Waters Of Dunkirk Skilled Nursing Facility, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Dunkirk, Indiana.
- Location
- 11563 W 300 S, Dunkirk, Indiana 47336
- CMS Provider Number
- 155571
- Inspections on file
- 23
- Latest survey
- March 30, 2026
- Citations (last 12 mo.)
- 3 (1 serious)
Citation history
Health deficiencies cited at Waters Of Dunkirk Skilled Nursing Facility, The during CMS and state inspections, most recent first.
A facility failed to protect cognitively impaired residents from sexual abuse when a resident with moderate dementia was observed performing oral sex on a resident with severe dementia and a documented history of sexually inappropriate behaviors. The male resident had prior episodes of inappropriate touching, exposure, and agitation when redirected from female peers, and his care plan for inappropriate personal boundaries had been resolved despite ongoing concerns. The female resident had impaired cognition, poor memory, and a care plan that allowed companionship and affectionate contact but did not reflect a formal assessment of her capacity to consent to sexual activity. Staff interviews and records showed that no sexual consent capacity assessment was completed before the incident and that behavior monitoring and interventions for the male resident’s hypersexuality were inconsistent, leading surveyors to cite the facility for failing to protect residents from abuse and to assess and manage sexual behaviors appropriately.
The facility failed to monitor and develop individualized interventions for sexually focused behaviors in multiple cognitively impaired residents. Several residents with dementia had documented histories of inappropriate touching, hypersexuality, or intimate relationships with other residents, yet behavior monitoring orders and tools focused only on depression, anxiety, or general boundary issues. One resident was observed performing oral sex on another resident, and another was found receiving oral sex, while another made explicit sexual comments and requests to CNAs. Care plans for companionship emphasized hand holding and social engagement but did not include specific monitoring or tailored interventions for sexual behaviors, and the facility had no formal assessment for sexual behaviors despite policy requiring daily monitoring of target behaviors and social services involvement in behavior care planning.
Two residents with dementia and significant cognitive impairment were involved in an incident where one was observed performing oral sex on the other, with the male resident’s pants partially down and his buttocks exposed. A QMA intervened, directed the male resident to leave, and reported the event to the charge nurse (an RN). The RN documented a behavioral note but did not immediately report the allegation to leadership, believing residents could have a sexual relationship. As a result, the DON and Administrator were not informed until the following day, delaying required notification to the State Agency, contrary to the facility’s abuse reporting policy that mandates immediate reporting of suspected abuse up the chain of command and to state authorities.
The facility failed to adhere to menus and residents' preferences, affecting several residents. Observations showed discrepancies between posted menus and actual meals served, with frequent shortages of items like hot dogs and milk. A resident who often refused meals did not receive her preferred hot dog due to shortages. Another resident reported unmet meal preferences, leading to dissatisfaction. The facility's outsourced dining service struggled with maintaining adequate food supplies, impacting residents' dietary needs.
The facility's dishwasher failed to meet sanitization requirements, operating at 113°F instead of the required 150°F, potentially affecting all 31 residents. Additionally, food storage practices were unsanitary, with uncovered items in the refrigerator and freezer, and a dirty toaster. Staff acknowledged these issues, which violated facility policies.
The facility failed to provide palatable and quality meals, as residents and staff reported issues such as watery eggs, overly salty gravy, and hard muffins. Residents with specific dietary needs were dissatisfied with the meals, which were often inedible. Staff interviews confirmed these complaints, and the facility's policies on meal presentation and satisfaction were not followed.
The facility failed to notify residents and their representatives in writing of transfer/discharge appeal rights during hospitalizations. Three residents were transferred to the hospital for various medical reasons, but there was no documentation of them receiving the necessary appeal rights paperwork. Interviews with staff revealed inconsistencies in providing these notifications, and the facility lacked a specific policy on transfer/discharge appeal rights.
The facility failed to ensure that the results from their last annual IDOH survey report were accessible to residents. The State Survey Binder was repeatedly observed on a lower shelf, making it difficult for residents with mobility limitations to access it. Interviews confirmed the binder's inaccessibility, and the Administrator was unaware of its relocation. The facility's policy required the survey results to be posted in a prominent, accessible area.
A resident with right side hemiplegia required extensive assistance for mobility, but a CNA, unaware of the need for a two-person assist, attempted a transfer alone, resulting in the resident sustaining a right ankle fracture. The facility lacked specific policies for staff-assisted transfers, and the CNA did not reference assignment sheets, leading to the improper transfer.
Failure to Protect Cognitively Impaired Residents From Sexual Abuse and Inadequate Consent Assessment
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from sexual abuse by not adequately assessing capacity to consent to sexual activity and not implementing effective interventions for a resident with known sexually inappropriate behaviors. Resident B had diagnoses including unspecified dementia, major depressive disorder, and a cognitive communication deficit, with an MDS showing moderate cognitive impairment and moderate impairment in decision-making for daily tasks. Her care plans addressed impaired cognition, poor safety awareness, and impulsiveness, and she used a position change alarm due to attempts to self-transfer. A care plan for promotion of safe intimate/sexual practices, created shortly before the incident, stated she was alert, aware, and coherent in choosing to engage in an intimate/sexual relationship and included interventions such as assessing her understanding of the nature of the act and her ability to refuse, encouraging appropriate touch, and reminding her that sexual partners must be able to provide mutual consent. Her representatives were notified that she was seeking companionship with a male resident and agreed to hand-holding and companionship, but they did not agree to more intimate acts. Resident C had diagnoses including unspecified dementia with behavioral disturbance and delusional disorders, with an MDS indicating severe cognitive impairment. His record documented a history of inappropriate personal boundaries manifested by inappropriate touching, such as rubbing another person’s back, reaching for a leg, and shoulder rubbing. He had been treated with medroxyprogesterone for hypersexuality and was also on risperidone. Behavior notes and staff interviews described increased friendliness and physical contact with multiple female residents, including patting arms, hand holding, rubbing arms and legs, and entering female residents’ rooms, sometimes becoming agitated or hostile when redirected. Staff, including a housekeeper and an RN, reported that he had been seen with his penis exposed in a lounge, asking a female resident to put her hands in his pants, pulling a female resident’s hand toward his genital area over clothing, and touching a female resident’s breast. Despite this pattern, his care plan for inappropriate personal boundaries was resolved, and the Social Service Director and DON indicated that, after discussions with the Ombudsman, care plans regarding sexual behaviors were resolved based on the view that such behaviors were residents’ rights rather than maladaptive behaviors. On the evening of 3/22/26, a Qualified Medication Aide observed Resident C in Resident B’s room with his pants partially down, exposing his buttocks, while Resident B, seated in her recliner and leaning forward, was performing oral sex on him. Resident B’s roommate was in the hallway at the time. The QMA instructed Resident C to leave; he became angry but complied. Resident B said little and, after the incident, had forgotten that anything had occurred. Subsequent nursing documentation noted that Resident B would not or could not discuss the incident, described the male resident as a friend, and denied unwanted touching. Interviews with Resident B’s representative indicated that Resident B had moderate to severe dementia, sometimes did not recognize family, frequently asked where she was and when she was going home, and that performing oral sex was not consistent with her prior behavior or values. Resident B later demonstrated significant disorientation, unable to state where she was, what town she was in, or the year, and denied having a male friend or male visitors in her room. Additional interviews and records showed that staff were aware of Resident C’s ongoing sexually focused behaviors and the need for redirection. Behavior notes shortly before the incident documented increased agitation and interactions with female peers, his anger when asked to visit females only in public areas, and an episode of inappropriate behavior with a confused female resident from whom he was redirected. The Psychiatric NP reported that the facility had been concerned about Resident C’s sudden focus on female residents and that he had required medication to prevent escalation of inappropriate touching. The NP also stated that staff had to redirect Resident C several times related to female residents and that he became agitated when redirected. The acting Administrator acknowledged that a Sexual Consent Capacity Assessment was not completed for the residents prior to the incident and that behavior documentation was only maintained if behaviors were considered maladaptive. The surveyors determined, using the reasonable person concept, that this failure to assess capacity to consent and to implement interventions to mitigate Resident C’s sexually inappropriate behaviors resulted in severe psychosocial harm, including dehumanization and humiliation, for Resident B. Other residents and staff expressed concerns related to Resident C’s behaviors. A cognitively intact resident reported hearing from staff and in the hallway that a female resident had performed oral sex on Resident C and expressed fear that he might enter her room and touch her, stating she did not want to be touched. The Social Service Director described Resident C as social with many female residents, with hypersexuality increasing as he formed more relationships, and acknowledged that staff struggled to distinguish between appropriate social interaction and infringement on residents’ rights. Several residents, including Residents F and E, had histories of dementia and prior care plans for inappropriate personal boundaries that were later resolved, and some had care plans for companionship with male peers that included general interventions such as assessing understanding and ability to refuse, but the records lacked individualized monitoring and interventions specifically addressing intimate or sexual behaviors for all involved residents. The combination of Resident C’s known sexually inappropriate behaviors, his severe cognitive impairment, Resident B’s moderate cognitive impairment and poor memory, the absence of a formal sexual consent capacity assessment prior to the incident, and the lack of sustained, effective behavioral interventions for Resident C led to the cited deficiency for failure to protect residents from sexual abuse. The surveyors concluded that the facility failed to ensure residents were protected from sexual abuse when Resident B, with moderate cognitive impairment, was found performing oral sex on Resident C, who had severe cognitive impairment and a known history of sexually inappropriate behaviors. They found that the facility did not assess the residents’ capacity to consent to sexual activity prior to the incident and did not implement interventions to mitigate Resident C’s sexually inappropriate behaviors. Using the reasonable person concept, they determined that this deficient practice resulted in severe psychosocial harm, including dehumanization and humiliation, for Resident B.
Failure to Monitor and Individualize Care for Sexually Focused Behaviors in Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to monitor and develop individualized interventions for cognitively impaired residents who exhibited sexually focused or intimate behaviors. Five residents with dementia or significant cognitive impairment had either documented sexually focused behaviors, hypersexuality, or intimate relationships with other residents, yet their behavior monitoring and care plans did not include specific assessments, monitoring, or individualized interventions for sexual or intimate behaviors. Instead, behavior monitoring orders and tools focused on depression, anxiety, delusions, or general boundary issues, and there was no structured assessment for sexual behaviors in use at the facility. One resident with moderate cognitive impairment and dementia (Resident B) had behavior monitoring ordered for depression-related symptoms and a care plan for impaired cognition and poor safety awareness, but no monitoring or individualized interventions for intimate or sexually focused behaviors. Social services documented that she sought companionship with a male resident, ate meals with him, and sat in the lounge with him, with her representatives agreeing to the relationship and the facility stating it would continue to monitor. Subsequently, staff observed her performing oral sex on a male resident in her room, after which staff intervened and removed the male resident. Prior to this event, her record lacked behavior monitoring or care plan interventions specifically addressing intimate or sexual behaviors. Another resident with severe cognitive impairment and delusional disorder (Resident C) had a history of inappropriate personal boundaries, including touching others’ arms and legs, and was treated with medroxyprogesterone for hypersexuality with multiple dose adjustments and a failed gradual dose reduction. His resolved care plan for inappropriate boundaries included general boundary-setting strategies, and a current care plan acknowledged his companionship with female peers and allowed affectionate acts such as hand holding and putting his arm around them. However, his clinical record did not include monitoring tools or individualized interventions specifically targeting intimate or sexual behaviors. Nursing and social service notes documented increased friendliness and physical contact with female residents, agitation when redirected, and an incident where he was found in a female resident’s room receiving oral sex, but behavior monitoring tools reflected only irritability, anxiety, and searching for family, not sexual behaviors. Residents D, E, and F, all with dementia and varying levels of cognitive impairment, had prior care plans for inappropriate personal boundaries that were later resolved and replaced with care plans describing mutual companionship with male peers, including hand holding and arm-around contact. These care plans emphasized acknowledging the need for connection, assessing understanding and ability to refuse, encouraging appropriate touch, offering privacy, and psychosocial visits, but did not include individualized monitoring or interventions specifically for sexually focused behaviors. Resident E exhibited verbally explicit sexual comments toward CNAs, including references to genital areas and suggesting sexual acts involving staff and another male resident, yet her behavior monitoring orders and tools addressed only depression and did not capture or target sexualized behaviors. Resident F’s record showed a long-standing close relationship with a male resident, family awareness of his frequent touching of her hands and legs, and discussion of possible environmental interventions, but her behavior monitoring focused on anxiety and searching for her daughter, with no documented monitoring or individualized interventions for intimate or sexual behaviors. The Social Service Director confirmed that the facility did not have a sexual behavior assessment, that behavior tools used by CNAs did not include sexual behaviors for these residents, and that decisions about resolving or framing care plans were influenced by discussions with the Ombudsman about residents’ rights rather than by structured behavioral health assessment and monitoring. Overall, the facility’s behavior management process, as described in policy and interviews, required nursing to monitor target behaviors daily and social services to maintain a list of residents with behaviors and assist with behavior care plans. However, for these five residents with documented sexually focused behaviors, hypersexuality, or intimate relationships, the facility did not implement behavior monitoring specific to sexual behaviors, did not develop individualized behavioral health interventions addressing those behaviors, and did not use a formal assessment tool for sexual behaviors. Behavior sheets and monitoring focused on other symptoms such as depression, anxiety, irritability, and confusion, leaving sexually focused behaviors unmonitored and without individualized, documented interventions in the clinical record.
Failure to Immediately Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that staff immediately reported an allegation of abuse to the Administrator, which delayed required reporting to the State Agency. Resident B, who had diagnoses including unspecified dementia with moderate cognitive impairment, major depressive disorder, and cognitive communication deficit, was observed on 3/22/26 by a Qualified Medication Aide (QMA 7) performing oral sex on Resident C in her room. QMA 7 saw Resident C standing in front of Resident B with his pants partially down, exposing his buttocks, while Resident B, seated in a recliner and leaning forward, was performing oral sex. QMA 7 instructed Resident C to leave the room, and he became angry but complied. QMA 7 then reported the incident to the charge nurse, and staff kept Resident C away from Resident B and other female residents. Resident C, who had diagnoses including unspecified dementia with severe cognitive impairment and delusional disorders, was later documented in an SBAR summary as having been observed receiving oral sex from a female resident, after which he was asked to leave the room and was closely monitored. When QMA 7 reported the initial observation to Registered Nurse (RN) 16, RN 16 did not report the allegation to anyone else at that time and only made a behavioral note, indicating she believed residents were allowed to have a sexual relationship. The Administrator later stated that the incident was not reported to the State Agency until the day after it occurred, because RN 16 did not notify the DON until the following morning, and the DON then notified the Administrator. This sequence of events conflicted with the facility’s Abuse Prevention Program policy, which required the person observing suspected abuse to immediately report it to the charge nurse, and the charge nurse to immediately report it to the Administrator, who must immediately notify the State Licensing and Certification Agency.
Inconsistent Menu Adherence and Food Shortages in Dining Services
Penalty
Summary
The facility failed to ensure that menus and residents' preferences were consistently followed, affecting 3 of 5 residents reviewed for dining services. Observations revealed discrepancies between the posted menu options and the meals actually served. For instance, a sign indicated options like grilled cheese and hot dogs, but these were not available on certain days, leading to unmet resident preferences. Resident 14, who often refused meals but would eat a hot dog, did not receive one because the kitchen ran out. This issue was compounded by frequent shortages of other items, such as milk and hot dogs, which disrupted meal service. Resident 12 reported that the meals served often did not match the menu or her requests. She noted that the facility frequently ran out of eggs and that her meal preferences, such as receiving scrambled eggs in a bowl, were not honored. This inconsistency led to dissatisfaction and a loss of appetite. Her clinical record indicated dietary needs for a consistent carbohydrate diet, which were not consistently met due to these discrepancies. Resident 26 also experienced issues with meal service, noting that her requests for alternatives like hot dogs and cottage cheese were not fulfilled due to shortages. She frequently received items she did not prefer, such as Italian dressing instead of ranch, and meals that did not match the posted menu. The facility's dining service, outsourced to another company, faced challenges in maintaining adequate food supplies, leading to these deficiencies in meeting residents' dietary needs and preferences.
Dishwasher and Food Storage Deficiencies
Penalty
Summary
The facility failed to ensure the high-temperature dishwasher functioned at the required sanitization level, potentially impacting all 31 residents receiving meals from the kitchen. During an inspection, the dishwasher's washing temperature was recorded at 113°F, below the required 150°F. The Maintenance Director confirmed the issue, noting the temperature had been below range since the previous Friday, yet the dishwasher continued to be used. The Dietary Manager initially believed the dishwasher was safe to use, and the Maintenance Assistant identified a loose thermostat wire as the cause of the problem. The facility's policy mandates stopping the dishwashing process if it is not sanitizing properly and contacting the appropriate personnel. Additionally, the facility failed to store and distribute food under sanitary conditions. Observations during a kitchen tour revealed uncovered drinks and fruit in the refrigerator, an uncovered bowl of fruit in the freezer, and loose biscuits. The toaster was found with crumbs and a white substance on it. Dietary staff acknowledged that items should have been covered and labeled, as per the facility's food storage policy, which requires food to be stored and prepared in a clean and sanitary manner in compliance with guidelines.
Facility Fails to Ensure Palatable and Quality Meals for Residents
Penalty
Summary
The facility failed to ensure the palatability and quality of meals served to residents, as evidenced by multiple complaints and observations. Residents reported that the food was often unappetizing, with issues such as green meatloaf, watery eggs, and overly salty gravy. Observations confirmed these complaints, with meals being described as bland, mushy, or excessively salty. The facility's outsourcing of kitchen services was noted as a potential factor in the decline of food quality. Several residents, including those with specific dietary needs due to medical conditions such as diabetes and gastroparesis, expressed dissatisfaction with the meals. They reported that the food was either over-seasoned or under-seasoned, and often inedible. The facility's failure to provide meals that met the residents' dietary requirements and preferences was evident in the repeated complaints and observations of uneaten food. Staff interviews corroborated the residents' complaints, with reports of hard muffins, watery eggs, and a lack of flavor in the meals. The facility's policies on meal presentation and resident satisfaction were not adhered to, as meals were not served attractively or at appropriate temperatures. The facility's administrator acknowledged previous concerns about food quality, but the issues persisted, indicating a systemic problem with the dining services.
Failure to Notify Residents of Transfer/Discharge Appeal Rights
Penalty
Summary
The facility failed to ensure that residents and their representatives were notified in writing of their transfer/discharge appeal rights during hospitalizations. This deficiency was identified in the cases of three residents who were transferred to the hospital for various medical reasons. Resident 77 was sent to the hospital for evaluation after experiencing large amounts of dark red stool, but there was no documentation indicating that the resident or their representative received written notification of appeal rights. Similarly, Resident 17, who was his own representative, was transferred to the emergency room on multiple occasions due to chest pain and other symptoms, yet there was no record of him receiving the necessary appeal rights paperwork. Resident 127 was transferred to the emergency room following complications with a catheter, but again, there was no indication that the resident or their representative was informed of the appeal rights in writing. Interviews with facility staff, including the Assistant Director of Nursing, LPN, Social Services Director, and Director of Nursing, revealed that while certain transfer documents were sent with residents to the hospital, the appeal rights paperwork was not consistently provided to residents or their representatives. The facility also lacked a specific policy on transfer/discharge appeal rights, contributing to the oversight.
Inaccessible Survey Results for Residents
Penalty
Summary
The facility failed to ensure that the results from their last annual Indiana Department of Health (IDOH) survey report were posted at an accessible height for residents. The State Survey Binder, which contained the survey results, was observed multiple times on the lower shelf of a sofa table, approximately four inches off the floor, right outside the Administrator's office. This placement made it difficult for residents, particularly those with mobility limitations, to access the binder. The deficiency was noted during observations conducted over several days, from March 17 to March 20, 2025. Interviews with Resident 23 and QMA 10 confirmed that the binder's location was not reachable by all residents due to mobility limitations. The Administrator, who was responsible for the binder, indicated that it was generally kept on the top shelf of the sofa table and was unaware that it had been moved to the bottom shelf. The facility's policy, dated August 2017, required that the most recent annual survey and the facility's response to the findings be clearly posted in a prominent area easily accessible to residents, their family members, and legal representatives, as well as the public.
Inadequate Staffing and Transfer Protocols Lead to Resident Injury
Penalty
Summary
The facility failed to ensure adequate staffing and consistent procedures for physical transfers, resulting in a resident, identified as Resident B, sustaining a fracture to her right ankle. Resident B, who had a history of right side hemiplegia and hemiparesis following a stroke, required extensive assistance for mobility. On the day of the incident, a CNA, who was unaware of the resident's need for a two-person assist, attempted to transfer Resident B alone. During the transfer, the resident's right foot did not turn with her body, causing pain and eventually leading to the discovery of an acute ankle fracture. Resident B's care plan indicated she required extensive assistance with transfers, and her condition included moderate cognitive impairment and dependency on staff for daily activities. Despite these documented needs, the CNA involved in the incident was not informed of the requirement for a two-person assist and had observed other staff transferring the resident independently. The CNA assignment sheets, which contained critical information about resident care needs, were not referenced by the CNA, leading to the improper transfer. Interviews with staff revealed a lack of awareness and communication regarding the resident's transfer needs. The Assistant Director of Nursing (ADON) acknowledged that the CNA was expected to reference assignment sheets, but there was no specific policy in place regarding staff-assisted transfers. Other CNAs confirmed that Resident B was a two-person transfer prior to her injury, and the facility's failure to ensure this protocol was followed directly contributed to the resident's injury.
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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