Wildwood Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Indianapolis, Indiana.
- Location
- 7301 E 16th St, Indianapolis, Indiana 46219
- CMS Provider Number
- 155334
- Inspections on file
- 43
- Latest survey
- January 9, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Wildwood Healthcare Center during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment and a history of stroke and heart failure was left unattended with medications by a nurse, contrary to facility policy requiring staff to observe medication consumption. The resident did not self-administer medications and brought the unattended medications to the night shift supervisor, who confirmed they were not his and disposed of them. Staff interviews confirmed the expectation that medications should not be left with residents.
A resident with a history of mental health diagnoses was subjected to verbal abuse by a CNA during a dispute over care. The resident and CNA exchanged derogatory language, with the CNA responding to the resident's insult by using the same term. The incident was witnessed by the resident's roommate, who confirmed the CNA's response. Facility staff were present or nearby but did not immediately address or report the verbal abuse allegation, resulting in a failure to protect the resident from staff verbal abuse.
A resident was moved to a different room without prior notification, contrary to the facility's policy. The move was intended to be temporary for renovations, but the resident was not returned to their original room. The Social Services Director did not complete the required notification, assuming the Unit Manager had informed the resident.
The facility failed to provide adequate assistance with ADLs for three residents. A resident with multiple sclerosis had conflicting care plans for bathing preferences, while another resident with diabetes had untrimmed fingernails despite willingness to have them cleaned. Additionally, a cognitively impaired resident was not shaved as required. These issues indicate a lack of adherence to care plans and necessary personal care.
A facility failed to follow a physician's order to hold insulin for a resident with low blood sugar and did not provide a pressure relief cushion for a resident at risk for skin issues. The resident received insulin despite low blood sugar readings, and another resident was observed without a necessary cushion in their wheelchair, contrary to care plans and facility policy.
The facility failed to apply a palm guard and initiate a ROM program for two residents. One resident with hemiparesis was observed without her prescribed splint and palm guard, while another resident with quadriplegia was not receiving restorative therapy despite a recommendation. The necessary documentation for restorative services was not provided, leading to a lack of care in maintaining or improving mobility.
A resident with a history of substance use disorder did not have a care plan addressing her needs, leading to an incident where she was found with low blood pressure and narcotics in her system. The facility failed to implement a care plan or obtain consent for treatment, despite the resident's history and facility policy.
The facility failed to ensure a medical storage room was free of expired supplies, including IV catheters and blood collection sets. An RN indicated that a pharmacy consultant checks for expired items quarterly, but was unaware why these items were not removed. The facility's policy states that medication storage conditions are monitored regularly.
A resident with multiple diagnoses, including type II diabetes and cognitive impairment, suffered a blistering burn on his hand due to the facility's failure to maintain and inspect a hydrocollator used in therapy. The hydrocollator had not been inspected since 2020, and its temperature was not checked before use. The Occupational Therapist did not follow the facility's procedure for using heat packs, resulting in the resident developing a blister after therapy.
A facility failed to change a resident's wound dressing twice daily as ordered by the physician. The resident, with a history of mental health disorders, had an open wound on the right elbow that was not properly managed, leading to increased drainage and a subsequent emergency room visit. The Orthopedic Nurse Practitioner confirmed the dressing had not been changed since a specific date, highlighting the facility's non-compliance with the treatment plan.
Failure to Ensure Proper Medication Administration
Penalty
Summary
A resident with a history of stroke and heart failure, and documented moderate cognitive impairment, was not administered medications according to facility policy. The resident reported that a nurse left medications on his bedside table and departed without ensuring the medications were taken. The resident then brought the medications to the night shift supervisor, who confirmed they were not his and disposed of them. The facility's policy requires that medications are not to be left unattended and that staff must observe residents consuming their medications. Interviews with staff confirmed that the resident does not self-administer medications and that it is the facility's expectation for staff to remain with the resident until medications are taken. The Director of Nursing acknowledged awareness of the incident, noting that the medications had been prepared by one LPN and returned to another, with an extra medication found in the cup. However, it was determined that no medication error occurred since the resident did not consume the incorrect medication. The incident demonstrated a failure to follow the facility's medication administration policy.
Failure to Protect Resident from Verbal Abuse by Staff
Penalty
Summary
A deficiency occurred when a resident, who was cognitively intact and had diagnoses including bipolar disorder, anxiety, depression, and attention deficit disorder, was subjected to verbal abuse by a staff member. The incident began when the resident requested assistance from a CNA, leading to a verbal altercation in which both the resident and the CNA exchanged derogatory language. The resident called the CNA a derogatory term, and the CNA responded in kind, using the same term towards the resident. This exchange was witnessed by the resident's roommate, who confirmed that the CNA did call the resident a derogatory name in retaliation. The facility's staff, including the Unit Manager and LPN, were present or nearby during the incident. The Unit Manager was informed by the resident that she did not want the CNA in her room anymore, but the resident was not interviewed about the specifics of the incident until the surveyor's visit. The Unit Manager stated she was unaware of the verbal abuse allegation and only knew the resident did not like the CNA. The CNA denied using derogatory language, but the roommate's account, both verbal and written, confirmed the CNA's use of inappropriate language. Other staff members, such as a Qualified Medication Aide, heard the CNA tell the resident not to call her a derogatory name but did not hear the CNA use the term herself. The facility's policy defines verbal abuse as the use of disparaging or derogatory language by staff towards residents. The incident was not immediately reported to facility leadership, and the resident was not promptly interviewed about the event. The exchange between the CNA and the resident, as corroborated by the roommate and other staff accounts, constituted a failure to protect the resident from verbal abuse as required by facility policy and regulatory standards.
Failure to Notify Resident of Room Change
Penalty
Summary
The facility failed to provide proper notification and documentation to a resident regarding a room change. Resident 23, who was cognitively intact and diagnosed with chronic obstructive pulmonary disease, was moved to a different room without prior notice. The resident discovered the change upon returning from lunch, finding their belongings moved to a room across the hall. The resident expressed a desire to return to their original room, but it was already occupied by other residents. The Social Services Director admitted to not notifying the resident about the room change, assuming the Unit Manager had done so. The move was intended to be temporary for room renovations, but the resident was not returned to their original room post-renovation. The facility's policy required Social Services to discuss room change options with residents and complete a Notification of Room Change in the electronic medical record, which was not done in this case.
Deficiencies in ADL Assistance and Care Planning
Penalty
Summary
The facility failed to ensure accurate care planning and assistance with activities of daily living (ADLs) for three residents. Resident 56, who is cognitively intact and diagnosed with multiple sclerosis, had conflicting care plans regarding their bathing preferences. The care plan indicated different days for showers, and during an interview, the resident expressed a preference for daily bed baths and showers on Fridays. This inconsistency in care planning was acknowledged by the Director of Nursing (DON), who noted that the care plan should have been updated. Resident 39, diagnosed with diabetes and other conditions, had long fingernails with a dark substance underneath, which were not trimmed or cleaned despite the resident's willingness. The DON indicated that it was the nurse's responsibility to trim the nails due to the resident's diabetic condition. Additionally, Resident 120, who is severely cognitively impaired and dependent on staff for personal hygiene, was observed with a moderate amount of facial hair over several days. The DON stated that CNAs were responsible for shaving the resident during baths, but this was not done. These deficiencies highlight a lack of adherence to care plans and failure to provide necessary personal care.
Failure to Follow Insulin Orders and Provide Pressure Relief Cushion
Penalty
Summary
The facility failed to adhere to a physician's order to hold insulin administration for a resident with diabetes when their blood sugar levels were below 100. Despite the order, the resident received seven units of Humalog insulin with meals on multiple occasions when their blood sugar readings were below the specified threshold. This oversight was confirmed through a review of the resident's medication administration record and an interview with the Director of Nursing, who acknowledged that the resident was the only one with such an insulin hold order. Additionally, the facility did not ensure that a resident at risk for skin alterations had an off-loading cushion in their wheelchair as care planned. The resident, who was cognitively intact and diagnosed with cerebral palsy, was observed sitting without the cushion on two separate occasions. The resident reported that the cushion had been removed for cleaning and was not returned. A Certified Nurse Aide confirmed the cushion was wet and indicated it would be replaced during the resident's next toilet use. The facility's policy on supportive surfaces was not followed, as the standard pressure redistribution seat cushion was not provided.
Failure to Apply Palm Guard and Initiate ROM Program
Penalty
Summary
The facility failed to ensure that a resident's palm guard was applied as ordered and did not initiate a range of motion (ROM) program for two residents. Resident 109, who has right side hemiparesis, was observed on multiple occasions without her right-hand splint or palm guard, despite a physician's order requiring their use to prevent further contracture and maintain functional status. The palm guard was found in a bin on her nightstand, and it was only applied after prompting by a Licensed Practical Nurse (LPN). The LPN indicated that restorative nursing usually applied the splints and palm guards, but they were not present on the day of observation. Resident 99, diagnosed with quadriplegia and other conditions, expressed a desire for restorative therapy, which was not being provided. The resident's care plan indicated total dependence on assistance for various activities, and an occupational discharge summary recommended restorative nursing therapy for ROM and brace management. However, the MDS Coordinator did not receive the necessary Therapy Referral to Restorative document from the Physical Therapy Director, which led to the lack of initiation of the restorative program. The facility's Restorative Program Policy was not followed, resulting in a failure to maintain or improve the residents' mobility.
Failure to Address Substance Use Disorder in Resident Care Plan
Penalty
Summary
The facility failed to ensure that a resident, who had a diagnosis of substance use disorder (SUD), had a care plan to address her individualized needs. The resident, who was cognitively intact, admitted to smoking weed within the facility premises and was involved in an incident where she was found with low blood pressure and was subsequently sent to the emergency room. At the hospital, she was administered Narcan and was found to have Suboxone in her system, despite her claims of not using drugs. The resident's clinical record lacked a care plan addressing her SUD, including strategies for encouraging participation in SUD programming, identifying triggers, and providing structured activities. Interviews with facility staff, including the Social Services Directors and the Director of Nursing, revealed that there was no consent form signed by the resident to receive or refuse drug and alcohol treatment, nor was there an order for Narcan in case of an emergency. The facility's policy on substance abuse was not adequately followed, as it suggested obtaining a physician's order for naloxone in emergencies and creating a care plan for residents with known substance abuse issues. The staff acknowledged the absence of a care plan and consent form for the resident, which should have been in place given her history of SUD. The facility's Director of Nursing confirmed that there were no AA or NA meetings provided at the facility, as there was no interest from the residents. Despite the resident's history and the facility's policy, the necessary steps to address her SUD were not implemented, leading to a deficiency in providing appropriate behavioral health care and services. The lack of a comprehensive care plan and emergency preparedness for the resident's SUD highlights the facility's failure to meet the required standards of care.
Expired Medical Supplies Found in Storage Room
Penalty
Summary
The facility failed to ensure that one of its two medical storage rooms was free of expired supplies. During an observation of the storage room on the 700 hall, multiple expired items were found, including BD Insyte Autoguard IV catheters, BD Vacutainer push button blood collection sets, BD Vacutainer safety-lok blood collection sets, Progressive Medical Administration sets with flow controllers, and a disposable inner cannula for use with a tracheotomy tube. These items had various expiration dates, all of which had passed. In an interview, a Registered Nurse (RN) indicated that the facility's pharmacy sends a consultant quarterly to check for expired items such as tubing and syringes. However, the RN was unaware of why the expired items had not been removed. The facility's Storage of Medications Policy states that medication storage conditions are monitored regularly by the consultant pharmacist, and corrective action is taken if problems are identified.
Failure to Maintain Hydrocollator Leads to Resident Burn
Penalty
Summary
The facility failed to implement necessary interventions to prevent a resident from being burned by a therapy modality. Specifically, the facility did not ensure the maintenance and inspection of a hydrocollator, a device used to heat therapy pads, was up to date. The hydrocollator had not been inspected since February 2020, and there was no current temperature log maintained. On the day of the incident, the temperature of the hydrocollator was not checked before use, and the Occupational Therapist (OT) did not follow the facility's policy and procedure for using the hydrocollator and heat pads. Resident H, who has diagnoses including type II diabetes, anxiety disorder, major depressive disorder, and paranoid schizophrenia, participated in an occupational therapy session where a moist heat pack was applied to his contractured left hand. The OT did not perform a temperature check on the hydrocollator before using it on Resident H. The heat pack was wrapped in a blue-bag and two towels, but the OT did not ensure the required six to eight layers of toweling were between the resident's skin and the heat pack. Although the OT checked with Resident H multiple times about the comfort of the heat pack, a blister developed on Resident H's hand the following day. The incident was reported to the Indiana Department of Health, and upon investigation, it was found that the hydrocollator's temperature was 180 degrees Fahrenheit, exceeding the recommended operating temperature of 160 to 165 degrees Fahrenheit. The facility's procedure for using moist heat packs was not followed, as the OT did not verify the water temperature in the hydrocollator or ensure the correct number of towel layers. This oversight resulted in Resident H receiving a blistering burn on his hand.
Failure to Adhere to Physician's Orders for Wound Care
Penalty
Summary
The facility failed to ensure that a resident's wound dressing was changed twice daily as per the physician's orders. Resident T, who had a history of obsessive-compulsive disorder, anxiety disorder, schizophrenia, and alcohol-induced dementia, was found to have an open area on his right elbow with yellow drainage, redness, and swelling. Despite the physician's orders for twice-daily dressing changes, the Treatment Administration Record (TAR) showed multiple instances where the dressing changes were not documented or completed, including on 4/30/24 and 5/1/24. The resident's family member reported that the facility had not been adhering to the dressing change schedule, which was confirmed by the Orthopedic Nurse Practitioner (Ortho NP) who observed that the dressing had not been changed since 4/29/24. The deficiency was further highlighted during an interview with the Ortho NP, who noted that the dressing was dated 4/29/24 without any indication of the time of day it was applied. This lack of adherence to the prescribed treatment regimen led to the resident being sent to the emergency room for evaluation and treatment after the wound increased in size and exhibited moderate yellow/green drainage. The facility's failure to follow the physician's orders for wound care resulted in a significant oversight in the resident's treatment plan.
Latest citations in Indiana
Surveyors observed that dietary staff repeatedly worked in kitchen and meal service areas with uncovered facial hair, despite facility policy and state sanitation requirements mandating effective hair restraints. Two dietary aides with short beards or mustaches were seen walking through food preparation areas, taking food temperatures, handling food, and plating meals at steamtables in dining rooms without any facial hair coverings, while the current policy required all hair, including facial hair, to be restrained to prevent contamination.
The facility failed to consistently provide and document required bed-hold policy notices when several residents were transferred to the hospital. In multiple cases, residents with dementia, psychotic disorders, COPD, chronic respiratory failure, altered mental status, and cerebral infarction were sent out for acute changes in condition, and while transfer notes reflected physician and family notifications, they lacked documentation that the bed-hold policy was discussed with the resident or responsible party. Notices of Transfer or Discharge often indicated a copy of the bed-hold policy was sent with the resident, but the records did not show signed and dated acknowledgment by the resident or appropriate representative, including in situations where a resident had moderate cognitive impairment, short-term memory issues, or a documented need for a proxy and a financial POA authorizing an agent for health care decisions.
Surveyors found that the facility failed to provide trauma‑informed and culturally competent care by not incorporating two residents’ extensive trauma histories and specific behavioral triggers into their care plans. One resident with documented homelessness, polysubstance abuse, severe accidents with multiple fractures, viral encephalitis with coma, physical and sexual abuse, loss of family contact, and a past suicide attempt had multiple behavior‑focused care plans that referenced identifying triggers but listed none and did not mention their physical, sexual, medical, or psychosocial trauma. Another resident with TBI from being struck by a truck, an 11‑month coma, long‑term state hospital residence, alleged shooting of a parent, and diagnoses including intermittent explosive disorder and borderline personality disorder had a PASRR identifying a specific trigger and notes of inappropriate sexual behavior, yet their care plans omitted these traumatic events, the identified trigger, and the sexual behavior. Staff interviews confirmed that residents were screened for trauma, but the trauma histories and triggers were not reflected in the individualized plans of care.
A resident with schizophrenia, post‑stroke hemiparesis, and mild cognitive impairment expressed feeling down and wanting to kill himself, but staff did not document asking about a specific plan, did not notify the physician or psychiatric NP as expected, and did not develop or update a care plan addressing depression or suicidal ideation. The SSD documented offering support and initiating 15‑minute checks once, but there was no further follow‑up or documentation of interventions after subsequent suicidal statements made in a care plan meeting with the resident’s father. The DON and Administrator reported that facility policy requires immediate notification of key staff, assessment for a plan and means of self‑harm, and thorough documentation, which were not carried out or reflected in the medical record for this resident.
A resident with schizophrenia, post-stroke hemiparesis, and mild cognitive impairment verbalized suicidal ideation, but the care plan did not address depression or suicidal thoughts, and required assessments and services were not accurately or timely documented. An SSD note recorded the resident saying he wanted to kill himself and referenced 15‑minute checks and a care plan update, yet the active care plan lacked depression/suicidal ideation interventions. Multiple late-entry Social Services notes were later added, describing follow-up visits and the resident denying suicidal ideation, but the SSD later reported she did not typically ask about a suicide plan and did not personally provide individual follow-up visits as described. These practices conflicted with the facility’s policy requiring factual, first-hand, and timely documentation of assessments and services.
A resident was observed with an Albuterol inhaler on an overbed table and later reported keeping the inhaler in a nightstand drawer, with no staff present during these observations. Record review showed the resident had no cognitive impairment on the admission MDS but lacked any documented self-medication administration assessment. The DON acknowledged that the required assessment had not been completed, despite facility policy requiring staff and the practitioner to evaluate each resident’s mental and physical abilities before allowing self-administration of medications.
Surveyors found that the facility submitted inaccurate direct care staffing data to CMS through the PBJ system over multiple days in a quarter. CASPER reports showed apparent gaps in 24-hour licensed nurse coverage, low weekend staffing, and a 1-star staffing rating, while internal staffing sheets documented that licensed nurses were present and the facility was fully staffed on those days. The Administrator reported that the discrepancies were due to PBJ data entry errors, despite a facility policy requiring all PBJ entries to be accurate, auditable, and verifiable against payroll, invoices, or contracts.
Surveyors found that the facility did not provide or document required written transfer/discharge notices and bed-hold policy information for four residents who were sent to the hospital, including individuals with conditions such as dementia, CHF, chronic respiratory failure, and CKD. In each case, progress notes showed that the resident was transferred for acute issues, but the clinical records lacked evidence that written notices were given to the residents or their representatives, and in one case lacked documentation that required information was sent to the receiving provider. Facility leadership, including the ADON, DON, and Administrator, acknowledged that the records did not contain the required documentation, despite a written policy requiring such notices and information exchange.
A resident with Alzheimer’s disease and depression, previously on an antidepressant, exhibited intermittent refusals of medications and care, occasional yelling at staff, and reports of unusual perceptions, such as believing men were in or near her room. Nursing notes over several months documented these refusals and complaints but did not show that the behaviors were evaluated or recorded as dangerous, non-redirectable, or causing significant distress, nor did they document specific non-pharmacological interventions attempted or their outcomes. Despite this, a psychiatric NP later added new diagnoses of schizoaffective disorder, borderline personality disorder, and delusional disorder and ordered an antipsychotic (Seroquel) without a comprehensive evaluation in the record to support these diagnoses. The facility’s psychotropic medication policy, which requires identification and documentation of target behaviors, use of nonpharmacological interventions, and ongoing behavior monitoring, was not followed for this resident.
The facility failed to keep PASARR Level I screenings accurate and current for three residents when new mental health diagnoses and psychoactive medications were initiated. One resident’s PASARR omitted a PTSD diagnosis and an added antidepressant, despite documentation of PTSD on the MDS and care plan and a physician order for Pristiq. Another resident’s PASARR listed only depression and dementia, even after additional diagnoses such as borderline personality disorder, delusional disorder, and schizoaffective disorder were added and an antipsychotic (quetiapine) was ordered, with the MDS later reflecting psychotic disorder, schizophrenia, and depression with antipsychotic and antidepressant use. A third resident’s PASARR did not include a depression diagnosis or newly ordered escitalopram and lorazepam, although the admission MDS documented depression with antianxiety and antidepressant use. These omissions occurred despite facility policy requiring a new Level I review after significant mental status changes, including new mental health diagnoses or new psychotropic medications.
Uncovered Facial Hair During Food Preparation and Meal Service
Penalty
Summary
The deficiency involves the facility’s failure to ensure that food was served in a sanitary and safe manner in accordance with professional standards and facility policy during multiple kitchen and meal service observations. During an initial kitchen observation, two dietary aides were seen walking through the kitchen food preparation area with uncovered facial hair. One aide had facial hair above and below the lip and along the jaw line, approximately one-fourth inch in length, and the other had a mustache of similar length; neither used any facial hair covering. These observations occurred while staff were present in the kitchen area where food was stored and prepared. During subsequent observations on the same day, the same two dietary aides were again observed with uncovered facial hair while directly involved in meal preparation and service. One aide walked through the kitchen while the noon meal was being prepared and placed into a transport cart for service in the south dining room, and later was observed plating the noon meal at the steamtable in that dining room, still without a facial hair covering. The other aide walked through the kitchen while the noon meal was being prepared and placed into the steamtable for the north dining room, took food temperatures, assisted with plating meals at the steamtable, and retrieved food items and supplies from the kitchen, all while having an uncovered mustache approximately one-fourth inch in length. The Dietary Manager stated that staff hair was to be covered when in the kitchen and during meal service, and the facility’s written policy and the cited Indiana Food Establishment Sanitation Requirements both required effective hair restraints, including for facial hair, to prevent contamination of food, equipment, and utensils.
Failure to Provide and Document Bed-Hold Policy at Time of Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure that required bed-hold policy information was provided and documented for four residents transferred to the hospital. For a resident with dementia, psychotic disorder, and autistic disorder who had a BIMS score of 0 indicating severe cognitive impairment, progress notes documented physician notification and guardian notification when the resident was sent to the hospital, but there was no documentation that the bed-hold policy was provided to the responsible party. A Notice of Transfer or Discharge later indicated a copy of the bed-hold policy was sent with the resident. Another resident with COPD and chronic respiratory failure, cognitively intact with a BIMS score of 13, experienced a decline in condition and was transferred to the hospital by ambulance; progress notes documented family notification but did not document any discussion of the bed-hold policy, although a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident. A third resident with altered mental status and cerebral infarction, with a BIMS score of 10 indicating moderate cognitive impairment and documented short-term memory impairment, experienced changes in condition and was transferred to the hospital. Progress notes stated the resident was their own responsible party and that no other notification was completed, and transfer documentation did not include the bed-hold policy, although an untimed Notice of Transfer or Discharge indicated a copy of the bed-hold policy was signed by the resident. A financial power of attorney document in the record showed the resident had designated an agent to act in consent or refusal of health care. For a fourth resident with dementia and osteomyelitis, transfer documentation and a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident, and the transfer form noted the resident required a proxy for decision making. The facility’s policy required that at the time of transfer to a hospital, written notice specifying the duration of the bed-hold policy and information on return to the next available bed be provided, and that a signed and dated copy of the bed-hold notice given to the resident or representative be kept in the resident file, which was not consistently documented for these residents.
Failure to Integrate Trauma Histories and Behavioral Triggers Into Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to identify and incorporate residents’ trauma histories and specific behavioral triggers into their care plans, despite documented histories of significant trauma and behavioral health issues. For one resident, extensive social service and progress notes documented homelessness, polysubstance abuse, major depressive and anxiety disorders, chronic pain, a history of severe car accidents with multiple fractures, viral encephalitis resulting in a three‑month coma, loss of child custody, multiple divorces, physical abuse by a spouse, the death of a fiancé who was struck by a car while in a wheelchair, lack of family contact, and a past suicide attempt by Valium overdose. Additional documentation noted a history of rape by a brother at age eight and prior placement under direct supervision and 15‑minute checks related to suicidal ideation. Despite these documented traumatic events and behavioral health concerns, the resident’s care plans did not identify a history of physical trauma, sexual trauma, homelessness, substance abuse, medical trauma, or attempted suicide. For this same resident, the MDS showed no cognitive deficit and identified behaviors such as verbal aggression and rejection of care, along with diagnoses including seizure disorder, depression, chronic pain syndrome, homelessness, and anxiety disorder. Multiple care plans addressed behaviors such as drug‑seeking, pretending to have seizures for attention or medication, making false allegations, verbal aggression when unable to smoke, and a desire for intimate relationships with consenting male residents. These care plans referenced goals such as effective coping skills, seeking staff support, and compliance with the smoking policy, and they called for identification and reduction of behavioral triggers. However, none of these care plans actually listed any specific triggers. The care plan addressing the resident’s right to consensual intimate relationships focused on assessment and education regarding consent but did not integrate the resident’s extensive trauma history. Staff interviews indicated the resident had displayed sexual behaviors since admission, including an incident where the resident expressed anger at another resident for not buying a soda after engaging in sexual acts. A second resident with a documented history of traumatic brain injury (TBI), dementia, seizure disorder, borderline personality disorder, anxiety, intermittent explosive disorder, tobacco use, and other behavioral/emotional disorders was also affected by the same deficiency. Social history and progress notes documented that this resident sustained a TBI after being hit by a semi‑truck while riding a bicycle at age 18, resulting in an 11‑month coma, followed by 13 years in a state hospital and subsequent residence in a group home. Additional documentation indicated the resident allegedly shot their father at age 26 after being sworn at and had a PASRR identifying TBI, intermittent explosive disorder, and borderline personality disorder, with a specific trigger of hearing the name of the current U.S. President. Progress notes also described inappropriate sexual behavior toward staff, including touching themselves intimately during personal care and refusing to stop when redirected. Despite this, the resident’s care plans, which addressed explosive disorder and history of altercations, risk for decreased psychosocial well‑being, and refusal to bathe or shower, did not list any specific behavioral triggers, did not reference the traumatic events such as being hit by a truck or shooting their father, and did not document the inappropriate sexual behavior. The Administrator and Social Service Director acknowledged that residents were to be screened for trauma and that trauma responses and PTSD should be added to care plans, but the specific trauma histories and triggers for these two residents were not incorporated into their plans of care.
Failure to Assess and Care Plan for Resident Suicidal Ideation
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess, investigate, and care plan for a resident’s suicidal ideation in accordance with its own policy and staff expectations. The resident had diagnoses including schizophrenia, cerebral edema, and hemiparesis/hemiplegia following a cerebral infarction, and a current MDS showed mild cognitive impairment (BIMS score 12). A progress note documented that the resident told the Social Services Director (SSD) he was feeling down and wanted to kill himself; the SSD offered assistance, activities, and initiated 15‑minute checks, and the note stated the care plan was updated. However, the note did not indicate that the SSD asked whether the resident had a plan to kill himself, and there were no additional notes regarding suicidal ideation or follow‑up. Review of the current care plan showed no problem, goal, or interventions addressing depression or suicidal ideation, and progress notes over the following month contained no documentation of physician notification related to the suicidal statement. Further record and interview evidence showed that the care plan conference summary did not document interventions for suicidal ideation, and the SSD acknowledged she did not normally ask residents expressing suicidal ideation if they had a plan. The SSD reported that the resident had admission paperwork mentioning suicidal ideation related to depression after a stroke and that the resident again vocalized suicidal ideation during a care plan meeting with his father, after which emotional support was offered and the father took the resident out on a leave of absence; no further visits or follow‑up were done. The DON stated that, upon notification of suicidal verbalization, staff should assess the resident, ask if there is a plan, remove potential means of self‑harm, immediately notify the psychiatric NP, and document the occurrence, and that a detailed progress note and updated care plan were expected but not present for this resident. The Administrator similarly stated that staff should ask about a plan, document interventions, notify the physician and family, and update the care plan, and indicated the resident should have had a care plan addressing depression with suicidal ideation. The facility’s written policy required immediate notification of the DON, SSD, and physician, an interview including asking about a plan and assessing mood and means for self‑harm, and thorough documentation of mood, behavior, and all actions taken, which were not reflected in the resident’s record.
Incomplete and Inaccurate Documentation of Suicidal Ideation and Follow-Up
Penalty
Summary
The facility failed to ensure accurate, complete, and timely documentation of assessments and services for a resident who verbalized suicidal ideation. Resident 6, who had schizophrenia, cerebral edema, and right-sided hemiparesis/hemiplegia following a cerebral infarction, had a BIMS score of 12 indicating mild cognitive impairment. The resident’s admission paperwork mentioned suicidal ideation related to depression after a stroke, and a Social Services note on 3/11/2026 documented that the resident was feeling down and said he wanted to kill himself. The Social Services Director (SSD) documented that she talked with the resident, coordinated with Activities, advised the resident to contact SSD or nursing if he wanted to talk, and that the resident was scheduled for 15-minute checks and the care plan was updated. However, the current care plan initiated on 2/26/2026 did not address depression or suicidal ideation. Multiple Social Services progress notes were later entered as late entries in April, with effective dates in March, stating that the resident had no plan and no longer had suicidal ideation, that he felt much better after 1:1 time, and that he continued his daily routine and therapy. These late entries described follow-up visits and reassessments of suicidal ideation on several consecutive days, but in interviews the SSD stated she did not normally ask residents about having a plan when they verbalized suicidal ideation and did not recall any other occurrences beyond the initial event. She further indicated she did not personally provide individual follow-up visits with this resident regarding suicidal ideation, despite the late-entry notes describing such visits. The DON acknowledged that late entries had been added to address concern about suicidal verbalization, and the Administrator stated that upon suicidal statements staff should ask about a plan, notify the physician and family, and update the care plan, and that this resident should have had a care plan addressing depression with suicidal ideation. The facility’s documentation policy required factual, first-hand, timely documentation, which was not followed in this case.
Failure to Complete Required Self-Administration Assessment for Inhaler Kept at Bedside
Penalty
Summary
Surveyors identified that a resident was allowed to keep and access an Albuterol inhaler without the facility completing the required self-administration medication assessment. During an initial tour, the resident was observed sitting in a wheelchair with a handheld Albuterol inhaler on the overbed table and no staff present in the room or hallway. On a subsequent observation, the resident again was in a wheelchair and reported that the Albuterol inhaler was stored in the top drawer of the nightstand, where it was found. Review of the clinical record showed an admission MDS indicating no cognitive impairment, but there was no documentation of a self-medication administration assessment. In an interview, the DON confirmed that the resident did not have the required self-medication assessment, despite the facility’s policy stating that staff and the practitioner must assess each resident’s mental and physical abilities to determine whether self-administering medications is clinically appropriate. This failure to complete and document a self-administration medication assessment for a resident who had an Albuterol inhaler kept at bedside constituted noncompliance with the facility’s own policy and with 410 IAC 16.2-3.1-11(a).
Inaccurate PBJ Staffing Data Submission to CMS
Penalty
Summary
The deficiency involves the facility’s failure to electronically submit complete and accurate direct care staffing information to CMS through the Payroll-Based Journal (PBJ) system for 22 days in a fiscal quarter. A CASPER report review on 4/6/26 showed that, according to PBJ data, the facility did not have licensed nursing coverage 24 hours per day on multiple specific dates across three months, had low weekend staffing, and held a 1-star staffing rating. However, review of the facility’s internal staffing sheets for that quarter indicated the facility was fully staffed and had licensed nurse coverage on all of the dates in question. During an interview, the Administrator stated that the PBJ information must have contained data entry errors, as she had verified licensed staff coverage on the timesheets. The facility’s PBJ policy in effect stated that all staffing data entered into the PBJ system would be auditable and verifiable through payroll, invoices, or contracts, but the submitted PBJ data did not accurately reflect the facility’s actual licensed nurse staffing as documented on internal records. No specific residents or clinical conditions were mentioned in the report, and the deficiency centers solely on inaccurate staffing data submission rather than direct resident care events.
Failure to Provide and Document Required Transfer/Discharge and Bed-Hold Notices
Penalty
Summary
The deficiency involves the facility’s failure to provide and document required written notices of transfer/discharge and bed-hold policies, as well as required information to receiving providers, for four residents who were transferred or discharged to the hospital. For a resident with generalized anxiety disorder, major depressive disorder, and dementia, progress notes showed that the resident was sent to the hospital via 911 for chest pain, lower back pain, and shortness of breath and later returned to the facility, but the clinical record lacked documentation that a written Notice of Transfer/Discharge and the bed-hold policy were provided to the resident or representative, and lacked documentation that required information was conveyed to the receiving facility. The ADON and the Administrator both confirmed there was no documentation that these written notices were provided. For a resident with congestive heart failure and muscle weakness who was sent to the emergency room for painful urination and bloody urine, the clinical record lacked documentation that a Notice of Transfer/Discharge or bed-hold policy was given to the resident or representative, which the DON confirmed. Another resident with chronic respiratory failure and diabetes was discharged to the hospital for respiratory failure, and a resident with chronic kidney disease and dementia was discharged to the hospital, but in both cases there was no documentation that a written notice of transfer/discharge or bed-hold policy was provided to the residents or their representatives. Review of the facility’s Transfer and Discharge policy, dated 1/15/26, showed that the policy required the facility to provide written transfer/discharge notices and bed-hold information to residents and representatives and to provide specified information to receiving providers, but the records for these four residents did not contain the required documentation.
Failure to Document Target Behaviors and Non-Pharmacological Interventions Before Initiating Antipsychotic
Penalty
Summary
The deficiency involves the facility’s failure to document how a resident’s behaviors presented danger or distress to self or others, and failure to document non-pharmacological interventions attempted prior to initiating an antipsychotic medication. Resident 6 had documented diagnoses of Alzheimer’s disease, depression, and severe cognitive impairment, and was receiving sertraline for depression. A PASSAR identified only depression and dementia, and the admission MDS listed Alzheimer’s disease and depression as active diagnoses. Over several months, nursing progress notes documented that the resident intermittently reported unusual perceptions, such as believing there were men causing trouble, a man in her room, or a man wanting to marry her and yelling through the walls, but there was no documentation that these episodes caused danger to the resident or others or that they resulted in unmanageable distress. From late April through mid-July, nursing notes primarily described the resident’s frequent refusals of evening and morning medications, blood sugar checks, blood pressure checks, insulin administration, hygiene care, and showers. Staff documented that the resident sometimes yelled at staff, said “Get out!”, was visibly upset by a room move, was leery of staff and asked to see name badges, and became upset about a pillow under her head until it was removed, after which she calmed down. The notes also recorded instances where the resident believed housekeeping had not cleaned her room or that she had not received medications when she had. However, there were no progress notes or assessments indicating that these behaviors were evaluated as dangerous, non-redirectable, or causing significant distress or functional impairment, and no detailed behavior monitoring logs were present as required by facility policy. On a psychiatric NP visit for initial psychotropic medication management, new mental health diagnoses of schizoaffective disorder, borderline personality disorder, and delusional disorder were added, and Seroquel 25 mg, an antipsychotic, was ordered. The clinical record did not contain a comprehensive evaluation to support these new diagnoses, and there was no documentation of target behaviors meeting the facility’s policy criteria for psychotropic use, such as behaviors representing danger to self or others, causing distress and impairment in functional abilities, or clearly attributable to psychosis or mania. The resident’s representative reported that the resident had no prior history of mental health disorders or psychiatric hospitalization and was unaware of the new diagnoses. The facility’s own psychotropic medication policy required identification and documentation of specific target behaviors, use and documentation of nonpharmacological interventions, and ongoing monitoring of behaviors and interventions, which were not reflected in the record for this resident.
Failure to Update PASARR Screens for New Mental Health Diagnoses and Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that Preadmission Screening and Resident Review (PASARR) Level I screenings were accurate and updated when new mental health diagnoses and psychoactive medications were initiated for multiple residents. For one resident with dementia, anxiety, depression, and post-traumatic stress disorder (PTSD), the PASARR completed on admission listed anxiety, depression, and dementia with sertraline and quetiapine, but did not include the PTSD diagnosis or the antidepressant Pristiq, despite the admission MDS and care plan documenting PTSD and a subsequent physician’s order for Pristiq. For another resident with Alzheimer’s disease, borderline personality disorder, delusional disorder, schizoaffective disorder, and depression, the PASARR only reflected depression and dementia with sertraline, even though additional mental health diagnoses were added later and an antipsychotic (quetiapine) was ordered for borderline personality disorder, and the quarterly MDS documented psychotic disorder, schizophrenia, and depression with antipsychotic and antidepressant use. A third resident had diagnoses including Alzheimer’s disease, depression, anxiety disorder, irritability and anger, and nonrheumatic aortic valve stenosis. The PASARR for this resident listed dementia and anxiety with Risperdal but omitted the diagnosis of depression and the medications escitalopram and lorazepam, although physician’s orders were in place for escitalopram for depression and lorazepam for anxiety, and the admission MDS documented depression with antianxiety and antidepressant use. Interviews with the Assistant Director of Nursing confirmed that new Level I PASARR screens should have been completed when new mental health diagnoses and psychoactive medications were added, and that the PASARR for one resident, completed prior to arrival, should have included all mental health diagnoses and medications. The facility’s own policy required notification of the state mental health authority within 14 days after a significant change in mental condition and specified that a new Level I screen is required for new mental health diagnoses or newly prescribed psychotropic medications, which was not followed in these cases.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
