investigate and Report Alleged Abuse Between Cognitively Impaired Residents
Penalty
Summary
The facility failed to identify and initiate a thorough investigation into an alleged violation of abuse involving two residents with dementia. On the evening in question, a Certified Resident Care Assistant (CRCA) discovered one resident in another resident's room, with one resident touching the other's breast and thigh while the latter was not wearing pants. The CRCA separated the residents and reported the incident to the Registered Nurse (RN) on duty, who then notified the Assistant Director of Health Services (ADHS). However, the full details of the incident, including the inappropriate touching and the lack of clothing, were not accurately communicated up the chain of command. The RN and ADHS both failed to recognize the incident as potentially reportable abuse, relying on incomplete information and not conducting a thorough investigation. The Executive Director (ED) was not notified, and the CRCA was not interviewed or asked to provide a written statement about what she witnessed. The facility's documentation of the event was incomplete and did not reflect the severity of the situation, as the notes only mentioned hands on the leg and shoulder, omitting the more serious details reported by the CRCA. Both residents involved were documented as having severe cognitive impairment and lacking capacity to consent to intimate contact. Despite this, the facility did not initiate a formal investigation, did not report the incident as required, and did not follow its own abuse, neglect, and exploitation procedural guidelines. No reportable incident was filed with the state, and management staff were unaware of the full extent of the incident until interviewed during the survey.
Failure to Complete Treatments as Ordered and Timely Address Medication Allergy
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders and failed to timely address a medication allergy for three residents. One resident with a history of urinary tract infections (UTIs) experienced a repeat allergic reaction to Bactrim, an antibiotic, after it was prescribed despite prior discussion of a possible allergy during a care plan meeting. The family reported swelling of the resident's lips after administration of Bactrim, with photographic evidence of similar reactions on two separate occasions. Documentation from the care plan meeting did not reference the allergy, and staff interviews revealed uncertainty and lack of documentation regarding the medication sensitivity discussed. The allergy was only formally documented in the resident's record after the most recent reaction occurred. Another resident with diabetes and skin impairments had a physician's order for foam dressing changes on specific days. The treatment was not completed on one occasion, with the reason documented as "not enough time." The nurse responsible indicated that due to time constraints during her shift, she was unable to complete all assigned treatments, including the required dressing change for this resident. The resident was cognitively intact at the time of the deficiency. A third resident with acute respiratory failure and chronic pulmonary edema had a physician's order for Profore two-step dressing changes to the lower extremities on scheduled days. The dressing change was not completed as ordered, with documentation indicating insufficient time or staff as the reason. Interviews with nursing staff confirmed that wound care tasks were delayed or missed due to workload, and the resident reported that his leg dressings were changed later than scheduled. Facility policy required adherence to physician recommendations for treatment, which was not followed in these instances.
Failure to Promote Resident Dignity
Penalty
Summary
The facility failed to promote a resident's dignity by instructing Resident H to use an incontinence brief instead of a bedpan and by allowing a staff member to curse within hearing distance of Resident F. Resident F, who had severe cognitive impairment and various behavioral symptoms, was involved in an incident where a staff member was heard cursing while providing care. The staff member, CRCA 3, was reportedly frustrated after being pushed by Resident F and falling onto an activity table, which broke. Although the cursing was not directed at Resident F, it was within his hearing range, and the incident was reported by the payroll coordinator and investigated by the facility. The investigation concluded with no findings of verbal abuse, and the staff member was allowed to return to work. However, the incident still raised concerns about maintaining a dignified environment for residents, especially those with cognitive impairments and behavioral issues. Resident H, who had a medical history of depression and an ostomy due to complications from a previous procedure, was also affected by the facility's failure to promote dignity. Resident H was continent of her bladder and used a bedpan for toileting due to being non-weight-bearing after a recent foot procedure. On the morning of 4/25/2024, Resident H requested a bedpan, but the night shift nurse instructed her to use her brief instead, stating that she would have to change her anyway. This interaction made Resident H feel upset, frustrated, and disrespected. The nurse eventually provided the bedpan after a brief argument, but the incident highlighted a lack of respect for Resident H's dignity and personal preferences. The facility's policy on Resident Rights Guidelines emphasizes treating residents with dignity, respect, and courtesy. However, the incidents involving Resident F and Resident H demonstrate a failure to adhere to these guidelines. The report indicates that the facility did not adequately promote a dignified existence for these residents, leading to feelings of frustration and disrespect. The deficiencies were identified through observations, interviews, and record reviews conducted by the surveyors.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility failed to provide showers as scheduled for two residents, Resident K and Resident B. Resident K reported not receiving her showers twice a week as scheduled, with staff offering showers at inconvenient times. Her record indicated she was admitted with multiple diagnoses, including metabolic encephalopathy, severe sepsis, and acute respiratory failure, and required substantial assistance for bathing. The care plan specified she should receive showers on Wednesdays and Saturdays after 6 p.m., but documentation showed she only received eight showers from March 1 to April 17, instead of the expected nine in March alone. Resident B, who was mildly cognitively impaired and dependent on staff for bathing, also did not receive showers as scheduled. His care plan indicated he should receive showers on Mondays and Thursdays. However, documentation revealed that in the two months he was at the facility, he only received four showers. The facility's policy stated that bathing should occur at least twice a week unless otherwise preferred by the resident. This deficiency was related to a complaint investigation.
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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