Waters Of Indianapolis, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Indianapolis, Indiana.
- Location
- 3895 S Keystone Ave, Indianapolis, Indiana 46227
- CMS Provider Number
- 155409
- Inspections on file
- 30
- Latest survey
- December 31, 2025
- Citations (last 12 mo.)
- 35
Citation history
Health deficiencies cited at Waters Of Indianapolis, The during CMS and state inspections, most recent first.
A male resident with moderate cognitive impairment and a history of sexually inappropriate behavior was found leaving the room of a female resident with similar cognitive deficits, who was discovered with her gown and brief disturbed after yelling for help. The female resident indicated inappropriate touching by pointing to her breast, and staff confirmed the male resident was not supposed to be in her room.
A facility failed to provide a complete description to state authorities regarding an allegation of sexual abuse involving a resident found in a compromised state after a male resident was observed leaving her room. Staff observed the resident's brief unfastened and gown pulled up, but the report submitted only briefly described the allegation, omitting key observed details.
Surveyors found that bathroom wall heater covers were removed, leaving exposed heating elements in three rooms, and that two bathroom door frames had rusted away, exposing jagged edges. The Maintenance Supervisor confirmed these conditions should not have been present, and no relevant maintenance policy was provided.
A dietary aide with facial hair was observed handling uncovered food and drinks in the kitchen without wearing a beard net, contrary to facility policy and state sanitation requirements. This lapse in personal hygiene standards had the potential to affect all residents receiving food from the kitchen.
An electrical cord from a floor buffer was left curled and raised in the middle of a hallway used by cognitively impaired, self-mobile residents. A resident with dementia and a history of falls was observed stepping over the cord at the technician's instruction, with no caution signs posted. Staff interviews confirmed the cord should not have been left in the walkway and that a caution sign was needed. The facility lacked a policy for accident prevention.
A deficiency occurred when a resident with severe cognitive impairment and high fall risk was allowed to keep her bed in the highest position, as per her preference, without this being addressed in her comprehensive care plan. Staff confirmed the omission, and facility policy required care plans to be updated for such issues.
A treatment cart containing various topical medications was found unlocked and unattended in a hallway near several residents in wheelchairs. An LPN confirmed the cart should have been locked, and facility policy requires medication carts to be secured or attended by authorized staff.
The facility did not complete the required two-step TB skin test for two residents, both of whom had significant medical conditions. In both cases, the necessary TB screening was either refused or not documented, and the alternative TB screening tool assessment was not completed at the time of admission as required by facility policy. This deficiency was confirmed by interviews with the RNC and DON.
A CNA administered medication to a resident without being authorized or qualified, bypassing the nurse and facility protocols. The resident, who was cognitively intact and had a physician's order for acetaminophen as needed, received two capsules from the CNA after requesting pain relief. The resident noticed the pills were different from his usual medication and reported feeling unwell, leading to an emergency room evaluation. Facility policy and state regulations prohibit CNAs from administering medications.
A resident's antidiabetic medication was misappropriated in a facility, despite being stored in a locked medication room accessible only to staff. The resident, who was cognitively intact and had Type 2 diabetes, had a physician's order for tirzepatide to be administered weekly. The medication box, which should have contained four doses, was found with only one remaining, and later, that dose also went missing. An internal investigation could not determine who took the medication.
A cognitively intact resident was not allowed to sign out for a leave of absence, despite facility policy indicating residents have the right to leave. The DON stated the resident could leave with family or friends but not with her boyfriend or alone. A physician's order restricted the resident from leaving, with no stop date provided.
A resident alleged being hit by a Floor Technician while wheeling down a hall, but the incident was not immediately reported to the administrator, and the initial report to the state survey agency was incomplete. Interviews revealed discrepancies in staff awareness and reporting, with one CNA unaware of the incident and another failing to act on overheard information. The facility's policy requires prompt reporting of suspected abuse, but a policy for state health department reporting was unavailable.
A resident reported being hit by a Floor Technician while in her wheelchair, but the facility failed to immediately remove the alleged perpetrator as required by their abuse policy. The incident was known to the DON and other staff, but no immediate action was taken to ensure the resident's safety or separate the staff member from residents.
The facility failed to store medications according to professional principles, as observed during medication pass observations. A QMA used a pill packet with a torn-off label, and an LPN did not date a newly opened bottle of eye drops. The DON confirmed these actions were against facility policy, and no policy was available for dating opened medications.
An LPN failed to maintain infection control by not performing hand hygiene before and after administering Zaditor eye drops to a resident. The LPN donned gloves without washing hands, administered the drops, and left the room without washing hands, contrary to the facility's policy.
A resident with a history of cerebral infarction and cognitive deficits was verbally abused by a CNA during a smoke break. The CNA, upset about the assignment, screamed and yelled at the resident, continuing the abuse inside the building. Despite the resident's request to stop, the CNA taunted and called her a snitch. The facility's policy defines such behavior as verbal abuse.
A facility failed to complete a self-medication administration assessment for a resident with medications left at their bedside. The resident, diagnosed with chronic obstructive pulmonary disease, alcohol dependence, and anxiety, was found with a cup of medications unattended. Interviews confirmed that medications should not be left in resident rooms, and the facility's policy required staff to ensure medication is swallowed.
A facility failed to perform required smoking assessments for a resident with multiple health conditions and moderate cognitive impairment. The resident, identified as a supervised smoker, had not been assessed since 9/19/22, despite the facility's policy requiring quarterly and annual assessments. The DON confirmed the oversight, which was contrary to the facility's Smoking Policy.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
A male resident with a history of Alzheimer's disease, hemiplegia, and moderate cognitive impairment was observed leaving the room of a female resident who was also moderately cognitively impaired and had diagnoses including hemiplegia, aphasia, and dementia. The female resident was found by staff with her gown pulled up and her brief unfastened on one side shortly after she was heard yelling. The male resident indicated he had gotten lost when questioned by staff. Upon assessment, the female resident was unable to verbally describe the incident but pointed to her breast, indicating inappropriate touching. This was the first reported incident of abuse involving the male resident. Staff interviews and record reviews confirmed that the male resident had previously exhibited sexually inappropriate behaviors and had a care plan addressing these behaviors. Despite this, he was able to enter the female resident's room and allegedly touch her inappropriately. The incident was documented as a reportable event, and the facility's policy on abuse prevention was reviewed as part of the investigation.
Failure to Fully Report Sexual Abuse Allegation to State Authorities
Penalty
Summary
The facility failed to ensure a full description of an allegation of sexual abuse was reported to the state health department for one of three residents reviewed for abuse. The incident involved a male resident observed leaving a female resident's room, after which the female resident was found lying in bed with her sheet pulled down, her brief unlatched on one side and bent down in the front, and her gown pulled up. Staff interviews and written statements indicated that the female resident was yelling, and when staff entered her room, they found her in a compromised state. The male resident was seen leaving her room and stated he had gotten lost. The CNA immediately notified the RN, who observed the same condition of the resident and questioned her about the incident. The resident was unable to verbalize details but pointed to her breast, indicating where she had been touched. The facility's reportable incident documentation only briefly described the allegation, stating that the female resident alleged the male resident touched her breast. However, the full circumstances observed by staff, including the resident's physical state and the sequence of events, were not fully detailed in the report to the state health department. The facility's policy required that all allegations of abuse be reported, but the report submitted lacked a comprehensive description of the incident as observed and documented by staff.
Failure to Maintain Safe and Comfortable Resident Environment
Penalty
Summary
Surveyors observed that the facility failed to maintain a safe and comfortable environment for residents, staff, and the public by leaving bathroom wall heater covers removed in three rooms within the secured memory care unit. The exposed metal heating elements, located approximately six inches from the floor, were visible in the bathrooms of rooms H-8, H-10, and H-11. The Maintenance Supervisor confirmed during an interview that the heaters were still operational and acknowledged that the heating elements should not have been left exposed to residents. Additionally, the facility failed to ensure that bathroom door frames were free from rust and decay in two rooms. The bathroom door frames in rooms H-10 and H-11 were found to have rusted areas, with the metal frames rusted away from the floor up by two to three inches, leaving jagged, rusted edges exposed. The Maintenance Supervisor confirmed that the door frames should not have been left in this condition. The facility was unable to provide a policy regarding the maintenance of bathroom wall heaters or the rusted door frames at the time of the survey.
Dietary Staff Failed to Wear Beard Net While Handling Food and Drinks
Penalty
Summary
During a kitchen observation, a dietary aide was seen working near uncovered prepared foods on the steam table and handling drinks for residents without wearing a beard net, despite having facial hair approximately one fourth inch in length on his chin. The aide was observed scooping ice and pouring drinks to be served to residents, with his facial hair uncovered in the food preparation area. Interviews with the Dietary Manager and Assistant Director of Nursing confirmed that facility policy and professional standards require all staff to wear hair restraints, including beard nets, when in the kitchen or around food and drinks. A review of the facility's Food Safety & Sanitation policy and Indiana Food Establishment Sanitation Requirements further supported the need for proper hair restraints to prevent hair from contacting exposed food. This failure had the potential to affect all residents receiving food from the kitchen.
Electrical Cord Left in Walkway Creates Accident Hazard for Cognitively Impaired Residents
Penalty
Summary
A deficiency was identified when an electrical cord from a floor buffer machine was observed lying in the middle of a walkway in the Memory Care Unit, used by residents, including those who are cognitively impaired and self-mobile. The cord, approximately 20 feet long and one inch in circumference, was curled and raised above the floor by eight to ten inches at multiple points, creating a tripping hazard. No caution signs were posted in the area during the floor technician's use of the buffer. The technician instructed a resident to step over the cord without moving it or ensuring the area was safe. The technician also stated that he did not believe a caution sign was necessary since the floor was not wet, but acknowledged the cord should be kept near the wall due to the high number of ambulatory residents in the unit. A resident with a diagnosis of dementia, who was moderately cognitively impaired and at risk for falls, was observed stepping over the cord as instructed by the technician. The resident's care plan indicated a risk of falls related to weakness and medications. Interviews with staff confirmed that the cord should not have been left in the middle of the hallway and that a caution sign should have been posted. Additionally, the facility did not have a policy for the prevention of accidents or potential hazards, as confirmed by the Regional Director of Operations.
Failure to Address Resident's Bed Height Preference in Care Plan
Penalty
Summary
A deficiency was identified when the facility failed to develop a person-centered comprehensive care plan that addressed all of a resident's needs, specifically the resident's preference to keep the bed in a high position despite being at high risk for falls. Observations showed the resident resting in bed with the bed in the highest position on multiple occasions, with the bed control device within reach and no staff present. The resident, who had diagnoses including vascular dementia and right-sided hemiplegia/hemiparesis following a stroke, was assessed as severely cognitively impaired and at high risk for falls. The care plan in place addressed fall risk related to right-sided deficits but did not address the resident's expressed preference for bed height. Interviews with staff confirmed that the resident had been educated about the safety concerns of keeping the bed elevated but continued to adjust it to the highest position. The Assistant Director of Nursing acknowledged that the clinical record lacked a care plan addressing this specific preference. Facility policy required comprehensive care plans to be reviewed and updated based on changes in the resident's condition or newly developed issues, but this was not done in this case.
Unattended and Unlocked Treatment Cart with Medications
Penalty
Summary
A treatment cart located in the Faith Hall was observed to be unlocked and easily accessible, with no staff present in the area. Several residents in wheelchairs were seated approximately four feet from the unattended cart. The cart contained multiple tubes of medications, including antifungal cream, fludocinonide cream, and gentamicin cream, all labeled with instructions to keep out of reach. During an interview, an LPN confirmed that the cart should have been locked. The facility's current policy requires that medication carts be locked or attended by authorized personnel, which was not followed in this instance.
Failure to Complete Required TB Screening for Two Residents
Penalty
Summary
The facility failed to implement proper infection control practices related to tuberculosis (TB) screening for two residents. One resident, with diagnoses including paraplegia, bipolar disorder, and chronic osteomyelitis, was admitted and had orders for a two-step TB skin test. The first step was refused by the resident, and the second step was not documented as administered. Although a TB screening tool assessment was eventually completed several months after admission, neither the first nor second step of the TB skin test was performed at the appropriate time. Interviews with the Regional Nurse Consultant (RNC) and Director of Nursing (DON) confirmed that the resident had refused all vaccines and TB skin tests, and that the TB screening tool assessment should have been completed at admission or at the time of refusal. Another resident, with diagnoses including congestive heart failure, right above-knee amputation, and kidney failure, was also admitted without documentation of either step of the two-step TB skin test. A TB screening tool assessment was completed many months after admission. The RNC and DON confirmed that this resident had not received the required TB tests upon admission, as required by facility policy. Review of the facility's TB testing policy indicated that all residents admitted from the community should have completed TB screening using the two-step method upon admission.
Unqualified Staff Administered Medication to Resident
Penalty
Summary
A certified nursing assistant (CNA) administered medication to a resident without being qualified or authorized to do so, in violation of facility policy and state regulations. The incident occurred when the resident requested pain medication for a headache, and the CNA, instead of notifying a nurse, retrieved two capsules from behind the nurses' station and gave them directly to the resident. The resident, who was cognitively intact and had a physician's order for acetaminophen as needed, noticed the pills did not resemble his usual Tylenol and subsequently reported feeling unwell. He informed the nurse, who then contacted the physician and sent the resident to the emergency room for evaluation. Toxicology results confirmed the medication given was acetaminophen. The facility's investigation included statements from the CNA, who admitted to giving the pills to avoid making the resident wait for a nurse, and from the RN on duty, who was unaware of the resident's pain or the medication administration. The CNA's job description and the Indiana State Department of Health Nurse Aide Curriculum both explicitly prohibit CNAs from administering medications. The resident's clinical record indicated ongoing pain issues, and the care plan required medication administration by qualified personnel, which was not followed in this instance.
Misappropriation of Resident's Medication
Penalty
Summary
The facility failed to protect a resident's rights to be free from misappropriation of property, specifically medications. Resident C, who was cognitively intact and diagnosed with Type 2 diabetes mellitus, had a physician's order for tirzepatide, an antidiabetic medication, to be administered weekly. However, it was discovered that the medication was missing from the medication room. The medication box, which should have contained four pre-filled syringes, was found to have only one remaining, and subsequently, even that dose went missing. The medications were stored in a locked medication room accessible only to staff members, but an internal investigation could not determine who took the syringes. The issue was reported by an LPN to the former DON when it was noticed that Resident C's medication was missing. The facility's abuse policy, which includes protection against misappropriation of resident property, was in place at the time of the incident. Despite the locked storage, the facility failed to ensure the security of Resident C's medication, leading to the misappropriation of the resident's property.
Violation of Resident's Right to Leave Facility
Penalty
Summary
The facility failed to uphold the resident rights of a cognitively intact individual, identified as Resident C, by not allowing her to sign out for a leave of absence. During an interview, Resident C reported that staff had informed her she could not leave the facility. The Director of Nursing (DON) confirmed that while Resident C was permitted to leave with family or friends, she was not allowed to leave with her boyfriend or on her own, despite being cognitively intact. The clinical record review showed that Resident C had diagnoses including alcohol abuse, psychoactive substance abuse, and bipolar disorder, and an Admission Minimum Data Set (MDS) assessment confirmed her cognitive intactness. A physician's order, dated 12/24/24, restricted Resident C from going out on a leave of absence, with no stop date provided. The facility's policy, titled 'Your Rights and Protections as a Nursing Home Resident,' indicated that residents have the right to leave the facility, which was not honored in this case.
Failure to Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident, identified as Resident B, who was wheeling down the hall and attempted to pass a Floor Technician who was buffing the floor. During this interaction, the Floor Technician allegedly hit Resident B's right shoulder with his left arm. Resident B expressed her intention to report the incident, although she did not believe the Floor Technician intended to hit her. The incident was not immediately reported to the administrator, and the initial report to the state survey agency did not include all known information about the allegation. Interviews revealed discrepancies in staff awareness and reporting of the incident. CNA 1 was unaware of the incident, while CNA 2 overheard Resident B's intention to report being hit but did not act on this information. The Director of Nursing (DON) was uncertain about the completeness of the initial incident report, which required corporate approval before submission. The facility's policy mandates prompt reporting of any suspected abuse, but the facility was unable to provide a policy regarding reporting to the state health department.
Failure to Follow Abuse Policy and Remove Alleged Perpetrator
Penalty
Summary
The facility failed to adhere to its abuse policy by not immediately removing an alleged perpetrator of abuse from the premises. The incident involved a resident, Resident B, who reported that a Floor Technician hit her on the shoulder while she was attempting to pass him in her wheelchair as he was buffing the floor. The resident did not believe the Floor Technician intended to hit her, but she expressed her intention to report the incident. The Floor Technician admitted to touching the resident's hand while pulling the power cord out of the wall. Despite the resident's report, the Floor Technician was not immediately removed from the facility, as required by the facility's abuse prevention policy. The Director of Nursing (DON) and other staff members, including CNA 1 and CNA 2, were aware of the resident's allegation. However, there was a lack of immediate action to ensure the resident's safety and to separate the alleged perpetrator from the resident. CNA 2 overheard the resident's intention to report the incident but did not take any action to verify or report the situation. The facility's policy mandates that staff suspected of abuse should be immediately barred from resident contact and suspended from duty, which was not followed in this case.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure medications were stored in accordance with accepted professional principles during a medication pass observation. A Qualified Medication Aide (QMA) was observed pulling a pill packet from the medication cart that had its label torn off, leaving no information about the resident, medication name, strength, or instructions. The QMA acknowledged that the medication packet with the removed label should not have been left in the cart as it was unclear who the medication was for or what it was. The Director of Nursing (DON) confirmed that such medication packets should be removed from the cart, and the facility's policy indicated that medication containers with damaged labels should be returned to the pharmacy. Additionally, during another medication pass observation, an LPN opened a new bottle of Zaditor eye drops for a resident but failed to date the bottle upon opening. The DON indicated that the bottle should have been dated when opened. The facility was unable to provide a policy regarding the dating of opened medications. These observations were part of a complaint investigation related to Complaint IN00451215.
Infection Control Breach During Eye Drop Administration
Penalty
Summary
The facility failed to maintain proper infection control during the administration of eye drops for one of the residents reviewed for medication administration. During a medication pass observation, an LPN administered Zaditor eye drops to a resident without performing hand hygiene before donning gloves. The LPN explained the procedure to the resident, donned gloves without washing hands, and administered the eye drops to both eyes. After the procedure, the LPN removed the gloves and left the room without performing hand hygiene. The Director of Nursing confirmed that the nurse should have washed her hands before putting on gloves, as per the facility's policy on eye drop administration, which requires handwashing before and after the procedure.
Verbal Abuse by CNA Towards Resident
Penalty
Summary
The facility failed to protect a resident's right to be free from verbal abuse by a Certified Nursing Assistant (CNA). The incident involved Resident B, who has a medical history including cerebral infarction, encephalopathy, and cognitive communication deficit. On the evening of October 17, 2024, CNA 3 was observed by a witness to be verbally abusive towards Resident B during a smoke break. The CNA was upset about having to take residents out for their smoke break, which was not part of their assignment. The witness reported that CNA 3 screamed and yelled at Resident B both inside the building and during the smoke break, continuing the abusive behavior upon returning inside. The witness further described that CNA 3 stood on a chair at the nurses' station, screaming at Resident B when the resident inquired about the delay in their scheduled smoke break. Despite Resident B's request for CNA 3 to stop, the CNA continued to taunt and verbally abuse the resident, calling her a snitch. The facility's Administrator confirmed that CNA 3's behavior was not in line with the facility's policies on abuse prevention, which define verbal abuse as the use of disparaging and derogatory language towards residents. The incident was reported, and CNA 3 was suspended and subsequently terminated following the investigation.
Failure to Complete Self-Medication Assessment
Penalty
Summary
The facility failed to ensure a self-medication administration assessment was completed for a resident, identified as Resident 125, who had medications left at their bedside. During a tour, it was observed that Resident 125, who was in a wheelchair, had a clear plastic cup containing six tablets, one capsule, and one gelcap on their bedside table, with no staff present in the room or hallway. A review of Resident 125's clinical record revealed diagnoses including chronic obstructive pulmonary disease, alcohol dependence, and anxiety, but lacked a Self-Medication Administration Assessment. Interviews with RN 2 and the Director of Nursing confirmed that medications should not be left unattended in resident rooms, and the facility's policy required staff to remain with residents to ensure medication is swallowed. The Director of Nursing provided a policy titled Medication Administration, dated October 2021, which was stated to be currently followed by the facility.
Failure to Conduct Required Smoking Assessments
Penalty
Summary
The facility failed to perform safe smoking assessments per its policy for a resident with multiple health conditions, including multiple sclerosis, muscle wasting, flaccid hemiplegia, and unsteadiness on feet. The resident, who had moderate cognitive impairment, was identified as a supervised smoker requiring supervision during smoking activities. The most recent Smoking Risk Assessment in the resident's clinical record was dated over a year and a half ago, on 9/19/22, and indicated the resident required a protective apron during smoking breaks and had moderate problems with general awareness, orientation, and injury potential related to smoking materials. During an interview, the Director of Nursing (DON) acknowledged that the resident should have had smoking assessments conducted both quarterly and annually, as per the facility's policy. The facility's Smoking Policy, provided by the DON, stated that residents should be assessed for safe smoking behavior prior to smoking at the facility and further assessed quarterly, annually, after an unsafe smoking episode, and after a change of condition. The failure to conduct these assessments as required by the policy led to the deficiency identified in the report.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
