Willow Crossing Health & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Columbus, Indiana.
- Location
- 3550 Central Ave, Columbus, Indiana 47203
- CMS Provider Number
- 155535
- Inspections on file
- 30
- Latest survey
- March 11, 2026
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Willow Crossing Health & Rehabilitation Center during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment, depression, anxiety, and dementia, who used a wheelchair, was observed on video removing linens from a cart and flipping it, after which a CNA forcefully pulled the resident’s wheelchair backward twice, causing the resident to fall to the floor. The CNA then left the resident lying on the floor near the nurse’s station, repeatedly walked past and around the resident, wheeled another resident around the resident on the floor, and mimed tipping the linen cart again, without providing assistance. When an RN returned from break, the CNA reported that the resident had flipped the cart and slid to the floor, and the RN followed fall protocol based on that account. The resident later reported no memory of the fall, and the facility’s abuse policy defined such willful, intimidating actions as abuse.
A resident with dementia, depression, anxiety, and a history of hallucinations had a violent behavioral outburst at the nurse’s station, verbally threatening to kill another resident, attempting to pull the other resident’s chair backward, and trying to grab the resident’s shirt. Staff separated the two residents, but then retreated into a nearby room without a window, leaving the aggressive resident alone and unmonitored at the nurse’s station, where he threw a drink, the phone, and attempted to throw the computer monitor. This occurred despite a care plan and a dementia aggression policy that called for ensuring safety and assessing the potential for harm to self or others.
The facility failed to follow physician's orders for two residents regarding medication hold parameters. One resident received Lisinopril despite having a systolic blood pressure below the specified threshold, while another received Amlodipine when their blood pressure was below the required level. Facility policies on medication administration were not adhered to, as confirmed by an RN and the Assistant Director of Nursing.
A resident with multiple health issues, including cognitive impairment and incontinence, developed a Stage III pressure ulcer due to the facility's failure to identify and assess a wound in a timely manner. Despite being at risk, the resident's wound was not documented by the DON when first noted, and it was only assessed by a wound specialist days later, by which time it had worsened.
The facility failed to document meal consumption for two residents, one with a history of weight loss and another with malnutrition. Despite care plans requiring monitoring of meal intake, records were incomplete for several meals. A QMA confirmed that meal consumption should be recorded after each meal, but the facility's policy was not consistently followed.
The facility failed to store medications appropriately in two medication carts. Loose pills and debris were found in both the Back 200 and Front 100 Medication Carts. A QMA indicated she did not clean the cart, and the ADON confirmed that loose pills should not be present. The facility's policy requires drugs to be stored safely and securely.
A resident with cognitive impairment and multiple diagnoses experienced a delay in urinalysis collection due to the facility's failure to follow timely specimen collection procedures. A physician's order for a urine dip test and subsequent urinalysis was not executed promptly, leading to a five-day delay in obtaining the urine sample.
The facility failed to follow infection control guidelines during dining service in the Dementia Unit. An Activity Aide handled meal trays without proper hand hygiene after touching a trash can, serving two residents without sanitizing her hands in between. A CNA indicated the correct protocol involves sanitizing hands after each tray and washing hands after every third tray or immediately if anything else is touched.
A resident with a UTI did not receive timely antibiotic treatment due to a failure in communication and protocol adherence. The resident's urine culture showed resistance to the current antibiotic, but the RN did not inform the NP, delaying the appropriate treatment.
The facility failed to store medications appropriately, with controlled medications being preset for the next pass and an unattended, unlocked medication cart observed. Staff indicated they usually preset medications, which is against policy. The DON confirmed that controlled medications should not be preset and carts should remain locked when unattended.
The facility failed to ensure food was served in a sanitary manner, with multiple staff members observed handling dinner rolls with bare hands and not following proper glove use protocols, contrary to the facility's policy.
The facility failed to protect resident information by leaving computer screens on medication carts unlocked and visible on multiple occasions. The DON and QMA were observed closing the screens after they were left unattended, displaying resident names and medication lists. The facility's Employee Handbook mandates protection of identifiable health information in compliance with HIPAA.
A resident with severe cognitive impairment was subjected to verbal threats and physical aggression by a CNA, who became agitated during care. The incident was witnessed by another CNA, who intervened and reported the abuse. The resident was unable to recall the incident due to low cognition. The facility's investigation substantiated the abuse, leading to the termination of the CNA.
The facility failed to follow physician's orders for a resident's blood pressure medication by not documenting the required blood pressure and heart rate prior to administration. Despite the medication being given daily, the necessary vital signs were not recorded, leading to a deficiency.
The facility failed to follow physician's orders for a resident with multiple diagnoses, including dementia and diabetes, by not ensuring the resident wore Blue Prevalon boots to prevent pressure ulcers. The resident was repeatedly observed without the prescribed boots, and staff did not document any refusal to wear them, contrary to facility policy.
A facility failed to provide appropriate urinary catheter care for a resident with frequent UTIs. A CNA was observed performing catheter care without following proper hygiene protocols, including not changing gloves after touching various surfaces and not using a clean area of the washcloth for each motion. The resident had a history of frequent UTIs and was moderately cognitively impaired.
The facility failed to implement interventions and complete behavior forms for a resident with severe cognitive impairment and dementia. The resident exhibited physical aggression and wandering behaviors, but the facility did not consistently document or implement effective interventions, such as the use of a door frame alarm. Staff interviews revealed inconsistencies in reporting and handling the resident's behaviors.
Failure to Protect a Resident From Staff-Inflicted Abuse and Inaccurate Fall Reporting
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical and mental abuse and to ensure accurate reporting of a fall event. Resident B, who was moderately cognitively impaired with diagnoses including depression, anxiety, and unspecified dementia, used a wheelchair and walker for mobility and had not exhibited behaviors during the MDS assessment period. A facility-reported incident and subsequent review of hallway video footage revealed that a CNA (CNA 2) was aggressive with the resident and caused him to fall from his wheelchair in a common area on the locked dementia unit. Video footage showed Resident B sitting in his wheelchair near the central nurse’s station, removing linens from a linen cart, throwing them on the floor, and flipping the cart so that it and additional linens fell around him. CNA 2 exited a nearby resident room, then aggressively grabbed the back of Resident B’s wheelchair with both hands and purposely, forcefully pulled the wheelchair backward toward the nurse’s station with two jerking motions. After the second pull, Resident B fell from the wheelchair, landing on his buttocks and then onto his back, partially out of camera view. CNA 2 stood over the resident briefly, then walked away to right the linen cart and return linens to it, moved the cart down the hallway, and re-entered a resident room, leaving Resident B on the floor. The video further showed that CNA 2 continued to leave Resident B on the floor while she wheeled another resident around him and walked past him multiple times, including standing at the nurse’s station looking down at him and pointing toward the linen cart, without providing assistance. Another resident in a wheelchair attempted to maneuver around Resident B, who tried to scoot out of the way and eventually sat up on his buttocks, appearing to yell toward the nurse’s station. CNA 2 later walked around Resident B and mimed tipping the linen cart and throwing linens without actually touching them, while Resident B remained on the floor. RN 3, who had been off the unit on lunch during the incident, stated that when she returned, Resident B was already sitting on the floor with his wheelchair in front of him, and she was told by CNA 2 that the resident had flipped the linen cart on himself and slid to the floor; she followed fall protocol based on that account. Resident B reported no memory of the fall. The facility’s abuse policy defined abuse as the willful infliction of injury, intimidation, or punishment resulting in physical harm, pain, or mental anguish, and included mental abuse such as humiliation and harassment.
Resident with Dementia Left Unsupervised During Violent Behavioral Outburst
Penalty
Summary
The deficiency involves the facility’s failure to ensure appropriate supervision and behavioral health services for a resident with major mental illness during a physical and verbal outburst. Resident B, who was moderately cognitively impaired and diagnosed with depression, anxiety, unspecified dementia, and a history of visual hallucinations, resided on a locked dementia unit and used a wheelchair and walker for mobility. On the night of the incident, Resident B approached the nurse’s station from behind where another resident, Resident F, was seated next to an RN. Resident B stated, "I'm going to kill you tonight. I don't need anything to do it; I will strangle you," then attempted to grab the back of Resident F’s chair and pull it backwards, and tried to grab Resident F’s shirt. Staff intervened to move Resident F away from Resident B. As Resident B continued toward staff and Resident F in an intimidating manner, he obtained a colored pencil from behind the nurse’s station desk and advanced toward them. The RN and a CNA then went into a resident’s room directly in front of the nurse’s station and closed the door, leaving Resident B alone and unmonitored at the nurse’s station during his outburst. The room door lacked a window, and no staff remained present to observe Resident B’s actions. While unmonitored, Resident B threw a drink, the phone, and attempted to throw the computer monitor off the desk. Resident B’s care plan, initiated the day before the incident, identified delusions that someone was out to get him and included interventions such as ensuring the resident’s safety and ascertaining potential for harm to self or others. The facility’s dementia aggression/anger policy directed staff to assess and decrease the level of danger for themselves and the resident with dementia, but during this event, staff actions resulted in the resident being left unsupervised during an active behavioral outburst.
Failure to Follow Medication Hold Parameters for Two Residents
Penalty
Summary
The facility failed to adhere to physician's orders regarding medication hold parameters for two residents, leading to deficiencies in quality of care. Resident 71, who was cognitively intact and diagnosed with conditions including schizoaffective disorder, heart failure, hypertension, diabetes, and depression, had a physician's order to receive Lisinopril with specific parameters to hold the medication if the systolic blood pressure (SBP) was less than 130 or the heart rate was less than 60. Despite these orders, the resident received the medication multiple times in January and February 2025 when the SBP was below the specified threshold. Similarly, Resident 5, who was also cognitively intact and diagnosed with stroke, coronary artery disease, hypertension, and dementia, had an order to receive Amlodipine with instructions to hold the medication if the SBP was less than 120. The medication was administered on several occasions in January and February 2025 when the resident's SBP was below the specified limit. This indicates a failure to follow the physician's orders and monitor the resident's vital signs as required. The facility's policies on physician orders and medication administration, which require checking vital signs before administering certain medications and holding them if the parameters are not met, were not followed. An RN interviewed confirmed the procedure to check vital signs and hold medication if necessary, but the records show this was not consistently done. The Assistant Director of Nursing provided the relevant policies, which emphasize the importance of adhering to physician's orders and ensuring follow-through, highlighting the discrepancy between policy and practice.
Failure to Prevent and Identify Stage III Pressure Ulcer
Penalty
Summary
The facility failed to prevent and identify a resident's wound before it developed into a Stage III pressure ulcer. The resident, who was moderately cognitively impaired, had multiple diagnoses including stroke, hemiplegia, malnutrition, dementia, and peripheral vascular disease. The resident was always incontinent of bowel, had an indwelling urinary catheter, and was dependent on staff for toileting, hygiene, and mobility. Despite being at risk for pressure ulcers, the resident had no pressure ulcers at the time of the last assessment. However, a red open area was noted above the resident's buttocks on a shower sheet dated 08/24/24, but there was no documented assessment of the wound by the Director of Nursing (DON) at that time. The wound specialist later assessed the wound on 08/29/24, documenting it as a Stage III pressure ulcer. The wound measured 1.2 cm by 1 cm with a depth of 0.1 cm, containing 70% granulation tissue and 30% slough. By 02/17/25, the wound had increased in size to about 3 cm in diameter with a depth of 1 cm and showed signs of undermining. The facility's policy required daily observation of residents receiving assistance with bathing and pericare, with any red or open areas to be reported for further assessment. However, the lack of timely documentation and assessment of the wound by the nursing staff contributed to the deficiency in care for the resident.
Failure to Document Meal Consumption for Residents
Penalty
Summary
The facility failed to document meal consumption values for two residents, leading to a deficiency in monitoring their nutritional intake. Resident 55, who was cognitively intact and had a history of weight loss, had missing meal consumption records on several occasions in January and February 2025. Despite having a care plan in place to monitor and encourage 100% meal consumption, the records lacked documentation for specific meals, indicating a failure to adhere to the care plan. Similarly, Resident 62, who was severely cognitively impaired and diagnosed with malnutrition, also had numerous undocumented meal consumption values in December 2024, January, and February 2025. The resident's care plan required monitoring of meal intake, but the facility did not consistently document this information. During an interview, a Qualified Medication Aide confirmed that meal consumption should be recorded after every meal, yet the facility's policy was not followed, resulting in incomplete records.
Medication Storage Deficiency in LTC Facility
Penalty
Summary
The facility failed to store medications appropriately in two of the three medication carts reviewed. On the Back 200 Medication Cart, loose pills were found in the bottom of the drawers, including two small round white tablets, one small oval white tablet, and one small oval blue tablet. The cart also contained several bits of debris and paper scattered throughout. During an interview, the Qualified Medication Aide (QMA) indicated that she did not clean the medication cart and only passed medications. Similarly, the Front 100 Medication Cart was found to have loose pills, including one small round white tablet, one medium round white tablet, and one large round white tablet, along with debris and paper scattered throughout the cart. The Assistant Director of Nursing (ADON) confirmed that there should not be any loose pills in the medication carts. The facility's current policy on storing drugs, dated April 2021, states that drugs and biologicals should be stored in a safe, secure, and orderly manner.
Delayed Urinalysis Collection for Resident
Penalty
Summary
The facility failed to obtain a urinalysis in a timely manner for a resident who was moderately cognitively impaired and had diagnoses including vascular dementia, diabetes, and stroke. A physician's order was given to perform a urine dip test, and if positive, to collect a urine sample for urinalysis and culture and sensitivity testing. The order was placed on January 2nd, but the urine sample was not collected until January 7th, resulting in a delay in diagnosis and treatment. Interviews with facility staff revealed that the process for obtaining and sending urine samples to the lab was not followed promptly. The RN responsible for entering the order and collecting the sample indicated that she would document any difficulties in obtaining a sample, but there was no mention of such documentation. The Assistant Director of Nursing confirmed that the delay in collecting the urine specimen was unusual, as the lab typically collected specimens daily. The facility's policy on specimen collection emphasized obtaining a fresh urine specimen as per physician's orders, which was not adhered to in this case.
Infection Control Breach During Dining Service
Penalty
Summary
The facility failed to adhere to infection control guidelines during dining service in the Dementia Unit Dining Room. During an observation, an Activity Aide was seen handling meal trays without proper hand hygiene. The aide opened a trash can lid with her bare hand, disposed of trash, and then proceeded to handle and serve meal trays to residents without sanitizing her hands in between these actions. This occurred twice, once when serving a meal tray to Resident 102 and again when serving Resident 15. The aide only sanitized her hands after serving the trays, not before handling them after touching the trash can. A Certified Nurse Aide later indicated that proper protocol involves sanitizing hands after every tray served and washing hands after every third tray, or immediately if anything other than the tray is touched. The facility's meal service policy, dated October 2014, was referenced but not followed in this instance.
Delayed Antibiotic Treatment for UTI
Penalty
Summary
The facility failed to ensure timely antibiotic treatment for a resident with a urinary tract infection (UTI). The resident, who was moderately cognitively impaired and had diagnoses including stroke, diabetes, renal insufficiency, and neurogenic bladder, was incontinent of bowel and bladder. On July 10, a family member requested a urine test for a UTI, and a urinalysis with culture and sensitivity (C&S) was ordered by the nurse practitioner (NP). The results, available on July 13, indicated that the bacteria present in the resident's urine were resistant to the antibiotic Macrodantin, which the resident was currently receiving. The RN received the C&S results on the evening of July 13 but did not review them, assuming that the NP would change the antibiotic if necessary on the following Monday. The RN did not contact the NP to inform them of the results, as the resident was already on an antibiotic. This oversight led to a delay in administering the appropriate antibiotic, ceftriaxone, which was not ordered until July 15. The facility's policy required that abnormal lab results be communicated to the NP for immediate action, but this protocol was not followed in this instance.
Failure to Store Medications Appropriately
Penalty
Summary
The facility failed to store medications appropriately for two of three medication carts reviewed and for six of fifteen resident medications reviewed. During an observation, it was found that controlled medications for several residents were preset for the next medication pass and stored in the top drawer of the medication cart. LPN 8 and QMA 9 both indicated that they usually preset resident medications for the next pass, which is against the facility's policy. The Director of Nursing confirmed that controlled medications should not be preset. Additionally, an unlocked medication cart was observed on the 200 Hall, parked outside a resident's room with no staff around. The QMA returned to the cart, prepared medications, and then locked the cart before returning to the resident's room. The Director of Nursing indicated that medication carts are to remain locked when unattended. The facility's current policy states that controlled medications must be stored by a double-lock in a separate area from all other medications.
Failure to Maintain Sanitary Food Service Practices
Penalty
Summary
The facility failed to ensure food was served in a sanitary manner during dining observations in both the Memory Care Unit and the Main Dining Room. Specifically, multiple CNAs and a QMA were observed handling dinner rolls with their bare hands, contrary to the facility's policy that requires gloves to be worn when touching ready-to-eat foods. For instance, CNA 3 and CNA 17 were seen removing dinner rolls from plastic packages with their bare hands and placing them on the table or on top of the packages. Similarly, QMA 16 and CNA 5 were observed handling food items without proper glove use, with CNA 5 even touching multiple food items and trays while wearing gloves, then removing the gloves without proper hand hygiene practices in between tasks. During an interview, QMA 9 indicated that gloves should be worn when touching a resident's food and that nothing else should be touched after donning gloves. The facility's current policy, titled 'Glove Use & Meal Service,' explicitly states that employees may not touch ready-to-eat foods with bare hands and must wear gloves. The observations and interviews indicate a clear deviation from this policy, leading to the cited deficiency in food service sanitation practices.
Failure to Protect Resident Information
Penalty
Summary
The facility failed to protect resident information by leaving computer screens unlocked and visible on multiple occasions. During an observation, a medication cart on the 200 Hall had a computer screen open to resident names and medication lists, with no staff present within 20 to 30 feet. The Director of Nursing (DON) closed the screen upon noticing it. In another instance, a computer tablet on a medication cart was left open to resident names and pictures while the Qualified Medication Aide (QMA) was in a resident's room. The QMA returned and picked up the tablet after a few minutes. Further observations revealed similar incidents where computer screens on medication carts were left open and unattended, displaying resident information. The DON was observed closing the screens on two separate occasions. During an interview, the DON confirmed that computer screens should be closed when staff are not present to prevent unauthorized access to resident information. The facility's Employee Handbook, dated April 2022, mandates that all identifiable health information be protected from unauthorized access, use, or disclosure, in compliance with the Health Insurance Portability and Accountability Act (HIPAA).
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to ensure a resident was free from mental and physical abuse. On 12/30/23, CNA 20 became agitated and spoke inappropriately to Resident 203 during care. Resident 203, who was severely cognitively impaired with diagnoses including hypertension, diabetes, Alzheimer's disease, stroke, anxiety, and stage 4 chronic kidney disease, was subjected to verbal threats and physical aggression. CNA 20 told Resident 203, 'if you hit me again I'll hit you back,' and then smacked the resident's face with a wet wipe and pushed her head down to the pillow when she attempted to sit up. This incident was witnessed by CNA 21, who intervened and reported the abuse to the QMA and ADON. The resident was unable to recall the incident due to her low cognition. The Administrator was informed of the incident on the same day, and CNA 20 was immediately asked to leave the building pending an investigation. Written statements were collected from witnesses, and the ADON assessed each resident for signs of abuse. The Social Service Director interviewed residents who could be interviewed. The abuse was substantiated, and CNA 20 was terminated from employment. The facility's policy on abuse prohibition, reporting, and investigation, last revised in January 2015, was reviewed and indicated that the facility should prohibit and prevent abuse, neglect, misappropriation of resident property, and exploitation.
Failure to Follow Physician's Orders for Blood Pressure Medication
Penalty
Summary
The facility failed to follow physician's orders related to hold parameters for a blood pressure medication for one resident. The resident, who was moderately cognitively impaired and had multiple diagnoses including dementia, heart failure, hypertension, stroke, diabetes, anxiety, and depression, was prescribed losartan 100 mg daily for hypertension. The physician's order specified that the medication should be held if the resident's systolic blood pressure was less than 110 or the heart rate was less than 60. However, the clinical record lacked documentation of the resident's blood pressure and heart rate prior to the administration of the medication from 03/29/24 to 04/18/24, despite the medication being administered daily during this period. Interviews with staff, including an RN, a Qualified Medication Aide, and a Clinical Consultant, confirmed that the blood pressure and heart rate should have been documented on the Electronic Medication Administration Record (EMAR) if there were hold parameters for the medication. The facility's policy on medication administration, revised in 04/2017, also indicated that pulse and blood pressure should be taken as ordered prior to administering certain cardiac or antihypertensive drugs. The failure to document these vital signs as required led to the deficiency noted in the report.
Failure to Follow Physician's Orders for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to prevent and follow physician's orders related to a pressure ulcer for a resident with multiple diagnoses, including dementia, heart failure, and diabetes. The resident had a physician's order to wear Blue Prevalon boots at all times to prevent pressure ulcers. However, during multiple observations on different days, the resident was found in bed without the prescribed boots. The boots were observed on the top shelf of her closet instead of on her feet. Additionally, during wound care, the staff did not place the boots back on the resident's foot after treatment, contrary to the physician's order. Interviews with the facility wound physician and a Qualified Medication Aide (QMA) confirmed that the resident should have some form of off-loading, such as boots or a pillow, to prevent pressure ulcers. The clinical record lacked documentation indicating that the resident refused to wear the boots. The facility's policy on pressure ulcer prevention, which includes repositioning residents every two hours and floating heels, was not followed. This failure to adhere to physician's orders and facility policy led to the deficiency.
Failure to Provide Appropriate Urinary Catheter Care
Penalty
Summary
The facility failed to provide appropriate urinary catheter care for a resident with frequent urinary tract infections. During an observation, a CNA was seen performing catheter care without following proper hygiene protocols. The CNA's gloves ripped, and she picked up the glove from the floor with her gloved hand, then continued to perform tasks without changing gloves. She also touched various surfaces and objects, including the resident's bedside table, nightstand, and bathroom fixtures, without changing gloves. Additionally, the CNA did not use a clean area of the washcloth for each motion while cleaning the catheter tubing, which contained dark urine with sediment. The resident's urinary catheter tubing was also observed lying on the bed, which is not a sanitary practice. The resident involved was moderately cognitively impaired and had a history of frequent UTIs, as indicated by multiple physician orders for antibiotics over several months. The facility's policy on catheter care, which aims to promote good hygiene and reduce infection risk, was not followed. The QMA confirmed that the resident had frequent UTIs and that catheter care was supposed to be performed every shift with proper hygiene protocols, including changing gloves if anything was touched before starting the catheter care.
Failure to Implement Interventions and Document Behaviors for Resident with Dementia
Penalty
Summary
The facility failed to implement interventions and complete behavior forms related to dementia care for a resident diagnosed with severe cognitive impairment, Alzheimer's disease, dementia, anxiety, depression, and psychotic disorder. The resident exhibited several behaviors, including physical aggression towards staff and other residents, wandering, and refusal to stay in his wheelchair. Despite these behaviors, the facility did not consistently document or implement effective interventions, such as the use of a door frame alarm, which lacked a physician's order and regular checks for functionality. The resident's aggressive behaviors were documented in multiple Mood and Behavior Communication Memos, indicating incidents of physical aggression towards staff and other residents. These incidents included hitting another resident, refusing to leave other residents' rooms, and being combative with staff. The interventions attempted, such as redirection, one-to-one observation, and providing a quiet environment, were often unsuccessful, and the outcomes of these interventions were frequently documented as unchanged or worsened. Interviews with staff revealed inconsistencies in the reporting and handling of the resident's behaviors. Staff members indicated that behavior sheets were not always completed, and there was confusion about the use of the door frame alarm, which was not consistently checked or ordered by a physician. The facility's policies on position change alarms and mood and behavior programs were not adequately followed, leading to a lack of proper documentation and intervention for the resident's behaviors.
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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