Bethany Pointe Health Campus
Inspection history, citations, penalties and survey trends for this long-term care facility in Anderson, Indiana.
- Location
- 1707 Bethany Rd, Anderson, Indiana 46012
- CMS Provider Number
- 155698
- Inspections on file
- 27
- Latest survey
- February 9, 2026
- Citations (last 12 mo.)
- 3 (1 serious)
Citation history
Health deficiencies cited at Bethany Pointe Health Campus during CMS and state inspections, most recent first.
A resident with COPD and dementia received a nebulizer treatment without staff present, despite lacking a physician order or documented care plan authorization to self-administer medications. The resident was observed in bed holding the nebulizer mask while the machine ran unattended until another staff member entered and turned it off, and the assigned nurse was on break. An RN acknowledged the resident was not able to self-administer but routinely allowed her to complete nebulizer treatments alone due to other medication priorities. Although a self-administration assessment later indicated the resident could self-administer ipratropium-albuterol, this was not yet incorporated into the clinical record, and facility policy required staff to remain with residents during nebulizer treatments unless formally authorized for self-administration.
A resident with Parkinson’s disease, dementia, and chronic incontinence, who required extensive assistance with toileting and personal hygiene, received perineal care from a QMA who did not change gloves or perform hand hygiene after cleaning the perineal area and disposing of a soiled brief, then proceeded to assist with dressing, transfer, and handling of oxygen tubing and nasal cannula. During the same care episode, a CNA placed a soiled bath blanket on the carpeted floor while making the bed, contrary to the facility’s linen-handling policy. The CNA later stated she would not normally place soiled linens on the floor, and the QMA acknowledged forgetting to change gloves after perineal care, while the Executive Director reported there was no policy specifically addressing glove changes after perineal care.
A resident with dementia and a history of exit-seeking behaviors was able to leave a secured unit unsupervised after a visitor entered the code and held the door open, despite the resident's care plan and prior use of a wander guard. The resident was missing for nearly an hour, crossing a highway and traveling almost a mile before being found and returned by a staff member. Staff did not immediately notice the resident's absence, and the facility's elopement prevention policy was not effectively followed.
Two residents who were discharged to the hospital did not receive required bed hold policy notifications, as documentation was either missing or incomplete. Although staff reported that bed hold forms were typically given to emergency personnel, there was no evidence in the clinical records that the residents or their representatives received the notifications, and the DON acknowledged discarding the policies after scanning related paperwork.
A resident with severe cognitive impairment and Alzheimer's disease, who required supervision due to impaired safety awareness and risk of elopement, was left unattended at a hospital waiting area during a medical appointment. The facility's transport driver, believing a family member would meet the resident, departed after leaving the resident with a receptionist, despite no family being present. The resident's need for supervision was documented in her care plan, and the facility lacked a policy on resident transportation.
Two residents receiving psychotropic medications did not have appropriate gradual dose reductions or documented clinical contraindications, and their care plans lacked identification of targeted behavioral symptoms for medication use. Pharmacy recommendations for dose reduction were declined by physicians without detailed risk-benefit analyses, and documentation of delusions and hallucinations was not resident-specific. Staff interviews and record reviews confirmed inconsistent and insufficient documentation related to the use of these medications.
Two residents were not re-offered or re-educated about pneumococcal vaccination after initially declining it upon admission, despite facility policy and CDC guidance requiring ongoing offerings. The Infection Preventionist confirmed that only influenza and COVID-19 vaccines were offered annually, not pneumococcal, and documentation lacked evidence of further vaccine offerings after admission.
The facility failed to provide appropriate dementia services, as residents were not engaged in meaningful activities or offered sensory materials. Staff struggled to modify activities to meet cognitive levels, and observations showed residents sitting idly without interaction. Clinical records indicated severe cognitive impairments, but the facility's program did not adequately address these needs.
A resident with severe cognitive impairment and respiratory conditions was not properly monitored for oxygen therapy, leading to a deficiency in care. Observations showed the resident's oxygen humidification was inadequate, and the portable oxygen tank was empty, resulting in the resident not receiving continuous oxygen. Staff interviews revealed inconsistencies in understanding oxygen titration orders, and facility policies for maintaining oxygen equipment were not followed.
Failure to Supervise Nebulizer Treatment for Non-Authorized Self-Administering Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide supervised nebulizer treatments to a resident who had not been authorized to self-administer medications. During an observation, the resident was found lying in bed holding a nebulizer mask to her face with the nebulizer machine running on the bedside table and no staff present. A CNA briefly entered the room to state she would return to provide care, then left, and the nebulizer continued without nursing supervision until the MDS Coordinator entered and turned off the machine. The MDS Coordinator stated she did not know if the resident could self-administer nebulizer treatments and noted the resident’s nurse was on break. Record review showed the resident had diagnoses including unspecified dementia without behavioral disturbance and a physician’s order for ipratropium-albuterol nebulizer treatments three times daily for COPD, with no order authorizing self-administration of nebulizer treatments. The resident’s progress notes and care plan contained no documentation related to self-administration of nebulization. An RN later stated the resident was not able to self-administer but that he typically allowed her to complete nebulizer treatments without staff present due to other medication priorities. A self-administration assessment, dated with an observation several days earlier but completed on the same day as the survey review, indicated it was appropriate for the resident to self-administer ipratropium-albuterol and store the medication in her room; however, this assessment was not yet reflected in the care plan or progress notes at the time of the observation. Facility policy required staff to remain with a resident during nebulizer treatment unless the resident had been assessed and authorized to self-administer.
Failure to Follow Hand Hygiene and Linen Handling Practices During Perineal Care
Penalty
Summary
The deficiency involves a failure to implement proper infection prevention and control practices during incontinence and personal care for one resident. During an observed care episode, a CNA and a QMA donned gloves and uncovered the resident, whose incontinence brief was soiled. The QMA provided perineal care, removed the soiled brief from under the resident, retrieved a trash can, and disposed of the brief, but did not change gloves or perform hand hygiene after completing perineal care. With the same gloves still on, the QMA then assisted the resident with dressing, helped the resident sit on the side of the bed, transferred the resident into a wheelchair, and handled the resident’s oxygen tubing and nasal cannula, placing it on the resident’s face and nose. During the same care episode, while the QMA and CNA were assisting the resident, the CNA placed a soiled bath blanket onto the carpeted floor while making the resident’s bed, despite a facility policy stating that soiled linen should not be placed on furniture or the floor. The CNA later stated the blanket was only slightly soiled and that she would not normally place soiled linens on the floor, and the QMA acknowledged he had forgotten to change gloves and would normally do so after providing perineal care. The resident involved had diagnoses including Parkinson’s disease and dementia, was moderately cognitively impaired per a recent MDS, was dependent for toileting hygiene, required substantial to maximal assistance with personal hygiene, and was always incontinent of bladder and frequently incontinent of bowel. During the exit conference, the Executive Director indicated there was no facility policy specifically related to changing gloves after providing perineal care.
Failure to Prevent Elopement of Resident with Dementia from Secured Unit
Penalty
Summary
A resident with a diagnosis of dementia, agitation, and a history of exit-seeking behaviors was admitted to the facility and initially placed on one-to-one supervision with a wander guard device applied to his ankle. The resident was assessed as an elopement risk, and his care plan included monitoring for wandering triggers and the use of a secured unit if needed. After several days of one-to-one supervision, the resident was transferred to a secured dementia unit, at which point the wander guard and one-to-one supervision were discontinued due to the unit's locked status. Despite residing on the secured unit, the resident was able to exit the facility when a visitor entered the code to the egress door and held it open, allowing the resident to leave unsupervised. Staff interviews and video footage confirmed that the resident exited the building with the assistance of the visitor and was not immediately noticed as missing by facility staff. The resident was unaccounted for outside the facility for approximately 50 minutes, during which time he walked across a four-lane highway and traveled nearly 0.7 miles away from the facility. The resident was eventually located by a staff member who was arriving for work and observed him walking near a park. The staff member returned the resident to the facility by car. At the time of the incident, the facility's policy required staff to attempt to prevent disoriented residents from exiting, but the policy was not effectively implemented in this case, resulting in the resident's unsupervised elopement.
Failure to Provide Bed Hold Policy Notification During Hospital Transfers
Penalty
Summary
The facility failed to provide required bed hold policy notifications to two residents who were discharged to the hospital. In both cases, the residents were cognitively intact and had been discharged with a return anticipated. For one resident, there was no documentation in the clinical record that a bed hold notice was provided or offered, despite the transfer/discharge form indicating that the bed hold policy should be attached. Nursing notes only indicated that appropriate documentation was sent with emergency personnel, but did not specify that the bed hold notice was included or received by the resident. For the second resident, although nursing notes stated that the notice of transfer and bed hold forms were completed, there was no indication in the clinical record of who received the bed hold form. Staff interviews revealed that the bed hold policy was typically given to emergency personnel to take to the hospital, but not directly to the resident or their representative, and that documentation of this process was lacking in the clinical record. The Director of Nursing admitted to discarding the bed hold policies after scanning the notice of transfer/discharge, resulting in the absence of these documents in the residents' records.
Resident with Dementia Left Unattended During Medical Appointment
Penalty
Summary
A resident with severe cognitive impairment and Alzheimer's disease was transported by facility staff to a hospital for a scheduled medical procedure. The resident, who had a care plan indicating impaired safety awareness and risk of elopement, was left unattended in the hospital waiting area without facility or family supervision. The transport driver reported that he was told by a dementia unit leader that the resident's family would meet her at the hospital. Upon arrival, the hospital receptionist mentioned the family would be coming, but no family member was present. The driver left the resident with the receptionist and departed to transport another resident, despite being aware that residents should not be left unsupervised unless a family member is present. The resident's family only became aware of the situation when a family friend saw the resident alone at the hospital and notified them, prompting a family member to arrive and stay with the resident during the procedure. The resident's clinical record and care plan documented her need for supervision due to dementia and impaired decision-making. The facility did not have a policy regarding transportation of residents at the time of the incident.
Failure to Ensure Gradual Dose Reduction and Documentation for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents receiving psychoactive medications had appropriate gradual dose reductions (GDR) or documented clinical contraindications, and did not identify or document targeted behavioral symptoms for the use of psychotropic medications for two of five residents reviewed. For one resident with diagnoses including delusional disorder, heart failure, obesity, and sleep apnea, the clinical record showed ongoing use of sertraline, quetiapine, and trazodone. Pharmacy consultant recommendations for GDR were declined by the physician without a resident-specific risk-benefit analysis or clear statement of contraindication. The care plans lacked identification of targeted behaviors for the use of these medications, and documentation of delusions and hallucinations was not resident-specific. Observations and staff interviews confirmed the presence of hallucinations and delusions, but the clinical record did not contain specific or consistent documentation of these symptoms. Another resident with dementia, psychotic and mood disturbances, and anxiety was prescribed multiple psychotropic medications, including amitriptyline, duloxetine, and quetiapine. Pharmacy recommendations for GDR were also declined by the physician, with only a general statement that "risk outweighs benefit" and no detailed risk-benefit analysis. The care plans did not specify targeted behaviors or symptoms for the use of these medications. Documentation in the medication administration record indicated delusions, but lacked resident-specific details. Staff interviews revealed that the resident had not recently reported hallucinations or delusions, though some behaviors such as packing belongings and attempting to take a roommate's items were noted. The clinical record did not contain specific documentation of hallucinations or delusions, and the resident's family had previously refused GDRs, though some changes were eventually made. The facility's policy required that psychotropic medications be used only when medically necessary, with appropriate documentation and ongoing efforts to reduce dosages unless contraindicated. However, in both cases, the required documentation of medical necessity, targeted behaviors, and resident-specific contraindications for GDR was lacking. The deficiency was identified through observation, interview, and record review, demonstrating a failure to comply with regulatory requirements for the use of unnecessary drugs and psychotropic medication management.
Failure to Offer and Educate on Pneumococcal Vaccines per CDC Guidance
Penalty
Summary
The facility failed to offer and educate residents regarding pneumococcal vaccines in accordance with CDC guidance for two out of five residents reviewed for infection control. One resident, with diagnoses including severe cognitive impairment and dementia, had a historical administration of the pneumococcal vaccine prior to admission and declined the vaccine upon admission after being provided education. However, there was no documentation of the vaccine being offered again since admission. Another resident, who was cognitively intact and had a history of paraplegia and other conditions, also had a historical pneumococcal vaccine prior to admission and declined the vaccine upon admission, with no further documented offerings since that time. During an interview, the Infection Preventionist stated that influenza, COVID-19, and pneumococcal vaccines are offered upon admission, with only influenza and COVID-19 vaccines being offered annually thereafter. The facility's policy indicated that pneumococcal vaccines should be offered per CDC recommendations and physician orders, but the records reviewed did not show ongoing offerings or education regarding the pneumococcal vaccine after the initial admission period for the affected residents.
Deficiency in Dementia Care Services
Penalty
Summary
The facility failed to provide appropriate dementia services to enhance the quality of life for residents on a dementia unit. Observations revealed that residents were not offered meaningful and purposeful activities or sensory materials. During multiple observations, residents were seen sitting idly without engagement or interaction from staff. Sensory items such as books, magazines, puzzles, games, art materials, and manipulative devices were not made available to the residents, despite being present in the facility. Interviews with staff, including an LPN and the Activity Assistant, highlighted a lack of understanding and training in providing suitable activities for residents with severe cognitive impairments. The Activity Assistant struggled to modify activities to meet the cognitive levels of the residents, often asking questions that required abstract reasoning, which the residents could not answer. Activities were not adjusted to accommodate the residents' cognitive limitations, and there was a lack of tactile or visual aids to support engagement. The clinical records of the residents involved indicated severe cognitive impairments, visual and hearing impairments, and a need for engagement in meaningful activities. Despite these documented needs, the facility's program did not adequately address them. The facility's policy and activity calendar suggested a structured program, but observations showed a lack of implementation and adaptation to the residents' needs. The Administrator and staff were unsure how to modify activities to suit the residents' cognitive abilities, leading to a deficiency in providing appropriate dementia care services.
Deficiency in Respiratory Care Due to Improper Oxygen Management
Penalty
Summary
The facility failed to properly monitor and maintain oxygen therapy for a resident, leading to a deficiency in respiratory care. Observations revealed that the resident was receiving oxygen via nasal cannula connected to an oxygen concentrator set at four liters per minute, but the humidification canister was either low or empty, preventing proper humidification. The resident, who had severe cognitive impairment and required maximal assistance, was observed to be lethargic and not feeling well, yet there was no provider notification of the increased need for oxygen titration. The resident's clinical record indicated a history of chronic obstructive pulmonary disease (COPD), pneumonia, heart failure, and ischemic cardiomyopathy. Physician orders for oxygen therapy were not consistently followed, as the resident's oxygen was set at four liters per minute without proper humidification, and the portable oxygen tank was found empty while the resident was in a wheelchair. Staff interviews revealed a lack of understanding and adherence to oxygen titration orders, with discrepancies in how high oxygen could be titrated without specific parameters. Facility policies required the use of humidification for oxygen orders at four liters per minute and specified procedures for maintaining oxygen equipment. However, these policies were not followed, as evidenced by the empty humidification canister and the resident's connection to an empty portable oxygen tank. The facility's failure to ensure continuous oxygen supply and proper equipment maintenance contributed to the deficiency in respiratory care for 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.
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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.
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