West Bend Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in South Bend, Indiana.
- Location
- 4600 W Washington Ave, South Bend, Indiana 46619
- CMS Provider Number
- 155355
- Inspections on file
- 26
- Latest survey
- March 13, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at West Bend Nursing And Rehabilitation during CMS and state inspections, most recent first.
A resident with multiple diagnoses, including dementia and anxiety, was prescribed Ativan to be given before dialysis sessions. Facility staff did not notify the resident's responsible party about the new medication or discuss its risks and benefits prior to administration, despite facility policy requiring such notification. Documentation only indicated that medications were reviewed, without specifying that Ativan was discussed.
A resident was administered Ativan prior to dialysis treatments without adequate assessment or documentation of behavioral need, following only a single reported incident of restlessness. Facility staff did not complete required behavioral assessments or monitor the resident's response to the medication, and the responsible party was not informed of its use. The resident was observed to be alert and without negative behaviors during this period, indicating the medication was used as a chemical restraint without sufficient justification.
A resident with dementia and anxiety was prescribed Ativan for use before dialysis, but staff failed to create a care plan addressing this psychotropic medication until more than two months after it was started, contrary to facility policy and best practices.
The facility failed to maintain sanitary conditions in its kitchen, dining rooms, and pantries, affecting all residents who consumed food from these areas. Observations revealed significant cleanliness issues, including buildup of substances on kitchen equipment, unsanitary conditions in dining areas, and inadequate food storage practices. Staff interviews highlighted a lack of clarity on cleaning responsibilities and food disposal, despite the existence of a cleaning schedule and adherence to the FDA Food Code.
A facility failed to maintain infection control standards during a dressing change for a resident with multiple health conditions. An LPN did not perform hand hygiene after removing a soiled dressing and placed clean supplies on the bed without a barrier, contrary to facility policy. The LPN later acknowledged these lapses in procedure.
A resident's surgical wound condition worsened, showing signs of infection, but the facility failed to notify the surgeon. Despite the resident's requests for dressing changes, the wound was not properly managed, and the facility's wound team made treatment changes without the surgeon's input. Interviews revealed a lack of communication and follow-up, with the surgeon's office confirming they were not informed of the condition change.
The facility failed to provide the required Notice of Transfer/Discharge forms for two residents transferred to an acute care facility. One resident, with chronic conditions, was sent to the ER unresponsive, and although her husband was notified, the necessary documentation was missing. Another resident, transferred due to back pain and vomiting, also lacked documented transfer paperwork for two hospitalizations. The absence of documentation was confirmed by the Administrator.
The facility failed to provide the Bed Hold Policy to two residents during hospital transfers. One resident, with chronic conditions, was sent to the ER unresponsive, and her husband was notified, but no documentation of the policy was provided. Another resident, hospitalized twice, did not recall receiving the policy, and the record lacked documentation of its provision. The ED confirmed the absence of necessary transfer paperwork.
The facility failed to conduct timely Care Plan meetings with two residents, leading to a deficiency in care planning. One resident did not have Care Plan meetings following several MDS assessments, except for one conducted after an annual MDS assessment. Another resident did not have quarterly Care Plan meetings as required, despite having an intact cognition and multiple diagnoses. The facility's policy mandates timely meetings, which were not adhered to in these cases.
A facility failed to perform and document daily dressing changes for a resident with a surgical wound, as ordered by a physician. The resident reported that the dressing had not been changed for two days, and upon inspection, it was found to be dated four days prior with signs of infection. An LPN admitted to not changing the dressing and incorrectly signing off on the Treatment Administration Record. The facility could not provide a relevant policy when requested.
A resident with a surgical wound did not receive daily dressing changes as ordered by the physician. The dressing was not changed for two days, despite the resident's requests, and was found to be loose with drainage. An LPN failed to communicate the need for dressing changes to the evening shift, and the Treatment Administration Record was inaccurately signed. The DON noted the absence of a specific policy on following physician orders.
A resident was prescribed cephalexin for a UTI, but a lab report showed no bacterial growth, indicating the antibiotic was unnecessary. The facility failed to notify the NP to discontinue the medication until five days after receiving the lab results, leading to a deficiency.
A resident with a history of hemiplegia, diabetes, and anxiety did not receive fresh ice water as per his preference, impacting his hydration needs. Despite the facility's policy to provide fresh water to all residents, the resident had to request water from the nurse's station, and his care plan did not address his preference for fresh ice water. Observations confirmed the absence of water in his room, and a CNA stated she only provided water upon request.
Failure to Notify Responsible Party of New Medication Prior to Administration
Penalty
Summary
The facility failed to ensure timely notification of a resident's responsible party regarding the initiation of a new medication, Ativan, and the associated risks and benefits prior to its administration. Interviews with the Social Service Director at a local dialysis center revealed that the resident, who had diagnoses including Alzheimer's disease, vascular dementia, chronic kidney disease, and adjustment disorder with anxiety, was prescribed Ativan to be administered before dialysis sessions. The dialysis center staff observed the resident arriving lethargic and requested discontinuation of the medication after several weeks. Documentation showed that the responsible party was not informed about the new medication at the time of its initial administration, and the addition of Ativan was not discussed during a care plan meeting, despite a note indicating that medications were reviewed. Further interviews with the Memory Care Director, Assistant Director of Nursing, and Director of Nursing confirmed that the responsible party was not notified about the prescription of Ativan prior to its administration. The only documentation of notification was a care plan note stating that medications were reviewed, but it did not specify that Ativan had been discussed. The facility's policy required that all changes in a resident's condition, including new medications, be communicated to the responsible party prior to the end of the assigned shift, with documentation of the notification and response. This policy was not followed in this instance, resulting in a deficiency.
Failure to Prevent Unnecessary Use of Psychotropic Medication as Chemical Restraint
Penalty
Summary
The facility failed to ensure that a resident was free from chemical restraint when Ativan, a psychotropic medication, was administered prior to off-site dialysis treatments without adequate assessment or documentation of need. The medication was prescribed following a single report of the resident being 'figgity' and pulling at his dialysis port, but there were no further documented incidents of negative behaviors or agitation. Despite this, Ativan was ordered and administered three times weekly before dialysis appointments for several months. Interviews with facility staff, including the Memory Care Director and Assistant Director of Nursing, revealed that no behavioral assessments were completed prior to the initiation of Ativan, nor were there follow-up assessments to monitor the resident's response or potential side effects. The Psychiatric Nurse Practitioner prescribed the medication based on a request from the Director of Nursing, who had been informed by the dialysis center of the resident's agitation. However, the only documented behavioral incident was from several weeks prior, and subsequent observations showed the resident to be alert, well-groomed, and without negative behaviors. The dialysis center later reported that the resident was arriving lethargic and that the responsible party was unaware of the Ativan use. The facility's own policy required assessment and documentation of symptoms and therapeutic goals prior to initiating psychotropic medications, but this was not followed. The lack of assessment, documentation, and monitoring led to the administration of a psychotropic medication without clear evidence of medical necessity, resulting in the resident being chemically restrained.
Failure to Timely Develop Care Plan for Psychotropic Medication Use
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan in a timely manner for a resident who was prescribed an anti-anxiety medication, Ativan, to be administered prior to dialysis sessions. The resident had multiple diagnoses, including Alzheimer's disease, vascular dementia, chronic kidney disease, and adjustment disorder with anxiety. The order for Ativan was given by the Psychiatric Nurse Practitioner following a request from the Memory Care Director, and the medication was administered regularly as prescribed. However, review of the resident's clinical record and care plans revealed that a care plan addressing the use of Ativan for anxiety was not initiated until over two months after the medication was started. Interviews with facility staff, including the Assistant Director of Nursing and the Director of Nursing, confirmed that a care plan should have been created immediately after the Ativan was ordered, but this was not done. The facility's policy on psychotropic management requires that symptoms and therapeutic goals be documented prior to initiating such medications, and that care plans be developed to promote the resident's highest practicable well-being. The lack of a timely care plan for the use of Ativan constituted a failure to meet these requirements.
Sanitation Deficiencies in Kitchen and Dining Areas
Penalty
Summary
The facility failed to maintain sanitary conditions in its kitchen, dining rooms, and pantries, affecting all 57 residents who consumed food from these areas. During a series of observations, surveyors noted significant cleanliness issues, including a thick buildup of black substance on the burner grates and grease accumulation on the gas range and surrounding areas. Additionally, a ceiling vent above a prep table was covered in a black substance resembling mold, and the handwashing sink was dirty with a red dried substance. The Culinary and Nutrition Manager acknowledged the need for cleaning, despite the existence of a cleaning checklist. In the dining areas, further unsanitary conditions were observed. The 2nd Floor Dining Room had a range and oven with food debris and grease buildup, which staff acknowledged should be cleaned by the kitchen. The Main Dining Room had a leaking ice machine with lime buildup and dirty walls, and several chairs had food debris on them. The Housekeeping Supervisor and Maintenance Director confirmed the issues, with responsibilities for cleaning divided between kitchen and housekeeping staff. In the pantries and kitchenettes, food storage practices were inadequate. Expired and undated food items were found, including hot chocolate, condiments, yogurt, and pizza sauce, some of which were leaking. Staff interviews revealed a lack of clarity on responsibilities for discarding expired items and cleaning. The Executive Director and Corporate Nurse indicated the facility followed the FDA Food Code but lacked a specific policy for kitchen maintenance. A cleaning schedule was provided, but it was not effectively implemented, leading to the observed deficiencies.
Infection Control Breach During Dressing Change
Penalty
Summary
The facility failed to maintain acceptable infection control standards during a surgical dressing change for a resident. During the observation, an LPN removed a soiled dressing from the resident's wound, then removed her gloves and donned a new pair from her uniform pocket without performing hand hygiene. Additionally, the LPN placed the clean dressing supplies directly on the resident's bed without using a barrier, which is against the facility's policy. The resident involved had multiple diagnoses, including chronic hematogenous osteomyelitis, infection following a procedure, chronic obstructive pulmonary disease, chronic diastolic heart failure, and peripheral vascular disease, among others. During an interview, the LPN acknowledged that she should have washed her hands after removing the soiled dressing and should have used a barrier for the dressing supplies. The facility's policy on dressing change clean technique, provided by the DON, specifies the need for a clean field and hand hygiene, which were not followed in this instance.
Failure to Notify Surgeon of Wound Condition Change
Penalty
Summary
The facility failed to notify a resident's surgeon of a change in the condition of a surgical wound, which was a requirement for one of the residents reviewed for skin conditions. The resident, who had undergone a left above-the-knee amputation revision and treatment for a wound infection, reported that her dressing had not been changed for two days, despite her requests to the evening shift staff. Upon observation, the dressing was found to be loose, with a large amount of reddish-brown drainage, and the wound showed signs of infection, including redness and an open area. The resident's medical history included chronic hematogenous osteomyelitis, chronic obstructive pulmonary disease, chronic diastolic heart failure, and peripheral vascular disease, among other conditions. The facility's records indicated that the wound had initially been well-approximated with no signs of infection. However, subsequent assessments showed a worsening condition, with the wound dehiscing and showing signs of infection. Despite these changes, the surgeon was not notified, and the facility's wound team and nurse practitioner made treatment changes without the surgeon's input. Interviews with facility staff revealed a lack of communication and follow-up regarding the notification of the surgeon. The LPN responsible for notifying the surgeon did not confirm whether the surgeon had received the notification or provided any treatment recommendations. The surgeon's office confirmed that they had not been contacted about the change in the wound's condition, and the facility's documentation did not include any record of communication with the surgeon regarding the changes in the resident's wound condition.
Failure to Provide Transfer/Discharge Documentation
Penalty
Summary
The facility failed to provide the required Notice of Transfer/Discharge form when residents were transferred to an acute care facility. For Resident 4, who had diagnoses including chronic obstructive pulmonary disease, respiratory failure, and heart failure, the record review showed that after being found unresponsive, the resident was sent to the emergency room. Although the resident's husband was notified by phone, there was no documentation that the Notification of Transfer/Discharge form was provided to either the resident or her husband. An interview with the Executive Director confirmed the absence of transfer paperwork in the resident's records. Similarly, for Resident 16, who was transferred to the hospital due to lower back pain and vomiting, the facility did not document the completion of a transfer/discharge assessment or provide the necessary forms. Despite the family and primary care physician being notified of the transfer, the records lacked documentation of the transfer paperwork for two separate hospitalizations. The Administrator confirmed the absence of the required documentation, and no policy regarding the documentation of a transfer/discharge assessment was provided during the survey.
Failure to Provide Bed Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to provide a copy of the Bed Hold Policy to residents when they were admitted to the hospital, as required. This deficiency was identified for two residents who were reviewed for hospitalization. Resident 4, who had diagnoses including chronic obstructive pulmonary disease, respiratory failure, and heart failure, was found unresponsive and sent to the emergency room. Although her husband was notified by phone of the transfer, there was no documentation that the Bed Hold Policy was provided to either the resident or her husband. Additionally, the facility's Executive Director (ED) confirmed the absence of transfer paperwork, including the Transfer/Discharge form for Resident 4. Similarly, Resident 16, who had been hospitalized twice in the last four months, did not recall receiving a bed hold policy. The nursing progress notes indicated that Resident 16 was sent to the emergency department due to lower back pain and vomiting, and later admitted to the hospital. Despite the notifications to the Director of Nursing, the resident's family, and the Primary Care Physician, the record lacked documentation that the Bed Hold Policy was provided during the transfers. The ED acknowledged the absence of transfer paperwork, including the notice of transfer and bed hold policy paperwork, and provided the current Bed Hold Policy, which mandates that residents be given the policy at the time of hospital transfer or therapeutic leave.
Failure to Conduct Timely Care Plan Meetings
Penalty
Summary
The facility failed to conduct timely Care Plan meetings with residents and/or their representatives for two residents, leading to a deficiency in care planning. Resident 47 did not have Care Plan meetings following several Minimum Data Set (MDS) assessments, except for one conducted after the annual MDS assessment in February 2024. Despite regular meetings with the Social Services Director, formal Care Plan meetings were not held as required. The Executive Director confirmed the lack of regular Care Plan meetings for Resident 47 after MDS assessments. Similarly, Resident 38 did not have Care Plan meetings on a quarterly basis as required. Despite having an intact cognition and a diagnosis of hypertension, general anxiety disorder, and depression, there was no documentation of Care Plan meetings from June 2024 through December 2024. The Social Service Director acknowledged the absence of formal Care Plan meetings after the quarterly assessments in August and November 2024. The facility's policy, dated August 2023, mandates that the Interdisciplinary Team (IDT) meet with residents and/or their representatives at a mutually agreed time and location, which was not adhered to in these cases.
Failure to Perform and Document Dressing Changes
Penalty
Summary
The facility failed to meet professional standards of quality care by not ensuring that a resident's dressing changes were completed as ordered. During an observation and interview, the resident reported that her dressing, which was supposed to be changed daily, had not been changed for two days. The dressing was dated four days prior, and upon inspection, it was found to have a large amount of reddish-brown thick drainage, an opening in the center of the wound, and erythema around the surgical site. The resident had requested the dressing change to be completed later in the day due to outings, but it was not done. A review of the resident's records showed a physician's order for daily dressing changes, which were documented as completed on the Treatment Administration Record for the days in question. However, during an interview, the LPN admitted to not changing the dressing and acknowledged that the dressing changes should not have been signed off as completed. The facility was unable to provide a policy regarding the dressing change procedure when requested.
Failure to Follow Physician's Order for Dressing Change
Penalty
Summary
The facility failed to ensure that a resident received treatment per the physician's order, specifically regarding the changing of a dressing on a surgical wound. The resident, who had a left above-the-knee amputation, was supposed to have her dressing changed daily. However, during an observation and interview, the resident indicated that the dressing had not been changed for the past two days, despite her requests to the evening shift staff. The dressing was dated four days prior, and upon inspection, it was found to be loose with a large amount of reddish-brown thick drainage, and the wound area was red and open. The resident's medical history included chronic hematogenous osteomyelitis, infection following a procedure, and other chronic conditions. The physician's order specified a detailed dressing change procedure, which was not followed. An LPN acknowledged that the dressing change was not communicated to the evening shift, and the Treatment Administration Record was inaccurately signed as completed. The Director of Nursing indicated that there was no specific policy on following physician orders, only a standard practice.
Failure to Discontinue Unnecessary Antibiotic
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary antibiotic medication, leading to a deficiency. Resident 41, who had diagnoses including acute osteomyelitis of the left ankle and foot and a stage 2 pressure ulcer on the left heel, was prescribed cephalexin for a urinary tract infection. The antibiotic was ordered on 11/28/2024 and was supposed to be discontinued on 12/4/2024. However, a lab report dated 11/30/2024 indicated no bacterial growth in the urine specimen, suggesting that the antibiotic was no longer necessary. Despite this, the facility did not notify the Nurse Practitioner to discontinue the antibiotic treatment until 12/5/2024, five days after the lab results were received. The Infection Preventionist confirmed that it was standard practice to stop antibiotics based on such lab results.
Failure to Provide Fresh Ice Water to Resident
Penalty
Summary
The facility failed to ensure that a resident received fresh ice water according to his preference, which was necessary to maintain proper hydration. Resident 21, who had a history of hemiplegia, hemiparesis, type 2 diabetes mellitus with hyperglycemia, and anxiety disorder, expressed during interviews that he did not receive fresh ice water daily as he desired. He reported that the last time water was delivered to his room was on two specific dates in November, and he had to go to the nurse's station to request water. Observations confirmed the absence of a water cup in his room. The resident's care plan, which required assistance or monitoring of nutrition, hydration, and elimination, did not address his preference for fresh ice water. A CNA indicated that she only provided water to residents who requested it and did not leave water in rooms unless asked. The facility's Hydration Management policy, which was revised in 2017, stated that fresh water or other preferred beverages should be passed to all residents on each shift unless medically contraindicated. However, this policy was not followed for Resident 21, leading to the deficiency.
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.
The facility failed to ensure timely electronic transmission of MDS assessment data to CMS for a resident. Record review showed an annual MDS that was more than 120 days overdue for submission. The MDS coordinator reported that two care area assessments on the annual MDS had remained incomplete until just before surveyor review, at which time the MDS was finished and submitted. The Administrator acknowledged there was no facility policy in place governing MDS transmissions.
Surveyors found that MDS assessments were inaccurately coded for two residents. One resident with a prior Level II PASARR for serious mental illness was incorrectly coded on the Annual MDS as not having a serious mental illness or related condition. Another resident with generalized anxiety disorder, major depressive disorder, and dementia, who was receiving Lorazepam for anxiety, was not coded with an active anxiety disorder diagnosis on the Quarterly MDS, despite active orders documented on the MAR. The MDS coordinator acknowledged both coding errors, and leadership reported there was no facility-specific MDS policy, relying instead on the RAI manual.
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 Timely Transmit MDS Assessment Data to CMS
Penalty
Summary
The facility failed to ensure timely electronic transmission of MDS (Minimum Data Set) assessment data to the CMS system for one resident. Review of the clinical record for Resident 36 on 4/9/26 showed an annual MDS assessment dated 2/23/26 that was more than 120 days overdue for submission to CMS. During an interview on 4/10/26 at 11:22 a.m., the MDS coordinator stated she still had two care area assessments left to complete on the annual MDS assessment and that she had just finished them and submitted the MDS to CMS, indicating the assessment had not been completed and transmitted within the required timeframe. In a separate interview on 4/10/26 at 12:05 p.m., the Administrator reported that the facility did not have a policy regarding MDS transmissions, further demonstrating the lack of an established process to ensure that MDS data were encoded and transmitted to the State and CMS within the required time limits.
Inaccurate MDS Coding for Mental Health and PASARR Status
Penalty
Summary
The deficiency involves the facility’s failure to ensure that MDS assessments accurately reflected residents’ clinical status for two residents. For one resident with diagnoses including bipolar disorder and anxiety, the Annual MDS dated 3/11/26 indicated the resident was not considered by the state Level II PASARR process to have a serious mental illness or intellectual disability/related condition, despite a Level II PASARR having been completed on 3/31/23. This discrepancy was identified through record review and confirmed in an interview with the MDS coordinator, who acknowledged that the MDS assessment did not accurately reflect the existing Level II PASARR information. For another resident with generalized anxiety disorder, major depressive disorder, and dementia, the Quarterly MDS dated 3/30/26 did not code anxiety as an active diagnosis. However, review of the MAR showed active orders as of 2/27/26 for Lorazepam, prescribed for generalized anxiety disorder, and the RAI manual specifies that active diagnoses should be identified using sources such as medication sheets and physician orders during the 7-day look-back period. In an interview, the MDS coordinator confirmed that the resident did have an active anxiety disorder diagnosis and that the MDS should have been coded “yes” for anxiety disorder but was incorrectly coded “no.” The Administrator and MDS coordinator also stated the facility did not have an MDS policy and relied on the RAI manual for completing assessments.
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