Clinton House Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Frankfort, Indiana.
- Location
- 809 W Freeman St, Frankfort, Indiana 46041
- CMS Provider Number
- 155295
- Inspections on file
- 38
- Latest survey
- September 9, 2025
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Clinton House Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
The facility did not schedule an RN for at least 8 consecutive hours on two days, despite having residents who required IV medications and higher acuity care. The DON confirmed the absence of RN coverage on those days, and no staffing policy was provided during the survey.
The facility did not ensure that daily nurse staffing data was posted at the beginning of each shift, resulting in outdated information being displayed. The process for posting staffing data relied on manual updates by the scheduler and manager on duty, which led to lapses when sheets were not pulled forward as required. No policy on nurse staffing data posting was provided during the survey.
The facility failed to complete baseline care plans within 48 hours for two residents. One resident, with multiple health issues including respiratory failure, lacked a baseline care plan for oxygen use. Another resident, readmitted after a hospital discharge, did not have a new baseline care plan documented. This was against the facility's policy requiring baseline care plans to be initiated within 48 hours of admission.
The facility failed to administer medication and notify the physician for two residents. One resident with congestive heart failure experienced significant weight gains without receiving prescribed diuretics or physician notification. Another resident with diabetes received insulin despite blood glucose levels being below the hold threshold. Facility policies on medication administration and physician notification were not followed.
The facility failed to properly store and sanitize respiratory equipment for three residents. A resident's nebulizer mask was not stored in a bag, another resident's CPAP/BiPap mask was found on the floor and not sanitized, and a third resident was using oxygen without a physician's order. The facility's policy required masks and tubing to be stored in a plastic bag when not in use.
The facility failed to complete assessments and obtain informed consent before using side rails for two residents. Despite assessments indicating no need for side rails, they were observed in use without documented consent or explanation of risks and benefits. This oversight contravened the facility's policy requiring such measures before bed rail installation.
The facility failed to ensure PRN psychotropic medications had stop dates for two residents. One resident had alprazolam orders without a stop date, and another had clonazepam orders lacking an end date. The DON and Clinical Support nurse acknowledged the oversight, which violated the facility's policy requiring PRN psychotropics to have a stop date within 14 days unless justified by the prescribing practitioner.
The facility failed to serve food at safe temperatures, as observed during a survey. A resident reported late delivery of room trays, resulting in cold food. Observations showed room trays delivered past the lunch period, with temperatures outside safe ranges. Multiple residents expressed concerns about cold food in rooms, discussed in resident council meetings. The facility's policy on food temperatures was not adhered to.
A resident suspected of having Clostridium Difficile (C-Diff) was not placed in contact isolation immediately after testing, contrary to physician orders and facility policy. Instead, the resident was on enhanced barrier precautions, which do not require PPE every time someone enters the room. The Director of Nursing confirmed that contact isolation should have been implemented while awaiting test results.
Failure to Provide RN Coverage for Required Hours
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was scheduled for at least 8 consecutive hours per day, 7 days a week, as required. Review of staffing schedules revealed that no RN was present in the facility on two specific Sundays. The facility assessment indicated that there were residents who required IV medications on average, and staff with specialized training, such as RNs, were to be assigned to areas with higher acuity needs. During an interview, the Director of Nursing confirmed that there was no RN present on the identified dates. The facility did not provide a staffing policy prior to the survey exit.
Failure to Post Current Nurse Staffing Data at Shift Start
Penalty
Summary
The facility failed to ensure that daily nurse staffing data was posted at the beginning of each shift on one of six survey observation dates. On the specified date, the posted nurse staffing data sheet was found to be outdated, displaying information from two days prior. According to the DON, the scheduler was responsible for creating and posting the daily staffing forms each morning, while on weekends, the manager on duty was supposed to post the pre-prepared sheets. However, the process relied on manually pulling forward the correct sheet each day, and if this was not done, the posted information would not reflect current staffing, especially in cases of call-ins or shift changes. The facility was unable to provide a policy on nurse staffing data posting prior to the survey exit.
Failure to Complete Baseline Care Plans Within 48 Hours
Penalty
Summary
The facility failed to ensure that baseline care plans were completed within 48 hours of admission for two residents. Resident B, who was observed wearing oxygen at 3 liters, did not have a baseline care plan for the use of oxygen despite being admitted with diagnoses including acute and chronic respiratory failure, type 2 diabetes, stage 3 chronic kidney disease, obstructive sleep apnea, and retention of urine. The Chief Nursing Officer confirmed the absence of a respiratory baseline care plan for Resident B, which was against the facility's policy requiring the initiation of a baseline care plan within 48 hours of admission. Similarly, Resident 34, who had diagnoses including pneumonia, acute on chronic systolic congestive heart failure, major depressive disorder, chronic kidney disease stage 3, and anxiety disorder, did not have a new baseline care plan upon readmission to the facility. The resident was initially admitted and had a baseline care plan meeting recorded, but after being discharged to the hospital and readmitted, no new baseline care plan meeting was documented. The Social Services Director confirmed that baseline care plan meetings were recorded in the clinical record, yet this was not done for Resident 34 upon readmission.
Failure to Administer Medication and Notify Physician
Penalty
Summary
The facility failed to administer an as-needed medication for weight gain and did not notify the physician of significant weight changes for two residents. Resident 34, who had diagnoses including pneumonia, acute respiratory failure, congestive heart failure, and chronic kidney disease, was supposed to be weighed daily with physician notification required for specific weight gains. Despite documented weight increases exceeding the thresholds, the facility did not administer the prescribed furosemide or notify the physician. The resident reported issues with breathing and leg swelling, which were not addressed as per the physician's orders. For Resident 68, who had multiple diagnoses including diabetes and vascular dementia, the facility failed to hold insulin doses as ordered when blood glucose levels were below 200. The MAR indicated that insulin was administered on numerous occasions despite blood glucose readings being below the threshold. This was confirmed by an LPN and the DON, who acknowledged that insulin was given against the hold order multiple times. The facility's policies on physician notification and medication administration were not followed, contributing to these deficiencies. The policies required physician notification based on assessment findings and adherence to medication orders, which were not observed in these cases. The lack of adherence to these protocols resulted in the failure to provide appropriate care as per the residents' medical needs and physician directives.
Improper Storage and Lack of Orders for Respiratory Equipment
Penalty
Summary
The facility failed to ensure proper storage and sanitation of respiratory equipment for three residents. Resident 58's nebulizer mask was found lying on top of the nebulizer machine instead of being stored in a bag. The resident had a history of traumatic brain injury and acute respiratory failure with hypoxia, and had a physician's order for albuterol sulfate via nebulizer. Both a CNA and the Director of Nursing acknowledged that the mask was not stored appropriately. Resident 27's CPAP/BiPap mask was observed on the floor and was not sanitized before being placed back on the machine. The resident, who had unspecified asthma and chronic respiratory failure with hypoxia, did not have an order or care plan for the CPAP/BiPap machine, despite using it every night. Additionally, Resident B was observed wearing oxygen at 3 liters without a physician's order. The Director of Nursing was unaware of the lack of an order for oxygen and indicated there was no policy for physician's orders. The facility's policy required that nebulizer, BiPap, CPAP masks, and oxygen tubing be stored in a plastic bag when not in use.
Failure to Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to ensure that proper assessments and informed consent were obtained before the use of side rails for two residents, identified as Resident O and Resident 63. For Resident O, observations on multiple dates revealed that a side rail was in use despite a previous assessment indicating that the resident did not require it for bed mobility. The clinical record lacked documentation of any discussion of risks and benefits with the resident or obtaining consent. Additionally, a physical therapy note indicated the use of the bedside rail during therapy, suggesting its use without proper authorization. Similarly, for Resident 63, observations confirmed the presence of a side rail without documented consent or explanation of risks and benefits. The side rail assessment form for this resident was incomplete, with no indication that the resident or their representative had been informed or agreed to the use of the side rail. The facility's policy required an assessment and informed consent before the installation of bed rails, which was not adhered to in these cases.
Failure to Ensure PRN Psychotropic Medications Have Stop Dates
Penalty
Summary
The facility failed to ensure compliance with regulations regarding PRN psychotropic medications for two residents. Resident K had a series of physician's orders for alprazolam, an anti-anxiety medication, with the most recent order lacking a stop date. The Director of Nursing (DON) acknowledged the oversight and confirmed the absence of documented clinical reasoning from the physician for the extended duration of the PRN orders. Resident K's medical history included conditions such as hemiplegia, fibromyalgia, type 2 diabetes, major depressive disorder, insomnia, anxiety disorder, PTSD, and unspecified psychosis. Similarly, Resident 183 had a physician's order for clonazepam, another anti-anxiety medication, without an end date. The DON and the Clinical Support nurse both recognized the absence of a stop date, which is contrary to the facility's policy that requires PRN psychotropics to have a stop date within 14 days unless a clinical rationale is provided by the prescribing practitioner. Resident 183's diagnoses included severe bipolar disorder with psychotic features, type 2 diabetes, and irritable bowel syndrome.
Failure to Serve Food at Safe Temperatures
Penalty
Summary
The facility failed to ensure that food was served at proper temperatures, as observed during a survey. Resident E reported that room trays were often delivered late, resulting in cold food. Observations on the specified date showed that room trays were delivered after the posted mealtime, with the last tray being delivered at 1:20 p.m., well past the lunch period ending at 1:00 p.m. A temperature check on the last room tray revealed that the cheeseburger was at 106 degrees Fahrenheit, the potato salad at 51 degrees Fahrenheit, and the watermelon at 65 degrees Fahrenheit, all of which were outside the recommended safe temperature ranges. The Dietary Manager confirmed that the hot foods should be served at 120 degrees Fahrenheit and cold foods at 45 degrees Fahrenheit, and indicated that food would be reheated if it did not meet these temperatures. Multiple residents, including Residents C, F, and G, expressed concerns about the food being cold when delivered to their rooms, with Resident F noting that food temperatures were not a concern when dining in the main dining room. These complaints had been discussed in monthly resident council meetings, as confirmed by the Interim Executive Director. The facility's policy on Food and Nutrition Services, as well as a document on safe food handling, outlined the requirements for maintaining appropriate food temperatures, which were not adhered to in this instance. This deficiency was related to a specific complaint, IN00441593.
Failure to Implement Immediate Contact Isolation for Suspected C-Diff Case
Penalty
Summary
The facility failed to place a resident in contact isolation immediately after being tested for Clostridium Difficile (C-Diff), a highly contagious bacteria, while awaiting test results. Resident B, who was under review for antibiotic use, was observed on enhanced barrier precautions instead of the required contact isolation. The resident's clinical record indicated multiple diagnoses, including acute and chronic respiratory failure, type 2 diabetes, stage 3 chronic kidney disease, obstructive sleep apnea, and retention of urine. A nursing progress note documented an episode of foul-smelling, mucus-like bowel movement, prompting the physician to order a stool sample and initiate antibiotic treatment with Flagyl. Despite a physician's order to place the resident in contact isolation every shift until C-Diff was ruled out, Resident B was not isolated for over 24 hours after testing. Enhanced barrier precautions, which do not require personal protective equipment (PPE) every time someone enters the room, were incorrectly used instead of contact isolation, which mandates PPE usage. The Director of Nursing confirmed that residents suspected of having C-Diff should be placed in contact isolation while awaiting laboratory results, as per the facility's current 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.
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