Warsaw Meadows
Inspection history, citations, penalties and survey trends for this long-term care facility in Warsaw, Indiana.
- Location
- 300 E Prairie St, Warsaw, Indiana 46580
- CMS Provider Number
- 155566
- Inspections on file
- 38
- Latest survey
- December 31, 2025
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Warsaw Meadows during CMS and state inspections, most recent first.
A resident with dementia and other conditions was allegedly subjected to verbal abuse by a CNA, who reportedly used profanity during care. The incident was not reported to the Administrator or proper authorities until several days after it occurred, contrary to facility policy requiring immediate reporting of abuse allegations.
A resident with a known history of behavioral issues physically assaulted another resident, causing extensive bruising and emotional trauma, and later verbally abused a second resident, resulting in fear and mental anguish. Staff failed to follow care plan interventions or implement timely supervision, and documentation of required monitoring was lacking.
A deficiency was cited due to the facility's failure to keep an area free from accident hazards and to provide adequate supervision to prevent accidents. The report notes that the environment was not maintained safely and supervision was lacking, but does not provide further specifics.
A resident at risk for skin breakdown developed multiple pressure ulcers due to inadequate interventions and monitoring. Despite being assessed as at moderate risk, the resident's care plan was not effectively implemented, leading to the development of stage 3 and stage 2 pressure ulcers. The facility failed to adhere to physician orders for wound care and incontinence management, contributing to the worsening of the resident's condition.
A resident with Alzheimer's and other psychiatric disorders repeatedly exhibited aggressive behaviors towards other residents, causing harm. Despite being placed on one-on-one supervision and discharged to a psychiatric hospital twice, the facility failed to implement new interventions to prevent further incidents. The Director of Nursing admitted that no new measures were added, violating the facility's abuse prevention policy.
The facility failed to store food under sanitary conditions in the main kitchen, affecting all residents who received food from this kitchen. Surveyors observed unlabeled and undated food items, including frozen meat patties, beverages, bread products, and juice pitchers. The Dietary Manager confirmed that all food and beverages should be labeled with the name and date, as per the facility's policy.
The facility failed to create comprehensive, person-centered care plans for residents with specific needs, including delusions, hallucinations, and hospice care. Despite being prescribed medications for their conditions, the clinical records for these residents lacked appropriate care plans. The Director of Nursing confirmed these omissions, which were contrary to the facility's policy requiring such care plans.
A resident with multiple health conditions, including diabetes and chronic kidney disease, did not receive a baseline or routine care plan meeting since admission. The resident reported not having access to test results until discharge. The Social Service Director confirmed the lack of scheduled meetings and undocumented interactions, contrary to the facility's policy requiring comprehensive, person-centered care plans.
The facility failed to provide adequate ADL care for three residents, including insufficient showering opportunities and personal hygiene assistance. A resident reported receiving only two showers in over a month, with inconvenient timing leading to refusals. Another resident missed scheduled showers, and a third was observed with poor hygiene despite needing total assistance. The DON was unaware of these issues, and documentation practices were inadequate.
A resident with cerebral palsy and other conditions did not receive an individualized activities program as outlined in their care plan. Observations showed the resident often without entertainment, despite preferences for TV and music. The facility's policy requires programs to meet individual needs, but interviews confirmed the resident's activities were not provided, leading to a deficiency.
A resident with a urostomy was repeatedly observed with an uncovered drainage bag, despite facility policy requiring it to be covered for dignity. Staff interviews confirmed the expectation for coverage, yet the deficiency persisted over several days.
The facility failed to properly label and store respiratory equipment for three residents, leading to deficiencies in respiratory care. A resident received oxygen therapy with undated tubing and without humidification, contrary to physician orders. Two other residents had improperly stored and undated respiratory equipment, despite having specific physician orders for oxygen therapy. The facility's policy required respiratory equipment to be stored in plastic bags and dated, which was not followed.
The facility failed to ensure narcotics were counted and documented every shift for one of the narcotic count log books. An observation revealed that the narcotic log book for Freedom cart 1 lacked signatures, indicating a missed narcotic count. QMA 2 confirmed that the log sheets should have been signed every shift. The facility's policy requires nursing staff to count controlled medications at the end of each shift, with both the incoming and outgoing nurses participating in the count.
The facility failed to properly store and label medications on two medication carts. Observations revealed improperly stored eye drops, unlabeled Colace and Antacid tablets, loose pills, and wound cleanser stored with medications. Staff acknowledged the errors, and facility policies on medication storage and labeling were provided.
Failure to Timely Report Alleged Verbal Abuse
Penalty
Summary
The facility failed to implement its abuse reporting policy by not reporting an allegation of verbal abuse in a timely manner for one resident. Resident B, who had multiple diagnoses including dementia, anxiety, depression, and cognitive communication deficit, was allegedly subjected to verbal abuse by a CNA who reportedly told the resident to "shut the f--- up" while assisting with toileting. The incident occurred on 12/6/25, but was not reported to the appropriate authorities or the Administrator until 12/10/25. CNA 3, who witnessed the event, initially reported it only to the Weekend Manager and did not escalate the allegation to the Unit Manager or Administrator as required by facility policy. Interviews revealed that the Weekend Manager was not made aware of the abuse allegation at the time it occurred, and the Administrator was not informed until four days later. The facility's abuse policy requires immediate reporting of abuse allegations, but this protocol was not followed. The delay in reporting was confirmed through staff interviews and record review, indicating a breakdown in communication and adherence to established procedures for reporting suspected abuse.
Failure to Prevent Resident-to-Resident Abuse and Emotional Distress
Penalty
Summary
The facility failed to prevent both physical and emotional abuse among residents, specifically involving two residents who were subject to abuse by another resident with a known history of behavioral issues. One resident, who had diagnoses including schizophrenia, alcohol abuse, and major depressive disorder, had a care plan in place due to a history of striking out at staff and peers. Despite this, staff did not follow the planned interventions, such as removing the resident from situations at the first signs of agitation and providing a safe space. This failure led to an incident where the resident physically assaulted another resident, resulting in extensive bruising to multiple areas of her body, including her forearm, elbow, breast, palm, wrist, fingers, and shoulders. The assaulted resident, who had a history of PTSD and other psychiatric diagnoses, experienced significant emotional trauma, including fear, crying, shaking, and symptoms that triggered her PTSD. Following the initial physical altercation, the same resident verbally abused and threatened another resident, causing her to experience mental anguish and fear. This resident, who was cognitively intact but had physical disabilities, reported feeling unsafe, kept a grabber stick under her pillow for protection, and expressed distrust in the facility. Staff interviews confirmed that the resident who committed the abuse had a pattern of angry outbursts and altercations, and that staff were aware of his behavioral history. However, one-to-one supervision and other preventative interventions were not implemented until after the second incident of abuse occurred. Documentation and communication lapses were also evident. The DON was not informed of the full extent of the altercations or the interventions that were (or were not) implemented. The executive director was aware of the incidents but could not produce documentation of one-to-one supervision. Staff interviews revealed concerns about the resident's behavior and the adequacy of supervision, but these concerns were not acted upon in a timely manner. The facility's own abuse policy required supervision and intervention for residents with behavioral needs, but these measures were not effectively carried out, resulting in physical harm and emotional distress to two residents.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, and supervision was insufficient to prevent potential or actual accidents. Specific details regarding the nature of the hazards, the supervision provided, or the individuals affected are not included in the report.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to provide appropriate interventions to prevent the development of pressure ulcers for a resident identified as being at risk. The resident, who had a history of peripheral vascular disease, diabetes mellitus type 2, heart failure, and lymphedema, was assessed to be at moderate risk for skin breakdown. Despite this, the resident developed multiple pressure ulcers, including a stage 3 ulcer on the left gluteal area, a stage 2 ulcer near the coccyx, and an unstageable wound on the left ischial area. The facility's care plan included interventions such as a pressure relief mattress and assistance with turning and repositioning, but these were not effectively implemented. The resident's pressure ulcers were not adequately monitored or treated according to physician orders. The resident reported that dressings were not changed routinely, and the prescribed treatment cream was not applied as ordered. Additionally, the resident's incontinence care was insufficient, with reports of infrequent brief changes leading to contamination of the wounds with stool. This lack of adherence to the treatment plan and inadequate incontinence management likely contributed to the worsening of the resident's pressure ulcers. Observations revealed that the resident did not have a low air loss mattress in place, contrary to the care plan, and there was no documentation of the resident refusing this intervention. Interviews with staff indicated a reliance on shower sheets for skin assessments, which were not consistently documented or available. The facility's policy on skin and wound management was not followed, as ongoing monitoring and preventative interventions were not effectively implemented for the resident at risk for skin compromise.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to implement effective interventions to prevent physical and verbal resident-to-resident abuse, resulting in harm to three residents. Resident B, diagnosed with Alzheimer's disease, psychotic disorder with delusions, depression, and dementia with agitation, exhibited physically abusive behaviors towards other residents. On multiple occasions, Resident B made physical contact with other residents, including incidents where he grabbed a resident's walker, causing her to fall, and hit another resident with a photo album. Despite these incidents, the facility did not add new interventions to prevent further occurrences. Resident B's aggressive behaviors were documented in several notes, indicating a pattern of physical and verbal aggression. The facility's records show that Resident B was placed on one-on-one supervision and was discharged to a psychiatric hospital twice, but these measures did not prevent further incidents upon his return. The facility's failure to identify triggers and implement additional interventions contributed to the recurrence of abuse. The Director of Nursing acknowledged that no new interventions were added for Resident B following the altercations. The facility's abuse policy, which mandates processes for screening, training, prevention, identification, and protection against abuse, was not effectively implemented in this case. This deficiency highlights the facility's inability to protect residents from abuse by other residents, as required by their policy.
Failure to Store Food Under Sanitary Conditions
Penalty
Summary
The facility failed to store food under sanitary conditions in the main kitchen, which had the potential to affect all 69 residents who received food from this kitchen. During an initial tour, surveyors observed several issues: two opened bags of frozen meat patties in the double-door freezer were unlabeled and undated; a tray of beverages in the double-door cooler was unlabeled, with only one cup bearing a date; multiple bread products in the dry pantry, including hot dog buns, hamburger buns, and English muffins, were without labels or dates; and two pitchers of juice in the walk-in fridge were also without dates or labels. The Dietary Manager confirmed that all food and beverages should have labels with the name of the item and dates. The facility's policy, provided by the Executive Director, stated that all food should be dated at the time of receipt and inventoried using the first-in, first-out method, with unserved leftovers labeled, dated, and stored for no more than three days.
Deficiencies in Person-Centered Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive, person-centered care plans for several residents, leading to deficiencies in meeting their specific needs. Resident 36, diagnosed with psychotic disorder with delusions, depression, dementia with agitation, and anxiety, was receiving antipsychotic and antidepressant medications. However, the clinical record lacked a person-centered care plan addressing the resident's delusions. The Director of Nursing acknowledged the absence of such a care plan during an interview. Similarly, Resident E, who had diagnoses including dementia, depression, and psychotic disorder, was noted to have delusions according to an Admission Minimum Data Set assessment. Despite being prescribed Depakote for delusions, the resident's clinical record did not include a person-centered care plan for this condition. The Director of Nursing confirmed the omission of the necessary care plan during an interview. Resident 55, with diagnoses of malnutrition, bipolar disorder, visual hallucinations, and depression, was receiving antipsychotic medication for visual hallucinations. However, the clinical record lacked a person-centered care plan for hallucinations. Additionally, Resident 16, who was receiving hospice care for end-stage cerebral atherosclerosis, had a care plan that was not person-centered, as confirmed by the Director of Nursing. The facility's policy required comprehensive, person-centered care plans, but these were not implemented for the residents in question.
Failure to Conduct Care Plan Meetings for a Resident
Penalty
Summary
The facility failed to provide a baseline care plan meeting and routine care plan meeting for a resident, identified as Resident 53, who was reviewed for care planning. During an interview, the resident reported that he had not been allowed to access his test results until discharge and had not participated in any care plan meetings since his admission. A review of the resident's electronic medical record confirmed the absence of documentation regarding a baseline or routine care plan meeting. The resident's diagnoses included alcohol abuse, diabetes mellitus type 2, idiopathic acute pancreatitis, cannabis use, iron deficiency anemia, and chronic kidney disease. The Social Service Director acknowledged that the resident had likely not had a baseline care plan meeting and that no meeting had been scheduled since admission. Despite frequent visits to the Social Service Director's office, these interactions were not documented. The facility's policy requires a comprehensive, person-centered care plan to be developed and implemented for each resident, involving the interdisciplinary team and the resident or their representative.
Deficiencies in ADL Care for Residents
Penalty
Summary
The facility failed to provide adequate activities of daily living (ADL) care for three residents, as observed and documented in the report. Resident 53 reported receiving only two showers in the past month and a half, with showers being offered at inconvenient times between 11 P.M. and 3 A.M., which he refused. The resident's care plan indicated a need for assistance with bathing due to various health conditions, but there was no documentation of his shower time preferences. The Director of Nursing (DON) was unaware of the issue and noted that refusals were documented, but accepted showers were not. Resident 9 also experienced inadequate showering opportunities, reporting missed showers on scheduled days. The resident's care plan required assistance with ADLs due to multiple health issues, including dementia and schizophrenia. The documentation showed sporadic shower occurrences and several refusals, but the resident was not care planned for refusals. The DON acknowledged the resident's tendency to refuse showers but did not have a system in place to document accepted showers. Resident 1 was observed with poor personal hygiene, including long, dirty fingernails, unkempt facial hair, and greasy hair. The resident required total assistance for ADLs due to severe cognitive impairment and multiple health conditions. Despite being dependent on staff for personal hygiene, the resident's care needs were not met, as confirmed by RN 14, who was unaware of the resident's shower schedule. The DON confirmed that the resident should have scheduled showers and grooming assistance, but these were not provided as per the facility's policy.
Failure to Implement Individualized Activities Program
Penalty
Summary
The facility failed to implement an individualized activities program for a resident, leading to a deficiency. Observations over several days revealed that the resident was often found in his room, either in bed or in a chair, without any form of entertainment such as television or music, despite being awake. The resident's care plan, dated June 4, 2024, emphasized the importance of engaging in activities like watching favorite TV shows, listening to music, and having access to books and newspapers. However, these preferences were not consistently met, as evidenced by the lack of stimulation observed during the survey. The resident's medical history includes cerebral palsy, epilepsy, intellectual disabilities, and other conditions, which necessitate a tailored approach to activities. The facility's policy on activity recreation programs, dated March 2015, mandates that programs should meet individual resident needs and reflect their schedules and choices. Interviews with the Activity Director and the Director of Nursing confirmed that the resident's television should have been on to allow him to watch his favorite shows, and staff should have monitored for overstimulation. Despite these requirements, the resident did not receive the activities he enjoyed, resulting in a failure to adhere to the care plan and facility policy.
Failure to Cover Urostomy Drainage Bag with Dignity Bag
Penalty
Summary
The facility failed to ensure that a resident's urostomy drainage bag was covered with a dignity bag, as observed on multiple occasions. Resident 264, who has a medical history including spina bifida, depression, paraplegia, morbid obesity, obstructive sleep apnea, stoma of the urinary tract, and colostomy status, was observed on several dates with an uncovered urostomy drainage bag. These observations occurred on 8/7/2024, 8/8/2024, 8/12/2024, and 8/13/2024, indicating a consistent failure to maintain the resident's dignity by not covering the drainage bag. Interviews with facility staff, including a Qualified Medication Aide (QMA) and the Assistant Director of Nursing (ADON), confirmed that the urostomy bag should have been covered with a dignity bag. The facility's policy on indwelling urinary catheter care, provided by the Director of Nursing (DON), emphasized the importance of keeping the drainage bag hidden under clothing to help the patient feel more comfortable. Despite this policy, the facility did not adhere to these guidelines, resulting in the deficiency.
Improper Labeling and Storage of Respiratory Equipment
Penalty
Summary
The facility failed to ensure proper labeling and storage of respiratory equipment and provide necessary respiratory services according to physician orders for three residents. Resident 30 was observed receiving oxygen therapy with undated tubing and without humidification, despite physician orders requiring these elements. The resident, who had multiple diagnoses including COPD and chronic respiratory failure, refused humidification due to discomfort, but the tubing was still required to be dated. The Director of Nursing confirmed that the oxygen tubing should have been dated, as per the facility's policy. Resident 215's respiratory equipment, including a nebulizer and oxygen nasal cannula, was improperly stored and undated. The resident, diagnosed with systemic lupus, COPD, and heart failure, had physician orders for continuous oxygen therapy and nebulizer treatments. Similarly, Resident 46's oxygen nasal cannula was found undated and improperly stored. This resident had emphysema and COPD, with orders for oxygen therapy as needed. The facility's policy required respiratory equipment to be stored in plastic bags and dated, which was not adhered to in these cases.
Failure to Document Narcotic Counts
Penalty
Summary
The facility failed to ensure that narcotics were counted and documented every shift for one of the four narcotic count log books reviewed, specifically for the Freedom cart 1. During a medication storage observation of the Freedom hall medication cart, it was noted that the narcotic log book lacked signatures on 8/3/2024, indicating that a narcotic count was not completed. In an interview, QMA 2 confirmed that the narcotic log sheets should have been signed every shift. The Director of Nursing provided the facility's policy on controlled substances, which stated that nursing staff must count controlled medications at the end of each shift, with both the nurse coming on duty and the nurse going off duty making the count together.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications on two medication carts, leading to deficiencies in medication management. During an observation of medication storage on Freedom hall med cart 1, a box of Xalanta eye drops was improperly stored with injectable medications. Additionally, a bottle of Colace pills and an opened bottle of Antacid tablets lacked resident identifiers or labels. The Qualified Medication Aide (QMA) acknowledged that the medications should have been labeled and stored correctly. On Freedom hall medication cart 2, three loose pills were found in two drawers, and a bottle of Derma Klenze wound cleanser was stored with liquid medications. Furthermore, two opened and undated bottles of lax granules and an opened package of Ipratropium Bromide ampules lacked resident identifiers. The Licensed Practical Nurse (LPN) confirmed that there should be no loose pills, medications should be labeled, and wound cleansers should not be stored with medications. The facility's policies on medication storage and labeling were provided by the Director of Nursing, indicating the requirements for labeling and storage of medications.
Latest citations in Indiana
Surveyors observed that dietary staff repeatedly worked in kitchen and meal service areas with uncovered facial hair, despite facility policy and state sanitation requirements mandating effective hair restraints. Two dietary aides with short beards or mustaches were seen walking through food preparation areas, taking food temperatures, handling food, and plating meals at steamtables in dining rooms without any facial hair coverings, while the current policy required all hair, including facial hair, to be restrained to prevent contamination.
The facility failed to consistently provide and document required bed-hold policy notices when several residents were transferred to the hospital. In multiple cases, residents with dementia, psychotic disorders, COPD, chronic respiratory failure, altered mental status, and cerebral infarction were sent out for acute changes in condition, and while transfer notes reflected physician and family notifications, they lacked documentation that the bed-hold policy was discussed with the resident or responsible party. Notices of Transfer or Discharge often indicated a copy of the bed-hold policy was sent with the resident, but the records did not show signed and dated acknowledgment by the resident or appropriate representative, including in situations where a resident had moderate cognitive impairment, short-term memory issues, or a documented need for a proxy and a financial POA authorizing an agent for health care decisions.
Surveyors found that the facility failed to provide trauma‑informed and culturally competent care by not incorporating two residents’ extensive trauma histories and specific behavioral triggers into their care plans. One resident with documented homelessness, polysubstance abuse, severe accidents with multiple fractures, viral encephalitis with coma, physical and sexual abuse, loss of family contact, and a past suicide attempt had multiple behavior‑focused care plans that referenced identifying triggers but listed none and did not mention their physical, sexual, medical, or psychosocial trauma. Another resident with TBI from being struck by a truck, an 11‑month coma, long‑term state hospital residence, alleged shooting of a parent, and diagnoses including intermittent explosive disorder and borderline personality disorder had a PASRR identifying a specific trigger and notes of inappropriate sexual behavior, yet their care plans omitted these traumatic events, the identified trigger, and the sexual behavior. Staff interviews confirmed that residents were screened for trauma, but the trauma histories and triggers were not reflected in the individualized plans of care.
A resident with schizophrenia, post‑stroke hemiparesis, and mild cognitive impairment expressed feeling down and wanting to kill himself, but staff did not document asking about a specific plan, did not notify the physician or psychiatric NP as expected, and did not develop or update a care plan addressing depression or suicidal ideation. The SSD documented offering support and initiating 15‑minute checks once, but there was no further follow‑up or documentation of interventions after subsequent suicidal statements made in a care plan meeting with the resident’s father. The DON and Administrator reported that facility policy requires immediate notification of key staff, assessment for a plan and means of self‑harm, and thorough documentation, which were not carried out or reflected in the medical record for this resident.
A resident with schizophrenia, post-stroke hemiparesis, and mild cognitive impairment verbalized suicidal ideation, but the care plan did not address depression or suicidal thoughts, and required assessments and services were not accurately or timely documented. An SSD note recorded the resident saying he wanted to kill himself and referenced 15‑minute checks and a care plan update, yet the active care plan lacked depression/suicidal ideation interventions. Multiple late-entry Social Services notes were later added, describing follow-up visits and the resident denying suicidal ideation, but the SSD later reported she did not typically ask about a suicide plan and did not personally provide individual follow-up visits as described. These practices conflicted with the facility’s policy requiring factual, first-hand, and timely documentation of assessments and services.
A resident was observed with an Albuterol inhaler on an overbed table and later reported keeping the inhaler in a nightstand drawer, with no staff present during these observations. Record review showed the resident had no cognitive impairment on the admission MDS but lacked any documented self-medication administration assessment. The DON acknowledged that the required assessment had not been completed, despite facility policy requiring staff and the practitioner to evaluate each resident’s mental and physical abilities before allowing self-administration of medications.
Surveyors found that the facility submitted inaccurate direct care staffing data to CMS through the PBJ system over multiple days in a quarter. CASPER reports showed apparent gaps in 24-hour licensed nurse coverage, low weekend staffing, and a 1-star staffing rating, while internal staffing sheets documented that licensed nurses were present and the facility was fully staffed on those days. The Administrator reported that the discrepancies were due to PBJ data entry errors, despite a facility policy requiring all PBJ entries to be accurate, auditable, and verifiable against payroll, invoices, or contracts.
Surveyors found that the facility did not provide or document required written transfer/discharge notices and bed-hold policy information for four residents who were sent to the hospital, including individuals with conditions such as dementia, CHF, chronic respiratory failure, and CKD. In each case, progress notes showed that the resident was transferred for acute issues, but the clinical records lacked evidence that written notices were given to the residents or their representatives, and in one case lacked documentation that required information was sent to the receiving provider. Facility leadership, including the ADON, DON, and Administrator, acknowledged that the records did not contain the required documentation, despite a written policy requiring such notices and information exchange.
A resident with Alzheimer’s disease and depression, previously on an antidepressant, exhibited intermittent refusals of medications and care, occasional yelling at staff, and reports of unusual perceptions, such as believing men were in or near her room. Nursing notes over several months documented these refusals and complaints but did not show that the behaviors were evaluated or recorded as dangerous, non-redirectable, or causing significant distress, nor did they document specific non-pharmacological interventions attempted or their outcomes. Despite this, a psychiatric NP later added new diagnoses of schizoaffective disorder, borderline personality disorder, and delusional disorder and ordered an antipsychotic (Seroquel) without a comprehensive evaluation in the record to support these diagnoses. The facility’s psychotropic medication policy, which requires identification and documentation of target behaviors, use of nonpharmacological interventions, and ongoing behavior monitoring, was not followed for this resident.
The facility failed to keep PASARR Level I screenings accurate and current for three residents when new mental health diagnoses and psychoactive medications were initiated. One resident’s PASARR omitted a PTSD diagnosis and an added antidepressant, despite documentation of PTSD on the MDS and care plan and a physician order for Pristiq. Another resident’s PASARR listed only depression and dementia, even after additional diagnoses such as borderline personality disorder, delusional disorder, and schizoaffective disorder were added and an antipsychotic (quetiapine) was ordered, with the MDS later reflecting psychotic disorder, schizophrenia, and depression with antipsychotic and antidepressant use. A third resident’s PASARR did not include a depression diagnosis or newly ordered escitalopram and lorazepam, although the admission MDS documented depression with antianxiety and antidepressant use. These omissions occurred despite facility policy requiring a new Level I review after significant mental status changes, including new mental health diagnoses or new psychotropic medications.
Uncovered Facial Hair During Food Preparation and Meal Service
Penalty
Summary
The deficiency involves the facility’s failure to ensure that food was served in a sanitary and safe manner in accordance with professional standards and facility policy during multiple kitchen and meal service observations. During an initial kitchen observation, two dietary aides were seen walking through the kitchen food preparation area with uncovered facial hair. One aide had facial hair above and below the lip and along the jaw line, approximately one-fourth inch in length, and the other had a mustache of similar length; neither used any facial hair covering. These observations occurred while staff were present in the kitchen area where food was stored and prepared. During subsequent observations on the same day, the same two dietary aides were again observed with uncovered facial hair while directly involved in meal preparation and service. One aide walked through the kitchen while the noon meal was being prepared and placed into a transport cart for service in the south dining room, and later was observed plating the noon meal at the steamtable in that dining room, still without a facial hair covering. The other aide walked through the kitchen while the noon meal was being prepared and placed into the steamtable for the north dining room, took food temperatures, assisted with plating meals at the steamtable, and retrieved food items and supplies from the kitchen, all while having an uncovered mustache approximately one-fourth inch in length. The Dietary Manager stated that staff hair was to be covered when in the kitchen and during meal service, and the facility’s written policy and the cited Indiana Food Establishment Sanitation Requirements both required effective hair restraints, including for facial hair, to prevent contamination of food, equipment, and utensils.
Failure to Provide and Document Bed-Hold Policy at Time of Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure that required bed-hold policy information was provided and documented for four residents transferred to the hospital. For a resident with dementia, psychotic disorder, and autistic disorder who had a BIMS score of 0 indicating severe cognitive impairment, progress notes documented physician notification and guardian notification when the resident was sent to the hospital, but there was no documentation that the bed-hold policy was provided to the responsible party. A Notice of Transfer or Discharge later indicated a copy of the bed-hold policy was sent with the resident. Another resident with COPD and chronic respiratory failure, cognitively intact with a BIMS score of 13, experienced a decline in condition and was transferred to the hospital by ambulance; progress notes documented family notification but did not document any discussion of the bed-hold policy, although a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident. A third resident with altered mental status and cerebral infarction, with a BIMS score of 10 indicating moderate cognitive impairment and documented short-term memory impairment, experienced changes in condition and was transferred to the hospital. Progress notes stated the resident was their own responsible party and that no other notification was completed, and transfer documentation did not include the bed-hold policy, although an untimed Notice of Transfer or Discharge indicated a copy of the bed-hold policy was signed by the resident. A financial power of attorney document in the record showed the resident had designated an agent to act in consent or refusal of health care. For a fourth resident with dementia and osteomyelitis, transfer documentation and a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident, and the transfer form noted the resident required a proxy for decision making. The facility’s policy required that at the time of transfer to a hospital, written notice specifying the duration of the bed-hold policy and information on return to the next available bed be provided, and that a signed and dated copy of the bed-hold notice given to the resident or representative be kept in the resident file, which was not consistently documented for these residents.
Failure to Integrate Trauma Histories and Behavioral Triggers Into Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to identify and incorporate residents’ trauma histories and specific behavioral triggers into their care plans, despite documented histories of significant trauma and behavioral health issues. For one resident, extensive social service and progress notes documented homelessness, polysubstance abuse, major depressive and anxiety disorders, chronic pain, a history of severe car accidents with multiple fractures, viral encephalitis resulting in a three‑month coma, loss of child custody, multiple divorces, physical abuse by a spouse, the death of a fiancé who was struck by a car while in a wheelchair, lack of family contact, and a past suicide attempt by Valium overdose. Additional documentation noted a history of rape by a brother at age eight and prior placement under direct supervision and 15‑minute checks related to suicidal ideation. Despite these documented traumatic events and behavioral health concerns, the resident’s care plans did not identify a history of physical trauma, sexual trauma, homelessness, substance abuse, medical trauma, or attempted suicide. For this same resident, the MDS showed no cognitive deficit and identified behaviors such as verbal aggression and rejection of care, along with diagnoses including seizure disorder, depression, chronic pain syndrome, homelessness, and anxiety disorder. Multiple care plans addressed behaviors such as drug‑seeking, pretending to have seizures for attention or medication, making false allegations, verbal aggression when unable to smoke, and a desire for intimate relationships with consenting male residents. These care plans referenced goals such as effective coping skills, seeking staff support, and compliance with the smoking policy, and they called for identification and reduction of behavioral triggers. However, none of these care plans actually listed any specific triggers. The care plan addressing the resident’s right to consensual intimate relationships focused on assessment and education regarding consent but did not integrate the resident’s extensive trauma history. Staff interviews indicated the resident had displayed sexual behaviors since admission, including an incident where the resident expressed anger at another resident for not buying a soda after engaging in sexual acts. A second resident with a documented history of traumatic brain injury (TBI), dementia, seizure disorder, borderline personality disorder, anxiety, intermittent explosive disorder, tobacco use, and other behavioral/emotional disorders was also affected by the same deficiency. Social history and progress notes documented that this resident sustained a TBI after being hit by a semi‑truck while riding a bicycle at age 18, resulting in an 11‑month coma, followed by 13 years in a state hospital and subsequent residence in a group home. Additional documentation indicated the resident allegedly shot their father at age 26 after being sworn at and had a PASRR identifying TBI, intermittent explosive disorder, and borderline personality disorder, with a specific trigger of hearing the name of the current U.S. President. Progress notes also described inappropriate sexual behavior toward staff, including touching themselves intimately during personal care and refusing to stop when redirected. Despite this, the resident’s care plans, which addressed explosive disorder and history of altercations, risk for decreased psychosocial well‑being, and refusal to bathe or shower, did not list any specific behavioral triggers, did not reference the traumatic events such as being hit by a truck or shooting their father, and did not document the inappropriate sexual behavior. The Administrator and Social Service Director acknowledged that residents were to be screened for trauma and that trauma responses and PTSD should be added to care plans, but the specific trauma histories and triggers for these two residents were not incorporated into their plans of care.
Failure to Assess and Care Plan for Resident Suicidal Ideation
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess, investigate, and care plan for a resident’s suicidal ideation in accordance with its own policy and staff expectations. The resident had diagnoses including schizophrenia, cerebral edema, and hemiparesis/hemiplegia following a cerebral infarction, and a current MDS showed mild cognitive impairment (BIMS score 12). A progress note documented that the resident told the Social Services Director (SSD) he was feeling down and wanted to kill himself; the SSD offered assistance, activities, and initiated 15‑minute checks, and the note stated the care plan was updated. However, the note did not indicate that the SSD asked whether the resident had a plan to kill himself, and there were no additional notes regarding suicidal ideation or follow‑up. Review of the current care plan showed no problem, goal, or interventions addressing depression or suicidal ideation, and progress notes over the following month contained no documentation of physician notification related to the suicidal statement. Further record and interview evidence showed that the care plan conference summary did not document interventions for suicidal ideation, and the SSD acknowledged she did not normally ask residents expressing suicidal ideation if they had a plan. The SSD reported that the resident had admission paperwork mentioning suicidal ideation related to depression after a stroke and that the resident again vocalized suicidal ideation during a care plan meeting with his father, after which emotional support was offered and the father took the resident out on a leave of absence; no further visits or follow‑up were done. The DON stated that, upon notification of suicidal verbalization, staff should assess the resident, ask if there is a plan, remove potential means of self‑harm, immediately notify the psychiatric NP, and document the occurrence, and that a detailed progress note and updated care plan were expected but not present for this resident. The Administrator similarly stated that staff should ask about a plan, document interventions, notify the physician and family, and update the care plan, and indicated the resident should have had a care plan addressing depression with suicidal ideation. The facility’s written policy required immediate notification of the DON, SSD, and physician, an interview including asking about a plan and assessing mood and means for self‑harm, and thorough documentation of mood, behavior, and all actions taken, which were not reflected in the resident’s record.
Incomplete and Inaccurate Documentation of Suicidal Ideation and Follow-Up
Penalty
Summary
The facility failed to ensure accurate, complete, and timely documentation of assessments and services for a resident who verbalized suicidal ideation. Resident 6, who had schizophrenia, cerebral edema, and right-sided hemiparesis/hemiplegia following a cerebral infarction, had a BIMS score of 12 indicating mild cognitive impairment. The resident’s admission paperwork mentioned suicidal ideation related to depression after a stroke, and a Social Services note on 3/11/2026 documented that the resident was feeling down and said he wanted to kill himself. The Social Services Director (SSD) documented that she talked with the resident, coordinated with Activities, advised the resident to contact SSD or nursing if he wanted to talk, and that the resident was scheduled for 15-minute checks and the care plan was updated. However, the current care plan initiated on 2/26/2026 did not address depression or suicidal ideation. Multiple Social Services progress notes were later entered as late entries in April, with effective dates in March, stating that the resident had no plan and no longer had suicidal ideation, that he felt much better after 1:1 time, and that he continued his daily routine and therapy. These late entries described follow-up visits and reassessments of suicidal ideation on several consecutive days, but in interviews the SSD stated she did not normally ask residents about having a plan when they verbalized suicidal ideation and did not recall any other occurrences beyond the initial event. She further indicated she did not personally provide individual follow-up visits with this resident regarding suicidal ideation, despite the late-entry notes describing such visits. The DON acknowledged that late entries had been added to address concern about suicidal verbalization, and the Administrator stated that upon suicidal statements staff should ask about a plan, notify the physician and family, and update the care plan, and that this resident should have had a care plan addressing depression with suicidal ideation. The facility’s documentation policy required factual, first-hand, timely documentation, which was not followed in this case.
Failure to Complete Required Self-Administration Assessment for Inhaler Kept at Bedside
Penalty
Summary
Surveyors identified that a resident was allowed to keep and access an Albuterol inhaler without the facility completing the required self-administration medication assessment. During an initial tour, the resident was observed sitting in a wheelchair with a handheld Albuterol inhaler on the overbed table and no staff present in the room or hallway. On a subsequent observation, the resident again was in a wheelchair and reported that the Albuterol inhaler was stored in the top drawer of the nightstand, where it was found. Review of the clinical record showed an admission MDS indicating no cognitive impairment, but there was no documentation of a self-medication administration assessment. In an interview, the DON confirmed that the resident did not have the required self-medication assessment, despite the facility’s policy stating that staff and the practitioner must assess each resident’s mental and physical abilities to determine whether self-administering medications is clinically appropriate. This failure to complete and document a self-administration medication assessment for a resident who had an Albuterol inhaler kept at bedside constituted noncompliance with the facility’s own policy and with 410 IAC 16.2-3.1-11(a).
Inaccurate PBJ Staffing Data Submission to CMS
Penalty
Summary
The deficiency involves the facility’s failure to electronically submit complete and accurate direct care staffing information to CMS through the Payroll-Based Journal (PBJ) system for 22 days in a fiscal quarter. A CASPER report review on 4/6/26 showed that, according to PBJ data, the facility did not have licensed nursing coverage 24 hours per day on multiple specific dates across three months, had low weekend staffing, and held a 1-star staffing rating. However, review of the facility’s internal staffing sheets for that quarter indicated the facility was fully staffed and had licensed nurse coverage on all of the dates in question. During an interview, the Administrator stated that the PBJ information must have contained data entry errors, as she had verified licensed staff coverage on the timesheets. The facility’s PBJ policy in effect stated that all staffing data entered into the PBJ system would be auditable and verifiable through payroll, invoices, or contracts, but the submitted PBJ data did not accurately reflect the facility’s actual licensed nurse staffing as documented on internal records. No specific residents or clinical conditions were mentioned in the report, and the deficiency centers solely on inaccurate staffing data submission rather than direct resident care events.
Failure to Provide and Document Required Transfer/Discharge and Bed-Hold Notices
Penalty
Summary
The deficiency involves the facility’s failure to provide and document required written notices of transfer/discharge and bed-hold policies, as well as required information to receiving providers, for four residents who were transferred or discharged to the hospital. For a resident with generalized anxiety disorder, major depressive disorder, and dementia, progress notes showed that the resident was sent to the hospital via 911 for chest pain, lower back pain, and shortness of breath and later returned to the facility, but the clinical record lacked documentation that a written Notice of Transfer/Discharge and the bed-hold policy were provided to the resident or representative, and lacked documentation that required information was conveyed to the receiving facility. The ADON and the Administrator both confirmed there was no documentation that these written notices were provided. For a resident with congestive heart failure and muscle weakness who was sent to the emergency room for painful urination and bloody urine, the clinical record lacked documentation that a Notice of Transfer/Discharge or bed-hold policy was given to the resident or representative, which the DON confirmed. Another resident with chronic respiratory failure and diabetes was discharged to the hospital for respiratory failure, and a resident with chronic kidney disease and dementia was discharged to the hospital, but in both cases there was no documentation that a written notice of transfer/discharge or bed-hold policy was provided to the residents or their representatives. Review of the facility’s Transfer and Discharge policy, dated 1/15/26, showed that the policy required the facility to provide written transfer/discharge notices and bed-hold information to residents and representatives and to provide specified information to receiving providers, but the records for these four residents did not contain the required documentation.
Failure to Document Target Behaviors and Non-Pharmacological Interventions Before Initiating Antipsychotic
Penalty
Summary
The deficiency involves the facility’s failure to document how a resident’s behaviors presented danger or distress to self or others, and failure to document non-pharmacological interventions attempted prior to initiating an antipsychotic medication. Resident 6 had documented diagnoses of Alzheimer’s disease, depression, and severe cognitive impairment, and was receiving sertraline for depression. A PASSAR identified only depression and dementia, and the admission MDS listed Alzheimer’s disease and depression as active diagnoses. Over several months, nursing progress notes documented that the resident intermittently reported unusual perceptions, such as believing there were men causing trouble, a man in her room, or a man wanting to marry her and yelling through the walls, but there was no documentation that these episodes caused danger to the resident or others or that they resulted in unmanageable distress. From late April through mid-July, nursing notes primarily described the resident’s frequent refusals of evening and morning medications, blood sugar checks, blood pressure checks, insulin administration, hygiene care, and showers. Staff documented that the resident sometimes yelled at staff, said “Get out!”, was visibly upset by a room move, was leery of staff and asked to see name badges, and became upset about a pillow under her head until it was removed, after which she calmed down. The notes also recorded instances where the resident believed housekeeping had not cleaned her room or that she had not received medications when she had. However, there were no progress notes or assessments indicating that these behaviors were evaluated as dangerous, non-redirectable, or causing significant distress or functional impairment, and no detailed behavior monitoring logs were present as required by facility policy. On a psychiatric NP visit for initial psychotropic medication management, new mental health diagnoses of schizoaffective disorder, borderline personality disorder, and delusional disorder were added, and Seroquel 25 mg, an antipsychotic, was ordered. The clinical record did not contain a comprehensive evaluation to support these new diagnoses, and there was no documentation of target behaviors meeting the facility’s policy criteria for psychotropic use, such as behaviors representing danger to self or others, causing distress and impairment in functional abilities, or clearly attributable to psychosis or mania. The resident’s representative reported that the resident had no prior history of mental health disorders or psychiatric hospitalization and was unaware of the new diagnoses. The facility’s own psychotropic medication policy required identification and documentation of specific target behaviors, use and documentation of nonpharmacological interventions, and ongoing monitoring of behaviors and interventions, which were not reflected in the record for this resident.
Failure to Update PASARR Screens for New Mental Health Diagnoses and Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that Preadmission Screening and Resident Review (PASARR) Level I screenings were accurate and updated when new mental health diagnoses and psychoactive medications were initiated for multiple residents. For one resident with dementia, anxiety, depression, and post-traumatic stress disorder (PTSD), the PASARR completed on admission listed anxiety, depression, and dementia with sertraline and quetiapine, but did not include the PTSD diagnosis or the antidepressant Pristiq, despite the admission MDS and care plan documenting PTSD and a subsequent physician’s order for Pristiq. For another resident with Alzheimer’s disease, borderline personality disorder, delusional disorder, schizoaffective disorder, and depression, the PASARR only reflected depression and dementia with sertraline, even though additional mental health diagnoses were added later and an antipsychotic (quetiapine) was ordered for borderline personality disorder, and the quarterly MDS documented psychotic disorder, schizophrenia, and depression with antipsychotic and antidepressant use. A third resident had diagnoses including Alzheimer’s disease, depression, anxiety disorder, irritability and anger, and nonrheumatic aortic valve stenosis. The PASARR for this resident listed dementia and anxiety with Risperdal but omitted the diagnosis of depression and the medications escitalopram and lorazepam, although physician’s orders were in place for escitalopram for depression and lorazepam for anxiety, and the admission MDS documented depression with antianxiety and antidepressant use. Interviews with the Assistant Director of Nursing confirmed that new Level I PASARR screens should have been completed when new mental health diagnoses and psychoactive medications were added, and that the PASARR for one resident, completed prior to arrival, should have included all mental health diagnoses and medications. The facility’s own policy required notification of the state mental health authority within 14 days after a significant change in mental condition and specified that a new Level I screen is required for new mental health diagnoses or newly prescribed psychotropic medications, which was not followed in these cases.
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