Brickyard Healthcare - Woodlands Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Newburgh, Indiana.
- Location
- 4088 Frame Rd, Newburgh, Indiana 47630
- CMS Provider Number
- 155252
- Inspections on file
- 28
- Latest survey
- June 23, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Brickyard Healthcare - Woodlands Care Center during CMS and state inspections, most recent first.
Surveyors found that food was not served in a sanitary manner, with soiled kitchen equipment and floors, debris on surfaces, and unlabeled partially used food items in the freezer. The Dietary Manager confirmed that opened food should be labeled and that kitchen staff are responsible for regular cleaning, but these practices were not followed.
A resident with mild cognitive impairment and anxiety disorder was not permitted to attend a resident council meeting after expressing a desire to participate. An LPN removed the resident from the meeting area, stating she was not on the attendance list, even though facility policy allows all residents to participate and the resident was a regular attendee. The resident's care plan supported involvement in activities, and she was documented as oriented and without behavioral issues.
A resident with an indwelling catheter was observed on multiple occasions with the catheter bag either on the floor or touching the floor, contrary to the care plan and infection control policy. The resident was dependent on staff for toileting and had a diagnosis of neurogenic bladder. The Infection Preventionist confirmed that catheter bags should not be on the floor.
A facility failed to follow Enhanced Barrier Precautions during Foley Catheter care for a resident with severe cognitive impairment and an indwelling catheter. Staff did not wear gowns as required, despite signage and policy indicating the necessity for gown and glove use to prevent the transmission of multidrug-resistant organisms.
The facility failed to maintain resident dignity and privacy during meal service and medical interactions. Staff entered residents' rooms without knocking or announcing themselves, and an LPN applied clothing protectors without consent. Additionally, a physician conducted medical assessments in a common area, compromising confidentiality.
In the ACU, a treatment cart was found with improperly stored and labeled medications affecting nine residents. The medications, including creams and powders, were not stored in the medication room as required by facility policy. Interviews with the DON and an LPN confirmed the medications should have been labeled with the resident's name and open date.
The facility failed to maintain a sanitary environment, with observations of unclean sit-to-stand devices, mechanical lifts, and resident wheelchairs. Interviews revealed inconsistencies in cleaning practices, with CNAs responsible for equipment cleaning, contrary to the facility's policy.
The facility failed to implement care plans for two residents, leading to deficiencies in care. A resident with a history of falls was not provided with necessary fall prevention interventions, and staff were not informed about these measures. Another resident with Chronic Lung Disease was left in a flat bed position during treatment, contrary to physician orders, causing breathing difficulties. The facility's policies on care plans and supervision were not effectively communicated or implemented.
A facility failed to revise care plans for a resident with severe cognitive impairment and multiple diagnoses, including dementia and anxiety. Despite a biopsy on the resident's cheek, the care plan was not updated to include new wound care interventions. Additionally, the care plan for nutritional risk was not revised to reflect a physician's order for weekly weights. The facility's policy requires comprehensive, person-centered care plans with measurable objectives, which was not followed.
A facility failed to properly care for a resident with a PICC line, leading to a deficiency in IV therapy administration. The resident's care plan required weekly dressing changes and measurements of the catheter length, but these were not documented. Staff also took blood pressure readings from the arm with the PICC line, contrary to care plan instructions. The DON was unaware of the care plan's measurement requirements, and the facility's policy on measuring catheter length was not followed.
A resident with chronic respiratory conditions was not receiving oxygen at the prescribed flow rate, as observed during a facility survey. The oxygen concentrator was set at two liters instead of the ordered three liters. Additionally, staff repeatedly took blood pressure readings on the resident's restricted limb, contrary to the care plan. These actions were inconsistent with the facility's policy on oxygen administration and care plan adherence.
A facility failed to provide appropriate dialysis care for a resident with end-stage renal disease and diabetes. The resident's care plan was not followed, as staff took blood pressure readings from a restricted limb and did not consistently monitor fluid restrictions. Interviews revealed staff were unaware of the resident's specific care needs, leading to deficiencies in care.
A facility failed to document the assessment of UTI symptoms for a resident receiving IV therapy. The resident, admitted with multiple diagnoses, had an incomplete Admission MDS Assessment. Despite a care plan to observe for UTI signs, a progress note indicated symptoms like lower back pain and confusion, but follow-up documentation was missing until days later. The facility's policy required timely documentation, which was not followed.
The facility failed to implement proper infection control measures for two residents requiring enhanced barrier precautions and contact precautions. A resident with open wounds did not have an EBP sign on their door, and staff did not wear appropriate PPE during wound care. Another resident under contact precautions for shingles lacked a comprehensive care plan addressing these precautions. Facility policies on wound treatment and EBP were not followed, leading to deficiencies in infection control practices.
Failure to Maintain Sanitary Food Service and Proper Food Labeling
Penalty
Summary
Surveyors observed that the facility failed to serve food in a sanitary manner according to professional standards during two separate kitchen inspections. The top of the dish machine was found to be soiled, and the kitchen floors had debris buildup around the edges, under racks, tables, and the three-compartment sink. Additional debris was noted on a pull-down plug above the food prep table and on a wall-mounted fan. In the walk-in freezer, partially used bags of tater tots and potato wedges were stored in clear bags without any labeling. The Dietary Manager confirmed that opened food should be labeled with an open date and use-by date, and that kitchen staff are responsible for sweeping and mopping floors after each shift, while deep cleaning is performed monthly by housekeeping. The facility's policy requires labeling and dating of all food items removed from their original containers.
Resident Excluded from Resident Council Meeting Despite Expressed Interest
Penalty
Summary
A resident with a diagnosis of anxiety disorder and mild cognitive impairment was not allowed to participate in a resident council meeting, despite expressing a desire to attend. On the day of the meeting, the resident was observed in the main dining room and indicated to an LPN that she wanted to stay for the meeting. The LPN informed her that she was not on the list and removed her from the room, resulting in her absence from the meeting. The resident's care plan included interventions to involve her in out-of-room activities and to invite her to favorite and new activities, and records showed she was a regular member of the resident council and had attended previous meetings. Facility policy stated that all residents are eligible and encouraged to participate in resident council meetings. The administrator confirmed that anyone who was alert and oriented could attend, regardless of whether they were on the list. The resident was documented as oriented to person, place, and situation by psychiatry, and had no behaviors noted on her most recent MDS assessment. Despite this, the facility created a list for the meeting that only included residents deemed alert and oriented, and the resident was excluded from participation based on this list.
Failure to Maintain Proper Catheter Bag Placement for Infection Control
Penalty
Summary
A deficiency was identified when a resident with a history of neuromuscular dysfunction of the bladder and urinary retention, who was dependent on staff for toileting and had an indwelling catheter, was observed with improper catheter bag placement. On two separate occasions, the resident's catheter bag was either on the floor or hanging from the bed in such a way that it touched the floor. These observations were made while the resident was lying in bed, and the bed was in its lowest position during one of the incidents. Review of the resident's care plan indicated a specific intervention to keep the catheter drainage bag below the level of the bladder and off the floor at all times. The facility's policy on indwelling catheter use and removal also required adherence to professional standards of practice and infection prevention and control procedures. During an interview, the Infection Preventionist confirmed that catheter bags should not be on the floor, indicating a failure to follow established infection control practices and standards.
Failure to Follow Enhanced Barrier Precautions During Catheter Care
Penalty
Summary
The facility failed to adhere to Enhanced Barrier Precautions (EBP) during the care of a resident with an indwelling urinary catheter. On the specified date, a Qualified Medication Aide (QMA) and a Certified Nursing Assistant (CNA) were observed providing Foley Catheter care to a resident without donning gowns, despite the presence of signage indicating the requirement for gown use. The resident's clinical record indicated severe cognitive impairment and the presence of an indwelling catheter, with care plans specifying the need for EBP during catheter care and other high-contact activities. The facility's policy on Enhanced Barrier Precautions, provided by the Administrator, outlined the necessity of gown and glove use to prevent the transmission of multidrug-resistant organisms, particularly for residents with indwelling medical devices. Despite this policy, the staff did not follow the required precautions during the observed care. The QMA later acknowledged that gowns and gloves should have been worn, indicating a lapse in adherence to the established infection control protocols.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to ensure the dignity and privacy of residents during meal service and medical interactions. Observations revealed that staff members, including CNAs, entered residents' rooms to deliver meal trays and beverages without knocking or announcing themselves. This occurred multiple times across different residents, indicating a pattern of behavior that disregards the residents' right to privacy and dignity. Additionally, during a meal observation, an LPN applied clothing protectors to residents without asking for their permission or explaining the action, further compromising the residents' dignity. Furthermore, a physician was observed conducting medical assessments in a common area where other residents, staff, and family members were present, which compromised the confidentiality of the residents' medical information. The facility's policy on promoting and maintaining resident dignity was not adhered to, as evidenced by these observations. The policy emphasizes the importance of treating residents with respect and maintaining their privacy, which was not followed in these instances.
Improper Storage and Labeling of Medications in ACU
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications in the Alzheimer Care Unit (ACU), affecting nine residents. During an observation, a treatment cart was found to contain multiple medications that were either unlabeled or lacked an open date. These included various creams, ointments, and powders, some of which were not stored in the designated medication room as per facility policy. The medications were found in a locked nightstand/treatment cart, contrary to the facility's policy that requires all drugs and biologicals to be stored in locked compartments within the medication room. Interviews with the Director of Nursing (DON) and a Licensed Practical Nurse (LPN) revealed that the medications should not have been stored in the treatment cart and should have been labeled with the resident's name, medical doctor, and medication name. Additionally, all medications, including ointments, creams, and powders, should have been dated with an open date. The facility's policy, as provided by the Regional Nurse, mandates that all medications be stored in medication rooms and only accessible to authorized personnel.
Deficiency in Maintaining a Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe and sanitary environment for residents, staff, and the public, as evidenced by multiple observations of unclean equipment and resident wheelchairs over a three-day period. Specifically, sit-to-stand devices and mechanical lifts in various hallways were found with dust, fiber debris, and white residue on multiple occasions. Additionally, resident wheelchairs were observed with food debris and chocolate milk splatters, indicating a lack of regular cleaning and maintenance. Interviews with residents and staff revealed inconsistencies in the cleaning practices for resident-care equipment. A resident reported that staff do not regularly clean wheelchairs, while a CNA stated that wheelchairs are cleaned weekly and as needed. Another resident was unaware if their wheelchair was cleaned, and a housekeeper indicated that CNAs are responsible for cleaning equipment, not the housekeeping staff. The facility's policy on cleaning and disinfection of resident-care equipment was provided, which emphasized the importance of routine cleaning and disinfection by each user, but the observations and interviews suggest this policy was not consistently followed.
Failure to Implement Care Plans for Fall Prevention and Respiratory Support
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for two residents, leading to deficiencies in their care. Resident 24, who has a history of falls and various medical conditions including dementia and abnormal gait, was observed without the necessary fall prevention interventions in place. Despite a care plan indicating the use of wedge pillows to prevent falls from a recliner, staff failed to implement this intervention, as observed on multiple occasions. Staff members were not adequately informed about the resident's fall interventions, leading to a lack of consistent care. Similarly, Resident 351, diagnosed with Chronic Lung Disease, experienced a deficiency in care when the head of the bed was not elevated during a treatment, despite physician orders and a care plan indicating the necessity of this intervention to alleviate shortness of breath. The resident expressed difficulty breathing, yet the staff delayed in adjusting the bed position. The facility's policies on comprehensive care plans and accident supervision were not effectively communicated or implemented, resulting in these care deficiencies.
Failure to Revise Care Plans for Resident
Penalty
Summary
The facility failed to ensure that care plans were revised for one of the two residents reviewed, specifically Resident 45. The resident's clinical record indicated diagnoses including unspecified dementia and anxiety, with a severe cognitive impairment noted in the most recent Quarterly MDS assessment. The resident required supervision for transfer and mobility, with substantial help needed for mobility. Despite having a biopsy on the right cheek on 6/19/24, the care plan for a seborrheic lesion dated 8/8/23 was not updated to reflect the new wound care interventions. Additionally, the care plan for nutritional risk due to inadequate food and beverage intake, triggered by a 10% weight loss, was not revised to include the physician's order for weekly weights, which was initiated on 6/14/24. During an interview, the MDS RN stated that care plans should be updated for surgeries and biopsies, but this was not done in Resident 45's case. The facility's policy on comprehensive care plans requires the development and implementation of a person-centered care plan with measurable objectives and timeframes, which was not adhered to in this instance.
Deficiency in PICC Line Care and Monitoring
Penalty
Summary
The facility failed to provide proper care for a resident with a peripherally inserted central catheter (PICC) line, leading to a deficiency in the administration of IV therapy. Resident 302, who was admitted with diagnoses including infection of joint prosthesis, anxiety, and hypertension, had a care plan that specified the PICC line dressing should be changed weekly and measurements of the catheter length and arm circumference should be taken. However, the facility did not adhere to these care plan instructions. The clinical record review revealed that staff repeatedly took blood pressure readings from the resident's right arm, where the PICC line was inserted, despite the care plan's directive to avoid this arm. Additionally, there was a lack of documentation regarding the catheter length in the resident's clinical record, and the Director of Nursing was unaware of the reason for the care plan's requirement to measure the PICC line during dressing changes. The facility's policy, provided by the clinical regional nurse, indicated that the external length of the catheter should be measured to ensure it had not migrated, yet this was not being done. These oversights and inconsistencies in following the care plan and facility policy contributed to the deficiency in the resident's care.
Failure to Administer Oxygen as Ordered and Adhere to Fistula Care Plan
Penalty
Summary
The facility failed to ensure a resident was receiving oxygen as ordered by the physician. During an observation, it was noted that a resident was receiving oxygen via nasal cannula from an oxygen concentrator set at two liters, despite the physician's order for three liters. A registered nurse confirmed the discrepancy and adjusted the oxygen flow to the correct setting. The resident, who was cognitively intact, had been diagnosed with chronic obstructive pulmonary disease and chronic respiratory failure with hypoxia, and required continuous supplementary oxygen to prevent or relieve hypoxia. Additionally, the facility failed to adhere to the care plan regarding the resident's fistula care. The resident's care plan specified that blood pressure should not be taken on the arm with the fistula access site. However, records indicated that staff repeatedly took blood pressure readings on the restricted limb on multiple occasions. This oversight was contrary to the care plan and the facility's policy on oxygen administration, which emphasized adherence to physician orders and care plan interventions.
Deficiency in Dialysis Care and Fluid Management
Penalty
Summary
The facility failed to provide appropriate dialysis care and services for a resident with end-stage renal disease and diabetes mellitus. The resident, who was moderately cognitively impaired and dependent on staff for assistance, had specific physician orders for dialysis and fluid restrictions. However, the clinical record lacked an order to obtain the resident's weight, which is crucial for monitoring fluid balance in dialysis patients. Additionally, the resident's electronic medication administration record showed that staff obtained blood pressure readings from the resident's restricted limb on multiple occasions, contrary to the care plan instructions. Interviews with facility staff revealed a lack of awareness and adherence to the resident's care plan. A CNA was unaware of which residents were on fluid restrictions, and an LPN indicated that nurses and CNAs should record fluid amounts for residents on fluid restrictions, but this was not consistently done. The facility's policy on hemodialysis care, which emphasizes adherence to professional standards and physician orders, was not followed, leading to deficiencies in the care provided to the resident.
Failure to Document UTI Assessment for Resident
Penalty
Summary
The facility failed to document the assessment for symptoms of a urinary tract infection (UTI) for a resident undergoing IV therapy. The resident, who was admitted with diagnoses including infection of joint prosthesis, anxiety, and hypertension, had an incomplete Admission MDS Assessment. The care plan initiated on 6/11/24 included observing for signs and symptoms of a UTI. However, a progress note on 6/24/24 indicated the resident complained of lower back pain, had ineffective pain medication, and showed signs of increased confusion and irritability, yet there was no follow-up documentation of these symptoms or the order request until 6/28/24. The clinical record lacked documentation of a bowel assessment and the need for Miralax administration. During an interview, the Regional Clinical Nurse confirmed that the resident received an order for PRN Miralax for possible UTI symptoms. The facility's policy on documentation required that all assessments, observations, and services be documented in the resident's medical record at the time of service or no later than the shift in which they occurred, which was not adhered to in this case.
Inadequate Infection Control and Precautionary Measures
Penalty
Summary
The facility failed to implement proper infection prevention and control measures for two residents requiring enhanced barrier precautions (EBP) and contact precautions. During an observation of wound care for Resident 352, it was noted that the nursing staff did not follow EBP protocols. Specifically, there was no EBP sign on the resident's door, and the staff did not wear the appropriate personal protective equipment (PPE) such as gowns, masks, or goggles during high-contact activities, despite the resident having open wounds. The resident's clinical records indicated multiple open lesions requiring daily dressing changes, which were not consistently followed as per physician orders. For Resident 45, who was under contact precautions due to shingles, the facility failed to develop a comprehensive care plan that included contact precautions. Although a contact precautions sign was present on the resident's door, the care plan lacked specific interventions for managing the resident's condition. The facility's policies on wound treatment management and enhanced barrier precautions were not adhered to, leading to deficiencies in infection control practices.
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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