Brickyard Healthcare - Brookview Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Indianapolis, Indiana.
- Location
- 7145 E 21st Street, Indianapolis, Indiana 46219
- CMS Provider Number
- 155076
- Inspections on file
- 36
- Latest survey
- January 28, 2026
- Citations (last 12 mo.)
- 11 (1 serious)
Citation history
Health deficiencies cited at Brickyard Healthcare - Brookview Care Center during CMS and state inspections, most recent first.
The facility failed to timely assess, document, and care plan behavioral health and sexual expression needs for three residents with significant psychiatric and cognitive conditions. One resident with schizophrenia and bipolar disorder repeatedly reported delusional and sexually focused interactions with a male resident, yet her care plan did not reflect later physician findings that she lacked capacity to consent to sexual activity, nor did it address redirection of others from her room or her identity‑shifting behaviors. The male resident, who had vascular dementia, schizophrenia, and chronic hepatitis C, was documented exposing himself and repeatedly entering the female resident’s room, and a physician later noted his impaired capacity and inability to describe STD or pregnancy prevention, but no care plan was developed indicating he could not consent to sexual activity or addressing his ongoing room‑entry behaviors. A third resident with metabolic encephalopathy and cognitive deficits developed new exit‑seeking, agitation, verbal aggression, and self‑injurious behaviors, including attempts to leave the building and calling 911 with suicidal statements, yet no elopement care plan was created and behavior care plans were not updated with new interventions. Staff interviews showed that CNAs received informal instructions to keep the two sexually involved residents apart, a QMA was not informed of this, and the SW was not notified of key sexual incidents, despite facility policies requiring behavior tracking, IDT involvement, and timely, person‑centered care planning for behavioral health and sexual expression.
A resident with DM2, CHF, HTN, CKD, and leg edema had multiple physician orders requiring that insulin and torsemide be held based on specific blood glucose and systolic BP parameters. Despite care plan directions to administer medications as ordered and monitor vital signs, staff repeatedly administered aspart and glargine insulin when blood glucose values were below the ordered hold thresholds, and gave daily torsemide without obtaining or documenting required pre-dose BP readings. The DON later confirmed that insulins were given when they should have been held and that the torsemide order was not correctly set up in the eMAR, contrary to the facility’s medication administration policy requiring adherence to physician orders and vital-sign-based parameters.
A QMA was observed administering oral medications in a manner that did not follow infection control standards. The QMA touched medication drawers and multiple medication cards, then popped a tablet into her bare hand before placing it into a medication cup with other medications for a resident, without performing hand hygiene at any time. The resident had diagnoses including type II DM. The DON later confirmed that staff are not supposed to touch tablets with bare hands, and the facility’s medication administration policy requires removing medications from their source without touching them with bare hands to prevent contamination or infection.
Surveyors found that two residents’ rooms were not kept in good repair or homelike condition. In one room, a sliding closet door was broken and not properly attached to its track, and staff acknowledged it had been in this condition for some time. In another room, the baseboard under the HVAC unit was pulled away from the wall, and the resident reported it had been like that for a long period. These conditions persisted despite facility maintenance procedures requiring staff to enter needed repairs into the TELS work order system to support a clean, comfortable environment.
Surveyors found that the facility did not provide an ongoing, individualized activity program for two residents. One resident with anoxic brain damage and a persistent vegetative state was repeatedly observed in bed or in a wheelchair with eyes open and no music or TV on, despite a care plan directing that music or television be left on during the day based on family reports of his preferences. Another cognitively intact resident with end stage renal disease and heart failure reported there were not enough or varied activities, stayed in her room most of the time, and stated she wanted arts and crafts, cards, music, and outdoor time, even though her care plan and preference assessment documented that group activities, reading materials, music, going outside, and religious services were very important to her. The Activity Director reported limited staffing for LTC activities and frequent meeting obligations, while facility policy required an ongoing activity program to support resident choices.
A resident with severe cognitive impairment and a known history of elopement risk exited a secured memory care unit unsupervised by climbing out of a bathroom window, which lacked adequate safety measures. The resident was found at a nearby gas station after crossing a busy intersection, having sustained an abrasion from a fall. Family had previously warned staff about the risk of window elopement, but the hazard was not addressed, and staff were unaware the bathroom windows could be opened.
A resident with a gastrostomy tube did not receive water flushes at the volume ordered by the physician, as the feeding pump was set to deliver 60 mL per hour instead of the prescribed 50 mL per hour. This discrepancy was confirmed by two nurses during separate observations, despite facility policy requiring adherence to physician orders for feeding tube care.
A resident with multiple complex medical conditions missed two scheduled appointments for tunneled catheter removal due to transportation issues and miscommunication about the need for a family member to accompany them. Staff did not confirm with the family member, and the facility lacked a policy for managing resident appointments, resulting in delayed care.
A resident with a history of complex medical needs, including a tracheostomy and gastrostomy, retained an IV access after completion of IV antibiotics, but there were no current physician orders or documentation for ongoing care, dressing changes, or monitoring of the IV site, despite facility policy requiring such measures.
A resident with a history of congestive heart failure and other conditions experienced anxiety when her call light was not answered for several hours after returning from the ER. Despite being generally well cared for, the resident's call light was ignored from 4:00 a.m. to 7:00 a.m., causing concern for her health. The DON confirmed the incident, and the staff involved claimed they did not notice the call light.
A resident with multiple medical conditions was transferred to a hospital after pulling out her gastric feeding tube. The facility failed to provide a copy of the bed hold policy with the transfer documentation, as required. Interviews with staff indicated that the policy should have been sent with the resident and retained in the chart, but this was not done.
A facility failed to investigate an allegation of misappropriation of property involving a resident with dementia. The incident involved the resident's wallet, credit card, and insurance card being taken. Although interviews were conducted, they focused only on abuse-related questions, neglecting the misappropriation aspect. The facility's policy requires a comprehensive investigation, which was not followed, leading to an incomplete investigation.
A facility failed to secure and document fentanyl patches for a resident with diabetes and chronic ulcers. The patches were not placed in a controlled substance lock box upon delivery, and staff did not sign the controlled drug shift audit form. The patches went missing, and despite a thorough search, they were not found. The facility's policy required narcotic patches to be secured and reconciled at each shift change, but this was not followed.
The facility was found to have deficiencies in food storage and staff hygiene practices. Frozen corn dogs were left open to air, and undated bags of lettuce were found in the refrigerator, with one showing discoloration. A dietary staff member with a goatee was observed without a beard restraint, contrary to facility policy. Additionally, a jacket was improperly stored near clean dishes.
A resident with a history of amputation and renal dialysis did not receive medication as ordered. The resident was supposed to receive amoxicillin clavulanate at bedtime after dialysis, but instead received amoxicillin as per a later physician order. The DON indicated that the wrong order was activated after the resident's hospitalization.
The facility failed to maintain a safe environment for two residents. One resident's bathroom had an exposed concrete toilet base missing the cove base, while another resident's call light was missing its button cover, rendering it non-functional. The Maintenance Supervisor acknowledged the oversight, and the facility lacked a specific call light policy.
A resident with decreased ability to perform ADLs was subjected to a lack of respect and dignity when a nurse forcefully attempted to make her perform her own incontinent care. Despite the resident's request for assistance from two people, the nurse placed a cold, wet towel in her hand and guided her arm to her pelvic area, insisting she could clean herself. This left the resident feeling upset and humiliated.
A resident, who was moderately cognitively impaired and dependent on assistance for personal care, reported feeling degraded and humiliated after a nurse allegedly forcefully guided her arm to her pelvic area during incontinent care. The facility's investigation into the incident was incomplete, lacking statements from key witnesses and the resident, leading to a deficiency citation.
A facility failed to provide individualized behavioral health care for a resident with dementia and agitation, leading to an incident of abuse. The resident's care plan lacked specific interventions for his aggressive behaviors, which included swinging fists at staff and hitting another resident. Despite known triggers for his agitation, such as loud noises, the facility did not document or address these in the care plan, resulting in a failure to adhere to their Behavioral Health Services policy.
A resident with multiple health conditions left the facility without signing out or taking necessary medications, and staff were unaware of his whereabouts. The facility's policy on therapeutic leave was not followed, as there was no coordination or documentation of the resident's absence.
Failure to Assess, Document, and Care Plan Behavioral Health and Sexual Expression Needs
Penalty
Summary
The deficiency involves the facility’s failure to timely develop and update behavior care plans and to document behaviors on tracking logs for three residents with significant behavioral health needs. For one resident with paranoid schizophrenia and bipolar disorder, the record showed repeated delusional reports and sexually focused interactions involving another male resident. She alleged inappropriate touching and assault by the male resident, but staff found the male resident in his own room and a head‑to‑toe assessment revealed no injury. Subsequent documentation described her as having chronic fluctuating psychosis, delusions, hallucinations, and poor judgment and insight. Despite a capacity-to-consent assessment indicating she could describe sexual activity and related risks, there was no physician assessment of her cognitive ability and insight to engage in a sexual relationship, and later physician documentation concluded she did not have decision‑making capacity to consent to sexual activity. Her care plan did not reflect that she was unable to consent to sexual activity, did not address redirection of others from her room, and did not address her behavior of identifying herself as different people. The male resident involved had vascular dementia with behavioral disturbance, schizophrenia, and chronic hepatitis C. He had existing care plans for impaired cognition and intrusive wandering, including redirection from other residents’ rooms. Nursing notes documented that he was found in the female resident’s room exposing himself, and later again found in her room, calm and fully clothed, and redirected. A capacity-to-consent assessment indicated he could describe sexual activity, avoid exploitation, and understood physical, emotional, and health consequences, but there was no physician assessment of his cognitive ability to consent to a sexual relationship. A physician progress note later documented that he wished to engage in an intimate relationship with the female resident, that his mental capacity was impaired, and that he could not describe how he would prevent pregnancy or STDs. The physician did not approve sexual activity because the female resident lacked capacity, and noted the male resident’s own impaired capacity. Despite these findings and repeated room‑entry behaviors, there was no care plan indicating he was unable to consent to sexual activity and no behavior care plan addressing his ongoing attempts to enter the other resident’s room. A third resident with metabolic encephalopathy, depression, anxiety, and cognitive communication deficits exhibited new exit‑seeking and escalating behavioral symptoms that were not incorporated into his care plans in a timely manner. Initially assessed as not an elopement risk, he attempted to leave the building, was redirected, and a provider note documented exit‑seeking behavior. Subsequent behavior notes described him pressing a keypad near an employee exit, cursing and refusing redirection, and later yelling, calling staff names, and throwing himself from his wheelchair to the floor in the dining room. An elopement evaluation was later updated to show a history of elopement and wandering with a score indicating elopement risk, and he called 911 stating he wanted to kill himself, leading to an emergency department visit for suicidal ideation. Despite these documented behaviors, there was no elopement care plan developed with interventions, and his behavior care plans were not updated with new interventions to address the exit‑seeking, agitation, and self‑injurious behaviors. The facility’s own behavioral health and sexual expression policies required assessment, IDT involvement, documentation of behaviors and triggers, and timely care plan development and revision, which were not carried out as described in the records and staff interviews. Staff interviews further demonstrated gaps in communication and implementation of behavior management and sexual expression policies. CNAs reported being informally told around New Year’s to keep the two sexually involved residents out of each other’s rooms, but a QMA stated he had not been informed of this and observed the residents frequently visiting each other’s rooms. The social worker reported not being made aware that the female resident had videotaped the male resident exposing himself or that the male resident had exposed himself to her, even though the facility’s sexual expression policy required staff to notify social services and the DON when residents engaged in intimacy or sexual activity. The staff development coordinator acknowledged awareness of the videotaping incident and that the executive director had been informed, but could not recall any specific interventions set up for either resident beyond staff informally looking in on them. The social worker also confirmed that the female resident did not have a care plan addressing redirection of others from her room or guidance on private visits, and that behavior care plans were supposed to be developed by social services with the IDT using behavior notes and charting, which had not occurred in these cases. Overall, the documented events show that for all three residents, the facility did not ensure that necessary behavioral health services were provided in a person‑centered, assessed, and care‑planned manner consistent with its own Behavioral Health Services and Sexual Expression of Residents policies. New and ongoing behaviors—including delusional reports, sexually focused interactions, exposure, intrusive room‑entry, exit‑seeking, agitation, verbal aggression, and self‑injurious behavior—were not consistently translated into updated behavior plans of care or specialized care plans (such as elopement or sexual consent status). Behavior tracking and communication to social services and the IDT were incomplete or delayed, and physician assessments regarding capacity to consent to sexual activity were either missing or not integrated into the care plans. These omissions and delays in assessment, documentation, and care planning constitute the behavioral health care and services deficiency identified by the surveyors.
Failure to Follow Insulin and Diuretic Parameters for a Medically Complex Resident
Penalty
Summary
The deficiency involves the facility’s failure to administer medications according to physician orders and established parameters for a resident with type 2 diabetes mellitus. The resident’s care plan, dated 1/10/25, directed staff to administer diabetic medications as ordered. A physician’s order dated 9/11/25 required 5 units of aspart insulin before meals, to be held if blood sugar was less than 100. Despite this, the January 2026 MAR showed that staff administered 5 units of aspart insulin on multiple mornings when the resident’s blood sugar readings were below 100 (94 on 1/8/26, 92 on 1/13/26, and 89 on 1/17/26). A subsequent order dated 1/21/26 changed the dose to 3 units of aspart insulin before meals, to be held if blood sugar was less than 110, yet the MAR documented administration of 3 units when blood sugar readings were below 110 on several occasions, including readings of 71 and 84 on 1/25/26, 93 on 1/26/26, and 102 on 1/27/26. The resident also had an order for glargine insulin related to diabetes management. A physician’s order dated 11/19/25 directed staff to administer 20 units of glargine insulin in the mornings, with instructions to hold the insulin if the resident’s blood sugar was less than 110. The January 2026 MAR indicated that staff administered 20 units of glargine insulin on multiple dates when the resident’s blood sugar was below 110, including readings of 94, 80, 92, 83, 89, 91, 106, 90, 71, 93, and 102 on various dates between 1/8/26 and 1/27/26. In an interview on 1/27/26, the Director of Nursing acknowledged that staff had administered the resident’s insulins when they should have been held according to the prescribed parameters. The deficiency also includes failure to follow physician orders for a resident with congestive heart failure, hypertension, chronic kidney disease, and leg swelling related to heart valve replacement. The care plan dated 1/22/25 instructed staff to monitor vital signs, notify the medical provider of abnormalities, and give medications as ordered. A physician’s order dated 9/23/25 required administration of 40 mg (two 20 mg tablets) of torsemide daily, with instructions not to give the medication if the resident’s systolic blood pressure was less than 100. The January 2026 MAR showed that the resident received 40 mg of torsemide every morning from 1/1/26 through 1/27/26, but there were no blood pressure readings obtained prior to administration as required by the order. The Director of Nursing stated she was unable to find blood pressure readings taken before giving the torsemide and reported that the order had not been set up correctly in the electronic medication system. The facility’s medication administration policy required medications to be administered as ordered by the physician and to obtain and record vital signs when applicable, holding medications when vital signs were outside prescribed parameters.
Improper Handling of Oral Medications Without Hand Hygiene
Penalty
Summary
Surveyors observed that the facility failed to maintain infection control practices during medication administration when a qualified medication aide (QMA) handled oral medications with bare hands. On 1/23/26 at 9:44 a.m., QMA 5 was seen at the medication cart touching medication drawers and multiple medication cards, then removing a tablet from a medication card by popping it into her bare hand and placing it into a medication cup containing other medications, identified at that time as belonging to Resident 53. During this process, QMA 5 did not perform hand hygiene with soap and water or hand sanitizer before handling the medication or at any point during the observation. Resident 53’s clinical record, reviewed on 1/22/26, showed diagnoses including type II diabetes mellitus. In an interview, the DON stated that staff should not touch medication tablets with their bare hands, and the facility’s medication administration policy specified that medications are to be administered in a manner to prevent contamination or infection and that staff should remove medications from their source while taking care not to touch them with bare hands. These observed actions and the lack of hand hygiene were inconsistent with the facility’s written medication administration policy and professional standards of practice intended to prevent contamination or infection.
Failure to Maintain Resident Rooms in Good Repair and Homelike Condition
Penalty
Summary
Surveyors identified that resident rooms were not maintained in a homelike condition and in good repair based on observations, interviews, and record review. In one room, the sliding closet door for Resident 10 was observed to be broken, with the door not attached inside the metal track and moving freely instead of gliding back and forth within the track. During an environmental tour with housekeeping staff and the Senior District Operations Manager, the same condition was confirmed, and it was noted that the metal track was bent and needed replacement. Housekeeping staff acknowledged that the closet door had been broken for a while. In another room, Resident 24’s room was observed with the bottom brown baseboard pulled away from the wall under the heating and air unit. During an interview, Resident 24 stated that the baseboard had been in that condition for a long time. The same damage was again observed during the environmental tour with housekeeping staff and the Senior District Operations Manager. The facility’s written Facility Maintenance Guidelines and Procedure stated that it was the facility’s intent to provide a clean, comfortable environment and that staff should place items they find in the normal course of their day into the TELS Work Order System when found, as well as when residents make requests, indicating that these room repair needs had not been addressed in accordance with facility procedures.
Failure to Provide Ongoing, Individualized Activity Program
Penalty
Summary
The deficiency involves the facility’s failure to provide an ongoing activity program that met the individualized needs and documented preferences of residents. For one resident with anoxic brain damage, a persistent vegetative state, muscle weakness, and a sleep disorder, surveyors repeatedly observed the resident in bed or in a high-back wheelchair with eyes open and no music or television on in the room, despite the care plan directing that music and television be left on during the day. The care plan, based on family input, indicated the resident enjoyed music and being read to and was dependent on staff to anticipate needs. During interview, the Activity Director stated she believed CNAs were responsible for ensuring the resident’s television or radio was on, but there was no indication this was consistently done. Another resident, cognitively intact per the MDS and with diagnoses including end stage renal disease, heart failure, and weakness, reported that there were not enough activities and that there was no variety, leading her to stay in her room most of the time. She acknowledged that bingo was offered but expressed a desire for additional options such as arts and crafts, card games, music, and going outside in good weather. Her care plan and preference evaluation documented that it was very important to her to have access to books, magazines, newspapers, music, group activities, going outdoors, and religious services. The Activity Director reported she had started in her role a few months earlier, that there had been no dedicated activity assistant for the LTC side until the previous day, and that she was frequently in meetings, limiting her availability. The facility’s own activity policy stated it would provide an ongoing activity program to support resident choices and promote self-esteem, pleasure, comfort, education, creativity, success, and independence, which was not consistently implemented for these residents.
Elopement of Cognitively Impaired Resident Through Unsecured Bathroom Window
Penalty
Summary
A cognitively impaired resident with a history of dementia, agitation, and behavioral disturbances, who was assessed as an elopement risk, was able to exit a secured memory care unit unsupervised through a bathroom window. The resident had previously demonstrated wandering behaviors, including attempts to leave the facility and a history of elopement or attempted elopement at home. The care plan identified the resident as an elopement risk and included interventions such as structured activities, diversions, and supervision, but did not address the risk posed by windows in the resident's room and bathroom. On the night of the incident, staff last observed the resident in his room at 2:15 a.m. During a subsequent check at approximately 4:00-4:15 a.m., the resident was found missing, with a chair placed under the bathroom window, which was open. The window's safety mechanisms, two plastic pieces intended to prevent it from opening fully, had been broken off. The resident exited through the window without staff knowledge, crossed a busy intersection, and was later found at a local gas station by emergency services. The resident reported falling while climbing out of the window and was observed with an abrasion on his arm. Family members had previously expressed concerns to staff about the risk of the resident attempting to escape through windows, noting that the bathroom window had been seen open and that the resident had a history of such behavior. However, staff and management were either unaware of the windows' ability to open or had not prioritized securing them in the resident's bathroom. The facility's elopement policy referenced door locks and alarms but did not specifically address window hazards, and not all windows had safety blocks installed prior to the incident.
Removal Plan
- Audit of all residents was completed and elopement assessments were updated
- Education was given to all staff on elopement protocol
- Elopement drills were conducted on every shift
- All windows in the facility were audited to ensure safety blocks were in place
- All identified windows missing safety blocks were installed
Failure to Follow Physician Orders for Feeding Tube Flushes
Penalty
Summary
A deficiency was identified when a resident with a gastrostomy tube did not receive water flushes according to the physician's orders. The resident, who had diagnoses including muscle weakness, dysphagia, diabetes mellitus, and gastrostomy status, was dependent on tube feeding and water flushes as documented in their care plan. The physician's order specified tube feeding at 65 mL per hour and water flushes at 50 mL per hour. During observations, it was found that the feeding pump was set to deliver 60 mL per hour of water flushes, which was confirmed by two different nurses at separate times. This setting did not match the physician's order for 50 mL per hour. The facility's policy required staff to follow physician orders for feeding tube care, including the frequency and volume of flushes, but this was not adhered to in this instance.
Failure to Ensure Resident Transport for Scheduled Medical Appointment
Penalty
Summary
The facility failed to ensure that a resident with complex medical needs, including anoxic brain damage, tracheostomy, gastrostomy, and vertebral osteomyelitis, was transported to scheduled appointments for the removal of a tunneled catheter. The resident was on IV antibiotics for an infection, and the care plan included monitoring and care of the IV site. Despite a physician's order for catheter removal, the resident missed two scheduled appointments due to transportation issues. On one occasion, the transportation company did not arrive as scheduled, and on another, the company arrived early and left before the appointment time, with staff not sending the resident due to a misunderstanding about the need for a family member to accompany the resident. Interviews revealed that staff did not confirm with the family member whether her presence was required, and the family member later clarified that she did not need to be present for the procedure. The Director of Nursing confirmed there was no facility policy regarding resident appointments. As a result, the resident's necessary medical procedure was delayed due to failures in coordination and communication regarding transportation and appointment attendance.
Failure to Maintain Orders and Monitoring for Resident's IV Access
Penalty
Summary
A deficiency was identified when a resident with significant medical conditions, including anoxic brain damage, tracheostomy, gastrostomy, and vertebral osteomyelitis, continued to have an intravenous (IV) access in place without current physician orders for its care and maintenance. The resident had previously been receiving IV antibiotics via a tunneled catheter, with orders for dressing changes and site monitoring that were discontinued after the antibiotic course ended. Despite the IV access remaining in place due to postponed removal appointments, there were no active orders for dressing changes, site monitoring, or catheter flushes. Observation of the resident confirmed the presence of the IV access with a dressing dated several days prior, and the Director of Nursing acknowledged that monitoring and dressing changes should have been ongoing. Review of the electronic health record revealed no documentation of current care or monitoring for the IV site. Facility policy required physician orders for IV therapy, regular site checks, and documentation, none of which were in place for this resident at the time of the survey.
Failure to Respond to Call Light in a Timely Manner
Penalty
Summary
The facility failed to ensure a resident's call light was responded to in a timely manner, resulting in the resident experiencing anxiety related to concerns about her health. The incident involved a resident who had been living at the facility for about six years and generally received attentive care. However, after returning from the emergency room for a nosebleed, the resident experienced a rapid heartbeat and activated her call light at 4:00 a.m. No staff responded until the day shift arrived around 7:00 a.m., causing the resident and her roommate to feel scared and anxious about the potential health risks. The resident, who was cognitively intact and had a medical history including congestive heart failure, diabetes with neuropathy, morbid obesity, and end-stage renal disease with dialysis, reported the incident to the facility's management. The Director of Nursing (DON) confirmed the resident's account and discussed the situation with the nurse and aide on duty during the incident. Both staff members claimed they did not notice the call light, and the nurse refused to sign a statement regarding the incident. The facility documented the failure to respond to the call light as a neglectful act, emphasizing the seriousness of the situation.
Failure to Provide Bed Hold Policy During Resident Transfer
Penalty
Summary
The facility failed to provide a copy of the bed hold policy to Resident D prior to her transfer to an area hospital. Resident D, who had a history of Wernicke's encephalopathy, CVA with left-sided hemiparesis and hemiplegia, dysphagia, gastrostomy, and moderate protein-calorie malnutrition, was transferred to the hospital after pulling out her gastric feeding tube. The nursing home to hospital transfer form was completed, but the clinical record did not include a copy of the bed hold policy, and the facility was unable to provide it before the survey exit. Interviews with RN 3 and the Corporate Nurse revealed that the facility was expected to send the bed hold policy with the resident to the hospital and retain a copy for the chart, but this was not done in this instance.
Failure to Investigate Misappropriation of Resident Property
Penalty
Summary
The facility failed to thoroughly investigate an allegation of misappropriation of property involving a resident diagnosed with dementia. The incident was reported to the Indiana Department of Health, indicating that the resident's wallet, credit card, and insurance card were taken. Although the facility conducted interviews with staff and residents, the investigation focused solely on abuse-related questions and did not address the misappropriation of property. The facility's policy requires a comprehensive investigation into all allegations, including misappropriation, but this was not adhered to in this case. The Administrator acknowledged that the investigation was incomplete, as the staff conducting interviews only asked questions related to abuse, neglect, and exploitation, omitting inquiries about the misappropriation of property. The facility's policy mandates identifying and interviewing all involved parties and thoroughly documenting the investigation, which was not done in this instance. This oversight resulted in a failure to properly investigate the reported misappropriation of the resident's property.
Failure to Secure and Document Narcotic Pain Medication
Penalty
Summary
The facility failed to ensure proper handling and documentation of a narcotic pain medication for Resident E, who was diagnosed with diabetes and chronic non-pressure skin ulcers. The resident was prescribed fentanyl transdermal patches for pain management, but the medication was not placed in a controlled substance lock box upon delivery. Additionally, the oncoming and off-going licensed personnel did not sign the controlled drug shift audit form during the shift change, which is a requirement for maintaining accurate records of controlled substances. The incident was discovered when a narcotic count during a shift change revealed that four fentanyl patches were missing. The investigation showed that the patches were delivered to the facility and signed for by an RN, but they were left unattended at the nursing station. The RN who received the delivery could not recall if the patches were among the medications she received due to the large volume of medications delivered that night. The patches were never placed in the controlled substance lock box, and the facility was unable to locate them despite a thorough search. Interviews with staff revealed that the narcotic count sheet and the fentanyl patches were missing, and the staff involved had been drug tested with negative results. The facility's policy required that narcotic patches be kept in a controlled substance lock box and reconciled at the end of each shift, with both nurses signing the shift change log. However, this procedure was not followed, leading to the loss of the fentanyl patches and a failure to maintain accurate records of controlled substances.
Deficiencies in Food Storage and Staff Hygiene Practices
Penalty
Summary
The facility failed to adhere to proper food storage and hygiene practices in the kitchen, as observed during a survey. During a tour of the kitchen, it was found that frozen corn dogs were left open to air in the walk-in freezer, and three bags of lettuce in the refrigerator were undated, with one bag showing visible discoloration. The Dietary Manager acknowledged these issues, indicating that the packaging should not be open to air and that the lettuce bags should have been dated. Additionally, a jacket was found hanging on a chair next to a drying rack of clean dishes, which the Dietary Manager confirmed was inappropriate. Furthermore, a dietary staff member with a full goatee was observed not wearing a beard restraint on two separate occasions, despite the facility's policy requiring facial hair longer than a quarter of an inch to be restrained. The policy for Dietary Employee Personal Hygiene mandates that all dietary staff must wear hair restraints to prevent hair from contacting food. The facility's Food Safety Requirements policy also emphasizes the importance of labeling, dating, and monitoring refrigerated food to ensure proper storage and safety.
Medication Administration Error for Dialysis Resident
Penalty
Summary
The facility failed to administer medication as ordered for a resident undergoing dialysis. The resident, who had a history of right leg amputation and was receiving renal dialysis, was discharged from the hospital with specific medication instructions. The discharge orders indicated that the resident should receive one tablet of 500/125 milligrams of amoxicillin clavulanate at bedtime after dialysis and one tablet of 500 milligrams of amoxicillin one hour prior to the dialysis appointment. However, a physician order dated later instructed the administration of four tablets of 500 milligrams of amoxicillin one hour prior to dialysis on specific days. The Medication Administration Record for December 2024 showed that the resident received 500 milligrams of amoxicillin as per the later order, but not the amoxicillin clavulanate as initially prescribed. An interview with the Director of Nursing revealed that the staff had activated the incorrect amoxicillin order following the resident's recent hospitalization.
Environmental Deficiencies in Resident Rooms
Penalty
Summary
The facility failed to maintain a safe and functional environment for its residents, as evidenced by two specific deficiencies. In the case of Resident 13, the bathroom was observed to have an elevated concrete base of the toilet that was exposed and missing the cove base. This condition was noted by the resident as appearing dirty and had been in this state for an extended period. The Maintenance Supervisor confirmed that the concrete base had been painted twice, but the replacement of the cove base was overlooked, and there was no work order in place to address this issue. For Resident 48, the call light in their room was missing its button cover, rendering it non-functional. This was observed over several days, and a Certified Nurse Aide confirmed that the call light was broken and in need of replacement. The facility's President of Risk and Regulatory indicated that there was no specific policy for call lights, and the Executive Director provided maintenance guidelines that suggested staff should report such issues in the TELS Work Order System. However, it appears this procedure was not followed, leading to the deficiency.
Resident's Dignity Compromised During Incontinent Care
Penalty
Summary
The facility failed to ensure a resident's right to be treated with respect and dignity, as evidenced by an incident involving a staff member and a resident with decreased ability to perform activities of daily living (ADLs). The resident, identified as Resident D, had diagnoses including asthma, morbid obesity, and hypertensive urgency, and was moderately cognitively impaired. She required assistance with bathing, dressing, and toileting, and needed partial to moderate assistance with personal hygiene. On the date of the incident, Resident D requested assistance from two people for incontinent care. However, when a nurse entered the room, she forcefully placed a cold, wet towel in the resident's hand and guided her arm to her pelvic area, insisting that the resident could clean herself since she had no ailments with her arms. This interaction left Resident D feeling upset, degraded, and humiliated, and she continued to feel sad about the incident. The Executive Director confirmed the incident, noting that the nurse's actions were intended to assist with the resident's rehabilitation efforts. However, Resident D perceived the nurse's actions as forceful, which contributed to her feelings of humiliation. The incident was related to a complaint, indicating a failure to honor the resident's right to a dignified existence and self-determination.
Incomplete Investigation of Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident, identified as Resident D, who was moderately cognitively impaired and dependent on assistance for personal care. On a specific date, Resident D required assistance with incontinent care and requested two people to help her. During the incident, a nurse allegedly grabbed Resident D's arm, placed a cold, wet towel in her hand, and forcefully guided her arm to her pelvic area, instructing her to clean herself. This interaction left Resident D feeling upset, degraded, and humiliated. The investigation into the incident was incomplete, as it lacked statements from key witnesses, including the physician's assistant and the certified nursing assistant who reported the incident. Additionally, there was no written statement from Resident D herself. The facility's policy on abuse, neglect, and exploitation requires a thorough investigation, including identifying and interviewing all involved persons and providing complete documentation. However, the investigation file did not meet these requirements, leading to a deficiency citation.
Failure to Provide Individualized Behavioral Health Care for Resident with Dementia
Penalty
Summary
The facility failed to provide individualized behavioral health care and services for a resident diagnosed with dementia with agitation, leading to an incident of abuse. Resident C, who was admitted with moderate dementia and agitation, exhibited increased anxiety and aggressive behaviors, including swinging closed fists at staff and hitting another resident. Despite these behaviors, the resident's care plan did not include specific interventions or strategies to address his aggression or triggers for his agitation. The clinical record for Resident C lacked documentation of behavior notes until several days after his admission, and there were inconsistencies in the administration and discontinuation of his medication, quetiapine, which was prescribed for agitation and depression. The facility's failure to document and address Resident C's behaviors and triggers in his care plan contributed to an incident where he physically assaulted another resident in the common dining room. The staff member present during the incident reported that loud noises triggered Resident C's aggressive behavior, a fact that was known from previous experiences with the resident. The facility's Behavioral Health Services policy emphasizes the importance of individualized, person-centered care plans that address residents' mental and psychosocial needs. However, the facility did not adhere to this policy, as evidenced by the lack of specific interventions in Resident C's care plan and the absence of behavior monitoring documentation. The Director of Nursing Services acknowledged that the care plan should have addressed Resident C's behaviors upon admission, given his diagnosis of dementia with agitation.
Failure to Supervise Resident During Unapproved Leave
Penalty
Summary
The facility failed to ensure proper follow-up and supervision for a resident, identified as Resident B, who was unable to be located during the night. Resident B, who has diagnoses including hypertension, muscle weakness, alcohol abuse, and diabetes mellitus, was cognitively intact and utilized a wheelchair. The resident had a history of taking leaves of absence, as indicated by signed forms for March, April, and May of 2024. However, there were no leave of absence forms for June 2024. On the night of June 2, 2024, Resident B left the facility without signing out or being redirected per policy, and returned later that night. The following night, staff noted Resident B was not in his room, and there was no record of him signing out, nor was there any indication of his whereabouts or if he had taken necessary medications. Interviews with Resident B and the Director of Nursing (DON) revealed concerns about the resident's unsupervised absence and lack of medication while away. The DON expressed worry about Resident B's ability to care for himself and manage his medications during his absence. The facility's policy on therapeutic leave required coordination with the resident for medication administration and documentation of the leave, which was not followed in this instance. The receptionist witnessed Resident B leaving but failed to inform the staff, highlighting a lapse in communication and adherence to the facility's procedures.
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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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