Waters Of Fort Wayne Skilled Nursing Facility, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Fort Wayne, Indiana.
- Location
- 5544 E State Blvd, Fort Wayne, Indiana 46815
- CMS Provider Number
- 155321
- Inspections on file
- 26
- Latest survey
- February 10, 2026
- Citations (last 12 mo.)
- 21
Citation history
Health deficiencies cited at Waters Of Fort Wayne Skilled Nursing Facility, The during CMS and state inspections, most recent first.
Two residents with significant ADL dependence and behavioral/vision impairments reported that a CNA repeatedly yelled at them, used harsh tones, and at times cursed at them and in the hallway, making them feel like children and leading them to tell the CNA to leave their room and to report concerns to the charge nurse. Both residents stated they did not want this CNA to provide their care, yet the CNA continued caring for at least one of them, and their care plans did not document their requests to avoid certain staff. Confidential staff/resident interviews corroborated that some staff yelled and cursed when providing care, and leadership was aware of prior verbal warnings to the CNA about her attitude but had no formal written warnings on file.
A resident with atrial fibrillation, diabetes, significant ADL dependence, and recent homelessness was repeatedly informed that insurance coverage was ending and that he would need to pay privately or leave, with discussions about discharge to a motel or other settings. Despite his expressed interest in Medicaid and his reports that he was not physically able to get in and out of his vehicle or out of bed due to pain, documentation did not show that he was assessed as safe for discharge, offered assistance with a Medicaid application, or given the required written discharge notice with appeal rights before an involuntary discharge was pursued. When a family payment failed to clear, he was told he had to leave that day without documented physician clearance or a safe discharge plan, and he ultimately called 911 for transfer to the hospital.
A resident with a history of dementia, heart failure, and a prosthetic heart valve did not receive prescribed doses of Coumadin on several occasions, and required PT/INR blood tests were missed without documentation or physician notification. This led to subtherapeutic INR levels and subsequent changes in medication dosing, contrary to facility policy and physician orders.
A resident with severe cognitive impairment and a history of falls was repeatedly left unattended in a Broda chair without a pillow, despite care plan and hospice recommendations. After the resident fell and sustained facial injuries, staff failed to complete required neuro checks, did not document all injuries, and did not update the care plan with new interventions. Staff interviews revealed a lack of awareness of required interventions, and hospice notes were not available in the chart, resulting in poor coordination of care.
The facility did not maintain complete and accurate documentation for two residents, including missing follow-up notes and injury details after a fall for a resident on hospice, and incomplete PT/INR lab records for a resident on anticoagulant therapy. Staff failed to include all relevant assessments and hospice notes in the clinical record, and interventions were not consistently updated or implemented as required.
Surveyors found that medications and biologicals on a medication cart were not consistently labeled with open dates or resident identifiers, as required by facility policy and regulations. Multiple medications, including inhalers, oral suspensions, and eye drops, were missing open dates or name labels. The ADON was observed adding dates during the inspection, and the DON confirmed the assigned RN was new to the cart and had received education on labeling practices.
The facility did not maintain required temperature logs for cooked foods, refrigerators, freezers, and the dishwasher, resulting in incomplete or missing documentation for multiple days and equipment. This failure was confirmed by staff and management, and affected nearly all residents who consumed food prepared in the facility kitchen.
Two residents with significant health conditions were observed over several days with untrimmed facial hair, despite care plans requiring staff assistance with ADLs. One resident's care plan did not address facial hair, while the other had a preference not to be shaved daily but was unaware of her grooming schedule and could not locate her preferred electric razor. Staff confirmed that women should not have visible facial hair and that grooming should be maintained according to facility policy.
A resident with multiple chronic conditions experienced significant weight loss over six months, despite being on weight monitoring and prescribed nutritional supplements. Staff discontinued nutrition risk monitoring prematurely, failed to alert the NP of continued weight loss, and did not provide recommended meal assistance or special interventions during meals, resulting in inadequate support for the resident's nutritional needs.
The facility failed to follow physician orders for weight monitoring for two residents, leading to deficiencies in care. One resident with heart failure experienced significant weight gain without timely physician notification, resulting in hospitalization. Another resident's weekly weight monitoring was not documented, with no indication of refusal or physician notification. These actions violated facility policies on weight monitoring and physician order compliance.
A facility failed to monitor side effects of antipsychotic medication for a resident with dementia, bipolar disorder, and anxiety. The resident was prescribed Abilify, but there were no physician orders to monitor side effects, and no documentation was found in the MAR or progress notes. The DON acknowledged the oversight, and the facility's policy requires monitoring for efficacy and adverse reactions, which was not followed.
A resident with a history of falls and multiple medical conditions experienced significant injuries after two falls. The facility failed to ensure proper assessment, monitoring, and follow-up, leading to the resident's decline and hospitalization.
A resident with PTSD and a need for modesty was exposed during personal care by two CNAs, who laughed at her despite her requests to be covered. The resident's care plan did not include her specific needs, leading to the incident.
A resident experienced verbal abuse from staff on two occasions, involving derogatory language and profanity. The incidents were reported by witnesses, and the facility's abuse prevention policy was not followed, resulting in the mistreatment of the resident.
Failure to Ensure Respectful and Dignified Staff–Resident Interactions
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were treated with respect and dignity during verbal interactions, specifically in relation to two residents who reported being yelled at and cursed at by a CNA. Resident O, who had diagnoses including diabetes, anxiety, and bipolar disorder and was dependent on staff for most ADLs, reported that CNA 6 repeatedly came into her room and “barked out orders,” telling her to get up, get dressed, go to the bathroom, and go down to eat in a raised voice with a harsh tone and attitude. She stated that CNA 6 sometimes cursed at her and her roommate and could be heard cursing in the hallway. Resident O reported these concerns to the charge nurse and told CNA 6 not to come into her room again, but indicated that CNA 6 continued to provide her care despite her request. Her care plan, which included interventions such as emphasizing dignity, using soothing and kind speech, not rushing her, and providing care consistent with her schedule, did not document her request to avoid care from certain staff. Resident P, who was blind with additional diagnoses of dementia and stroke, and who was dependent on staff for ADLs, reported overhearing CNA 6 yelling at her roommate on several occasions and stated that the CNA also yelled at her. She responded by cursing at the CNA and telling her to get out of the room and reported her concerns to the charge nurse. Resident P stated that she felt like a child when yelled at, expressed anger and concern for her roommate, and indicated she did not want CNA 6 to provide her care. Her care plan, which included interventions to approach her calmly and explain care before providing it, also did not reflect her request to avoid certain staff. Confidential interviews indicated that some staff were not always respectful, with reports of staff yelling in hallways, yelling at residents, and cursing during care, and specifically identified CNA 6 as yelling at Resident O and cursing in the hallways. The Interim DON acknowledged awareness of prior verbal warnings to CNA 6 about her attitude and manner of speaking with residents but stated there were no formal written warnings in the employee file and that she had not been informed of the residents’ wishes not to receive care from CNA 6.
Failure to Provide Required Notice and Discharge Planning Before Involuntary Discharge
Penalty
Summary
The deficiency involves the facility’s failure to provide required written notice with appeal rights and discharge planning prior to an involuntary discharge for one resident. The resident had persistent atrial fibrillation, diabetes, and required assistance with ADLs including toileting hygiene, dressing, personal hygiene, and bed mobility, and was receiving PT. He had no cognitive impairment and had previously been homeless, living in his car, and was admitted for continued medical management, therapy, and safe discharge planning. His care plan documented his wish to discharge to the community and the need for community referral, with interventions to establish and evaluate a pre-discharge plan. During the stay, the resident expressed interest in obtaining Medicaid and in moving to assisted living or a pay-by-the-week motel. A discharge planning meeting documented that his managed insurance would no longer pay for his care as of a specified date, and staff discussed discharge versus remaining and paying privately. The resident wanted to appeal the insurance decision and was informed he would be responsible for costs if he remained after coverage ended. However, at that time he was not provided a written discharge notice, and the documentation did not indicate that he was physically able to be safely discharged or that assistance with a Medicaid application was offered, despite his earlier expressed interest. Subsequent discharge planning notes recorded that a family member’s payment temporarily covered his room and board and that staff and the resident discussed discharge locations, payment, transportation, and using therapy time to get stronger, with a planned discharge date. Again, the notes did not document that he was physically able to be safely discharged, that he was offered help applying for Medicaid, or that he received a written discharge notice with appeal rights, even though he was told he would be discharged on a specific date. Later, when a family check failed to clear, the resident was informed he owed the facility and was told he needed to leave that day, despite his report that he could not get out of bed due to pain. There was no physician documentation that he was safe for discharge, no discharge plan put in place, and no written discharge notice with appeal rights or Medicaid assistance documented prior to his involuntary discharge attempt, leading him to call 911 for transfer to the hospital.
Failure to Administer Anticoagulant and Monitor Labs as Ordered
Penalty
Summary
The facility failed to ensure that physician orders for anticoagulant medication and required blood test monitoring were followed for a resident receiving Coumadin therapy. Specifically, the resident, who had diagnoses including dementia, heart failure, and a prosthetic heart valve, was prescribed Warfarin Sodium (Coumadin) with instructions for daily administration and PT/INR blood tests twice weekly. Record review showed that several doses of Coumadin were not administered on specific dates, with no documented reason for the missed doses and no evidence that the physician or nurse practitioner was notified. Additionally, a scheduled PT/INR lab test was not performed as ordered, again without documentation or notification to the appropriate medical provider. As a result of these missed doses and lab tests, the resident's PT/INR levels were found to be below the therapeutic range, prompting subsequent adjustments to the Coumadin dosage. Interviews with staff revealed that PT/INR testing was dependent on the availability of test strips, and if unavailable, samples were sent to the hospital. Facility policies required that all physician orders be implemented and that residents on Coumadin be monitored through regular blood testing, but these protocols were not consistently followed for this resident.
Failure to Assess, Document, and Prevent Falls for a Cognitively Impaired Resident
Penalty
Summary
The facility failed to thoroughly assess injuries following falls, determine the root cause of falls, and develop effective interventions to prevent further falls for a resident with Alzheimer's dementia and a history of falls. The resident, who was non-ambulatory, dependent on staff for all activities of daily living, and receiving hospice care for end-stage dementia, was repeatedly observed seated in a Broda chair without a pillow, despite care plan interventions and hospice recommendations. Staff were often not present or attentive while the resident was in common areas, and the resident was able to sit up and lean forward in the chair, which contributed to her falling out of the chair and sustaining injuries, including a nosebleed and bruising around the eye. After the fall, documentation was incomplete and inconsistent. There was no documentation of the resident's bruise to her right eye, and required neurological checks were not completed according to facility policy. The care plan was not updated to include the hospice intervention of placing a pillow in front of the resident while seated at a table, and staff were unaware of this intervention. Additionally, hospice nurse notes were not available in the resident's chart, hindering coordination of care between hospice and facility staff. Interviews with staff revealed a lack of awareness regarding the resident's required interventions and inconsistent follow-through with post-fall assessments and documentation. The facility's policy required thorough assessment, documentation, and care plan updates following falls, but these steps were not consistently followed. The failure to implement and document effective interventions, assess injuries, and update care plans contributed to the deficiency cited by surveyors.
Incomplete Documentation of Falls, Hospice Services, and Anticoagulant Therapy
Penalty
Summary
The facility failed to maintain complete and accurate documentation for two residents regarding falls, hospice services, and anticoagulant therapy. For one resident with Alzheimer's dementia receiving hospice care, there was incomplete documentation following a fall from a Broda chair. Although the care plan identified a risk for falls and interventions were updated, the clinical record lacked documentation of observed injuries, such as bruising around the eye, and did not include required 72-hour follow-up notes. Neurological checks were not performed as scheduled, and hospice progress notes were not available in the resident's record, requiring staff to contact the hospice provider for information. Additionally, an intervention noted by hospice staff was not incorporated into the resident's care plan or observed in practice. For another resident with dementia, heart failure, and a prosthetic heart valve, the facility did not maintain accurate records of PT/INR lab results required for monitoring anticoagulant therapy. The care plan required regular PT/INR testing and prompt reporting of critical results, but the clinical record showed missing or unscheduled lab results and incomplete documentation on the Medication Administration Record (MAR). Facility staff sometimes used a log book at the nurses' station to record PT/INR results, but these logs were not included in the resident's clinical record as required by facility policy. Interviews with staff and administration confirmed that documentation practices did not align with facility policy, which requires all assessments and records from facility staff and contracted professionals to be included in the resident's clinical record. The lack of thorough and timely documentation affected the facility's ability to coordinate care and ensure accurate records for both residents.
Failure to Label Medications with Open Dates and Resident Identifiers
Penalty
Summary
Surveyors observed that the facility failed to ensure medications and biologicals were properly labeled with open dates and resident identifiers, as required by professional standards and facility policy. During an inspection of a medication cart, multiple medications belonging to several residents were found without open dates, including inhalers, oral suspensions, ophthalmic solutions, and liquid supplements. Additionally, some unopened medications and eye drops lacked resident name labels. The Assistant Director of Nursing (ADON) was present during the observation and began adding open dates to the medications that were missing them. The ADON also indicated a misunderstanding regarding the required dating of inhalers. The Director of Nursing (DON) later confirmed that the nurse assigned to the cart was new and had been educated on labeling practices by the usual nurse, who was on vacation. Record reviews for the affected residents showed that they had various diagnoses, including chronic obstructive pulmonary disease, asthma, myotonic muscular dystrophy, and hemiplegia, and were prescribed medications such as albuterol, Breo Ellipta, atropine sulfate, sucralfate, milk of magnesia, and bismuth subsalicylate. The facility's policy requires medications to be labeled in accordance with state and federal laws, as well as facility requirements. Despite this, the survey found multiple instances where medications were not labeled with open dates or resident names, constituting a failure to comply with labeling and storage regulations.
Failure to Maintain Food and Equipment Temperature Logs
Penalty
Summary
The facility failed to maintain complete and accurate temperature logs for cooked foods, refrigerators, freezers, and the dishwasher throughout the month of June 2025. Observations revealed missing and incomplete documentation for food temperature logs, with no records available for several days in June for any of the three meals served. Additionally, temperature logs for two of three refrigerators were incomplete, and one refrigerator had no log at all. Only one freezer log was available for three freezers, and it was also missing multiple entries. The dishwasher temperature log was not dated with the month or year, and several meals were not recorded. These deficiencies were confirmed through interviews with facility staff and the Regional Dietary Manager, who acknowledged the missing and incomplete logs after a thorough search. Facility policies required that dish machine temperatures be logged after each meal and kept on file for one year, and that refrigerator and freezer temperatures be checked and recorded twice daily. The food temperature tray line policy also required temperatures to be recorded before serving. Despite these policies, the required documentation was not maintained, affecting 38 of 39 residents who consumed food prepared in the facility kitchen. No additional logs for the missing days or months were found, and the lack of documentation was confirmed by both staff and management.
Failure to Provide Grooming Assistance for Residents Unable to Perform ADLs
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) related to grooming for two residents who were unable to perform these tasks themselves. Observations over several days showed that one resident had multiple long chin hairs that remained untrimmed, despite a care plan indicating staff were responsible for meeting all ADLs. The care plan did not specifically address facial hair for this resident. The resident's diagnoses included macular degeneration, osteoporosis, and weakness, indicating a need for staff assistance with personal grooming. A second resident was observed with a full beard and mustache that were not shaved over multiple days. This resident's care plan included a preference to not be shaved daily, but during an interview, the resident was unaware of her grooming schedule and indicated she was overdue for shaving. She also expressed a refusal to be shaved with a regular razor, preferring an electric razor, which she could not locate. Staff interviews confirmed that residents should be shaved on shower days or as needed, and that women should not have visible facial hair. The facility's policy required staff to maintain good grooming and hygiene for residents unable to perform ADLs.
Failure to Ensure Adequate Nutrition and Weight Maintenance
Penalty
Summary
A deficiency occurred when the facility failed to ensure adequate nutrition and weight maintenance for one resident with multiple medical diagnoses, including anxiety, osteoarthritis, depression, glaucoma, anemia, cataracts, macular degeneration, neuropathy, and a pacemaker. Over a six-month period, the resident experienced a weight loss of 12.77%, dropping from 141 lbs to 123 lbs. The resident was placed on weight monitoring and classified as Nutrition at Risk due to a wound, but this monitoring was discontinued in March after staff determined weights were stable, despite continued weight loss. The resident was prescribed a nutritional supplement (Boost) twice daily starting in late February, but still lost an additional 3.5 lbs after the supplement was initiated. Progress notes from the physician inaccurately stated there was no weight loss, and the Nutrition at Risk Quarterly Review recommended only continued monitoring without further interventions. Meal consumption records showed the resident ate less than 50% of meals for 35 out of 90 recorded meals in June. Interviews revealed that the nurse practitioner was unaware of the ongoing weight loss and expected to be alerted by the DON or the facility's computer system if a resident lost 10% of their weight in six months, which did not occur. The registered dietician noted the weight loss followed a pattern and was not alarmed, relying on the DON or ADON to communicate follow-up needs. Observations showed the resident was not provided with special utensils, visual aids, or redirection during meals, despite care plan interventions indicating the need for assistance and encouragement with eating, as well as monitoring for significant weight changes and offering meal substitutes when intake was low.
Failure to Follow Physician Orders for Weight Monitoring
Penalty
Summary
The facility failed to adhere to physician orders for weight monitoring for two residents, leading to deficiencies in care. Resident 10, who had multiple diagnoses including heart failure, was ordered to have daily weights taken to monitor for significant weight changes. However, the facility did not document weights on several days in July 2024, and there was a failure to notify the physician of significant weight gains as required. This oversight resulted in Resident 10 experiencing a substantial weight gain over a short period, which was not promptly addressed, leading to her hospitalization. Resident 6, diagnosed with paraplegia and chronic osteomyelitis, was also subject to weight monitoring orders, requiring weekly weights to be recorded every Thursday. The facility failed to document weights on several occasions in July and August 2024, and there was no indication that the resident refused the weights or that the physician was informed of the missed recordings. This lack of documentation and communication represents a failure to follow physician orders and facility policy. The facility's policies on weight monitoring and following physician orders were not adhered to, as evidenced by the lack of systematic weight recording and failure to notify physicians of significant weight changes. The deficiencies highlight a breakdown in the facility's processes for monitoring and responding to residents' weight changes, which are critical for managing conditions such as heart failure and other health issues.
Failure to Monitor Antipsychotic Medication Side Effects
Penalty
Summary
The facility failed to monitor the side effects of antipsychotic medication for a resident diagnosed with unspecified dementia, bipolar disorder, and anxiety. The resident was prescribed Abilify (aripiprazole) 5 mg daily for bipolar disorder, starting on 5/21/2024. However, there were no physician orders to monitor the side effects of this medication. The care plan, dated 6/23/2024, included interventions to administer medications as ordered and monitor for adverse side effects and effectiveness, but this was not documented in the Medication Administration Record (MAR) or progress notes for August 2024. During an interview, the Director of Nursing (DON) acknowledged that there should have been a physician order to monitor side effects. The facility's policy on psychotropic medication requires monitoring for efficacy and adverse reactions, but this was not followed in this case. The policy also emphasizes that psychotropic drugs should only be used when necessary and after other interventions have failed. Despite these guidelines, the facility did not document monitoring for side effects or effectiveness of the medication for the resident in question.
Failure to Ensure Proper Follow-Up After Resident Falls
Penalty
Summary
The facility failed to ensure proper identification, assessment, and follow-up for acute changes in a resident's condition following two falls. Resident B, who had diagnoses including congestive heart failure, dementia, diabetes, and a history of repeated falls, experienced significant injuries after these falls. The first fall resulted in a mild headache and soreness, while the second fall led to lacerations, bruising, and a large hemothorax, which required hospitalization and the insertion of a chest tube to drain the blood. Despite these injuries, the facility's documentation and follow-up were inadequate, as evidenced by the lack of consistent neurological checks and pain assessments, and the failure to move the resident closer to the nurse's station as recommended by the IDT (Interdisciplinary Team). The resident's condition deteriorated, leading to hospitalization due to shortness of breath and other acute symptoms. The facility's failure to properly assess and monitor the resident's condition after the falls contributed to the resident's decline and subsequent hospitalization.
Failure to Provide Trauma-Informed Care
Penalty
Summary
The facility failed to ensure triggers were identified and resident-specific approaches were initiated in providing trauma-informed care for Resident C. Resident C, who has a history of PTSD, depression, and anxiety, expressed that she felt helpless and ridiculed by staff due to her need for modesty. She reported an incident where two CNAs exposed her during personal care, despite her repeated requests to be covered. The CNAs laughed at her, making her feel vulnerable and ridiculed. The resident's care plan did not include her specific needs for modesty and privacy, which contributed to the incident. The facility's records indicated that Resident C had a history of trauma and required specific interventions to avoid re-traumatization. However, her care plan lacked detailed interventions to address her PTSD and modesty needs. The CNAs involved were not aware of her preferences, leading to the incident. The facility's policy on trauma-informed care emphasized the importance of creating a safe environment and respecting individual choices, but this was not effectively implemented in Resident C's case.
Failure to Protect Resident from Verbal Abuse
Penalty
Summary
The facility failed to protect a resident, identified as Resident B, from verbal abuse by staff members on two separate occasions. The first incident involved a Certified Nursing Assistant (CNA 2) who, during an argument about the room's temperature, used derogatory language towards Resident B, including calling him a derogatory term and mocking his inability to walk. This incident was reported by another CNA who witnessed the inappropriate interaction. Resident B, who has a history of trauma related to abuse and is cognitively intact, felt disrespected and reported that his call light was ignored by CNA 2. In a second incident, another staff member, CNA 4, was recorded speaking inappropriately to Resident B, using profanity and encouraging him to argue. This recording was made by another resident, Resident C, who reported the incident to the Director of Nursing (DON) after a delay. The facility's policy on abuse prevention, which includes education on resident rights and the definition of abuse, was not adhered to in these instances, leading to the verbal mistreatment of Resident B.
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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