Westpark A Waters Community
Inspection history, citations, penalties and survey trends for this long-term care facility in Indianapolis, Indiana.
- Location
- 1316 N Tibbs Ave, Indianapolis, Indiana 46222
- CMS Provider Number
- 155389
- Inspections on file
- 29
- Latest survey
- October 10, 2025
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Westpark A Waters Community during CMS and state inspections, most recent first.
A resident with GERD was found to have a chewable calcium carbonate tablet left unattended at bedside without an assessment or documentation supporting their ability to safely self-administer medication, contrary to facility policy requiring interdisciplinary evaluation and physician order.
Three residents did not receive scheduled doses of controlled medications, including pain and anti-anxiety drugs, due to the facility's failure to timely reorder and obtain prescriptions from the pharmacy. Missed doses were documented for residents with significant pain and psychiatric needs, and staff interviews confirmed delays in medication reordering and supply.
Multiple residents reported and were observed experiencing long delays in call light response, lack of engagement from staff and management, and disrespectful or dismissive behavior from staff, including refusal to assist with personal hygiene and derogatory remarks. Staff were also observed failing to follow privacy protocols and not providing timely care, resulting in residents feeling neglected and devalued.
Staff were unable to administer all prescribed medications to three residents due to unavailability of medications in the medication cart, Cubex, and overflow cart, resulting in a medication error rate of 29%. The DON and an LPN confirmed that pharmacy delivery delays were a recurring problem, causing residents to miss multiple essential medications during observed medication passes.
Twelve residents, many with complex medical conditions, reported that meals were repetitive, poorly seasoned, sometimes cold, and served in small portions. Residents described food as unappetizing, with some noting spoiled smells, tough meat, and overcooked or flavorless items. Direct observation confirmed issues with meal presentation and preparation.
A resident with dementia, congestive heart failure, and a history of myocardial infarction was discharged to another LTC facility without proper documentation in the EHR, including the absence of a physician's discharge order and required notifications, as mandated by facility policy.
A resident with paraplegia and major depressive disorder, who was cognitively intact, was not invited to any care plan meetings after admission, with only one meeting documented. Although a quarterly care plan meeting was scheduled, it was cancelled and not rescheduled, and the facility could not provide a reason for this. Facility policy requires quarterly review and resident notification for care plan meetings, but these steps were not followed.
A resident with multiple health conditions and limited mobility was not provided timely perineal care despite being care planned for assistance. The resident reported difficulty cleaning himself after a bowel movement and stated that staff refused to help, resulting in prolonged discomfort. Staff failed to respond promptly to his requests, and a QMA indicated the resident should clean himself, contrary to the care plan and facility policy.
Two residents did not receive medications as ordered: one received cardiac medications despite vital signs outside prescribed parameters, and another missed multiple doses of both fast-acting and long-acting insulin without documented reasons. The DON and Nurse Consultant confirmed these deviations from physician orders and facility policy.
Two residents did not receive prescribed medications as ordered due to delays in pharmacy delivery and lack of availability in the facility's medication dispensing system. One resident missed several doses of trazodone for insomnia, while another did not receive a scopolamine patch for nausea as scheduled. These lapses occurred despite facility policy requiring timely pharmacy services.
A resident with a history of substance use and depression was given half of a 10 mg oxycodone tablet when the ordered 5 mg dose was unavailable. An LPN saved the remaining half tablet in the narcotics lock box instead of destroying it in the presence of two licensed staff, as required by policy. Documentation was incomplete, and the remaining half tablet was later administered by another staff member.
A resident with severe cognitive impairment, as documented in the clinical record and MDS assessment, electronically signed a binding arbitration agreement during admission. Facility staff reported that admission paperwork, including the arbitration agreement, could be signed electronically by residents even when no guardian or family member was present, leading to the agreement being signed without proper assessment of the resident's capacity.
Staff failed to follow infection control protocols during medication administration, including not performing hand hygiene before resident contact, not donning new gloves before handling medications, touching medications with bare hands, administering medications after they were dropped on a cart, and not disinfecting insulin pen hubs prior to use for three residents. Facility policies requiring hand hygiene and proper glove use were not followed.
The facility failed to maintain the floors in good repair, affecting all 39 residents. An environmental tour revealed cracks, broken tiles, and improperly installed vinyl flooring in various areas. Interviews with residents and staff confirmed the flooring issues, with descriptions of bumpy and uneven surfaces. The facility's leadership acknowledged the problems, attributing them to the building's age and improper installation.
The facility failed to ensure food items were stored closed and labeled with open dates, potentially affecting 38 of 39 residents. Several food items in the refrigerators and freezers were found opened and not labeled with open dates, contrary to the facility's food storage and date marking policies.
The facility failed to immediately notify the Administrator of abuse allegations for two residents. One resident reported being physically abused by another resident, and another reported verbal abuse by a roommate. Both incidents were not promptly reported to the Administrator, violating the facility's abuse prevention policy.
A facility failed to provide scheduled showers as per a resident's care plan and preferences. Despite the resident's cognitive intactness and preference for showers, records showed inconsistencies with the care plan, indicating a failure to adhere to the resident's needs and preferences.
The facility failed to administer medications and monitor conditions as ordered for three residents. One resident did not receive Haloperidol as per the Psyche NP's recommendation, another resident's elevated blood sugar levels were not rechecked as required, and a third resident's blood pressure was not monitored before administering metoprolol.
A resident with type 2 diabetes mellitus, who had signed a consent for vision services, reported vision problems and a desire to see an eye doctor. Despite vision services being available, the resident was not seen during the scheduled visit. The Social Services Director confirmed the consent but cited delays with the vision service provider.
The facility failed to provide dental services for two residents with type 2 diabetes mellitus, despite signed consents and observed dental issues. The Social Services Director was unaware of one resident's dental problems and had not followed up on the other's pending payer source status.
Failure to Assess Resident for Safe Self-Administration of Medication
Penalty
Summary
A resident with a diagnosis of gastro-esophageal reflux disease (GERD) was observed to have a medication cup containing a pink tablet, identified as a chewable calcium carbonate tablet (TUMS), left unattended on their bedside table. The resident was not present in the room during the observations, nor was any staff member. The medication was ordered to be administered three times daily, but there was no documentation or assessment indicating that the resident had been evaluated for the ability to safely self-administer medications. The Director of Nursing confirmed that no self-administration assessment had been conducted for this resident and acknowledged that medications should not have been left at the bedside. Facility policy requires an interdisciplinary assessment and physician order before allowing residents to self-administer and store medications in their rooms, but this process was not followed in this instance.
Failure to Timely Obtain and Administer Controlled Medications
Penalty
Summary
The facility failed to ensure that controlled medications were obtained and available for administration to three residents as ordered by their physicians. For one resident with a history of GERD and recent bilateral leg fractures, hydrocodone-acetaminophen was not available for several scheduled doses, resulting in missed pain medication. The resident reported that the facility often ran out of her pain medication, and the DON confirmed that staff were not reordering medications in a timely manner when supplies were low. Another resident with chronic pain due to migraine and sciatica missed multiple scheduled doses of oxycodone, with documentation showing several instances where the medication was not administered as ordered. The resident reported severe pain during these periods without medication. A third resident, with diagnoses including anxiety and schizoaffective disorder, did not receive scheduled doses of clonazepam on multiple occasions due to delays in reordering and waiting for a new prescription. The DON acknowledged that the medication had not been reordered timely, and the facility's policy required a valid prescription before narcotics could be ordered from the pharmacy.
Failure to Ensure Resident Dignity and Timely Response to Needs
Penalty
Summary
The facility failed to ensure that residents were treated with dignity and respect, as evidenced by multiple observations, interviews, and record reviews involving 15 residents. Several residents reported that staff did not engage with them or listen to their concerns, with one resident stating that management prioritized budget over resident needs and rarely interacted with residents. During a resident council meeting, numerous residents agreed that call lights often went unanswered for extended periods, sometimes over thirty minutes, and that staff would sometimes turn off call lights without providing assistance, leaving residents feeling helpless and undervalued. One resident expressed that the long wait times for assistance made him feel like he wanted to die. Direct observations confirmed that call lights were left unanswered for significant periods, with staff walking past without responding. In one instance, a resident waited in her wheelchair for over 30 minutes after activating her call light before receiving assistance. Residents also reported overhearing staff discussing spending time on their phones instead of providing care. Additionally, there were reports of staff making disrespectful or derogatory remarks to residents, such as calling a resident a drug addict and dismissing their pain complaints. Some staff were described as rude, and management was noted to rarely leave their offices to check on resident needs. Further deficiencies included staff failing to provide necessary personal care, such as refusing to assist a resident with hygiene needs after a bowel movement, stating it was not their job. Observations also noted that staff did not consistently follow facility policies for maintaining resident privacy and dignity, such as knocking and announcing themselves before entering rooms. The facility's own dignity policy outlined expectations for respectful communication and prompt care, but these standards were not consistently met, as evidenced by the findings.
Medication Availability Failures Lead to High Medication Error Rate
Penalty
Summary
The facility failed to ensure that prescribed medications were available and administered as ordered, resulting in a medication error rate of 29% during observed medication passes. On multiple occasions, staff, including an LPN and the DON, were unable to locate or obtain several prescribed medications for three residents. These medications were not available in the medication cart, Cubex machine, or overflow cart, and had been previously reordered from the pharmacy but had not yet been delivered. As a result, residents did not receive all of their prescribed morning medications. Specifically, one resident did not receive four of thirteen prescribed medications, another did not receive six of fourteen, and a third was missing at least one medication. The DON confirmed that delays in pharmacy delivery were a recurring issue, often requiring additional follow-up with the pharmacy. The observed medication administration errors involved missing essential medications such as vitamins, inhalers, patches, and other prescribed drugs, directly leading to the cited deficiency.
Failure to Provide Palatable and Properly Prepared Food
Penalty
Summary
The facility failed to provide palatable, attractive, and appropriately prepared food for 12 of 14 residents reviewed. Multiple residents, all cognitively intact, reported dissatisfaction with the quality, taste, and variety of the food served. Specific complaints included repetitive menus, poor taste, lack of seasoning, and food being served cold or in small portions. During a resident council meeting, several residents agreed that the food quality had declined, possibly due to a change in suppliers. Direct observation of a test tray revealed unappetizing presentation, overcooked noodles with a slimy texture, and missing components such as cheese on the chicken parmesan. Residents with significant medical histories, including hypertension, congestive heart failure, diabetes, malnutrition, and chronic obstructive pulmonary disease, reported issues such as spoiled-smelling meat, tough and inedible meat, soggy and flavorless food, and insufficient portion sizes. One resident noted weight loss since admission, attributing it to inadequate food portions. Another resident stated that the food was often cold and tasted bad. These findings were based on interviews, record reviews, and direct meal observations.
Failure to Document Resident Discharge and Required Notifications
Penalty
Summary
A deficiency occurred when the facility failed to adequately document the discharge process for a resident with diagnoses including congestive heart failure, dementia, and myocardial infarction. The resident was admitted to the facility and later discharged to another LTC facility. Although a care plan meeting note indicated discussions about alternative living arrangements due to the resident's dementia and need for 24-hour supervision, and a Discharge MDS assessment noted the discharge, there was no documentation of a physician's discharge order in the electronic health record (EHR). Additionally, there was no other documentation or discussion of discharge or discharge planning found in the resident's EHR. The facility's policy requires a physician's order for discharge and documentation of notifications to the resident, responsible party, and family members, but these steps were not documented for this resident. The Regional Director of Operations confirmed that no additional discharge documentation was available.
Failure to Conduct Quarterly Care Plan Meetings
Penalty
Summary
The facility failed to ensure that care plan meetings were conducted quarterly for a resident with diagnoses including paraplegia and major depressive disorder. Review of the clinical record showed that the resident was cognitively intact and had not been invited to any care plan meetings since admission in January, with only one care plan meeting progress note available from late January. The MDS Nurse confirmed that a quarterly care plan meeting scheduled after late April had been cancelled and was not rescheduled, and could not provide a reason for this lapse. Facility policy requires that residents be notified and encouraged to attend care plan conferences, and that comprehensive care plans be reviewed and updated at least quarterly, but no evidence was provided that these requirements were met for this resident.
Failure to Provide Timely Perineal Care for Dependent Resident
Penalty
Summary
A deficiency was identified when staff failed to provide timely perineal care to a resident who was unable to perform this activity independently. The resident, who had diagnoses including chronic obstructive pulmonary disease, chronic heart failure, pulmonary embolism, weakness, vertigo, and difficulty walking, was documented as needing assistance with toileting hygiene and perineal care according to his care plan. Despite these documented needs, the resident reported difficulty reaching his bottom to wipe after a bowel movement and stated that staff told him it was not their job to help him. The resident further indicated that he still had stool on his bottom from the previous day, causing discomfort, and that his request for assistance from a CNA was not fulfilled in a timely manner. Observation confirmed that no staff entered the resident's room after his request for help, prompting him to activate his call light. A Qualified Medication Aide eventually entered the room but expressed the belief that there was no reason the resident could not clean himself. The facility's policy required staff to provide routine and as-needed assistance with activities of daily living, including perineal care, as outlined in the resident's care plan. The failure to provide this assistance as required led to the identified deficiency.
Failure to Follow Medication Administration Parameters and Orders
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders and established parameters for two residents. For one resident with diagnoses including hypertension and congestive heart failure, digoxin and metoprolol were administered despite physician orders specifying that these medications should be held if the resident's pulse was below 60 beats per minute. Documentation showed that on multiple occasions, both medications were given when the resident's pulse was below the prescribed threshold. The Director of Nursing confirmed that these medications should have been withheld under those circumstances. For another resident with a history of substance use and major depressive disorder, insulin orders were not followed as prescribed. The resident was to receive both fast-acting and long-acting insulin at specific times, but the Medication Administration Record indicated several missed doses without documentation explaining the omissions. The Nurse Consultant was unable to provide any reason for the missed insulin administrations. The facility's Medication Administration Policy required vital signs to be obtained as necessary and medications to be administered as ordered, but these procedures were not followed in these cases.
Failure to Provide Timely Pharmacy Services for Medications
Penalty
Summary
The facility failed to ensure that medications were received in a timely manner from the pharmacy for two residents. One resident with diagnoses including hypertension and congestive heart failure had a physician's order for trazodone to be administered nightly for insomnia. According to the Medication Administration Record, this resident did not receive the prescribed trazodone for three consecutive days because the medication was not delivered from the pharmacy and was not available in the facility's medication dispensing system. Another resident with dysphagia and a history of aspiration pneumonia, who was dependent on a feeding tube, had a physician's order for a scopolamine transdermal patch to be applied every 72 hours for nausea. The Medication Administration Record indicated that the patch was not applied on two separate days due to it not being available, as it had not been sent to the facility in a timely manner after being reordered from the pharmacy. The facility's Pharmacy Services policy requires routine and timely pharmacy services, but this was not met in these instances.
Failure to Properly Destroy and Document Partial Dose of Controlled Substance
Penalty
Summary
A deficiency occurred when a partial dose of a controlled substance, oxycodone, was not destroyed and recorded in the presence of two licensed personnel as required by facility policy and federal regulations. A resident with a history of cocaine abuse, opioid use, and major depressive disorder, who was cognitively intact, had a physician's order for oxycodone 5 mg every six hours as needed for pain. On one occasion, the facility ran out of the 5 mg tablets, and an LPN obtained a one-time order to administer half of a 10 mg oxycodone tablet. The LPN split the tablet, administered half to the resident, and saved the remaining half in a medication cup stored in the narcotics lock box for later use, rather than destroying it as required. The Controlled Drug Receiving Record/Disposition Form showed that the half tablet was administered, but the record lacked the administering staff member's signature for the initial dose. The remaining half tablet was later administered and signed off by staff on the following shift. The LPN involved admitted to saving the half tablet for the next shift and forgetting to complete the narcotic record sheet. Facility policy, provided by the Nurse Consultant, specified that unused partial tablets must be destroyed and recorded in the presence of two licensed personnel, which was not followed in this instance.
Failure to Prevent Severely Cognitively Impaired Resident from Signing Arbitration Agreement
Penalty
Summary
The facility failed to ensure that a resident with severe cognitive impairment did not enter into a binding arbitration agreement. The clinical record review showed that the resident had a diagnosis including stroke and was assessed as severely cognitively impaired on the admission MDS. Despite this, the resident was able to make himself understood and respond to simple direct questions. On admission, the resident electronically signed a Voluntary Binding Arbitration Agreement, which included language stating that the agreement should not be submitted to a resident deemed incompetent by two physicians. Interviews with facility leadership revealed that there was not always a guardian or family member available to complete admission paperwork with the resident. The admission paperwork process allowed for electronic signing of all forms, including the arbitration agreement, regardless of the resident's capacity to make such decisions. This resulted in the resident with severe cognitive impairment signing the agreement without proper assessment of decision-making capacity or involvement of a legally authorized representative.
Infection Control Lapses During Medication Administration
Penalty
Summary
The facility failed to maintain proper infection control practices during medication administration for three residents. In one instance, an LPN was observed administering medications to a resident with hypertension and did not clean the medication cart before preparing medications. A capsule was dropped onto the cart and then picked up with bare hands and placed into a medication cup. The LPN also handled and opened capsules without performing hand hygiene or wearing gloves. The LPN stated she did not consider a pill dropped unless it fell on the floor and routinely opened capsules without gloves. In another case, the DON administered insulin to a resident with diabetes but did not cleanse the hub of the insulin pen before attaching the needle, although she performed hand hygiene and donned gloves. Additionally, during medication administration for a resident with chronic obstructive pulmonary disease and chronic bronchitis, the DON failed to perform hand hygiene after contact with high-traffic surfaces and before entering the resident's room. The DON also touched and moved pills with a gloved finger after administering a nasal spray, without changing gloves or performing hand hygiene. Facility policies required hand hygiene before and after glove use and before resident contact, as well as cleansing the insulin pen hub prior to use, but these were not followed.
Facility Fails to Maintain Floors in Good Repair
Penalty
Summary
The facility failed to maintain the floors in good repair, affecting all 39 residents. During an environmental tour, several areas of concern were noted, including cracks in the floor tiles, broken tiles, stained and dirty tiles, and improperly installed vinyl flooring. Specific locations with issues included hallways outside various rooms, the metal threshold between building sections, and the area by the janitors' closet. The cracks and damage varied in size, with some cracks extending up to 25 feet long and 3 inches wide, and divots in the floor measuring up to 2 inches by 2 inches and 1/4 inch deep. Interviews with residents and staff confirmed the flooring issues. One resident described the floors as being like a roller coaster in some parts of the building, while another mentioned the bumpy nature of the flooring. The Executive Director, Regional Director of Operations, and Director of Maintenance acknowledged that the building floors had settled, causing the cracks, and that the vinyl flooring had been installed improperly, leading to unevenness. Despite regular cleaning and waxing, some tiles remained permanently stained due to their age.
Failure to Properly Store and Label Food Items
Penalty
Summary
The facility failed to ensure food items were stored closed and labeled with open dates, potentially affecting 38 of 39 residents who consume food prepared in the kitchen. During an observation of the kitchen, several food items in the refrigerators and freezers were found opened and not labeled with open dates. Specifically, a half-full container of orange sherbet, a box containing individual lime sherbet containers, a bag of french fries, a bag of chicken, and a half-full bag of spring salad mix were all found without open dates. Cook 5 confirmed that all food items should be labeled with open dates and sealed shut. The facility's food storage policy and date marking policy both require that opened food items be labeled with the date they were opened and used by the safe food storage guidelines or the manufacturer's expiration date.
Failure to Immediately Report Abuse Allegations
Penalty
Summary
The facility failed to immediately notify the Administrator of an allegation of abuse for two residents. Resident 1 reported that another resident grabbed and kicked him in the back of his wheelchair. Although the incident was documented in a nursing progress note and a risk management entry, the Executive Director was not informed until two days later. The nurse responsible for the documentation assumed the Executive Director would find out through the risk management system, which was not the correct protocol. Resident 1 did not sustain any apparent injuries, but the delay in reporting the incident to the Administrator was a clear deficiency in the facility's abuse reporting procedures. In another case, Resident 28 reported verbal abuse by her roommate to a nurse, but this information was not relayed to the Executive Director or management staff. The verbal abuse incident, which occurred several months prior, was not reported to the Indiana State Department of Health until the Executive Director was informed during an interview. The facility's Abuse Prevention Program policy mandates immediate reporting of any abuse allegations to the Administrator, which was not followed in these instances. This delay in reporting and investigating the abuse allegations constitutes a significant deficiency in the facility's compliance with abuse prevention protocols.
Failure to Provide Scheduled Showers as Per Resident's Care Plan
Penalty
Summary
The facility failed to provide showers as care planned and preferred for a resident diagnosed with parkinsonism and tremors. The resident's care plan, initiated on 8/1/23, indicated a need for assistance with ADL care, including bathing per resident preference twice weekly and as needed. Despite the resident's preference for showers and his cognitive intactness, he reported not always receiving his scheduled showers. The resident believed his shower day was Friday, but the DON indicated his showers were scheduled for Wednesday and Sunday evenings. The CNA confirmed that the resident normally did not refuse showers. Review of the shower records for March and April revealed inconsistencies with the care plan. The resident received showers on 3/6, 3/9, 3/23, 3/27, and 3/30, a bed bath on 3/16, and refused a shower on 3/20. This did not align with the scheduled shower days, indicating a failure to adhere to the resident's care plan and preferences. The facility's ADL policy emphasizes providing care as planned and according to resident preferences, which was not consistently followed in this case.
Failure to Administer Medications and Monitor Conditions as Ordered
Penalty
Summary
The facility failed to clarify and administer a resident's medication as ordered, ensure physician orders were followed for a resident with elevated blood sugars, and monitor blood pressure as ordered prior to administering medication for three residents. Resident 10, diagnosed with paranoid schizophrenia, did not receive Haloperidol as per the Psyche NP's recommendation. The medication was incorrectly ordered for intramuscular administration, and an LPN changed the order without proper authorization, leading to the resident receiving an incorrect dosage and schedule of Haloperidol from 3/24/24 through 4/3/24. Resident 21, diagnosed with type 2 diabetes mellitus, had elevated blood sugar levels on two occasions. The physician's order required rechecking the blood sugar levels within 1-2 hours after administering insulin, but the clinical records did not indicate that these rechecks were performed. The Regional Nurse Consultant confirmed the absence of notations for the required rechecks on 3/6/24 and 3/7/24. Resident 11, diagnosed with hypertension and congestive heart failure, was to receive metoprolol twice daily with the condition to hold the medication if the systolic blood pressure was less than 100. The MAR indicated that the medication was administered as ordered, but there were no recorded blood pressures at the time of administration to ensure compliance with the physician's order. The DON confirmed that blood pressures should have been taken prior to administering the medication, but this was not done as required.
Failure to Provide Vision Services
Penalty
Summary
The facility failed to ensure vision services were provided for a resident with type 2 diabetes mellitus. The resident, who was admitted to the facility and had signed a consent for vision services, reported having trouble with his vision and expressed a desire to see an eye doctor. Despite vision services being available at the facility, the resident was not seen during the scheduled visit. The Social Services Director confirmed the consent but was unsure why the resident had not been seen, citing delays with the vision service provider.
Failure to Provide Dental Services
Penalty
Summary
The facility failed to ensure dental services were provided for two residents, both diagnosed with type 2 diabetes mellitus. Resident 38, admitted on an unspecified date, had signed a dental consent on 12/6/23 but had not seen a dentist since admission. An observation on 4/2/24 revealed Resident 38 had missing and broken teeth and was experiencing dental issues. Similarly, Resident 25, also admitted on an unspecified date, had signed a dental consent on 8/9/23 but had not received dental services. An observation on 4/2/24 showed Resident 25 had a dark, rotten front tooth and expressed a desire to see a dentist. Despite dental service visits on 3/22/24 and 4/3/24, neither resident was seen by the dental provider on those dates. The Social Services Director (SSD) confirmed that both residents had signed consents for dental services and acknowledged that it should take approximately a month to arrange routine dental services. However, she was unaware of Resident 38's dental issues until a care plan meeting on 4/2/24 and had not followed up on Resident 25's pending payer source status since receiving a dental report on 12/18/23. The facility's policy mandates providing medically related social services, including dental care, to maintain residents' well-being, but this policy was not adhered to in these cases.
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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