Auburn Village
Inspection history, citations, penalties and survey trends for this long-term care facility in Auburn, Indiana.
- Location
- 1751 Wesley Road, Auburn, Indiana 46706
- CMS Provider Number
- 155666
- Inspections on file
- 33
- Latest survey
- October 16, 2025
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Auburn Village during CMS and state inspections, most recent first.
A resident with anxiety, depression, and respiratory failure experienced respiratory distress and urgently requested ADL assistance. A CNA reported the resident's breathing difficulty to an RN, who responded dismissively and refused to check on the resident. The CNA relayed this response to the resident, who became further distressed. Facility policy required staff to treat residents with dignity and respect, but this was not followed during the incident.
Surveyors observed multiple lapses in kitchen cleanliness, including unclean equipment, improper food labeling, and staff not restraining hair, with 70 residents consuming food prepared in these conditions. Staff and the Dietary Manager acknowledged the issues, which were not in line with facility policies for cleaning and food labeling.
A resident who was cognitively intact and required assistance with eating requested to dine in the main dining room for increased socialization, but was repeatedly seated in the assisted dining room despite expressing his preference. Staff cited dignity and safety concerns, though the resident was comfortable with assistance in public and had no documented safety or swallowing issues. The care plan and facility actions did not reflect the resident's choice, contrary to facility policy requiring respect for resident wishes.
A resident with chronic pain and frequent pain episodes interfering with sleep was not offered or documented to have received non-medication pain interventions as ordered by the physician prior to administration of PRN pain medications. Despite clear orders and facility policy, nursing staff did not document or provide these interventions, and the care plan lacked specific non-pharmacological strategies.
A resident with muscular dystrophy and pain requested massage therapy for discomfort, but despite repeated requests and documentation of need, the service was not provided in a timely manner. Staff were unclear about responsibility for arranging massage therapy, and the resident's care plan did not address this intervention, resulting in the resident not receiving the specialized rehabilitative service.
A resident with severe cognitive impairment and multiple mobility-limiting diagnoses was observed with wrist contractures and reported limited hand use. Although the care plan required daily ROM exercises, there was no documentation in the MAR, TAR, or aide task sheets that these were provided. The DON confirmed ROM was not documented or tracked due to the lack of a restorative program and policy.
The facility failed to follow public health recommendations during a Legionella outbreak investigation, affecting a resident who tested positive for Legionnaires' disease. Despite IDOH's advice to remove showers from service and use bottled water, the facility continued using showers due to resident preferences and did not install recommended filters. Staff lacked training on Legionella, and residents were not informed of the risks.
A facility failed to identify and address the underlying causes of distress in a resident with a history of childhood sexual trauma. The resident exhibited behaviors such as nonsensical speech, aggression, and inappropriate comments, but the care plans lacked specific strategies for managing these issues. Interviews with staff revealed that while the resident denied specific triggers, the facility did not adequately use observations to identify potential stressors, leading to insufficient individualized care.
Failure to Provide Dignified and Respectful Care During Resident Distress
Penalty
Summary
A deficiency occurred when staff failed to ensure respectful and dignified communication and care for a resident with anxiety, depression, and respiratory failure, who was cognitively intact and dependent on a tracheostomy and ventilator. The resident's care plan included interventions for anxiety and guidance for staff to use calm, consistent communication with firm boundaries. On the day in question, the resident experienced respiratory distress and expressed urgent needs for assistance with activities of daily living (ADLs). A CNA observed the resident appearing to have difficulty breathing and reported this to an RN, who responded that they did not care and refused to check on the resident. The CNA relayed this dismissive comment to the resident, further impacting the resident's emotional state. Progress notes indicated the resident was demanding immediate care, refused assistance from an available aide, and became upset when their needs were not met promptly. The RN, along with another nurse and a respiratory therapist, remained at the nurses' station and did not immediately respond to the CNA's concerns. The respiratory therapist eventually went to the resident after a delay. The resident reported feeling anxious, crying, and experiencing rapid breathing during the incident. Facility policy required staff to treat residents with dignity, respect, and sensitivity, especially during intimate care tasks, but this standard was not upheld in this instance.
Failure to Maintain Kitchen Cleanliness and Food Safety Standards
Penalty
Summary
The facility failed to maintain kitchen cleanliness and adhere to food safety protocols, as evidenced by multiple observations. Moisture was found in two out of three pans on the drying rack, and the stand mixer in the cooking and clean storage area had yellow particles and discoloration on its bowl, paddle, and main unit. An unlabeled fruit cup with a red liquid puddle was found in the mini fridge, and an employee was observed with unrestrained hair while working in the kitchen. Additionally, a food processor lid was placed right side up on a toaster with visible crumbs and dry brown particles, resulting in food and liquid transfer from the processor to the toaster. Brown stains and a dry, round, white food-like substance were also observed in the dining room near the coffee maker. Interviews with the Dietary Manager and staff confirmed awareness of these issues, including the need for hair restraints and proper cleaning and storage of kitchen appliances. The Dietary Manager indicated that 70 of 81 residents consumed food prepared in the facility's kitchen. Facility policies require proper cleaning of small appliances and labeling of food items, but these procedures were not consistently followed, contributing to the deficiency.
Failure to Honor Resident Dining Location Choice
Penalty
Summary
The facility failed to honor a resident's right to choose their dining location, despite the resident's clear and repeated requests. Observations showed the resident consistently seated in the assisted dining room with staff providing eating assistance. The resident, who is cognitively intact with a BIMS score of 15 and requires assistance with eating due to muscular dystrophy, expressed during a resident council meeting and in interviews that he wished to dine in the main dining room to increase socialization. Staff interviews confirmed that the resident's preference was communicated, but the Activities Director informed him he could not eat in the main dining room due to a perceived dignity issue, as directed by the Administrator and corporate staff. The resident stated he was comfortable receiving assistance in front of others. The Director of Nursing later cited safety concerns as the reason for the resident's placement in the assisted dining room, but did not specify any safety issues that could not be managed in the main dining room. The resident's care plan was updated to require all meals in the assisted dining room, but did not address his choice of dining location. Medical records indicated no swallowing or chewing problems, and the resident was on a regular diet. Facility policy requires resident wishes to be respected, but this was not followed in this case.
Failure to Implement Non-Medication Pain Interventions as Ordered
Penalty
Summary
The facility failed to implement non-medication pain interventions as ordered by the physician for a resident with chronic pain syndrome, low back pain, right leg pain, and polyneuropathy. The resident, who was cognitively intact, experienced frequent pain that interfered with sleep and was prescribed both pharmacological and non-pharmacological pain management strategies. Physician orders specifically required that non-medication pain interventions be offered prior to administering PRN pain medications. However, review of the resident's Medication Administration Record (MAR) and nursing notes showed that non-pharmacologic interventions were not documented or offered prior to the administration of PRN pain medications, despite the resident receiving Norco for moderate to severe pain on multiple occasions. Interviews with nursing staff and the DON confirmed that non-medication pain interventions were expected to be documented in the MAR when PRN pain medications were given, but this was not done for the resident in question. The DON also acknowledged that the resident's care plan did not specify non-medication pain interventions, even though such interventions were included in the physician's orders. The facility's pain management policy indicated that both pharmacological and non-pharmacological interventions may be implemented, but the required non-medication interventions were not provided or documented for this resident.
Failure to Provide Requested Massage Therapy for Resident with Muscular Dystrophy
Penalty
Summary
The facility failed to ensure that specialized rehabilitative services, specifically massage therapy, were provided as required for a resident diagnosed with muscular dystrophy and major depressive disorder. The resident, who was cognitively intact and had limitations in range of motion in both upper extremities, repeatedly expressed his desire for massage therapy to address discomfort and pain. He communicated this need to staff and during a Resident Council meeting, and it was noted in progress notes that he had previously benefited from massage therapy. Despite a progress note indicating a referral to Physical Therapy for ultrasound and massage therapy, there was no corresponding physician order for physical therapy, and the resident was not evaluated for massage therapy until several weeks after his initial request. The care plan for the resident addressed pain management but did not include interventions related to massage therapy or range of motion relief. Staff interviews revealed confusion regarding responsibility for providing massage therapy, with the DON indicating Occupational Therapy was handling it, while the Director of Therapy confirmed the resident had not been evaluated for massage therapy until prompted by the survey. Additionally, the resident's request for transportation to receive massage therapy at the VA hospital was not facilitated, and his inquiries were not consistently communicated among staff. The lack of timely assessment and provision of the requested rehabilitative service resulted in the resident not receiving massage therapy as required.
Failure to Provide and Document Range of Motion Care for Resident with Contractures
Penalty
Summary
A resident with diagnoses of rheumatoid arthritis, Parkinson's Syndrome, and Alzheimer's was observed to have contractures in both wrists and reported limited use of their hands, which prevented participation in activities. The resident's care plan identified limited mobility and contractures, with a goal to prevent further immobility complications and an intervention for daily gentle range of motion (ROM) exercises as tolerated. Despite these documented needs and interventions, there was no evidence in the Medication Administration Record, Treatment Administration Record, or nurse aide task sheets that ROM exercises were provided or documented for the resident. The Director of Nursing confirmed that ROM was not documented due to the absence of an official restorative program and stated that nurse aides were expected to perform ROM exercises during routine care without recording them. Additionally, the facility did not have an official policy for contracture care.
Failure to Follow Legionella Outbreak Recommendations
Penalty
Summary
The facility failed to ensure education about and follow public health authority recommendations during the investigation of a communicable disease outbreak involving Legionella bacteria. An anonymous complaint to the Indiana Department of Health (IDOH) indicated that Legionella bacteria had been found in water samples collected at the facility, and recommendations made to prevent disease were not being followed. This deficiency affected one resident, Resident M, who tested positive for Legionnaires' disease after being hospitalized, and had the potential to affect 68 residents residing in the facility. The facility was notified by IDOH of a Legionella outbreak investigation based on Resident M's positive urine test for Legionella and diagnosis of Legionnaires' disease. The resident had spent 12 days of the 14-day incubation period at the facility, prompting an outbreak investigation. IDOH provided recommendations for immediate water precautions, including removing ice machines from service, using bottled water for drinking, and removing showers from service until point-of-use filters could be installed. However, the facility did not fully implement these recommendations, as they continued to use showers per residents' preferences and did not install the recommended filters on showerheads. Interviews with facility staff revealed a lack of training on Legionella or other waterborne illnesses. Staff were not instructed to monitor for symptoms of pneumonia in high-risk residents or themselves, and there was no documentation indicating that residents had been notified of the presence of Legionella in the water. The facility's water management program identified showers in resident rooms as high-risk locations for Legionella bacteria, yet the facility elected not to follow the full extent of IDOH's recommendations, citing cost and resident preferences.
Failure to Address Trauma-Related Distress in Resident
Penalty
Summary
The facility failed to adequately identify, assess, and address the underlying causes of distress in a resident who is a survivor of childhood sexual trauma. The resident, who has a complex medical history including anxiety, major depressive disorder, paranoid schizophrenia, and insomnia, displayed various behaviors indicative of distress. These behaviors included speaking in nonsensical terms, swearing, making sexually inappropriate comments, and exhibiting physical aggression. Despite these behaviors, the facility did not effectively determine specific triggers or stressors that could be contributing to the resident's distress. The resident's care plans were found to be lacking in several areas. While the care plans addressed some behaviors and provided general interventions, they did not include specific strategies for managing the resident's obsessive-compulsive disorder or depression. Additionally, the care plans did not consider pain or male caregivers as potential stressors for the resident's aggression or refusal of care. The facility's approach to the resident's care was not sufficiently individualized to address the resident's unique needs and history of trauma. Interviews with facility staff, including the Social Service Director and the Director of Nursing, revealed that while the resident denied having specific trauma-related triggers, the staff acknowledged that triggers could be identified through observation rather than self-report. However, the facility's care plan approach did not include specific traumatic topics to be avoided or specific stressors for aggression or resistance to care. This lack of detailed and individualized care planning contributed to the facility's failure to provide appropriate treatment and services to the resident.
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.
