Brickyard Healthcare -sycamore Village Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Kokomo, Indiana.
- Location
- 2905 W Sycamore St, Kokomo, Indiana 46901
- CMS Provider Number
- 155367
- Inspections on file
- 43
- Latest survey
- January 9, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Brickyard Healthcare -sycamore Village Care Center during CMS and state inspections, most recent first.
A resident with multiple comorbidities, morbid obesity, and total dependence for transfers experienced repeated accidents during care and mechanical lift transfers. During incontinence care, the resident was positioned near the edge of a smaller bed while using an overhead trapeze and fell to the floor, later describing that the bed was too small and she was too close to the edge. On another occasion, three CNAs used a mechanical lift when the sling strap stitching failed, causing the resident to fall from just above the bed and strike her back and shoulder on the lift legs, with staff unable to confirm that the sling used was the correct size or weight capacity. Observations showed staff using large blue slings without clear weight-limit tags, a unit manager unable to explain missing labeling, and no facility policy for mechanical lift use despite manufacturer guidance on proper sling selection and application. In a further incident, the mechanical lift struck the resident’s overhead trapeze, knocking it down so it hit the back of the resident’s head, demonstrating unsafe coordination of equipment around the bed and inadequate hazard control during transfers.
The facility failed to ensure compromised controlled substance medications were not stored in medication carts. Observations revealed compromised cards with slits or tape on the North and South carts. Residents with insomnia, anxiety, and pain had medications like quviviq, oxycodone, alprazolam, Norco, tramadol, and Clonazepam improperly stored. LPNs acknowledged the issue, and the DON confirmed the need for proper destruction of such medications.
The facility failed to ensure SNF-ABN forms were accurately completed for two residents discharged from Medicare services. One resident's form lacked a selection for therapy continuation, while another's form was missing a choice about remaining in the facility. The Social Service department was responsible for assisting with form completion, but the forms were left blank, contrary to facility policy.
The facility failed to update PASARR evaluations for two residents, resulting in incomplete documentation of their mental health conditions and medications. One resident's PASARR did not include anxiety disorder, PTSD, or insomnia, despite being prescribed medications for these conditions. Another resident's PASARR omitted antianxiety and hypnotic medications. The Social Service Director confirmed the omissions, which were contrary to the facility's policy requiring updated reviews for new mental health conditions.
The facility failed to obtain admission weights for two residents, one with type 2 diabetes and chronic heart failure, and another with essential hypertension and morbid obesity. Both residents were weighed several days after admission, contrary to staff interviews indicating weights should be taken on the admission day. The facility lacked a policy on admission weights.
A facility failed to follow its protocol for administering medication through a g-tube for a resident with dysphagia. An RN did not verify the g-tube placement or use the prescribed water flush before and after medication administration, instead using normal saline, contrary to the facility's policy. The DON confirmed the correct procedure was not followed, leading to the deficiency.
A facility failed to obtain a physician's order, informed consent, and assessment before using bed rails for a resident. The resident was observed with bilateral side rails, which were already attached when he moved in. The care plan did not include the use of side rails, and the Director of Nursing acknowledged the oversight. The facility's policy requires a person-centered approach and proper procedures for bed rail use, which were not followed in this case.
The facility failed to ensure proper PPE use and correct signage for two residents under transmission-based precautions. A nurse entered a resident's room without a gown, despite orders for enhanced barrier precautions. Another resident's room had inconsistent signage for precautions, leading to staff confusion. Interviews confirmed the need for proper PPE and signage as per physician orders.
A facility failed to follow physician-ordered parameters for administering blood pressure medications to a resident with hypertension and other conditions. Despite orders to hold medication if systolic blood pressure was below 120, records showed diltiazem was given multiple times when the resident's blood pressure was below this threshold. Interviews confirmed that medications should have been held, as per facility policy.
A resident with Multiple Sclerosis did not receive timely pharmaceutical services, missing 19 days of Buprenorphine due to the facility's failure to obtain the medication. Despite having a physician's order, the facility was unable to administer the medication, and the resident was discharged without it. The Director of Nursing was unaware of the medication's purpose, and the Executive Director had no further information on the issue.
Failure to Ensure Safe Bed Care and Mechanical Lift Transfers for a Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe environment and provide adequate supervision and safe equipment use during care and transfers for a dependent resident. Resident C had multiple medical diagnoses including COPD, CHF, hypertension, morbid obesity, and bilateral knee osteoarthritis, and was documented on the MDS as dependent on staff for transfers and substantially/fully dependent for bed mobility and toileting. Care plans identified self-care deficits and fall risk, with interventions such as use of a trapeze bar, assistance with transfers, non-skid footwear, and maintaining a safe environment. Despite these identified needs, the resident experienced several incidents during incontinence care and mechanical lift transfers. In one incident, during incontinence care, the resident was turned toward the window while holding the overhead trapeze and fell from the bed. Documentation indicated the resident turned to her left side, her hand slipped from the trapeze, and she fell from the bed, sustaining a scratch to the right lower leg. The resident and her daughter reported that the bed was too small and that the resident was too close to the edge of the bed during care, leading to her rolling or sliding off. A CNA described the resident sliding off the bed into a split position between the bed and the window while the CNA was providing peri care. This occurred even though the resident had been care planned as at risk for falls and dependent for transfers and bed mobility. In a separate incident, the resident was being transferred with a mechanical (Hoyer) lift when the sling strap broke and the resident fell to the floor. Three CNAs were involved in the transfer; one CNA reported the resident was lifted slightly off the bed when the stitching on the strap came loose, causing the resident to fall and hit her back and shoulder on the lift legs, with subsequent complaints of lumbar and back pain. Staff interviews revealed uncertainty about which sling pad was used and whether it was the correct weight limit for the resident. Observations showed staff using a large blue lift pad and declining the resident’s request to cross the leg straps, while the resident reported that staff had crossed the straps on multiple prior occasions and that she felt like she would slide out when the larger pad was used. A unit manager pulled a sling from storage that lacked a visible weight limit on the tag and stated she did not know why it was not labeled, and the facility had no policy on mechanical lift use, despite manufacturer guidance that correct sling size and application are critical to prevent accidents. In an additional incident, during another mechanical lift transfer, the lift contacted the resident’s overhead trapeze bar, knocking it down so that it struck the back of the resident’s head and caused a bump. The resident reported soreness at the back of her head, and the Executive Director confirmed that the trapeze bar dropped and hit the resident’s head. Across these events, the facility did not ensure that the environment around the bed and trapeze was arranged to prevent contact with the lift, did not consistently ensure appropriate sling selection and labeling based on resident weight, and did not have a facility policy governing mechanical lift use, all contributing to repeated accidents during care and transfers for this resident. The facility’s own "Accidents and Supervision" policy stated that residents’ environments would remain as free of accident hazards as possible and that each resident would receive adequate supervision and assistive devices to prevent accidents, with all staff involved in observing and identifying potential hazards. However, the repeated falls from the bed during peri care, the fall from the mechanical lift due to a broken sling strap, and the incident in which the lift knocked down the trapeze bar onto the resident’s head demonstrate that the facility did not adhere to these expectations for this resident. The survey findings are tied to Intake 2680656 and cite regulatory provisions 3.1-45(a)(1) and 3.1-45(a)(2).
Compromised Controlled Substance Storage in Medication Carts
Penalty
Summary
The facility failed to ensure that compromised controlled substance medications were not stored in the medication carts, as observed in two of the four medication carts inspected. On the North medication cart, five compromised controlled substance cards were found. For Resident 14, a card of quviviq for insomnia had clear tape covering the back of the number 6 slot. Resident 42 had a card of oxycodone with a slit on the back of the card in the number 22 slot and a card of alprazolam with a slit in the number 23 slot. Resident 51 had a card of Norco with a slit on the back of the card in the number 8 slot, and Resident 23 had a card of tramadol with a slit in the number 30 slot. LPN 13 acknowledged that there should not be tape or slits on the back of the cards and admitted to not checking the backs when counting narcotics. On the South medication cart, one compromised controlled substance card was found. A card of Clonazepam for Resident 75 had a slit on the back of the card in the number 29 slot. LPN 12 confirmed that the pills should not be taped or opened on the back of the cards and should be destroyed by two nurses. The Director of Nursing also indicated that staff should not tape the backs of narcotics cards and that the pills needed to be destroyed. The facility's policy on Controlled Substance Administration & Accountability requires that two licensed staff witness any disposal or destruction of a controlled substance and document it accordingly.
Incomplete SNF-ABN Forms for Two Residents
Penalty
Summary
The facility failed to ensure that the Skilled Nursing Facility-Advanced Beneficiary Notice (SNF-ABN) forms were accurately completed for two residents who were discharged from Medicare services but remained in the facility. For Resident 45, the ABN form provided on October 8, 2024, indicated that their coverage was ending on October 10, 2024. However, the section of the form where the resident was supposed to choose an option regarding the continuation of physical and occupational therapy was left blank. Similarly, for Resident 91, the ABN form provided on December 4, 2024, indicated that their coverage had ended on December 2, 2024, but the section for choosing an option about remaining in the facility was also left blank. Interviews with the Business Office Manager and the Social Service Director revealed that the Social Service department was responsible for assisting residents in completing these forms, and the Business Office would only assist if Social Services was unavailable. The Business Office Manager assumed that if one form had an option chosen, all forms would have an option chosen, which was not the case. The Social Service Director confirmed that one of the three options for coverage should have been selected and that the forms should not have been left blank. The facility's policy on Advance Beneficiary Notices, dated 2024, stated that the Business Office Manager or designee is responsible for issuing notices and ensuring that documentation complies with form instructions, which was not adhered to in these instances.
Failure to Update PASARR Evaluations for Residents
Penalty
Summary
The facility failed to ensure that Preadmission Screening and Resident Review (PASARR) evaluations were updated and accurate for two residents. For Resident 95, the PASARR notice indicated that a Level II screen was not required, as there was no evidence of a serious mental health condition. However, the PASARR did not include diagnoses of anxiety disorder, post-traumatic stress disorder, or insomnia, despite the resident being prescribed medications for these conditions. The Social Service Director confirmed that the PASARR was missing these diagnoses and medications. Similarly, for Resident 52, the PASARR indicated no Level II was required and no mental illness was suspected. However, the resident was prescribed antianxiety and hypnotic medications that were not included in the PASARR mental health medication section. The Social Service Director acknowledged that another PASARR should have been completed when new psychotropic medications were added, but this was not done. The facility's policy requires that any resident exhibiting a newly evident or possible serious mental disorder be referred for a Level II resident review, which was not adhered to in these cases.
Failure to Obtain Admission Weights for Residents
Penalty
Summary
The facility failed to ensure that admission weights were obtained for two residents, Resident D and Resident H, upon their admission. Resident D, who had diagnoses including type 2 diabetes mellitus, muscle wasting and atrophy, and chronic heart failure, was admitted and not weighed until five days later, with the first recorded weight being 284 pounds. Similarly, Resident H, with diagnoses including muscle wasting and atrophy, essential hypertension, and morbid obesity, was admitted and not weighed until six days later, with the first recorded weight being 306 pounds. The facility's clinical admission assessments for both residents had sections for entering weights, but these were left blank. Interviews with LPNs and a Regional Dietician confirmed that admission weights should be obtained on the day of admission, especially for residents with a history of heart failure. However, the facility lacked a policy addressing the requirement for obtaining admission weights.
Failure to Follow G-Tube Medication Administration Protocol
Penalty
Summary
The facility failed to adhere to its policy and procedures for administering medications through a gastrostomy tube (g-tube) for a resident diagnosed with dysphagia and requiring a g-tube. During an observation, a Registered Nurse (RN) was seen administering medication to the resident without verifying the placement of the g-tube or flushing it with the prescribed amount of water before and after medication administration. Instead, the RN used a prefilled normal saline syringe, which is against the facility's policy that mandates the use of water for flushing the g-tube. The resident's clinical record indicated a physician's order to check the g-tube placement and flush it with 30 ml of water before and after administering medication. However, the RN admitted to not checking the placement or residual before administering the medication. The Director of Nursing confirmed that normal saline should not be used for flushing a g-tube, and the facility's policy requires verification of tube placement and flushing with water. This oversight in following the established procedures led to the deficiency noted in the report.
Failure to Obtain Consent and Assessment for Bed Rail Use
Penalty
Summary
The facility failed to ensure proper procedures were followed before the use of bed rails for a resident, identified as Resident 95. During multiple observations, Resident 95 was seen with bilateral side rails attached to his bed. The resident mentioned that the side rails were already on the bed when he moved in and believed they were to prevent him from rolling out of bed. However, the facility did not have a signed consent from the resident for the use of these side rails. Additionally, a review of the resident's clinical record revealed the absence of a physician's order, an informed consent, and an assessment for the use of the side rails. The care plan for Resident 95, which was last revised in November 2024, indicated a self-care performance deficit but did not include the current use of side rails. The Director of Nursing confirmed that an assessment and consent should have been completed before attaching side rails to the resident's bed. The facility's policy on the proper use of bed rails emphasizes a person-centered approach and requires correct installation, use, and maintenance of the rails. Despite this policy, the facility did not obtain the necessary consent and assessment for Resident 95, leading to the deficiency.
Failure to Ensure Proper PPE Use and Signage for Precautions
Penalty
Summary
The facility failed to ensure proper use of personal protective equipment (PPE) and correct signage for transmission-based precautions for two residents. In the first instance, a registered nurse entered the room of a resident under enhanced barrier precautions without wearing a gown, despite a physician's order and care plan indicating the need for such precautions due to the resident's conditions, including hypoxia, cardiomegaly, and pressure ulcers. The nurse acknowledged the oversight during an interview, and another staff member confirmed the requirement for gown and gloves during high-contact care. In the second instance, the facility did not maintain appropriate signage for a resident requiring enhanced barrier precautions due to enterocolitis caused by Clostridium difficile. Observations revealed inconsistent signage, with both enhanced barrier and contact precaution signs posted, despite the contact precautions order having been completed. Interviews with staff, including the Director of Nursing, highlighted confusion regarding the correct precautions to follow, as the enhanced barrier precautions were still in effect per the physician's order.
Failure to Follow Blood Pressure Medication Parameters
Penalty
Summary
The facility failed to adhere to physician-ordered parameters for administering blood pressure medications to Resident 87, who was diagnosed with essential primary hypertension, type 2 diabetes mellitus with diabetic chronic kidney disease, chronic kidney disease stage 3, and dementia. The physician's orders specified that diltiazem and later lisinopril should be held if the resident's systolic blood pressure was less than 120. However, the Medication Administration Records (MAR) indicated that diltiazem was administered on multiple occasions in October, November, and December 2024, despite the resident's systolic blood pressure being below the specified threshold. Interviews with the Dementia Unit Manager and an LPN revealed that a check mark on the MAR indicated the medication had been given, and if the blood pressure was below the ordered parameter, the medication should have been held and marked with a specific code. The facility's current medication administration policy, as provided by the Director of Nursing, also stated that medications should be held for vital signs outside the physician's prescribed parameters. This oversight in following the physician's orders led to the deficiency noted in the report.
Failure to Provide Timely Pharmaceutical Services for Resident
Penalty
Summary
The facility failed to ensure timely pharmaceutical services for a resident, identified as Resident E, who was undergoing pain management. Resident E, diagnosed with Multiple Sclerosis, anxiety disorder, and muscle spasms, was admitted to the facility with a prescription for Buprenorphine, an opioid medication. Despite having a physician's order to administer Buprenorphine three times a day, the facility did not administer the medication on several occasions, leading to a total of 19 missed days of medication. The deficiency was further compounded by the facility's inability to obtain the medication from the pharmacy. Nursing progress notes indicated that the facility was out of Buprenorphine and that a new prescription was required before the pharmacy could fill the order. Despite attempts to resolve the issue, including contacting the pharmacy and waiting for a new order from a Nurse Practitioner, the medication remained unavailable, and Resident E was discharged without it. The facility's policy on pharmaceutical services, which mandates timely and accurate medication administration, was not adhered to in this case. The Director of Nursing was unaware that Buprenorphine was prescribed for Multiple Sclerosis, and the Executive Director had no additional information regarding the medication's unavailability. The facility's failure to provide the necessary medication and ensure proper pharmaceutical services resulted in a significant lapse in Resident E's care.
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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