Brickyard Healthcare - Woodbridge Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Evansville, Indiana.
- Location
- 816 N First Ave, Evansville, Indiana 47710
- CMS Provider Number
- 155390
- Inspections on file
- 33
- Latest survey
- August 5, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Brickyard Healthcare - Woodbridge Care Center during CMS and state inspections, most recent first.
A resident with end stage renal disease did not receive consistent monitoring of their dialysis access site as ordered, with several shifts lacking documentation of required assessments. The resident also refused or left dialysis treatments early on multiple occasions, but there was no evidence that the physician was notified of these events, contrary to facility policy.
A resident with severe cognitive impairment and a history of cerebral infarction had their Norco medication and count sheet go missing from the medication cart. The issue was discovered during a hospice visit when a nurse checked the medication supply. Despite the missing medication, the resident showed no signs of pain or distress. The incident was reported, and all nurses were drug tested with no concerns identified.
The facility failed to provide timely showers for four dependent residents, as documented in the report. A resident with cerebral palsy reported not receiving showers on scheduled days, confirmed by facility records. Another resident with end-stage renal disease and dementia missed several scheduled showers, as did a resident with severe cognitive impairment. A cognitively intact resident also reported not receiving showers for two weeks. The facility did not use shower sheets, and refusals were documented in the Point of Care Tasks.
The facility failed to maintain a sanitary environment, with persistent urine odors observed in various areas over multiple days. Despite a policy to minimize odors, the issue was not effectively addressed, as noted by an LPN and through multiple observations.
A resident with quadriplegia and other complex medical conditions was transported in an improperly fitted manual wheelchair because their personal electric wheelchair could not fit in the facility's mobility van. The manual wheelchair did not support the resident's trunk, contrary to a prior assessment indicating that only a power wheelchair met the resident's mobility needs. The facility's policy required therapist evaluations, but this was not adequately followed, resulting in a deficiency in accommodating the resident's mobility needs.
A resident with pressure ulcers refused wound treatments multiple times, and the facility failed to notify the physician of these refusals or the resident's treatment timing preferences. Additionally, MRI results indicating osteomyelitis were not promptly communicated to the physician, contributing to the deficiency.
A resident, fully dependent on staff due to quadriplegia, was allegedly slapped by an employee during evening care. The employee was suspended and later resigned without participating in the investigation. The facility's policy requires immediate reporting of abuse, but there was a lack of communication and clarity in handling the incident.
The facility failed to provide proper documentation during the transfer of two residents to the hospital. One resident with complex medical needs was transferred without documents on one occasion and with illegible documents on another. Another resident with end-stage renal disease was transferred without the necessary paperwork, including transfer orders and bed hold information.
A facility failed to accurately complete the MDS assessment for a resident with cerebral palsy and flaccid neuropathic bladder. The Quarterly MDS inaccurately documented the resident's catheter and colostomy status, which was later acknowledged by the MDS nurse as needing correction. This discrepancy highlights a lapse in following the facility's policy on accurate resident assessments.
The facility failed to implement physician orders and develop comprehensive care plans for three residents regarding unnecessary medications. One resident had incomplete documentation for monitoring side effects and interventions related to their medications. Another resident had missed doses and lacked documentation for monitoring side effects of various medications. A third resident's record lacked an order to monitor for side effects of an antiplatelet medication and did not have a care plan addressing its use.
A resident received an incorrect insulin dose due to improper priming of a Humalog Insulin Kwikpen by an RN. The RN administered 6 units instead of the required 4 units, misunderstanding the priming process. An LPN incorrectly stated that priming was unnecessary, contrary to the user manual and facility policy, which both require priming to ensure accurate dosing.
The facility failed to provide restorative services as outlined in the care plans for three residents, leading to a deficiency in maintaining or improving their range of motion (ROM). A resident with dementia had a care plan for AROM exercises, but records showed numerous dates in 2024 where no exercises were provided. Another resident with Parkinson's disease and dementia also missed several scheduled AROM sessions. A third resident with end-stage renal disease and dementia had a similar lapse in care. The Occupational Therapist noted that nursing staff were responsible for these therapies, but the facility's policy required the restorative nurse to ensure program implementation.
A resident with a history of falls and cognitive intactness experienced multiple falls due to inadequate care plan updates and incomplete documentation. Despite known risks and facility policies requiring care plan revisions after falls, the facility failed to consistently update the care plan with new interventions, contributing to ongoing fall risks.
A facility failed to follow physician orders and care plans for a resident requiring hemodialysis. Despite orders to avoid taking blood pressure from the resident's arm with a fistula, staff repeatedly did so. Additionally, the facility did not consistently record the resident's weight after dialysis sessions, as required. These deficiencies were confirmed through staff interviews and record reviews.
The facility failed to serve food at appropriate temperatures, as a meal tray test showed non-compliance with temperature standards. Interviews with residents revealed dissatisfaction with food temperatures, and the Dietary Manager confirmed the expected standards. The facility's policy requires hot foods to be at least 135°F and cold foods at or below 41°F.
The facility failed to ensure safe storage of foods for a resident, as their refrigerator had blank temperature logs with no recorded temperatures. The resident, who was cognitively intact but fully dependent on staff, had a refrigerator that was not monitored as per facility policy. An LPN indicated that staff were supposed to record temperatures during rounds, but this was not done.
The facility failed to maintain accurate documentation and medication administration for residents. A resident received a duplicate sertraline order due to a transcription error, while another resident's therapeutic leaves were not properly documented or authorized. Additionally, a resident's skin assessments were inconsistent with treatment orders, indicating incomplete documentation.
The facility failed to clean multi-resident use glucometers according to the manufacturer's instructions. A nurse was observed cleaning a glucometer for only 2 seconds, while the correct procedure required a 30-second contact time with a bleach wipe. Conflicting information from staff and the infection preventionist contributed to the deficiency.
Failure to Provide Safe and Appropriate Dialysis Care and Physician Notification
Penalty
Summary
The facility failed to provide safe and appropriate dialysis care for a resident with end stage renal disease who was dependent on renal dialysis. The resident had physician orders for dialysis treatments three times a week and required daily and nightly monitoring of the left dialysis permacath site. However, documentation showed that the required monitoring of the dialysis access site was not completed on several shifts, as indicated by missing entries in the Treatment Administration Record (TAR) for specific dates. The resident's care plan also required routine observation of the permacath, which was not consistently documented. Additionally, the resident refused or left dialysis treatments early on multiple occasions, as recorded in the dialysis/observation communication forms. Despite these refusals and early terminations, there was no documentation in the resident's progress notes that the physician was notified of these events, which was required by facility policy. Interviews with staff confirmed that physician notification and documentation should occur when a resident refuses or leaves dialysis early, but this was not done in these instances.
Misappropriation of Resident's Narcotic Medication
Penalty
Summary
The facility failed to prevent the misappropriation of a resident's narcotic medication, specifically Norco, for a resident with severe cognitive impairment and a history of cerebral infarction, diabetes, and aphasia. During a hospice visit, it was discovered that the resident's Norco medication and the associated count sheet were missing from the medication cart. This incident was identified when a hospice nurse inquired about the need for a refill, prompting a facility nurse to check the medication supply. The facility's records indicated that the resident was at risk for pain due to their medical history, and interventions included administering pain medications as ordered. Despite the missing medication, the resident did not display signs of pain or psychosocial distress during monitoring. The incident was reported to the appropriate authorities, and all nurses were drug tested with no concerns identified. A full reconciliation of all narcotics in the building was completed, and no discrepancies were found.
Failure to Provide Timely Showers for Dependent Residents
Penalty
Summary
The facility failed to provide timely showers for four dependent residents, as observed and documented in the report. Resident 4, who is cognitively intact but dependent on staff for hygiene due to cerebral palsy, reported not receiving showers on scheduled days. The facility's records confirmed missed showers on several occasions from February to June. Despite interventions in place for uncooperative behavior, such as offering bed baths, the resident indicated that showers were not provided as scheduled. Resident 13, who requires moderate assistance for bathing due to end-stage renal disease and dementia, also missed several scheduled showers. The facility's documentation system showed that showers were not given or refused on multiple dates. Similarly, Resident 2, who is severely cognitively impaired and dependent on staff for bathing, missed numerous scheduled showers. Resident 6, who is cognitively intact and dependent on staff for bathing, reported not receiving showers for two weeks, with records indicating multiple missed showers. The facility did not use shower sheets, and refusals were documented in the Point of Care Tasks.
Facility Fails to Maintain Sanitary Environment Due to Persistent Urine Odors
Penalty
Summary
The facility failed to maintain a safe and sanitary environment for residents, staff, and the public, as evidenced by persistent urine odors in various areas of the facility over multiple days. Observations were made on five out of six days, where the smell of urine was detected in the 100 Unit Hallway, 200 Unit Hallway, Basement Hallway, conference rooms, common areas, and stairwells. These observations were made at different times of the day, indicating a consistent issue with odor management and sanitation. During an interview, an LPN acknowledged that the facility should be free of smells, highlighting awareness of the issue among staff. The facility's policy on maintaining a safe and homelike environment was reviewed, which stated that housekeeping and maintenance services should be provided to minimize odors by promptly disposing of soiled linens and reporting lingering odors to the Housekeeping Department. Despite this policy, the facility did not effectively address the odor issue, leading to the deficiency noted in the report.
Improper Wheelchair Accommodation for Resident
Penalty
Summary
The facility failed to provide reasonable accommodations for a resident's mobility needs by transporting the resident in an improperly fitted manual wheelchair. The resident, who was observed sitting in the manual wheelchair in the hallway, expressed a desire to get out of the wheelchair and go to bed. The manual wheelchair was not the resident's personal wheelchair but was used by staff for transportation because the resident's personal electric wheelchair could not fit in the facility's mobility van. The resident's clinical record indicated multiple diagnoses, including quadriplegia, post-traumatic seizures, COPD, stage four pressure ulcers, and muscle/joint contracture, and the resident was fully dependent on staff for various activities of daily living. An occupational therapist was not aware until recently that the resident's trunk was not being supported in the manual wheelchair used for transportation. A Functional Mobility and Wheelchair Assessment indicated that manual wheelchair use was contraindicated for the resident due to their diagnoses, and a power wheelchair was necessary for safe and independent mobility. The facility's policy required a licensed therapist to perform evaluations upon physician referral, but it appears this was not adequately followed, leading to the deficiency in accommodating the resident's mobility needs.
Failure to Notify Physician of Treatment Refusals and MRI Results
Penalty
Summary
The facility failed to notify a resident's physician about the refusal of wound treatments for a resident with multiple pressure ulcers. The resident, who was cognitively intact and fully dependent on staff for daily activities, had several physician orders for wound care that were not followed due to the resident's refusal during sleep hours. Despite the resident's refusals being documented multiple times over a period of weeks, the physician was not informed of these refusals or the resident's preference for treatment timing. Additionally, the facility did not communicate the results of an MRI indicating osteomyelitis to the resident's physician in a timely manner. The facility's policy on promoting resident self-determination was provided, but a specific policy on physician notification was not available. This lack of communication and adherence to treatment protocols contributed to the deficiency identified by the surveyors.
Failure to Protect Resident from Physical Abuse by Staff
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse by staff. The incident involved a resident who was cognitively intact and fully dependent on staff for daily activities due to quadriplegia and muscle/joint contracture. During evening care, an employee allegedly made physical contact with the resident's head. The employee was suspended pending investigation but chose not to participate and resigned. The investigation revealed that the employee had slapped the resident's face after the resident's head involuntarily touched the employee's nametag during a shirt change. The facility's policy on abuse, neglect, and exploitation mandates immediate reporting of alleged violations to the appropriate authorities. However, there was a lack of communication and clarity in the administration's handling of the incident. The administrator was absent during the incident, and the regional support consultant reported the incident to the state agency. Despite the employee providing a written statement, it was reported that the employee had not given a statement because they did not meet with the administration in person.
Deficiency in Resident Transfer Documentation
Penalty
Summary
The facility failed to ensure proper documentation was provided during the transfer or discharge of residents, leading to deficiencies in the care process. Resident 8, who has multiple complex medical conditions including quadriplegia and stage four pressure ulcers, was transferred to the hospital on two occasions. On one occasion, no documents were sent with the resident, and on another, the documents provided were illegible, necessitating the reprinting of forms. This lack of proper documentation could potentially impact the continuity of care for the resident during hospital visits. Similarly, Resident 54, who suffers from end-stage renal disease and hypertension, was transferred to the emergency room due to chest pain and shortness of breath. However, the facility failed to provide the necessary transfer order and paperwork, including discharge and bed hold information. The facility's policy requires that specific information be provided to the receiving provider, but in this case, the documentation was not located, indicating a lapse in adherence to the established procedures.
Inaccurate MDS Assessment for Resident with Bladder Management Needs
Penalty
Summary
The facility failed to ensure the accurate completion of the Minimum Data Set (MDS) assessment for a resident, identified as Resident 4, who was reviewed for unnecessary medications and bladder management. The resident's clinical record indicated diagnoses of cerebral palsy and flaccid neuropathic bladder. The Quarterly MDS assessment inaccurately documented that the resident had an indwelling, suprapubic, and external catheters with a colostomy, while a subsequent Significant Change MDS noted only an indwelling and suprapubic catheter, omitting the external catheter and colostomy. This discrepancy was acknowledged by the MDS nurse during an interview, who confirmed the need for correction. The facility's policy on conducting accurate resident assessments emphasizes the importance of reflecting the resident's status at the time of assessment and ensuring that qualified staff conduct these assessments. Despite this policy, the inaccuracy in Resident 4's MDS assessment was identified, indicating a lapse in adherence to the policy. The Regional Support Person acknowledged the facility's commitment to following the Resident Assessment Instrument (RAI) and the potential existence of a policy for MDS accuracy, yet the deficiency in the assessment process was evident.
Failure to Implement Physician Orders and Develop Care Plans for Medications
Penalty
Summary
The facility failed to implement physician orders and develop comprehensive care plans for three residents regarding unnecessary medications. Resident 4, who has diagnoses including major depressive disorder, anxiety, chronic pain, hypertension, and osteoarthritis, was found to have incomplete documentation in the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for monitoring side effects and interventions related to their medications. Specific dates in April, May, and June lacked documentation for pain monitoring, electrolyte imbalance, and side effects of antianxiety, antidepressant, and antipsychotic medications. Resident 9, diagnosed with dementia, anxiety, bipolar disorder, and major depressive disorder, also had incomplete documentation in the MAR and TAR. The facility failed to administer the Rivastigmine patch on several occasions and did not document reasons for missed doses of Diazepam. Additionally, there was a lack of documentation for monitoring side effects of antianxiety, antidepressant, antipsychotic, and mood stabilizer medications on specific dates in June. Resident 15, with a diagnosis of nonrheumatic aortic valve stenosis, was receiving an antiplatelet medication, Aspirin, but the clinical record lacked an order to monitor for side effects such as bleeding. Furthermore, there was no care plan addressing the use of antiplatelet medication or monitoring for bleeding. The Director of Nursing and MDS Coordinator acknowledged the absence of necessary documentation and care plans during interviews.
Improper Insulin Administration Due to Incorrect Priming Procedure
Penalty
Summary
The facility failed to ensure proper administration of insulin for a resident, as observed during a survey. On July 10, 2024, a Registered Nurse (RN) was seen preparing a Humalog Insulin Kwikpen for a resident with a blood glucose level of 200. The RN set the pen to administer 6 units of insulin, explaining that 4 units were for the resident's sliding scale insulin requirement and 2 units were to prime the pen. However, the RN administered all 6 units to the resident without following the correct priming procedure. Further investigation revealed discrepancies in staff understanding of insulin pen usage. A Licensed Practical Nurse (LPN) stated that insulin pens do not require priming, contradicting the Humalog Kwikpen user manual, which specifies that priming is necessary to ensure accurate dosing. The Director of Nursing confirmed that the pen should be primed with 2 units before administering the required dose. The facility's Insulin Pen policy also supported the need for priming, indicating a lack of adherence to established procedures.
Failure to Provide Restorative Services as Per Care Plans
Penalty
Summary
The facility failed to provide restorative services as outlined in the care plans for three residents, leading to a deficiency in maintaining or improving their range of motion (ROM). Resident 2, diagnosed with dementia, weakness, and intellectual disabilities, had a care plan for active range of motion (AROM) exercises for the bilateral lower extremities, initiated in September 2022. However, there were numerous documented dates in 2024 where no restorative AROM was provided, indicating a lapse in the prescribed care. Similarly, Resident 7, with Parkinson's disease and dementia, had a care plan for daily AROM exercises for the bilateral lower extremities, initiated in May 2023. The records showed multiple dates in 2024 where these exercises were not performed. Resident 13, diagnosed with end-stage renal disease, hypertension, and dementia, also had a care plan for AROM exercises for both upper and lower extremities, initiated in March 2024. Again, there were several dates in 2024 where the exercises were not conducted. The Occupational Therapist indicated that it was the nursing staff's responsibility to perform these restorative therapies, but the facility's policy required the restorative nurse to ensure the implementation of each resident's program.
Failure to Update Care Plan and Document Falls
Penalty
Summary
The facility failed to adequately reduce the risk of falls for a resident, identified as Resident 6, who had a history of multiple falls. The resident, who was cognitively intact and dependent on staff for transfers, had a history of hemiplegia and hemiparesis following a cerebral infarction, and was at risk for falls. Despite these known risks, the facility did not consistently update the resident's care plan with new interventions following each fall. For instance, after a fall on 7/20/23, the care plan was not updated with the intervention of laying out clothes to prevent reaching, and similar omissions occurred after subsequent falls. The documentation of falls and subsequent actions was inconsistent and incomplete. On several occasions, such as the fall on 8/14/23, the clinical record lacked a post-fall evaluation, IDT note, or updated care plan. Additionally, there were discrepancies in the documentation, such as the fall on 1/12/24, where the care plan was not updated despite staff education on safe transferring. The resident also experienced a significant fall on 6/11/24, resulting in a nose fracture, which was attributed to the call light being out of reach, yet the care plan was only updated after the incident. The facility's policies required that the care plan be reviewed and revised upon a resident's status change, including after falls. However, the facility did not consistently adhere to these policies, as evidenced by the lack of timely updates to the care plan and incomplete documentation of falls. The facility's failure to implement and document specific interventions to reduce fall risks contributed to the ongoing risk of falls for Resident 6.
Failure to Follow Dialysis Care Plan and Physician Orders
Penalty
Summary
The facility failed to adhere to physician orders and implement the care plan for a resident requiring hemodialysis. Resident 13, who was admitted with diagnoses including end-stage renal disease, hypertension, and dementia, had specific physician orders and care plans in place. These included obtaining weight after dialysis treatments on specified days and monitoring the left upper extremity for signs of infection due to a newly placed fistula. However, the facility did not consistently follow these orders. Blood pressure readings were repeatedly taken from the resident's restricted limb, where the fistula was located, despite clear instructions not to do so. Additionally, the facility failed to record the resident's weight after dialysis sessions on multiple occasions, as required by the physician's orders. The lack of adherence to these orders and care plans was confirmed through interviews with facility staff and a review of the resident's clinical records. The facility's policy on comprehensive care plans emphasized the importance of following physician orders to maintain the resident's well-being, yet there was no specific policy in place to ensure compliance with these orders.
Failure to Serve Food at Palatable Temperatures
Penalty
Summary
The facility failed to ensure that food was served at palatable temperatures, as evidenced by a meal tray test conducted on the 200 Unit Hall. The test revealed that the chicken thigh was at 126.5 degrees Fahrenheit, the potato at 125.5 degrees Fahrenheit, the cottage cheese at 48.2 degrees Fahrenheit, the dessert chocolate eclair pudding at 67.5 degrees Fahrenheit, and the salad at 53.6 degrees Fahrenheit. These temperatures did not meet the facility's policy, which requires hot foods to be held at 135 degrees Fahrenheit or greater and cold foods to be kept at or below 41 degrees Fahrenheit. Interviews with residents indicated dissatisfaction with the food temperatures. One resident mentioned that the food is cold, while another stated that the food is not always hot and that CNAs do not serve the food immediately. The Dietary Manager confirmed that the expected temperatures for meats and vegetables should be greater than 165 degrees Fahrenheit and cold items should be less than 41 degrees Fahrenheit. The facility's policy on food temperatures was provided by the Administrator, which aligned with these standards.
Failure to Ensure Safe Storage of Resident's Food
Penalty
Summary
The facility failed to ensure the safe storage of foods brought in externally for a resident, identified as Resident 8, who was reviewed for resident refrigerators. During an observation, it was noted that Resident 8's refrigerator had two blank temperature logs for June and July 2024 taped to the outside door, with no temperatures recorded. Resident 8, who was admitted with diagnoses including quadriplegia and contracture of muscle/joint, was cognitively intact but fully dependent on staff for eating, toileting, bathing, and transfers, as per the most recent Quarterly MDS Assessment. An interview with an LPN revealed that staff were supposed to record the temperature of resident room refrigerators each morning during rounds, but this was not done for Resident 8's refrigerator. The facility's policy, provided by the Regional Support Consultant, stated that resident-owned refrigerators must be inspected and maintain proper temperature, which was not adhered to in this case.
Deficiencies in Documentation and Medication Administration
Penalty
Summary
The facility failed to ensure accurate and complete documentation for several residents, leading to deficiencies in medication administration and record-keeping. For Resident 15, a transcription error resulted in a duplicate medication order for sertraline, causing the resident to receive both a 100 mg tablet and a 50 mg tablet instead of a single 150 mg dose. This error was identified in the medication administration notes, but the confusion persisted until the Regional Nurse acknowledged the transcription mistake and the need for correction. Resident 8's clinical record lacked documentation for therapeutic leaves of absence, as staff did not consistently record when the resident left or returned to the facility. Additionally, there was no evaluation or physician's order for these leaves, contrary to the facility's policy. For Resident 26, discrepancies were found in the skin assessments, with a weekly review indicating intact skin despite a physician's order for treatment of an abrasion on the foot. The nurse responsible was unable to locate the wound or recall the treatment, highlighting incomplete and inaccurate documentation.
Inadequate Cleaning of Multi-Resident Use Glucometers
Penalty
Summary
The facility failed to ensure that multi-resident use glucometers were cleaned according to the manufacturer's instructions. During an observation, a registered nurse was seen cleaning a glucometer with a Micro-kill Bleach wipe for only 2 seconds before placing it back in the medicine cart. A qualified medication aide later indicated that the correct procedure was to wipe the glucometer for 30 seconds and let it air dry. The infection preventionist provided conflicting information, stating that the glucometer should be wrapped in a bleach wipe for 3 minutes. The facility's policy and the manufacturer's instructions both required the glucometer to remain wet for the contact time specified on the wipe's directions, which was 30 seconds according to the Micro-kill Bleach Wipes instructions. This inconsistency in cleaning practices led to the deficiency.
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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