Charlestown Place At New Albany
Inspection history, citations, penalties and survey trends for this long-term care facility in New Albany, Indiana.
- Location
- 4915 Charlestown Rd, New Albany, Indiana 47150
- CMS Provider Number
- 155668
- Inspections on file
- 58
- Latest survey
- March 20, 2026
- Citations (last 12 mo.)
- 31 (1 serious)
Citation history
Health deficiencies cited at Charlestown Place At New Albany during CMS and state inspections, most recent first.
A resident admitted with multiple comorbidities, morbid obesity, limited mobility, and no documented pressure injuries to the buttocks or sacrum was identified as high risk for skin breakdown but remained totally dependent on staff for repositioning and care. The admission assessment noted excoriations in groin areas but did not stage a pressure injury, while later skin checks documented a stage 1 pressure injury to the medial buttocks as present on admission. The care plan listed general skin integrity interventions but was not updated with new measures despite ongoing redness and the resident’s dependence for mobility and incontinence care. After a reported slip from bed and noted shearing, the resident developed full-thickness skin tears to both buttocks and the sacrum, with wound orders initiated for cleansing and dressings and later debridement of the buttock and sacral areas. The sacral/buttock wound progressed to tunneling with foul odor, and the resident was ultimately transferred to the hospital, where sepsis was diagnosed as likely due to the infected sacral wound, leading surveyors to cite the facility for failure to prevent and appropriately manage a stage 4 pressure ulcer.
Two residents with cardiovascular diagnoses received antihypertensive medications despite physician orders specifying to hold the medications if certain vital sign parameters were not met. In both cases, medications were administered when blood pressure or heart rate readings were below the ordered thresholds, contrary to facility policy and physician instructions.
A resident receiving IV antibiotics via a PICC line did not have documented dressing changes as required by facility policy, which mandates changes at least every 7 days or sooner if the dressing is compromised. Staff confirmed the expectation for regular dressing changes, but the clinical record lacked evidence that these were completed during the resident's treatment.
Three residents with chronic respiratory conditions received nebulizer treatments without documented respiratory assessments before, during, or after medication administration, despite physician orders and facility policy requiring such monitoring. Staff confirmed that these assessments should have been completed and documented to ensure treatment effectiveness.
A resident with end stage renal disease and a dialysis fistula did not have physician dialysis orders or required monitoring documented after returning from the hospital, despite care plan interventions and previous orders for regular assessments and vital sign checks. Facility leadership confirmed that these orders should have been in place upon readmission.
A deficiency was cited for not ensuring a resident's right to dignity, self-determination, communication, and the exercise of their rights. The report does not specify the exact actions or events that led to this finding.
A resident with hypertension received Lisinopril on multiple occasions when their systolic blood pressure was below the physician-ordered threshold, despite clear instructions to hold the medication if the SBP was less than 110. Nursing staff and facility policy both indicated that medications should not be given when vital signs are out of parameters, but the medication was still administered.
Three residents who elected dental care through the facility's third-party provider did not receive timely routine dental services. One resident with chronic conditions had no record of dental authorization or care since admission, while another with failure to thrive and depression also lacked documentation of dental services. A third resident with dementia experienced a five-month delay before being seen by a dentist, resulting in the need for multiple extractions. The facility's records showed inadequate management of dental consents and service provision.
A resident with dementia and cognitive communication deficit was admitted without timely completion of required admission paperwork, including the admission agreement and multiple consent forms. The admission process was not completed within the facility's expected timeframe, as the Admissions Coordinator was unaware of the delay caused by a previous staff member.
The facility did not consistently notify the emergency department of a resident's pending arrival or provide required bed hold policy information to residents prior to hospital transfers. Multiple residents with serious medical conditions were transferred without proper documentation or communication, as confirmed by record review and staff interviews.
The facility failed to document neurological checks for two residents after unwitnessed falls. One resident with cognitive and physical impairments was found on the floor, and although assessed, the neurological check was not documented. Another resident with dementia and muscle weakness also lacked documented neurological assessment after a fall. An LPN confirmed the requirement for such checks, and the DON provided guidelines for neurological assessments, which were not followed.
A facility failed to provide proper respiratory care for a resident with COPD, obstructive sleep apnea, and congestive heart failure. The resident's nebulizer was found unbagged, and there was no documentation of required respiratory assessments before and after nebulizer treatments. Staff interviews confirmed that assessments should include monitoring lung sounds, cough type, respirations, oxygen saturation, and heart rate, but these were not conducted or recorded as per facility policy.
A resident with a history of hemiparesis and convulsions received an extra dose of Keppra due to an LPN's failure to verify the MAR, leading to hospitalization for altered mental status. The error occurred when the LPN administered an additional dose found in the pharmacy rollpack without checking the MAR, contrary to facility policy.
A resident with multiple diagnoses, including acute respiratory failure and hypertension, experienced low blood pressure and continuous shortness of breath. Despite these symptoms, the facility failed to notify the physician, as confirmed by an RN and the Director of Nursing's protocol document.
A facility failed to ensure accurate assessment and documentation of a resident's vital signs for skilled charting. A resident with multiple diagnoses, including atrial fibrillation and congestive heart failure, had the same set of vital signs repeatedly documented over several days without current assessments. Interviews confirmed that staff should obtain current vital signs for skilled charting, but the clinical record lacked documentation for specific days, indicating a deficiency in assessment protocols.
The facility failed to document urine output for residents with indwelling catheters, affecting three residents. One resident with obstructive and reflux uropathy had missing documentation across several dates. Another resident with stage 4 kidney disease had a missing entry for a night shift, and a third resident with obstructive and reflux neuropathy had missing documentation on two night shifts. The DON acknowledged the lack of a policy on physician's orders, contributing to these lapses.
A facility failed to follow a physician's fluid restriction order for a resident with congestive heart failure. The resident's fluid intake exceeded the prescribed limit on multiple days, and there was no documentation of the order's implementation. The DON indicated a possible communication lapse from the physician to the nursing staff.
The facility failed to maintain and document respiratory care for three residents. A resident's nebulizer mask was improperly stored and undated, and two residents lacked documentation of equipment maintenance. Another resident was on oxygen without a physician's order. The DON confirmed the need for proper orders and maintenance, as outlined in the facility's guidelines.
A resident with CHF and edema experienced a significant medication error when the facility failed to administer an increased dosage of Lasix as ordered by the physician. The resident's condition warranted an increase from 20 mg to 40 mg twice daily, but the medication administration record lacked documentation of the increased dosage on the evening of September 3 and any administration on September 4. The DON confirmed the medication should have been administered, but it was not.
The facility failed to document the administration of narcotics for 12 residents, leading to discrepancies between recorded and actual counts of medications. Observations revealed that LPNs and QMAs did not consistently sign out narcotics upon administration, contrary to the facility's policy. This resulted in incorrect narcotic counts, as confirmed by interviews with staff and record reviews.
The facility failed to dispose of expired and discontinued medications, as observed in multiple medication carts and a medication room. Unused naloxone, expired eye drops, and insulin pens without open dates were found. Staff interviews revealed that expired medications were typically returned to the pharmacy or given to the ADON or DON for destruction, with checks conducted two to three times weekly.
The facility's kitchen was found to have significant sanitation issues, including dust on air vents, expired food items, and a buildup of grease and food particles on equipment. Despite a cleaning schedule, these issues persisted, indicating a failure to maintain cleanliness as per facility policies.
A resident experienced discomfort due to an inadequate bed size, with observations showing his feet touching the footboard, limiting his movement. Despite being cognitively intact and reporting the issue, no action was taken to address his concern. The resident's medical conditions, including paraplegia, likely worsened the discomfort. A previous incident noted a discolored area on his foot due to pressure, which was temporarily addressed with a foam wedge. The Maintenance Director was unaware of the issue, suggesting a lack of communication.
The facility failed to ensure a clean and sanitary environment for two residents, as their toilets were observed to be unclean over several days. Despite protocols for daily cleaning, the toilets contained dark and brown substances, indicating a lapse in housekeeping duties. Interviews with staff confirmed the expectation of daily cleaning, yet the unsanitary conditions persisted.
A facility failed to prevent the misappropriation of a resident's narcotic medication. A resident with Alzheimer's and dementia was prescribed Norco, and during a shift change, five tablets were found missing. An LPN admitted to leaving the medication cart keys unattended, but there was no evidence to prove who took the medication. The incident was reported to the unit manager and DON for follow-up.
A facility failed to follow medication hold parameters for a resident prescribed Digoxin, which was to be withheld if the heart rate was below 60. Despite the resident's heart rate being below this threshold on two occasions, the medication was administered, and there was no documentation of physician notification. An LPN confirmed the medication should have been held and the physician notified.
The facility failed to accurately document medication administration for several residents, including discrepancies in MARs and controlled substance records. A resident's Norco administration was not recorded in the controlled substance record, while another resident's Lorazepam, Clonazepam, and Morphine administration were inconsistently documented. Additionally, a resident's Tramadol administration was missing from the controlled substance record, and another resident's insulin administration and wound treatment orders were not properly documented or communicated.
A facility failed to follow medication parameters for a resident with hypertension. The care plan required holding Lisinopril if the resident's SBP was below 100 or heart rate was below 60. Despite this, the medication was administered when the resident's SBP and heart rate were below these thresholds. An RN confirmed that medications should be held if parameters are not met, indicating a failure to adhere to prescribed orders.
The facility failed to notify the physician of a resident's multiple instances of loose stools, which was a change in condition. Despite the resident's diagnoses of dementia and cognitive communication deficit, there was no nursing documentation or physician notification. Interviews revealed that the facility's point of care system did not flag loose stools, and aides were expected to report such changes to the nurse.
The facility failed to ensure a resident's room was free of hazards and did not provide adequate education on the risks. A resident with multiple diagnoses sustained burns from lying on a phone charger cord plugged into an extension cord. Additionally, a non-hospital grade power strip was found in the resident's room, used for a refrigerator and medical devices, against facility policy.
The facility failed to develop a care plan for a resident with dementia and stage 3 pressure ulcers who consistently refused to turn and reposition. Despite documentation of the resident's refusal in progress and wound notes, no care plan was created to address this issue, leading to a deficiency in care planning.
The facility failed to complete physician-ordered treatments for pressure ulcers for two residents. Resident D had multiple missed treatment entries for stage 3 pressure ulcers on the coccyx and buttocks, while Resident E had missed treatment entries for a stage 3 pressure ulcer on the coccyx. An RN confirmed that treatments should be signed off once completed.
Failure to Prevent and Manage Progressive Sacral and Buttock Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to prevent the development and deterioration of a severe pressure ulcer in a resident who was admitted without documented pressure injuries to the buttocks or sacrum, despite being identified as at increased risk for skin breakdown. On admission, the resident had diagnoses including a displaced intertrochanteric fracture of the left femur, difficulty walking, morbid obesity, and bilateral hip osteoarthritis. The admission nursing evaluation documented normal skin color and temperature, with excoriations noted on the chest and bilateral iliac crest/groin areas, and a surgical dressing on the left thigh, but no pressure injuries were documented. A Braden Scale completed at admission identified the resident as at increased risk for pressure sores, with limited cognition, chairfast status, limited mobility, and friction and shear as potential problems. The care plan initiated the day after admission identified potential for skin impairment related to decreased mobility and included general interventions such as incontinence care, treatments as ordered, observation of skin during care, turning and repositioning, use of a pressure-reducing mattress and wheelchair cushion, weekly skin checks, and a wheelchair cushion, but no new or revised interventions were added when the care plan was revised several days later. Subsequent skin checks documented a stage 1 pressure injury to the medial buttocks that was considered present on admission, although the admission assessment had only described excoriation and did not stage a pressure injury. A skin check dated approximately nine days after admission described the buttocks as having a generalized stage 1 pressure ulcer/injury to the medial buttocks without undermining or tunneling, and a later skin check again documented a stage 1 pressure injury to the medial buttocks, still described as present on admission. The resident’s MDS indicated she was cognitively intact but totally dependent on staff for toileting, hygiene, showering, and transfers using a sit-to-stand device, and required substantial assistance for bed mobility and position changes. The DON later reported that the resident slipped from the bed on an early March date and that shearing was subsequently noticed, which was described as the resident’s skin tears. Despite the resident’s high risk status, dependence on staff for repositioning, and documented redness on the coccyx and buttocks, there is no indication in the record that the facility implemented additional or modified interventions beyond the original care plan to address the evolving skin issues. A wound note dated in early March documented that the resident, in addition to her post-surgical left proximal and distal wounds, had full-thickness skin tears to the right and left buttocks and sacrum. A physician’s order for non-pressure wounds of the coccyx and bilateral buttocks directed cleansing with normal saline, application of calcium alginate, and dressing as needed. A nurse’s note the same day indicated the resident was seen via telehealth by the wound nurse with the assistant DON, and the plan was for twice-daily dressing changes using Dakin’s solution, calcium alginate, and abdominal gauze. The following day, a wound note documented selective debridement of the right buttock and surgical excisional debridement of the sacrum. A subsequent alert note described the buttock/sacrum wound as tunneling with foul odor, requiring flushing with Dakin’s and normal saline, and application of Santyl, calcium alginate, and border gauze. Shortly thereafter, the resident was sent to the hospital for lethargy, altered mental status, and elevated temperature, and the hospital documented a diagnosis of sepsis likely due to an infected sacral wound. The surveyors determined that the facility failed to prevent the development and progression of a stage 4 pressure ulcer on the sacrum and full-thickness skin tears on the bilateral buttocks, and failed to ensure appropriate services were provided to these wounds, resulting in deterioration to a stage 4 pressure injury requiring surgical debridement and hospitalization for sepsis within three weeks of admission.
Removal Plan
- staff education/in-services on daily wound monitoring
- assess all residents for identifying skin impairments
- review all resident care plans regarding skin issues
- ensure pressure injury prevention interventions are in place for at-risk residents
- wound team to complete a risk management assessment of physician notification, obtaining new orders, transcribing new orders, contacting families regarding new orders, updating care plans with new interventions, and providing therapy referrals as needed
Failure to Follow Medication Administration Parameters for Cardiovascular Residents
Penalty
Summary
The facility failed to follow physician-ordered medication administration parameters for two residents with cardiovascular conditions. For one resident diagnosed with hypertension and heart failure, the care plan required administration of Metoprolol Tartrate with instructions to hold the medication if the systolic blood pressure was less than 110. Despite this, the medication was administered on multiple occasions when the resident's systolic blood pressure was below the specified threshold, including readings of 104 and 90. Staff confirmed during interview that medications should not be given if vital signs are outside of ordered parameters. Similarly, another resident with cerebrovascular disease and hypertension had a physician's order for Metoprolol Succinate Extended Release, to be held if the heart rate was less than 60. The medication administration records showed that the medication was given on several dates when the resident's heart rate was below 60, with documented rates as low as 53. The facility's policy required medications to be administered in accordance with accepted standards of practice, which was not followed in these instances.
Failure to Document and Perform Required PICC Line Dressing Changes
Penalty
Summary
The facility failed to ensure that a resident's peripherally inserted central catheter (PICC) line dressing changes were completed as required during the administration of intravenous antibiotics. The resident, who had a diagnosis including cellulitis of the lower right leg, was ordered to receive Cefepime HCl intravenously three times daily for a specified course. Review of the clinical record revealed a lack of documentation indicating that PICC line dressing changes were performed throughout the antibiotic treatment period. Facility policy, as provided by the President of Clinical Operation, requires that IV dressings be changed at least every 7 days or sooner if damp, loosened, or soiled. Staff confirmed that dressing changes should occur every 7 days, but there was no evidence in the record that this was done for the resident in question.
Failure to Document Required Respiratory Assessments for Nebulizer Treatments
Penalty
Summary
The facility failed to ensure that respiratory assessments were conducted and documented for residents receiving nebulizer treatments. Specifically, three residents with diagnoses such as chronic respiratory failure, chronic obstructive pulmonary disease, dyspnea, and wheezing were ordered to receive nebulized medications including Budesonide and Ipratropium-Albuterol. However, their clinical records did not contain documentation of respiratory assessments before, during, or after the administration of these medications, as required by facility policy and physician orders. Staff interviews confirmed that respiratory assessments, including pulse, respiratory rate, and lung sounds, should be obtained and documented prior to, during, and after nebulizer treatments to monitor effectiveness and resident response. The facility's own procedure for administering medications via nebulizer also outlined these assessment requirements. Despite this, the records for the affected residents lacked evidence that these assessments were performed or recorded at the required times.
Failure to Ensure Monitoring and Orders for Dialysis Care After Hospital Readmission
Penalty
Summary
The facility failed to ensure appropriate monitoring and care for a resident with end stage renal disease who was dependent on hemodialysis. The resident had a care plan and physician orders in place that required specific interventions, including checking the dialysis fistula site for infection, monitoring vital signs before and after dialysis, obtaining post-dialysis weights, and assessing the fistula for bruit and thrill every shift. Despite these orders, the clinical record lacked documentation of any physician dialysis orders following the resident's readmission from the hospital, covering a period from 11/15/25 to 12/10/25. Observations confirmed the presence of a dialysis fistula, and interviews with facility leadership acknowledged that dialysis orders should have been reinstated upon the resident's return from the hospital. The absence of documented dialysis orders and related monitoring during this period indicated a failure to provide safe and appropriate dialysis care and services as required by the resident's condition and care plan.
Failure to Honor Resident Rights to Dignity and Self-Determination
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report notes that the facility did not ensure these resident rights were upheld, but does not provide specific details about the actions or inactions that led to this deficiency, nor does it mention any particular events or residents involved.
Failure to Hold Antihypertensive Medication for Low Blood Pressure
Penalty
Summary
A deficiency occurred when a resident with a diagnosis of hypertension received blood pressure medication, Lisinopril 10 mg daily, despite physician orders specifying that the medication should be held if the resident's systolic blood pressure (SBP) was less than 110. The resident's care plan indicated altered cardiovascular status due to hypertension, and the medication administration record showed multiple instances where the medication was administered even though the resident's SBP was below the ordered threshold. Specifically, the medication was given on several dates when the SBP ranged from 100 to 109, all below the physician's specified parameter. During interviews, nursing staff confirmed that medications should not be administered if vital signs are out of the ordered parameters. Facility policy also required that medications be administered in accordance with physician orders and that vital signs be obtained and recorded as necessary prior to administration. Despite these requirements, the medication was not held as ordered, resulting in a failure to provide care according to the resident's clinical needs and physician instructions.
Failure to Provide Timely Routine Dental Services
Penalty
Summary
The facility failed to provide timely routine dental services for three residents who had elected to receive dental care through the facility's third-party provider. For one resident with diagnoses including iron deficiency anemia, anxiety, and chronic pain, there was no documentation of dental authorization, consent, or any dental services provided since admission, despite the resident's indication that she had not been seen by a dentist since entering the facility. The Social Services Director (SSD) confirmed that there was no effective system in place for managing dental consents and that the resident had not received dental services as required. Another resident, diagnosed with adult failure to thrive and depression, also reported not being seen by a dentist since admission, with the clinical record lacking any documentation of dental authorization, consent, or services provided. A third resident, with dementia and dysphagia, experienced a significant delay in dental care; the resident's POA had communicated concerns about dental issues upon admission and again several months later, but the resident was not seen by a dentist until five months after admission, at which point extensive dental extractions were needed. In all cases, the facility's records did not show timely completion of dental consents or provision of routine dental care as required.
Delayed Completion of Admission Paperwork
Penalty
Summary
The facility failed to ensure that a resident's admission paperwork was completed in a timely manner. Specifically, the clinical record for a resident with diagnoses including dementia and cognitive communication deficit showed that several required admission documents, such as consent to treat, CPR consent, bed rail consent, digital photography of wounds consent, psychoactive medication consent, pharmacy enrollment agreement, COVID-19 disclosure, POST form consent, and the admission agreement, were not signed promptly upon admission. The admission agreement, in particular, was not completed within the expected 48 to 72-hour timeframe after the resident's entry to the facility. During an interview, the Admissions Coordinator acknowledged that the admission process for the resident had been problematic and that she was unaware the previous Admission Assistant had not finalized the admission agreement as required. The facility's policy stipulated that the admission agreement should be signed at the time of or soon after admission, but this was not adhered to in this case, resulting in a delay in the completion of essential admission documentation.
Failure to Provide Hospital Notification and Bed Hold Information During Resident Transfers
Penalty
Summary
The facility failed to ensure that required information was provided to the receiving emergency department and that bed hold policies were communicated to residents prior to hospital transfers or discharges. In one instance, a resident with venous insufficiency and diabetes was transferred to the hospital for altered mental status, but there was no documentation that the emergency department was notified of the resident's pending arrival. Additionally, the clinical record did not show that the bed hold policy was provided to the resident before discharge. Staff interviews confirmed that the emergency department was not called and that there was no documentation of bed hold information being given at the time of transfer. Similar deficiencies were found for other residents with various diagnoses, including a left femur fracture, benign prostatic hyperplasia with stage 5 kidney disease, and atrial fibrillation with congestive heart failure. In each case, the clinical records lacked documentation that bed hold information was provided to the residents prior to their discharge to the hospital. The findings were confirmed through record review and staff interviews, indicating a pattern of noncompliance with requirements for transfer/discharge documentation and communication.
Failure to Document Neurological Checks After Unwitnessed Falls
Penalty
Summary
The facility failed to ensure that neurological checks were completed for residents who experienced unwitnessed falls, specifically affecting Resident H and Resident K. Resident H, who has diagnoses including cognitive communication deficit, tremors, and paraplegia, was found on the floor on his right side. Although the progress note indicated that neurological checks were within normal limits and the resident denied any pain or injury, the clinical record lacked documentation of a completed neurological assessment for the fall. Similarly, Resident K, diagnosed with muscle weakness, dementia with behavioral disturbance, and cognitive communication deficit, was found lying on the floor with his left lateral side touching the floor. The progress note mentioned that the resident was assessed for injury and the fall protocol was initiated, but there was no documentation of a completed neurological assessment. An LPN confirmed that neurological checks should be implemented and fully completed following an unwitnessed fall. The Director of Nursing provided a document outlining the procedure for neurological assessments after such incidents, but the assessments were not documented in these cases.
Failure to Ensure Proper Respiratory Care and Equipment Storage
Penalty
Summary
The facility failed to ensure proper respiratory care for a resident diagnosed with chronic obstructive pulmonary disease (COPD), obstructive sleep apnea, and congestive heart failure. The resident's nebulizer was observed unbagged on top of the nebulizer machine, contrary to the facility's policy requiring respiratory equipment to be stored in a plastic bag when not in use. Additionally, the clinical record lacked documentation of respiratory assessments before and after nebulizer treatments from January 1 to January 25, 2025, despite the resident being scheduled to receive Ipratropium-Albuterol via inhalation four times daily. Interviews with nursing staff revealed that respiratory assessments, including monitoring lung sounds, type of cough, respirations, oxygen saturation, and heart rate, should be completed and documented on the medication administration record (MAR) to ensure the effectiveness of breathing treatments. However, these assessments were not conducted or recorded for the resident in question. The facility's policy on respiratory infection control and medication administration procedures emphasized the importance of obtaining and recording vital signs prior to medication administration, which was not adhered to in this case.
Significant Medication Error Due to Policy Non-Compliance
Penalty
Summary
The facility failed to prevent a significant medication error for one of the residents reviewed. Resident C, who had a medical history including left-sided hemiparesis/hemiplegia following a cerebral infarction and convulsions, was prescribed Keppra, an anti-convulsant, to be administered at 3:00 a.m. and 3:00 p.m. daily. However, on February 3, 2025, the resident inadvertently received an additional dose of Keppra at 8:00 p.m., which was not documented in the medication administration record (MAR) as an ordered dose. The error occurred when an agency nurse, LPN 5, administered the extra dose without verifying the MAR, as required by the facility's medication administration policy. This oversight led to the resident being sent to the hospital for further evaluation due to altered mental status and an abnormal CT scan of the head. The Director of Nursing confirmed that the nurse did not adhere to the facility's policy of checking the MAR before administering medications, which contributed to the medication error.
Failure to Notify Physician of Resident's Low Blood Pressure and Shortness of Breath
Penalty
Summary
The facility failed to notify the physician of a resident's low blood pressure and continuous complaints of shortness of breath. The resident, identified as Resident K, had a clinical record review on December 27, 2024, which revealed diagnoses including diabetes, acute respiratory failure with hypoxia, congestive heart failure, and hypertension. The resident's September 2024 Medication Administration Record indicated that staff were to observe the resident for shortness of breath across all shifts. The record showed that the resident experienced shortness of breath on September 3, 2024, during the night shift and on September 4, 2024, during all three shifts. On September 4, 2024, a progress note indicated that the resident reported feeling weak and was assessed with a blood pressure of 80/50 while lying and 93/37 while sitting, which is significantly lower than the standard blood pressure of 120/80. Despite these symptoms, there was no documentation of physician notification regarding the resident's low blood pressure and shortness of breath. An interview with RN 4 confirmed that the physician should have been notified immediately under these circumstances. The Director of Nursing provided a document outlining the protocol for reporting changes in condition, which includes notifying the physician of low blood pressure and dyspnea.
Failure to Accurately Assess and Document Vital Signs
Penalty
Summary
The facility failed to ensure that licensed staff accurately assessed and documented a resident's vital signs for skilled charting. Resident K, who had diagnoses including atrial fibrillation, hypertension, congestive heart failure, and acute respiratory failure with hypoxia, did not have vital signs recorded daily as required. The clinical record review revealed that the same set of vital signs, obtained on 8/29/24, was repeatedly documented in the daily skilled notes for several days, indicating a lack of current assessments. Interviews with staff, including RN 4 and the Director of Nursing, confirmed that the nursing staff should obtain current vital signs prior to completing skilled charting and should not use another nurse's previous recordings. The Director of Nursing specified that vital signs should be obtained each shift for the first 72 hours upon admission and then daily thereafter. The clinical record lacked documentation of vital signs for 8/30/24, 8/31/24, and 9/1/24, highlighting a deficiency in the facility's adherence to proper assessment protocols.
Failure to Document Urine Output for Residents with Catheters
Penalty
Summary
The facility failed to ensure proper documentation of urine output for residents with indwelling catheters, affecting three out of four residents reviewed. Resident B, diagnosed with obstructive and reflux uropathy, had a care plan requiring urine output monitoring. However, the medication administration records for October, November, and December 2024 showed missing documentation on several dates and shifts. RN 4 confirmed that urine output should be documented every shift, but this was not consistently done. Resident F, with stage 4 kidney disease and uropathy, also had a care plan to document urine output as ordered. The December 2024 treatment administration record lacked documentation for a night shift. Similarly, Resident G, diagnosed with obstructive and reflux neuropathy, had missing documentation for urine output on two night shifts in December 2024. The Director of Nursing acknowledged the absence of a policy regarding physician's orders, contributing to the documentation lapses. This deficiency was related to a specific complaint, IN00447226.
Failure to Follow Fluid Restriction Order
Penalty
Summary
The facility failed to adhere to a physician's fluid restriction order for a resident diagnosed with congestive heart failure. The physician's note, dated September 1, 2024, indicated that the resident had gained 5 pounds in 24 hours and required a fluid intake restriction of 1,500 cc per day. However, the resident's fluid intake records for the following days showed consumption of 2,900 cc on September 2, 1,580 cc on September 3, and 2,560 cc on September 4, exceeding the prescribed limit. The clinical record did not document the implementation of the fluid restriction order on September 1, 2024. During an interview, the Director of Nursing suggested that the physician might not have communicated the order to the nursing staff. The facility's procedure document titled 'Encouraging and Restricting Fluids' was provided, which outlines the purpose and guidelines for fluid intake management.
Deficiencies in Respiratory Care Maintenance and Documentation
Penalty
Summary
The facility failed to ensure proper maintenance and documentation of respiratory care for three residents. Resident B, diagnosed with asthma and chronic obstructive pulmonary disease, had a nebulizer face mask that was not stored in a bag and was undated. The clinical record for Resident B also lacked documentation of daily and weekly maintenance of the respiratory equipment, despite a physician's order for nebulizer treatment. During an interview, a registered nurse confirmed that nebulizer equipment should be rinsed, air-dried, and stored in a bag, with tubing dated and changed weekly. Resident H, with chronic obstructive pulmonary disease and chronic respiratory failure, also lacked documentation of daily and weekly maintenance of respiratory equipment, despite having a physician's order for inhalation suspension. Additionally, Resident K, who had congestive heart failure and acute respiratory failure with hypoxia, was on oxygen without a documented physician's order for its administration. The Director of Nursing acknowledged that an order should have been in place for the oxygen. The facility's respiratory infection control guidelines, provided by the Director of Nursing, outlined the necessary procedures for maintaining respiratory therapy equipment, which were not followed in these cases.
Failure to Administer Increased Lasix Dosage
Penalty
Summary
The facility failed to implement a physician's order to increase a resident's Lasix dosage, resulting in a significant medication error. Resident K, who had diagnoses including congestive heart failure and edema, was initially prescribed Lasix 20 mg daily. On September 1, 2024, due to increased pitting edema and a five-pound weight gain, the physician ordered an increase to Lasix 20 mg twice daily for three days. The medication administration record showed compliance with this order until the morning of September 3, 2024. However, on September 3, 2024, a nurse practitioner noted the resident's shortness of breath and further weight gain, leading to a new order for Lasix 40 mg twice daily for two days. The medication administration record lacked documentation of the increased dosage on the evening of September 3 and any administration on September 4. The Director of Nursing confirmed the medication should have been administered as ordered, but it was not. The facility did not have a specific policy on medication administration, relying instead on state guidance.
Failure to Document Narcotic Administration
Penalty
Summary
The facility failed to ensure proper documentation on the Controlled Drug Receipt/Record/Disposition Form for administered narcotics for 12 residents. During observations of medication carts in various halls, discrepancies were noted between the recorded counts of narcotics and the actual number of tablets present. For instance, Resident 32's tramadol count was off by one tablet, and the last dose was not signed out correctly. Similar issues were observed with other residents, such as Resident 76, whose oxycodone/APAP and diazepam counts did not match the records, and Resident 96, whose hydrocodone/APAP count was also incorrect. The record reviews revealed that the discrepancies were due to the failure of the nursing staff to sign out narcotics at the time of administration. Interviews with LPNs and QMAs confirmed that they did not consistently document the administration of narcotics as required. For example, LPN 6 admitted to not signing out narcotics when pulling them, and LPN 4 acknowledged not marking the narcotics upon administration. This lack of documentation led to inconsistencies in the narcotic counts, as evidenced by the discrepancies found during the survey. The facility's Controlled Substances policy, revised in April 2019, mandates that controlled substances be reconciled upon receipt, administration, disposition, and at the end of each shift. However, the survey findings indicate that this policy was not consistently followed, leading to the observed deficiencies. The Director of Nursing confirmed that the narcotics should be signed out on the sheet once administered to keep track of the remaining number, but this procedure was not adhered to by the staff.
Failure to Dispose of Expired and Discontinued Medications
Penalty
Summary
The facility failed to ensure that discontinued and expired medications were promptly disposed of, as observed during four out of seven medication storage inspections. On the 300 Hall medication cart, two unused boxes of naloxone hydrochloride with an expiration date of September 2023 were found without a resident's name. On the 400 Hall medication cart, discontinued lubricating eye drops for a resident and a Lantus flexpen without an open date were found. The LPN indicated that the nurse probably forgot to mark the open date on the pen. Further observations on the 800 Hall medication cart revealed multiple issues, including expired tiotropium bromide, unlabeled vials of Spiriva and Albuterol, and a Lispro flexpen that was expired 28 days after opening. In the 900 Hall medication room, expired medications such as formoterol inhalant and micafungin were found. Interviews with staff indicated that expired or discontinued medications were usually returned to the pharmacy or given to the ADON or DON for destruction. The DON confirmed that medication carts and refrigerators were checked two to three times weekly for expired or discontinued medications.
Kitchen Sanitation Deficiency
Penalty
Summary
The facility failed to maintain cleanliness and sanitation in the kitchen, as observed during multiple inspections. During an initial tour with the Dietary Manager and the Regional District Manager, several issues were identified, including gray dust on ceiling air vents, expired food items in the walk-in refrigerator, and a significant buildup of yellow grease and food particles on kitchen equipment such as fryers, steamers, ovens, and stove burners. Additionally, the toaster had a heavy buildup of crumbs, and the wall behind the fryer was stained with yellow and white streaks. These conditions were observed again during a follow-up inspection, indicating a lack of corrective action. The facility's cleaning schedule and policies were reviewed, revealing that certain cleaning tasks were marked as completed despite evidence to the contrary. The Regional Dietary Manager acknowledged the difficulty in cleaning the stove burners and mentioned that staff would consume leftover hot dogs after residents' meals. The facility's policies, revised in 2017, emphasized the importance of maintaining clean and sanitary food service equipment and areas, yet the observed conditions demonstrated a failure to adhere to these standards.
Inadequate Bed Accommodation for Resident
Penalty
Summary
The facility failed to provide a bed and mattress that could accommodate the height of a resident, identified as Resident 60, leading to discomfort and potential harm. Observations on multiple occasions revealed that the resident's feet were touching the footboard of the bed, and he was unable to move comfortably. The resident, who was cognitively intact, expressed that the bed was too small and had informed the staff, but no action was taken to address his concern. The resident's medical history included conditions such as abnormal posture, muscle weakness, and paraplegia, which likely exacerbated the discomfort caused by the inadequate bed size. A nurse's note from the previous year indicated that the resident had developed a discolored area on his foot due to pressure against the footboard, which was addressed temporarily by placing a foam wedge under his knees. However, the issue of the bed size was not resolved. The Maintenance Director was unaware of the problem and suggested that the bed could potentially be switched out for a larger one, indicating a lack of communication and follow-up on the resident's needs.
Failure to Maintain Clean and Sanitary Toilets for Residents
Penalty
Summary
The facility failed to maintain a clean and sanitary environment for two residents, identified as Residents E and H, as required by resident rights. Resident E, who has diagnoses including hypertension, anxiety, and depression, was observed in her room where she reported that her toilet had not been cleaned in over a week. Observations on multiple days confirmed the presence of a dark black substance at the bottom of the toilet bowl and a brown splattered substance on the side. Similarly, Resident H, with diagnoses including right-sided hemiplegia and diabetes, reported that their toilet had not been cleaned for over a week. Observations of Resident H's toilet on consecutive days revealed similar unsanitary conditions. Interviews with the housekeeping staff, including the assistant housekeeping supervisor and the housekeeping supervisor, revealed that resident bathrooms were supposed to be cleaned daily. However, the assistant housekeeping supervisor acknowledged that the matter in the toilet bowl appeared to have been there for some time. The facility's Executive Director provided a document outlining the 7-Step Daily Washroom Cleaning procedure, which mandates daily cleaning and sanitization of the commode, including the tank, seat, bowl, and base. Despite this protocol, the facility failed to ensure the cleanliness of the residents' toilets, resulting in a deficiency in maintaining a safe and sanitary environment.
Misappropriation of Resident's Narcotic Medication
Penalty
Summary
The facility failed to prevent the misappropriation of a resident's property, specifically narcotic medication, for one of the residents reviewed. Resident C, who had diagnoses including Alzheimer's disease, dementia with agitation, anxiety, and depression, was prescribed Norco for pain management. On a particular day, the narcotic count was found to be missing five tablets during a shift change. The discrepancy was discovered when the oncoming night shift nurse, LPN 11, counted the narcotics with the day shift nurse, LPN 10, and found the count to be incorrect. LPN 10 admitted to leaving the medication cart keys on top of the cart while she went to the bathroom for approximately ten minutes. During this time, the narcotics went missing. Despite the missing medication, there was no evidence to prove that LPN 10 took the narcotics. The incident was reported to the unit manager and the DON, who followed up on the situation. The facility was unable to determine who was responsible for the missing medication.
Failure to Follow Medication Hold Parameters
Penalty
Summary
The facility failed to adhere to medication administration hold parameters for a resident with a heart condition. Resident C, who had diagnoses including palpitations, orthostatic hypotension, and syncope, was prescribed Digoxin with specific instructions to hold the medication if the heart rate was below 60 and to notify the physician. On two occasions, the resident's heart rate was below the threshold: 47 on one day and 55 on another, yet the medication was administered both times. Additionally, there was no documentation indicating that the physician was notified about the resident's low heart rate. An LPN confirmed that the medication should have been held and the physician notified when the heart rate was out of range. The facility's policy on administering medications, dated April 2019, mandates that medications be administered safely and as prescribed, in accordance with prescriber orders.
Deficiencies in Medication Administration Documentation
Penalty
Summary
The facility failed to ensure accurate documentation of medication administration records and controlled substance records for several residents. For Resident C, the Medication Administration Record (MAR) indicated that Norco, a pain medication, was administered on specific dates, but the controlled substance record lacked corresponding documentation. This discrepancy was confirmed during an interview with an LPN, who acknowledged that the medication should have been signed off on both records. Resident F's records showed similar issues with missing documentation for the administration of Lorazepam, Clonazepam, and Morphine Sulfate Oral Solution. The MARs for June, July, and August 2024 lacked documentation of medication administration on multiple dates and times, despite physician orders indicating regular administration schedules. The controlled substance record also lacked documentation for certain dates, indicating a failure to accurately record medication administration. For Resident H, the MAR indicated that Tramadol was administered on a specific date, but the controlled substance record did not reflect this. Additionally, Resident D's records lacked documentation of sliding scale insulin administration or refusal upon admission, as well as notification to the orthopedic wound physician before discontinuing a treatment order. These deficiencies were identified through interviews with the DON and an LPN, highlighting a lack of proper documentation and communication regarding medication and treatment orders.
Failure to Follow Medication Parameters for Hypertensive Resident
Penalty
Summary
The facility failed to ensure that the nursing staff adhered to medication parameters for a resident diagnosed with hypertension. The resident's care plan required medications to be administered as ordered by the physician, which included holding Lisinopril if the resident's systolic blood pressure (SBP) was less than 100 or if the heart rate was less than 60. Despite these parameters, the medication administration record (MAR) for April and May 2024 showed that Lisinopril was administered on multiple occasions when the resident's SBP and heart rate were below the specified thresholds. Specifically, the medication was given when the resident's heart rate was 59 and when the SBP was as low as 85. An interview with a registered nurse confirmed that medications should be held if parameters are not met, indicating a failure to follow the prescribed orders.
Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to ensure the physician was notified of a resident's loose stool, which was a change in condition for Resident B. Resident B, who had diagnoses including dementia and cognitive communication deficit, experienced multiple instances of loose stools over several days in November 2023. Despite these occurrences, there was no nursing documentation or physician notification regarding the resident's condition. The bowel record indicated loose stools on 11/19/23, 11/20/23, and 11/22/23, but no follow-up actions were documented. Interviews with the Director of Nursing and an LPN revealed that the facility's point of care system did not flag loose stools, and aides were expected to report such changes to the nurse. The Director of Nursing confirmed that the facility's policy required prompt notification of the attending physician for changes in a resident's medical condition. This deficiency was identified during a complaint investigation and related to Complaint IN00430915.
Failure to Ensure Resident's Room Free of Hazards and Provide Adequate Education
Penalty
Summary
The facility failed to ensure a resident's room was free of potential hazards and did not provide adequate education on the risks associated with these hazards. Resident D, who has diagnoses including diabetes, major depressive disorder, and paraplegia, was found lying on a phone charger cord that was plugged into an extension cord. This resulted in burns on his back. The resident had previously been educated about not keeping items behind him in bed, but there was no documentation of education specifically related to the risks of lying on a phone charger cord. Additionally, the resident's room contained a power strip that was not hospital grade and was used for a refrigerator and medical devices, which is against the facility's policy. The incident was discovered when Resident D turned on his call light for assistance, and a nurse found him lying on the melted phone charger cord. The resident sustained three small burn areas on his back. Interviews with the resident and staff revealed that the resident had not been adequately educated on the dangers of lying on electrical cords. The facility's policy on electrical safety was not followed, as evidenced by the presence of a non-hospital grade power strip in the resident's room. The Maintenance Director acknowledged that power strips should not be used for medical devices and that the power strip in Resident D's room had been missed during monthly checks.
Failure to Develop Care Plan for Resident's Refusal of Care
Penalty
Summary
The facility failed to ensure a plan of care was in place for a resident's refusal of care. Resident D, who had diagnoses including dementia and stage 3 pressure ulcers to the coccyx, left buttock, and right buttock, consistently refused to turn and reposition. Despite the resident's refusal being documented in progress notes and wound notes, there was no care plan addressing this refusal. Interviews with the wound nurse, CNAs, and an RN confirmed that the resident had been non-compliant with turning and repositioning for about 2-3 months, yet no care plan was developed to address this issue. The clinical record review revealed that the resident's refusal to turn and reposition was not documented in a care plan. The Director of Nursing provided a copy of the Comprehensive Care Plan, which indicated that any services not provided due to the resident's exercise of rights, including the right to refuse treatment, should be documented. However, this was not done for Resident D, leading to a deficiency in the facility's care planning process.
Failure to Complete Pressure Ulcer Treatments as Ordered
Penalty
Summary
The facility failed to ensure that treatments for pressure ulcers were completed as ordered by the physician for two residents. Resident D had stage 3 pressure ulcers on the coccyx, left buttock, and right buttock. The treatment administration record (TAR) for February 2024 showed that treatments were not documented as completed on multiple dates for the left and right buttocks and the coccyx. Additionally, a new treatment order for the coccyx on 2/11/24 was also not documented as completed on 2/18/24. An RN confirmed that treatments should be signed off on the TAR once completed. Resident E had a stage 3 pressure ulcer on the coccyx. The care plan indicated that treatments should be completed as ordered by the physician. The February 2024 TAR showed that treatments were not documented as completed on 2/8/24, 2/9/24, and 2/18/24. The facility's policy on pressure ulcers, dated 4/2018, stated that the physician would order pertinent wound treatments, but the documentation showed a lack of adherence to this policy.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
