Waters Of Peru Skilled Nursing Facility, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Peru, Indiana.
- Location
- 317 Blair Pike, Peru, Indiana 46970
- CMS Provider Number
- 155039
- Inspections on file
- 25
- Latest survey
- August 5, 2025
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Waters Of Peru Skilled Nursing Facility, The during CMS and state inspections, most recent first.
A nurse gave a resident with severe cognitive impairment and an order for pudding-thick liquids two servings of unthickened water after administering medications, despite the resident's dependence on staff for all ADLs and a diagnosis of dysphagia. Facility policy required pudding-thick liquids for this resident.
Surveyors found that OTC medications on a medication cart in the Memory Care unit were not properly labeled, with several bottles missing required information such as the resident's full name, physician name, expiration date, drug name, and strength. A QMA confirmed that these labeling elements were necessary, and facility policy aligned with state law but was not followed in these instances.
A resident with a suprapubic catheter and multiple medical conditions was observed on several occasions with a covered urinary drainage bag touching the floor at the bedside. The care plan required catheter care every shift and proper positioning of the drainage bag, and staff confirmed the bag should not have been in contact with the floor. Facility policy also required measures to prevent urinary tract infections.
The facility failed to distribute physician-ordered snacks to residents and did not adhere to proper food handling practices. Snacks for six residents were found undelivered, and a hard-boiled egg was improperly stored. Additionally, staff were observed handling food and tableware inappropriately, including using bare hands and contaminating eating surfaces. These actions were not in compliance with the facility's policies.
A facility failed to provide written bed hold information to a resident's representative upon hospital transfer. The resident, with severe cognitive impairment, was sent to the ER for evaluation. Although the bed hold policy was reportedly sent with EMT staff, there was no documentation of written notification to the representative. The DON admitted the policy was not mailed, and typically, families were notified by phone for cognitively impaired residents.
A facility failed to complete a resident's Care Area Assessment (CAA) in a timely manner. The resident, admitted with conditions including dementia and chronic kidney disease, required substantial assistance for ADLs and had issues with urinary incontinence, dental care, and communication. Despite these needs, the comprehensive care plan was not completed within the required timeframe, as confirmed by the MDS Coordinator. The facility's policy required the CAA to be completed within 14 days of admission, with the care plan to follow within 7 days.
The facility failed to develop comprehensive person-centered care plans for two residents, one with behavioral issues and another receiving hospice care. A resident with multiple diagnoses, including psychotic disorder, lacked a personalized care plan that considered their preferences. Another resident receiving hospice care did not have a care plan coordinating with the hospice provider, despite being admitted to hospice services. The facility's policy requires person-centered plans, which was not followed in these instances.
A resident's care plans were not updated to reflect current conditions and preferences, including outdated information about activities, an eye infection, and a pressure injury. The care plans inaccurately stated the resident resided on a locked memory care unit. Interviews with the DON and Activity Director confirmed the care plans were not revised as required.
A facility failed to implement an activities program that met a resident's interests and hobbies. The resident, with conditions including dementia and depression, was observed in bed with the TV positioned out of view, despite having preferences for music and TV. The care plan noted her ability to make decisions about activities, but her room lacked a card for TV preferences, and the TV was improperly positioned. The Activity Director confirmed these oversights, contrary to the facility's policy to meet residents' interests and well-being.
A resident with paraplegia was injured during a transfer when a Hoyer lift tipped over, causing a scalp laceration. The incident occurred because the lift's legs were not extended or locked, leading to instability. Despite staff having completed competency training, the facility's policy on mechanical lift usage was not followed.
The facility failed to provide adequate nutritional interventions for a resident who experienced significant weight loss and was malnourished. Despite being identified as underweight, the resident's nutritional needs were not adequately addressed, and supplements were inconsistently provided. Another resident showed signs of dehydration, with dry lips and a coated tongue, and was unable to access fluids due to a lack of assistance. The facility's policies on weight monitoring and hydration were not effectively implemented, leading to deficiencies in care.
A facility failed to adhere to physician's orders for a resident's oxygen therapy and did not store oxygen tubing properly. The resident, with chronic respiratory failure and COPD, was found with an oxygen concentrator turned off, resulting in low oxygen saturation. The LPN responsible was unaware of the resident's location and condition, and the facility's policy on oxygen management was not followed.
A facility failed to ensure proper infection control during peri care for a resident. Two CNAs were observed providing care, with one CNA using the same area of a washcloth for multiple body parts and failing to change gloves or perform hand hygiene before handling clean items. The CNA acknowledged the oversight, which was against the facility's policy for incontinence care.
Failure to Provide Thickened Liquids as Ordered
Penalty
Summary
A registered nurse administered thin liquids to a resident who had a physician's order for pudding-thick liquids. During a random observation, the nurse gave the resident a soufflé cup of crushed medications mixed with pudding, followed by two separate servings of approximately 60 ml of cold water, which the resident drank and swallowed. The resident did not respond verbally or physically to the nurse's questions about wanting a drink. The nurse then escorted the resident to the dining room for lunch. The resident's medical record indicated diagnoses including paraplegia, dysphagia, diabetes, cerebral infarction, bladder dysfunction, and chronic kidney disease. The most recent assessment documented severe cognitive impairment, a mechanically altered diet, and total dependence on staff for all activities of daily living, including eating. The facility's current policy required pudding-thick liquids for this resident, and the nurse later acknowledged she should not have given unthickened water, stating she did not know why she had done so.
Failure to Properly Label Over-the-Counter Medications on Medication Cart
Penalty
Summary
Surveyors observed that the facility failed to properly label over-the-counter (OTC) medications on one of two medication carts inspected in the Memory Care unit. Specifically, two boxes of Chloraseptic lozenges for one resident were found without any labeling to identify the resident. For another resident, multiple OTC medications—including Lutein, B6 vitamins, stool softener, Centrum vitamins, magnesium, and allergy relief—were found with incomplete labeling. The bottles were marked only with initials, first names, or lacked any identifying information, and did not include all required details such as the resident's full name, physician name, expiration date, drug name, strength, and directions for use. During an interview, a Qualified Medication Aide (QMA) confirmed that OTC medications should be labeled with the resident's first and last name, pharmacy provider, open date, drug name, strength, and directions for use. The facility's policy, as provided by the Executive Director, also requires that nonprescription medications be labeled in accordance with Indiana law, which includes the resident's name, physician name, expiration date, drug name, and strength. The observed deficiencies indicate that the facility did not adhere to its own policy or state requirements for medication labeling.
Urinary Drainage Bag Not Maintained in Sanitary Position
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices by not maintaining a urinary drainage bag in a sanitary manner for a resident with a suprapubic catheter. On multiple occasions, direct observation revealed that the resident's covered urinary drainage bag was touching the floor at the bedside. The resident had significant medical conditions, including paraplegia, a stage 3 sacral pressure ulcer, urinary retention, neuromuscular dysfunction of the bladder, and chronic kidney disease, and was assessed as having severe cognitive impairment. The care plan required catheter care every shift and specified that the urinary drainage bag should be maintained below the bladder level to facilitate urine flow. Staff interviews confirmed that the drainage bag should not have been in contact with the floor. The facility's policy also required appropriate treatment and services to prevent urinary tract infections.
Deficiencies in Snack Distribution and Food Handling Practices
Penalty
Summary
The facility failed to ensure that physician-ordered snacks were provided to residents and that food handling practices adhered to professional standards. During an observation of a food storage area, snacks intended for six residents were found in a refrigerator, dated from the previous day, indicating they had not been distributed as required. Additionally, a hard-boiled egg was improperly stored in the side door of the refrigerator without a container. The Social Service Director confirmed that the snacks should have been distributed the previous night, and the egg should have been properly stored. The facility's policy on Clinical Nutrition Documentation, which outlines the procedure for distributing snacks, was not followed. In a separate observation, staff were seen handling food and tableware inappropriately in the dining room. Staff members were observed using their bare hands to remove bread from a sandwich bag, thumbing the eating surfaces of dinner plates, and cupping the tops of glassware while serving residents. These actions were observed over two consecutive days and involved multiple residents. The Director of Nursing acknowledged that these practices were not in line with the facility's policy on Handling Tableware, which requires that eating surfaces remain uncontaminated during handling.
Failure to Provide Written Bed Hold Information
Penalty
Summary
The facility failed to provide written bed hold information to a resident's representative upon the resident's transfer to a hospital. The resident, who had severe cognitive impairment with a BIMS score of 6, was sent to the emergency room for evaluation due to abdominal distention and hyperactive bowel sounds. Although the nursing staff documented that the bed hold policy was sent with the emergency medical technician staff, there was no documentation in the clinical record indicating that the written notification was provided to the resident's representative. During interviews, the Director of Nursing (DON) acknowledged that the facility had not mailed the bed hold policy to the family and typically notified the family or patient representative by phone when the patient was cognitively impaired. The DON also mentioned that all residents and families receive a copy of the bed hold policy at the time of admission. However, the facility's policy requires providing the bed hold information in written form and/or by telephone conversation prior to transfer, which was not adhered to in this case.
Failure to Complete Care Area Assessment in Timely Manner
Penalty
Summary
The facility failed to complete the Care Area Assessment (CAA) for a resident in a timely manner, as required by regulations. The resident, who was admitted with diagnoses including dementia, a history of malignant neoplasm of the bladder, and chronic kidney disease, had an Admission Minimum Data Set (MDS) assessment completed on 7/2/2024. This assessment indicated the resident was cognitively intact but required substantial assistance for activities of daily living (ADLs) and had issues with urinary incontinence, dental care, and communication. These areas triggered the need for further evaluation and care planning. Despite the MDS assessment indicating the need for comprehensive care planning, the facility did not complete the resident's care plan within the required timeframe. The MDS Coordinator confirmed that the comprehensive care plan should have been completed within 14 days of the assessment reference date, but it was not. The facility's policy, based on the Resident Assessment Instrument Manual, required the CAA to be completed no later than 14 days after admission, with the care plan to be completed within 7 days after the CAA. This deficiency was identified during a record review and interview process.
Deficiency in Comprehensive Care Plans for Residents with Behavioral and Hospice Needs
Penalty
Summary
The facility failed to create a comprehensive person-centered care plan for two residents, one with behavioral issues and another receiving hospice care. Resident 5, who has a history of central nervous system disorder, diabetes, violent behavior, insomnia, psychotic disorder with delusions, anxiety disorder, and major depressive disorder, was on Risperidone for psychotic disorder. The care plan for Resident 5, dated 5/7/2024, included interventions such as administering psych medication, monitoring medication side effects, and social services visits. However, the care plan lacked personalization and did not incorporate the resident's preferences, such as enjoying baseball and old movies, as noted by the Social Service Director. Resident 24, who was receiving hospice care due to heart failure, COPD, and acute respiratory failure, also lacked a comprehensive care plan. Despite a significant change MDS assessment indicating hospice services and a physician's order confirming hospice admission, the medical record did not contain a care plan for hospice care. The MDS Coordinator acknowledged the absence of a hospice care plan, which should have included contact information and coordination with the hospice company. The facility's policy on comprehensive care plans emphasizes the need for person-centered plans with measurable objectives and timetables, which was not adhered to in these cases.
Failure to Update Resident Care Plans
Penalty
Summary
The facility failed to revise and update care plans for a resident, identified as Resident 18, who was residing in the memory care unit. The resident's diagnoses included dementia, intellectual disabilities, Down syndrome, depression, and congestive heart failure. The care plans were outdated and did not reflect the resident's current condition or preferences. For instance, the care plan for activities, dated January 2024, did not align with the resident's current activity preferences as indicated in the Minimum Data Set (MDS) assessment from May 2024. Additionally, the care plan inaccurately stated that the resident resided on a locked memory care unit and received specialized programming, which was not the case. Furthermore, the care plans included outdated information regarding the resident's health conditions. A care plan from May 2024 mentioned an eye infection and non-compliance with isolation, but there was no documentation of an eye infection at the time of the review. Similarly, a care plan from May 2024 indicated the presence of a pressure injury, yet there was no documentation or observation of such an injury during the survey. Interviews with the Director of Nursing and the Activity Director confirmed that the care plans were not updated as required. The facility's policy stated that comprehensive care plans should be reviewed and updated quarterly or more frequently if there are changes in the resident's condition, which was not adhered to in this case.
Failure to Implement Resident-Centered Activities Program
Penalty
Summary
The facility failed to implement an activities program that incorporated the resident's interests and hobbies for one of the residents reviewed. Resident 18, who has diagnoses including dementia, intellectual disabilities, Down syndrome, depression, and congestive heart failure, was observed multiple times lying in bed with the television positioned in a way that she could not see it. Despite having adequate hearing and documented activity preferences such as listening to music and being around animals, the resident was not engaged in these activities. The care plan indicated that the resident was cognitively impaired but capable of making decisions about activity involvement, preferring not to attend some group activities. Observations revealed that the resident's room lacked a pink card indicating her television preferences, and the television was not positioned for her to view. The Activity Director acknowledged that the resident should have been able to watch TV and that the pink list should have been in her room. The facility's policy stated that activities should meet the interests and well-being of residents, but this was not adhered to in the case of Resident 18, as evidenced by the lack of appropriate activity engagement and the improper setup of her room.
Improper Use of Mechanical Lift Leads to Resident Injury
Penalty
Summary
The facility failed to properly use a mechanical lift during a transfer, resulting in an accident involving Resident 9. The resident, who has diagnoses including paraplegia, obesity, and muscle weakness, was dependent on assistance for transfers. During a transfer from bed to wheelchair using a Hoyer lift, the lift tipped over, causing a 3-centimeter laceration to the resident's scalp. The incident occurred because the lift's legs were not extended or locked, leading to instability. The resident was sent to the emergency room for evaluation and returned with sutures and a headache. The incident was reported to the Indiana Department of Health, and interviews with staff revealed that CNA 12 and CNA 10 were involved in the transfer. CNA 10 indicated that CNA 12 did not extend or lock the lift's legs, which contributed to the accident. Both CNAs had completed competency checklists for using the Hoyer lift, with CNA 12 having completed annual training earlier in the year. The facility's policy on mechanical lift usage emphasizes the importance of extending the lift's legs for stability, which was not followed in this case.
Deficiencies in Nutrition and Hydration Management
Penalty
Summary
The facility failed to provide adequate nutritional interventions for Resident 24, who was observed to be thin and frail. Despite being identified as malnourished and underweight, with a body mass index of 15.8, the resident's nutritional needs were not adequately addressed. The resident experienced significant weight loss, with a 12.2% decrease in approximately two weeks, and interventions such as Ensure Clear supplements were inconsistently provided. The resident's care plan indicated nutritional risk, but no new nutritional recommendations were made during a period when the resident was not on hospice services, and the resident was eventually discontinued from nutritional monitoring. Resident 18 was observed with signs of dehydration, including dry and cracked lips and a coated tongue, and her water pitcher was not within reach. The resident, who required assistance with eating and drinking due to conditions such as dementia and Down syndrome, was left without adequate support to access fluids. Observations showed that the resident struggled to reach her water pitcher and was not assisted by staff during meal times, leading to insufficient fluid intake. The facility's policies on weight monitoring and hydration were not effectively implemented, as evidenced by the lack of timely interventions for significant weight changes and inadequate fluid provision. The Dietary Manager acknowledged that more options should have been implemented for Resident 24, and the Social Service Director noted the need for increased fluid intake for Resident 18. These deficiencies highlight a failure to adhere to the facility's own policies regarding nutrition and hydration management.
Failure to Follow Oxygen Therapy Orders and Storage Protocols
Penalty
Summary
The facility failed to follow physician's orders for oxygen use and appropriately store oxygen tubing for a resident receiving oxygen therapy. During observations, Resident 24 was seen with a nasal cannula draped over a wheelchair and later connected to an oxygen concentrator that was not turned on. The resident, who has chronic respiratory failure and COPD, was found with an oxygen saturation of 84 percent, which improved to 93 percent after the oxygen concentrator was turned on by LPN 13. The LPN was unaware that the resident had been placed in bed and had not transitioned from a portable oxygen tank to the concentrator. The resident's care plan indicated the need for continuous oxygen at 3 liters per minute, but this was not adhered to. Interviews revealed that the LPN responsible for the transition of oxygen was not aware of the resident's location and condition, and the CNA indicated that nasal cannulas should be stored in a respiratory bag when not in use. The facility's policy on oxygen storage and administration was not followed, as only staff educated on these procedures should manage and administer oxygen.
Infection Control Breach During Peri Care
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices during peri care for a resident. On July 22, 2024, two CNAs were observed providing peri care to a resident. CNA 3 washed her hands and applied gloves, while CNA 7 assisted in positioning the resident. CNA 3 used a soapy washcloth to clean the resident's groin area but failed to change the area of the washcloth between strokes, using the same area for multiple parts of the body. After cleaning, CNA 3 did not remove her gloves or perform hand hygiene before applying a clean brief and handling the resident's belongings, such as the pillow and clothes. During an interview, CNA 3 acknowledged that she did not remove her gloves and wash her hands as required by the facility's policy. The facility's policy, provided by the Social Service Director, outlines the steps for incontinence care, including using a separate area of the cloth for each stroke, removing gloves, and performing hand hygiene before applying clean linens or briefs.
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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