Bethel Pointe Health And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Muncie, Indiana.
- Location
- 3400 W Community Dr, Muncie, Indiana 47304
- CMS Provider Number
- 155546
- Inspections on file
- 35
- Latest survey
- February 13, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Bethel Pointe Health And Rehab during CMS and state inspections, most recent first.
A resident with cognitive intactness, mobility limitations, incontinence, and skin integrity issues required staff assistance with ADLs and had a documented preference for showers on specific days. The care plan specified one-staff assistance for bathing and hygiene, but bathing records showed multiple refusals without documentation of re-approach, education, or nurse/family notification, and several scheduled shower days were left completely blank. Staff interviews described the resident as generally cooperative with care and confirmed that refusals should be re-approached and documented, yet the clinical record lacked evidence that showers were consistently offered or provided according to the resident’s preferences and facility policy.
A resident with a feeding tube due to a stroke did not receive adequate site care, as the facility failed to document and implement necessary orders for gastrostomy tube site care. Interviews revealed that the site was not cleaned or the dressing changed regularly, and the care plan lacked interventions for feeding tube site care, leading to a deficiency.
The facility failed to properly label and dispose of insulin vials and pens in two medication carts. An RN and an LPN confirmed that insulin should be used within 28 days of opening, but observations revealed undated and misdated insulin vials and pens. The DON confirmed the expectation for proper dating and disposal according to facility policy.
The facility failed to post complete nurse staffing information daily, affecting all residents. Observations showed that only the first shift's staffing details were visible, with no updates for the second and third shifts. The DON was unaware of the issue, which persisted over several days, violating the facility's policy requiring clear and accessible staffing information.
The facility failed to complete and document wound care treatments for two residents, leading to a deficiency. A resident with multiple sclerosis and diabetes had missing documentation for wound treatments on the right shin and heel, while another resident with Alzheimer's had incomplete records for left ankle wound care. The DON confirmed the lack of documentation for required treatments.
The facility failed to securely store and properly dispose of medications, as observed in the Wound Nurse's office where an unlocked cabinet contained various medications for multiple residents, including those who had been discharged. Staff interviews revealed confusion and non-compliance with the facility's policies on medication storage and disposal, leading to improper handling of medications.
A facility failed to obtain an apical pulse before administering digoxin to a resident with atrial fibrillation. The RN administered the medication without checking the pulse, relying on an undocumented reading from the night shift. Interviews revealed that the standard practice was to check the pulse and hold the medication if it was below 60 bpm. The DON confirmed that physician's orders should be followed, and the facility's policy required pre-administration checks.
A facility failed to monitor and implement interventions for a resident's pressure injury, leading to its progression from stage 2 to unstageable. The resident, with multiple health issues, was not consistently repositioned, and there were gaps in wound assessments and treatments. Staff interviews revealed a lack of awareness and communication about the resident's condition, and the facility's policy on pressure injury prevention was not effectively followed.
A resident with a history of urinary tract infections and chronic kidney disease was observed with an improperly positioned catheter bag and tubing, which were repeatedly found lying on the floor mat. Despite staff presence, the facility failed to adhere to its policy of ensuring catheter bags and tubing were not on the floor, as confirmed by staff interviews and observations.
Failure to Provide/Offer Showers per Resident Preference and Inadequate Bathing Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide or offer showers according to a resident’s stated preferences and to maintain proper hygiene. Resident B, who was cognitively intact and required substantial staff assistance for lower body dressing, footwear, bathing, shower transfers, and toileting hygiene, had care plans indicating a need for one staff to assist with a.m./p.m. care, dressing, and bathing. A specific choices care plan documented the resident’s preference for showers on Tuesday and Friday day shifts, and there was no indication in the care plan that the resident was noncompliant with bathing. The resident also had unhealed pressure ulcers, a surgical wound, and MASD, with interventions that included education and reminders regarding good hygiene and daily changing of clothing and undergarments. Review of bathing documentation showed multiple dates on which the resident either refused or had no recorded bathing activity despite the established shower schedule. On some scheduled shower days, refusals were documented (e.g., certain Tuesdays and Fridays), but the clinical record did not contain any documentation of additional attempts, resident education, or notification of a nurse or family regarding these refusals. On several other scheduled shower days, the bathing record was left blank, with no indication that bathing was offered or provided. This lack of documentation made it impossible to determine whether the resident was actually offered showers in accordance with his preferences on those dates. Interviews with staff further highlighted inconsistencies between the resident’s documented refusals and staff recollections. CNA 3, who was assigned to the resident on the day he went to a community appointment, described the resident as pleasant, cooperative with care, and compliant with toileting and daily cleaning and dressing, and was unsure if the resident refused showers. Other staff, including QMA 4 and QMA 5, stated that residents were to be offered bathing according to their preferences, that refusals required multiple re-approaches and nurse notification, and that it was not acceptable to leave bathing or refusals uncharted. The DON acknowledged that there was no additional information available to show the resident’s bathing on the dates with blank documentation and that the record lacked any nurse or family notification regarding shower refusals, resulting in an inability to verify that showers were offered as required by the resident’s care plan and facility policy.
Deficiency in Feeding Tube Site Care for Resident
Penalty
Summary
The facility failed to provide adequate care for a resident with a feeding tube, leading to a deficiency in the care provided. Resident 47, who had a feeding tube due to a stroke, was found to have insufficient documentation and orders for the care of her gastrostomy tube site. The clinical record lacked specific orders for site care, and the care plan did not include interventions for feeding tube site care. Despite having a physician order to change the enteral tube as needed, there were no documented orders for regular site care, which is typically included in the Treatment Administration Record (TAR) for residents with feeding tubes. Interviews with staff and the resident revealed that the feeding tube site was not cleaned and the dressing was not changed every shift or daily, as would be expected. The Corporate Nurse Consultant confirmed that the facility lacked documentation to show that the feeding tube site care had been performed. The facility's policy on the care and treatment of feeding tubes emphasized the need for interventions to prevent complications, yet the resident's care plan did not adequately address these needs. This oversight in care and documentation led to the deficiency noted in the report.
Improper Labeling and Disposal of Insulin in Medication Carts
Penalty
Summary
The facility failed to ensure proper labeling and disposal of insulin vials and pens, which are critical for managing diabetes mellitus in residents. During an observation of the East hall medication cart, an open vial of Glargine insulin was found undated, and a vial of Lispro insulin was misdated with three different dates. The Registered Nurse (RN) accompanying the surveyor confirmed that the cart served eight diabetic residents and acknowledged that insulin should be used within 28 days of opening. The Director of Nursing (DON) also confirmed that misdated insulin should be disposed of if the open date is uncertain. Similarly, during an observation of the Center hall medication cart, an open Lantus Solostar insulin pen was found undated, and a vial of Lispro insulin had illegible markings. The Licensed Practical Nurse (LPN) confirmed that the cart served five diabetic residents and reiterated the 28-day usage policy. The DON emphasized that insulin should be dated upon opening and reviewed with each dose to ensure it is not used beyond the expiration period. The facility's policies on medication labeling and expiration were provided, indicating that all medications must be labeled legibly and multi-use vials should be discarded within 28 days unless otherwise specified by the manufacturer.
Incomplete Nurse Staffing Information Posting
Penalty
Summary
The facility failed to post complete nurse staffing information daily, which had the potential to affect all 103 residents. Observations on multiple days revealed that the nurse staffing information for the second and third shifts was not visible to residents and visitors. The postings were only showing the first shift's staffing details, and the information was not updated at the beginning of each shift as required. This issue persisted from March 18 to March 21, 2025, with the Director of Nursing (DON) unaware that the postings had not been changed daily. The facility's policy, last revised in August 2024, mandates that nurse staffing information be readily available and visible in a clear format to residents and visitors. The policy requires the posting of the facility name, current date, resident census, and the total number and actual hours worked by RNs, LPNs, and CNAs per shift. However, the facility did not comply with this policy, as the postings were not updated for the second and third shifts, and the information was not presented in a prominent place accessible to residents and visitors.
Failure to Document and Complete Wound Care Treatments
Penalty
Summary
The facility failed to complete ordered wound treatments and assessments for two residents, leading to a deficiency in care. Resident B, diagnosed with multiple sclerosis, dementia, malnutrition, and type II diabetes, had several physician's orders for wound care on the right shin and heel. However, the electronic treatment administration record (eTAR) lacked documentation of these treatments being completed on multiple occasions, including specific dates in July 2024. Additionally, there was a failure to document the drainage amount for the right heel wound on several dates as required by the physician's order. Similarly, Resident C, diagnosed with Alzheimer's disease, malnutrition, and iron-deficient anemia, had physician's orders for wound care on the left ankle. The eTAR lacked documentation of the treatments being completed on several dates in August 2024, including both daily and bedtime applications. Furthermore, the drainage amount for the left ankle wound was not documented for a series of dates. During an interview, the Director of Nursing (DON) confirmed that all treatments should be completed and documented per physician's order, acknowledging the lack of documentation for wound descriptions and dressing changes.
Improper Medication Storage and Disposal
Penalty
Summary
The facility failed to ensure medications were stored securely and disposed of according to policy and compliance regulations. During an observation of the Wound Nurse's office, a small, unlocked two-drawer file cabinet was found containing various medications for multiple residents, some of whom had been discharged from the facility. These medications included ondansetron, hydroxyzine pamoate, finasteride, lisinopril, atorvastatin calcium, and many others, which were not stored in accordance with the facility's policy that requires all drugs and biologicals to be stored in locked compartments. Interviews with the facility staff, including the Administrator, Wound Nurse, RN 1, RN 2, ADON, and the Rehab Unit Manager, revealed a lack of adherence to the facility's medication storage and disposal policies. The Administrator acknowledged that the medications should not have been in the Wound Nurse's office. The Wound Nurse and other staff members indicated that medications should have been sent with residents upon discharge or destroyed if not picked up by families. However, there was confusion among staff regarding the procedures for handling medications of discharged residents, with some staff unaware of the time frame for holding medications before destruction. The facility's current policies, titled 'Medication Storage' and 'Drug Disposition,' outline the requirements for storing and disposing of medications, including the destruction of unused drugs within seven days if not returned to the pharmacy or released to the resident. Despite these policies, the facility failed to comply, resulting in medications being improperly stored in an unsecured location, which was acknowledged by the staff during interviews.
Failure to Obtain Apical Pulse Before Digoxin Administration
Penalty
Summary
The facility failed to ensure that an apical pulse was obtained prior to the administration of digoxin for one resident during medication administration. During an observation, a registered nurse (RN) administered multiple medications, including digoxin, to a resident without checking the resident's pulse beforehand. The resident had a diagnosis of atrial fibrillation, and the physician's orders for digoxin did not include specific parameters for when to hold the medication or notify the physician. The resident's pulse records showed inconsistent documentation, with the last recorded pulse being several days prior to the observation. Interviews with nursing staff revealed that the standard practice was to check the pulse and blood pressure before administering digoxin, and to hold the medication if the pulse was below 60 beats per minute. However, the RN relied on a pulse reading taken by the night shift nurse earlier that day, which was not documented in the resident's record. The Director of Nursing (DON) confirmed that physician's orders should be followed, and a pulse should be obtained before administering digoxin. The facility's policy on medication administration also required pre-administration checks, such as pulse and blood pressure, to be performed before preparing medications.
Failure to Monitor and Treat Pressure Injury
Penalty
Summary
The facility failed to adequately monitor and implement interventions for a pressure injury in one of the residents, identified as Resident C. Observations revealed that Resident C was frequently positioned on her right side on a low air loss mattress, and there was a lack of consistent repositioning. The resident's clinical record indicated multiple diagnoses, including dementia, chronic heart failure, and severe malnutrition, which increased her risk for pressure injuries. Despite these risks, the care plan lacked updated interventions after December 2023, and there were significant gaps in wound assessments and treatments. Resident C's pressure injury was initially noted in a Physiatry Progress Note in January 2024, but there was no documented wound assessment or treatment until the end of that month. Subsequent assessments showed the progression of the wound from a stage 2 to an unstageable pressure injury, with varying degrees of granulation, slough, and eschar. The facility's documentation was inconsistent, with missing assessments and unclear wound descriptions, leading to inadequate treatment and monitoring of the pressure injury. Interviews with staff, including the Wound Nurse and the DON, highlighted a lack of awareness and communication regarding the resident's condition. The Wound Nurse was unaware of earlier documentation indicating the presence of a pressure sore, and the DON could not locate assessments corresponding to the initial findings. The facility's policy on pressure injury prevention and management was not effectively implemented, as evidenced by the lack of timely and appropriate interventions to promote healing and prevent further deterioration of the resident's condition.
Improper Catheter Care and Positioning
Penalty
Summary
The facility failed to ensure proper positioning of an indwelling catheter and tubing for a resident, identified as Resident C, which led to potential contamination. Observations revealed that the resident's catheter bag and tubing were repeatedly found lying on the floor mat, which is against the facility's policy. On multiple occasions, the catheter bag was observed hanging off the bed frame and touching the floor mat, with the tubing extending towards the door. Despite staff presence and room checks, the improper positioning of the catheter bag and tubing was not corrected. Resident C's clinical record indicated a history of urinary tract infections, chronic kidney disease, and dementia, with a significant cognitive impairment. The resident was dependent on staff for various activities, including toileting and personal hygiene. The facility's policy, as provided by the Director of Nursing, clearly stated that catheter bags and tubing should not rest on the floor, yet this was not adhered to, as evidenced by the observations and staff interviews. Staff members, including a CNA and an LPN, acknowledged the expectation to ensure catheter bags were not on the floor, but this was not consistently practiced.
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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