Stonebrooke Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in New Castle, Indiana.
- Location
- 990 N 16th St, New Castle, Indiana 47362
- CMS Provider Number
- 155160
- Inspections on file
- 26
- Latest survey
- October 23, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Stonebrooke Rehabilitation Center during CMS and state inspections, most recent first.
A resident with multiple chronic conditions and cognitive intactness reported that a CNA was rough and rushed during incontinence care, causing discomfort and feelings of disrespect. Despite informing staff, no grievance was filed, resulting in a failure to uphold the resident's right to dignified care.
Two residents experienced verbal abuse from CNAs during care, including rude language, silencing gestures, and the use of profanities. Both residents, who had significant medical and cognitive needs, were left distressed by these interactions, which were corroborated by staff interviews and facility records.
A resident with chronic pain syndrome, major depressive disorder, and hypertension, who was cognitively intact, experienced alleged verbal abuse by a CNA. The incident was not immediately reported to the ED as required by facility policy; instead, a written statement was submitted to directors the following day, delaying proper notification and investigation.
A resident with stage 2 pressure ulcers and severe cognitive impairment was observed sitting in a wheelchair without the required pressure redistribution cushion, despite care plan and policy directives. The cushion had been removed for cleaning and left on the floor, and staff did not ensure its timely replacement, resulting in noncompliance with wound prevention protocols.
Two residents did not receive ordered nutritional interventions: one was not provided with a required adaptive drinking device, resulting in difficulty consuming fluids, and another was not weighed as ordered despite significant recent weight loss. Staff failed to follow physician orders and facility policy regarding adaptive equipment and weight monitoring, and documentation of refusals or attempts was lacking.
Two residents with severe cognitive impairment and dementia were observed engaging in intimate behaviors, including kissing and unsupervised time together in their shared room, without effective staff intervention. Staff were unsure of the appropriate care plan interventions, and the facility lacked a dementia care policy, resulting in a failure to address the residents' behaviors as required.
A resident with pressure ulcers, who was dependent on staff for toileting, received incontinence care during which CNAs placed soiled washcloths directly on the bed sheet instead of immediately bagging them. The soiled fitted sheet was not changed after care, and later, dried stool was found on the sheet and a washcloth was left in the windowsill. Staff interviews confirmed that proper infection control protocols for handling soiled linens were not followed.
Two residents with severe cognitive impairment and dependence on staff for ADLs did not receive showers as preferred, despite care plans and documented preferences indicating the importance of showers. Instead, both residents were given bed baths on multiple occasions, and staff and family interviews confirmed the residents' preferences were known but not consistently honored.
A resident with advanced dementia, heart failure, and malnutrition experienced a significant decline in eating and drinking abilities, requiring staff assistance with meals. Despite ongoing monitoring for weight loss, staff failed to consistently document the resident's meal intakes over several weeks, with numerous missing entries for breakfast, lunch, and dinner, contrary to facility procedures.
The facility failed to maintain a clean and sanitary kitchen, with issues such as incorrect use-by dates, undated food items, improper storage of boxes on the floor, and moldy buns. These deficiencies persisted over several days and had the potential to affect all 72 residents receiving food from the kitchen.
The facility failed to maintain resident rooms in good repair, with issues such as peeling cove base, missing paint, and damaged headboards observed in multiple rooms. The Maintenance Director acknowledged the ongoing problem and noted that staff actions contributed to the damage, despite a training program being in place.
The facility failed to complete a Minimum Data Set (MDS) Assessment for a resident discharged from hospice services. Despite the facility's policy requiring a significant change assessment, no such assessment was completed in October 2023. The MDS Coordinator acknowledged the oversight.
The facility failed to accurately indicate hospice services for a resident with Alzheimer's and did not correctly code oxygen therapy for two residents with chronic conditions. The MDS assessments did not reflect the actual care being provided, leading to discrepancies in the residents' records.
The facility failed to continue treatment for a resident with pressure ulcers and did not implement necessary interventions for pressure ulcer prevention and treatment for three residents. One resident did not receive prescribed Medihoney treatment for several days, another had a reddened ear due to lack of ear protectors on oxygen tubing, and a third resident's heels were not consistently offloaded, leading to pressure areas.
A resident with a history of falls and multiple health conditions fell out of bed because the prescribed bedside mat was not in place, resulting in skin tears. The facility's Fall Management Policy was not adequately followed.
The facility failed to ensure a dietary staff member did not work while experiencing gastrointestinal illness symptoms and did not wait 48 hours after symptoms stopped before returning to work. The staff member returned to work the next day to handle food, contrary to facility policy and CDC guidelines.
The facility failed to provide an ongoing activity program for two residents in the dementia care unit. Staff and family members confirmed that the unit had been without an activity assistant since June 2023, leading to residents sitting idle. The facility did not have a specific dementia care policy, and documentation showed no activity participation for the past three months.
Failure to Provide Dignified Incontinence Care
Penalty
Summary
A resident reported that a CNA failed to provide dignified incontinence care by being rough and rushing during care, which resulted in the resident feeling sore and disrespected. The resident stated that she had communicated her concerns directly to the CNA, asking him to be gentler, but the behavior did not change. She also reported the issue to a nurse and other CNAs, but was unable to identify their names. Despite these reports, no grievance was filed on her behalf regarding the matter. The resident was cognitively intact and able to make reasonable and consistent decisions, with no behavioral issues noted. She had multiple complex medical diagnoses, including heart failure, respiratory failure, COPD, diabetes, and morbid obesity, and was frequently incontinent of urine and always incontinent of bowels. Facility policy, as provided by the Executive Director, states that residents have the right to be treated with dignity and respect, including during personal care. The failure to provide dignified care and to address the resident's grievance led to the deficiency.
Failure to Protect Residents from Verbal Abuse by Staff
Penalty
Summary
The facility failed to protect residents from verbal abuse, as evidenced by two separate incidents involving two residents. In the first case, a resident with diagnoses including lymphedema, hypertensive heart disease, and PTSD, who was cognitively intact but dependent on staff for toileting, reported that a CNA entered her room in an upset manner, spoke to her rudely, repeatedly told her to be quiet, and used hand gestures to silence her while providing incontinence care. This interaction left the resident tearful and apologetic for her condition, and was corroborated by another CNA, the occupational therapist, and the social service director, all of whom observed or were informed of the resident's distress following the incident. In the second case, a resident with multiple diagnoses including bipolar disorder, major depressive disorder, anxiety, traumatic brain injury, and hemiplegia, who was moderately impaired in decision-making and dependent on staff for mobility and toileting, was subjected to harsh language and cursing by a CNA during care. The incident was witnessed by another CNA, who reported hearing the staff member use profanities towards the resident. The facility's records confirmed the incident and indicated that the staff member was suspended during the investigation and subsequently terminated for resident abuse or neglect. Both incidents demonstrate a failure to maintain an environment free from verbal and mental abuse as required by facility policy.
Failure to Timely Report Alleged Verbal Abuse Incident
Penalty
Summary
The facility failed to timely report an incident of alleged verbal abuse involving a resident with chronic pain syndrome, major depressive disorder, and hypertension, who was cognitively intact. On the day of the incident, a CNA observed another CNA hush the resident, make hand gestures for her to stop talking, and throw dirty linens on the floor while making a derogatory comment about being soiled. The CNA who witnessed the event wrote a statement and placed it under the doors of all directors that night, resulting in the report being received the following day. The CNA acknowledged that the Executive Director (ED) should have been notified sooner. Other staff, including an Occupational Therapist (OT) and the Social Service Director (SSD), became aware of the resident's distress on the same day, but the resident did not disclose the details of the incident to the SSD until the next day. The Director of Nursing (DON) and the ED were not made aware of the alleged abuse until the morning after the incident, when they received the written statement. The facility's abuse policy required immediate notification of the charge nurse and the ED when abuse is witnessed or suspected, which was not followed in this case.
Failure to Provide Pressure Redistribution Cushion for Resident with Pressure Ulcers
Penalty
Summary
A deficiency occurred when staff failed to ensure that a pressure redistribution cushion was in place for a resident with stage 2 pressure ulcers. The resident, who had diagnoses including dementia, repeated falls, and chronic pain syndrome, was identified as being at risk for pressure ulcers and required a pressure-reducing device for her chair according to her care plan. Observations revealed that the resident's chair cushion was not in use and was instead found on the floor beside the chair on two separate occasions. The resident's daughter reported that the cushion had been soiled the previous day, and staff had removed the cover for washing, leaving the cushion on the floor. Further review of the resident's clinical record and care plan confirmed the need for a Roho cushion in the chair or wheelchair as an intervention to prevent skin breakdown. Despite this documented requirement, the resident was observed sitting in a wheelchair without the necessary cushion, and the facility's policy stated that all residents utilizing a wheelchair should have a pressure redistribution cushion. The Executive Director confirmed that it was nursing's responsibility to ensure the cushion was in place.
Failure to Provide Ordered Nutritional Support and Monitoring
Penalty
Summary
The facility failed to ensure that two residents received appropriate nutritional care as ordered. One resident with diagnoses including hemiplegia, hemiparesis, and malnutrition was observed during a meal without the prescribed adaptive drinking device (nosey cup). Instead, the resident was provided a regular cup, resulting in difficulty drinking, with most of the liquid spilling onto the resident's chin and napkin. The LPN confirmed that the nosey cup was not provided and was not listed on the meal ticket, despite a physician's order and facility policy requiring adaptive devices to be supplied as ordered. Another resident with Alzheimer's disease and a history of significant weight loss was not weighed bi-weekly as ordered by the physician. The clinical record showed missing weight documentation for an entire month, and there was no record of refusals or attempts to obtain the weight. The resident's care plan identified them as being at nutritional risk and required weight monitoring, but this intervention was not consistently implemented. The DON acknowledged that nursing staff were responsible for obtaining and documenting weights and refusals, but could not explain the lack of documentation.
Failure to Implement Interventions for Intimate Behaviors in Residents with Dementia
Penalty
Summary
The facility failed to implement appropriate interventions for two residents with dementia who were observed engaging in intimate behaviors, including kissing and holding hands, in the memory care unit's common area. Staff, including a CNA and an RN, were aware of the behaviors but were either unsure of the care plan interventions or unable to intervene effectively. The residents, both diagnosed with Alzheimer's disease, dementia, and other mental health conditions, were severely impaired in daily decision-making and had a history of wandering that intruded on the privacy of others. Despite being care planned for behaviors, staff could not identify or implement specific interventions during the observed incidents. During the observation period, the two residents continued to hold hands and enter their shared bedroom unsupervised with the door shut for at least 25 minutes, without staff intervention. The Memory Care Coordinator and other staff expressed uncertainty about how to address the situation, noting that this specific behavior had not been previously observed. Additionally, the facility lacked a dementia care policy, and there was confusion among staff regarding access to care plans and the appropriate use of dementia care training to manage such behaviors.
Failure to Maintain Infection Control During Incontinence Care
Penalty
Summary
The facility failed to maintain proper infection control measures during incontinence care for a resident with pressure ulcers. The resident, who was severely cognitively impaired, at risk for pressure ulcers, and dependent on staff for toileting, was observed receiving care from two CNAs. Both CNAs donned gowns and gloves due to the resident being on Enhanced Barrier Precautions for wounds. During the cleaning process, soiled washcloths were placed directly onto the resident's fitted bed sheet instead of being immediately bagged. After cleaning, the soiled pad was removed and replaced, but the fitted sheet, which had come into contact with the soiled washcloths, was not changed. The resident was then covered with a clean sheet over the unchanged fitted sheet. Later, a washcloth with dried stool was found in the resident's windowsill, and smears of dry stool were observed on the fitted bed sheet. Interviews with staff confirmed that soiled linens and washcloths should have been placed in a plastic bag after use and that the soiled sheet should have been changed and bagged for transport to the soiled utility room. The facility's perineal care competency checklist also indicated that a plastic bag should be available for soiled linens, but this protocol was not followed during the observed care.
Failure to Provide Showers According to Resident Preferences
Penalty
Summary
The facility failed to honor and facilitate resident self-determination by not providing showers as preferred for two residents who were dependent on staff for activities of daily living (ADLs). Resident B, with diagnoses including diabetes mellitus, major depressive disorder, anxiety disorder, glaucoma, cataract, hearing loss, and anorexia, was assessed as severely impaired for daily decision making and required staff assistance for showers. Documentation indicated that it was very important for this resident to have showers, and the care plan specified showers twice weekly. However, shower reports showed that Resident B received complete bed baths instead of showers on multiple occasions across March, April, and May, despite the resident's stated preference and care plan interventions. Similarly, Resident E, who had dementia, chronic kidney disease, repeated falls, and chronic pain syndrome, was also severely cognitively impaired and dependent on staff for showering. The care plan and preference documentation indicated a preference for showers twice weekly. Despite this, shower reports revealed that Resident E received bed baths instead of showers on several documented dates in April and May. Interviews with staff and family confirmed awareness of the residents' preferences, but the facility did not consistently provide showers as preferred.
Failure to Consistently Document Meal Intake for High-Risk Resident
Penalty
Summary
The facility failed to consistently document meal intakes for a resident with significant medical concerns, including vascular dementia, heart failure, and moderate protein-calorie malnutrition. The resident was identified as severely cognitively impaired, required supervision or assistance with meals, and had experienced notable weight loss in the previous six months. Staff interviews confirmed that the resident had a marked decline in eating and drinking abilities prior to being sent to the hospital, with minimal intake even when fed by staff. The interdisciplinary team, including the Registered Dietitian and Certified Dietary Assistant, documented significant weight loss and ongoing monitoring for this issue. A review of the resident's meal intake records for February and March revealed numerous instances where meal consumption was not documented, including multiple days with missing entries for breakfast, lunch, or dinner. The facility's procedure required nursing staff to document the percentage of food consumed after each meal, but this was not consistently followed. The lack of routine documentation occurred despite the resident's high risk for nutritional decline and ongoing monitoring for weight loss.
Failure to Maintain Sanitary Kitchen and Proper Food Storage
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen, as evidenced by multiple observations of improper food storage and handling. During a kitchen tour, a holding refrigerator was found to contain a container of diced ham with an incorrect use-by date, a prepared salad with undated cubed ham, and undated bacon bits. Additionally, multiple boxes were stored on the floor of the main freezer and dry storage room. A bulk storage bin contained a plastic cup in contact with a food substance, and moldy buns were found on a rack outside the kitchen. These issues persisted over several days, despite being noted in multiple observations. The Dietary Manager was interviewed and indicated that the facility was aware of some of the issues, such as the need to discard the bulk storage bin and the lack of space in the freezer. However, the manager was unaware of the moldy buns. The facility's food storage policy, which requires food to be stored off the floor, properly labeled, and within specified time frames, was not followed. This failure had the potential to affect all 72 residents who receive food from the kitchen.
Facility Failed to Maintain Resident Rooms in Good Repair
Penalty
Summary
The facility failed to ensure resident rooms were in good repair, specifically related to the walls, headboard, and cove base in the bathrooms for six residents. Observations noted peeling cove base in one resident's bathroom, missing paint alongside the walls behind the headboards in multiple rooms, and a flexible strip of material hanging down from a headboard onto a resident's bed. These issues were confirmed during an environmental tour with the Maintenance Director and Housekeeping Supervisor, who acknowledged the ongoing problem with wall repairs and the impact of staff actions on the condition of the walls. The Maintenance Director indicated that the facility has a system for nursing staff and housekeeping to input work orders for environmental concerns, which are then directed to him. However, he noted that the repairs are limited by the amount of work he is allowed to conduct monthly. Despite implementing a training program for staff regarding the proper placement of beds to prevent damage, the problem persists, and approval for further repairs is pending.
Failure to Complete MDS Assessment for Resident Discharged from Hospice
Penalty
Summary
The facility failed to complete a Minimum Data Set (MDS) Assessment for a resident who was discharged from hospice services. The clinical record for the resident, who had a medical diagnosis of dementia, indicated that she was discharged from hospice services on October 12, 2023. However, no significant change MDS Assessment was completed for the resident in October 2023, despite the facility's policy requiring such an assessment when a terminally ill resident enrolls or revokes hospice program. The MDS Coordinator acknowledged that the Significant Change Assessment for the resident was missed.
Inaccurate MDS Assessments for Hospice and Oxygen Therapy
Penalty
Summary
The facility failed to accurately indicate the use of hospice services for one resident and failed to accurately code oxygen therapy for two residents. Resident 43, diagnosed with Alzheimer's disease, had an Annual MDS Assessment that did not reflect the resident's 6-month prognosis or hospice services, despite a hospice certification indicating terminal illness and a life expectancy of less than six months. The MDS nurse admitted to not completing a significant change assessment due to confusion over the payor source for hospice services. Resident 10, who had diagnoses including pneumonia, chronic respiratory failure, emphysema, and high blood pressure, was observed receiving oxygen therapy through a nasal cannula. However, the Admission MDS assessment did not indicate that the resident received oxygen therapy. Similarly, Resident 65, diagnosed with dementia, high blood pressure, anemia, and atrial fibrillation, was observed using oxygen therapy, but the Quarterly MDS assessment did not reflect this. The MDS Coordinator acknowledged the inaccuracies and stated she would enter modifications to correct the records.
Failure to Ensure Continuation of Pressure Ulcer Treatment and Prevention
Penalty
Summary
The facility failed to ensure continuation of treatment for a resident with pressure ulcers and did not implement necessary interventions for pressure ulcer prevention and treatment for three residents. Resident 55, who had multiple pressure ulcers, did not receive the prescribed Medihoney treatment for the right heel and left buttock from 3/6/24 to 3/12/24. The Director of Nursing confirmed the absence of treatment orders during this period, and the resident was under hospice care starting 3/2/24, with hospice conducting a comprehensive review of the resident's orders. Resident 10, who was on oxygen therapy, did not have ear protectors on the oxygen tubing as ordered, resulting in a reddened area on the right ear. The resident reported soreness, and an LPN assessed the ear, confirming the redness and placing a temporary tissue pad. Resident 136, who had developed pressure areas on both heels, was observed with her heels touching the bed due to a sliding pillow. The care plan indicated the use of a heel offloading pillow, but the resident's heels were not consistently offloaded. An LPN confirmed the presence of a blister on the left heel and the need for regular monitoring and dressing changes.
Failure to Implement Fall Interventions
Penalty
Summary
The facility failed to ensure fall interventions were in place after a fall had occurred for a resident. The resident had a history of falls and was at risk due to conditions such as cerebral infarction, hemiplegia, dementia, glaucoma, and weakness. The care plan included the use of a bedside mat while resting in bed, which was initiated on a specific date. However, during a fall event, the resident fell out of bed while sleeping, and the mat was not at the bedside. The incident resulted in the resident sustaining skin tears. The facility's Fall Management Policy required specific care plan interventions to address each resident's fall risk factors, but these were not adequately implemented in this case.
Failure to Adhere to Infection Control Policies
Penalty
Summary
The facility failed to ensure a dietary staff member did not work while experiencing signs and symptoms of a gastrointestinal illness and did not ensure 48 hours had passed since symptoms started. During a kitchen tour, it was noted that the Dietary Manager was out ill. An interview with the Dietary Manager revealed that she had symptoms of a gastrointestinal illness while at work and went home, but returned to work the next day to handle food. The facility's policy requires employees to consult the Director of Nursing Services or Infection Preventionist before returning to work after an infectious illness and to provide a physician's statement of fitness. The CDC guidelines also state that individuals should not handle food or provide healthcare for at least 48 hours after symptoms stop. The facility did not adhere to these guidelines, leading to the deficiency.
Lack of Ongoing Activity Program in Dementia Care Unit
Penalty
Summary
The facility failed to provide an ongoing activity program on the dementia care unit for two residents, Resident C and Resident D. Interviews with staff members, including CNAs and the Dementia Care Coordinator, revealed that the dementia care unit had been without an activity assistant since June 2023. Staff members did their best to provide activities, such as self-initiated packets and coloring, but these efforts were insufficient. The Dementia Care Coordinator was overburdened with multiple roles, including social services and activities, until a new activity assistant was hired in late February 2024. Interviews with family members of Resident C and Resident D confirmed the lack of activities, with residents often sitting idle in the dining room. Resident C's family member noted that the resident had severe cognitive impairment and enjoyed activities like sewing, bingo, and socialization, but these were not provided. Similarly, Resident D's family member expressed dissatisfaction, stating that the facility had promised various activities, but none were provided until recently. Resident D also had severe cognitive impairment and enjoyed activities like cooking, playing with her dog, and being outside, which were not facilitated by the facility. The facility's failure to provide adequate activities was further corroborated by the lack of documentation showing Resident C and Resident D's participation in any activities for the past three months. The Administrator confirmed that the facility did not have a specific dementia care policy and followed state guidelines for dementia training. The Director of Nursing provided an activity policy stating that the facility would offer an ongoing program of activities to meet the residents' interests and well-being, but this was not implemented effectively. This deficiency relates to Complaint IN00430463.
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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