Cloverleaf Of Knightsville
Inspection history, citations, penalties and survey trends for this long-term care facility in Knightsville, Indiana.
- Location
- 9325 N Crawford St, Knightsville, Indiana 47857
- CMS Provider Number
- 155542
- Inspections on file
- 27
- Latest survey
- February 13, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Cloverleaf Of Knightsville during CMS and state inspections, most recent first.
The facility failed to address two residents with dignity during meal service. A CNA called a resident "Honey" despite her care plan indicating a preference for her first name. Another resident was assisted while the CNA stood, contrary to policy, and was addressed as "Honey" and "Sweet girl" without care plan indication. Both residents had severe cognitive impairments.
A facility failed to monitor a resident's weight as ordered, despite the resident having chronic kidney disease stage 3 and prediabetes. The resident's weight was not documented on specified dates, and there was no record of refusal. The initial weight was not recorded in the electronic health record at admission, and subsequent weights were inconsistently documented. The DON confirmed the lack of documentation, and the facility's policy on weight assessment was not followed.
A resident's indwelling urinary catheter, drainage bag, and tubing were not maintained properly, as they were observed in contact with the floor on multiple occasions. The resident, who had severe medical conditions and cognitive deficits, was receiving hospice services. The facility's policy required that catheter tubing and drainage bags be kept off the floor, but this was not followed.
A resident with end-stage renal disease reported that staff did not check her dialysis access site after treatments, leading to an incident where the site bled and soaked through the bandage. Observations confirmed the lack of monitoring, and the care plan did not include specific instructions for access site observation. Despite physician orders to check for bruit and thrill and assess vitals post-dialysis, these were not consistently followed, as confirmed by staff interviews.
A facility failed to properly monitor and document a resident's behaviors, despite physician's orders and care plans indicating the need for such monitoring due to multiple diagnoses, including anxiety and depression. The lack of documentation in the Treatment Administration Records (TAR) and progress notes over several months was attributed to issues with the documentation system and inadequate nurse education. The behavior committee's recommendations against medication dose reductions were based on verbal reports rather than documented evidence.
A facility failed to maintain a medication error rate below 5%, with errors observed in the administration of medications to three residents. RNs crushed medications that should not be crushed and failed to prime an insulin pen, violating facility guidelines. Additionally, privacy was not provided during insulin administration.
The facility failed to label insulin pens with the date they were opened for three residents, as observed during a survey. Staff interviews confirmed the requirement to date insulin pens upon opening, but this was not adhered to, resulting in a deficiency. The residents involved had Type 2 diabetes, and the facility's policy requires dating multidose containers, which was not followed.
A resident with end-stage renal disease and diabetes repeatedly requested not to be served vegetables, but the facility failed to document and honor this preference. Despite staff interviews indicating awareness of the resident's dislike for vegetables, the dietary tray slip did not reflect this, leading to continued service of unwanted food.
The facility failed to properly store and dispose of food, as observed during a kitchen inspection. Expired corn and wilted lettuce were found in the refrigerator, and cucumbers were not labeled with a date. A staff member confirmed that food should be labeled and discarded after three days if opened, but these items were not handled accordingly. Facility policies require food to be labeled, dated, and discarded if over 72 hours old or without identification.
A resident with a history of recurrent UTIs and VRE was on long-term antibiotic therapy without proper physician assessment or documentation of education to the responsible party. The facility did not conduct additional urinalysis or cultures after admission, and the antibiotic stewardship policy requiring treatment duration was not followed.
Failure to Address Residents with Dignity During Meal Service
Penalty
Summary
The facility failed to ensure residents were addressed in a dignified manner during meal service, as observed in two separate dining incidents involving two residents. During a lunch meal observation, a CNA addressed Resident 56 as "Honey" from across the table, despite the resident's care plan indicating a preference to be called by her first name. Resident 56, who has severe cognitive impairment and a history of dementia and cerebral infarction, was independent with eating according to her MDS assessment. The care plan did not include a preference for being called "Honey." In another incident, the same CNA assisted Resident 31 with her meal while standing, which is against the facility's policy that requires staff to sit while assisting residents. The CNA also addressed Resident 31 as "Honey" and "Sweet girl," without any indication in the care plan that the resident preferred these terms. Resident 31, who has severe cognitive impairment and requires maximum assistance with eating, was diagnosed with unspecified dementia and complex partial seizures. The Director of Nursing confirmed that staff should not stand while assisting residents and should address them by their preferred names.
Failure to Monitor Resident's Weight as Ordered
Penalty
Summary
The facility failed to monitor a resident's weight as ordered, which was identified during an interview and record review. Resident 59, who has chronic kidney disease stage 3, prediabetes, and a history of repeated falls, was supposed to have his weight monitored daily for three days and then weekly for four weeks as per a physician's order. However, the records showed that the resident's weight was not documented on the specified dates, and there was no record of the resident refusing to have his weight taken. The initial weight was not recorded in the electronic health record at the time of admission, and subsequent weights were inconsistently documented. The Director of Nursing confirmed the lack of documentation for the daily weights as per the physician's order. A paper report sheet indicated a weight of 198.7 pounds for the resident, which was not entered into the electronic health record until a later date. The facility's policy on weight assessment and intervention requires that weights be measured on admission and recorded in the medical record, with any resident refusals documented. This policy was not adhered to, leading to the deficiency in monitoring the resident's weight as ordered.
Failure to Maintain Catheter Hygiene
Penalty
Summary
The facility failed to maintain a resident's indwelling urinary catheter, drainage bag, and tubing in a manner that prevented contact with the floor. During multiple observations, the resident's catheter bag was seen in contact with the floor while the resident was in bed, which was in a low position. Additionally, the catheter's tubing was observed resting on the electrical cord of the resident's oxygen concentrator, which was also in contact with the floor. These observations occurred on different occasions, indicating a consistent issue with the catheter's maintenance. The resident involved had significant medical conditions, including stage 3 chronic kidney disease, a stage 4 pressure ulcer in the sacral region, and muscle wasting and atrophy. The resident also had a severe cognitive deficit and was receiving hospice services. The care plan for the resident included the use of a Foley catheter due to wounds, but it lacked documentation on monitoring the catheter bag or tubing to prevent floor contact. The facility's policy on catheter care, which was provided by the Administrator, clearly stated that catheter tubing and drainage bags should be kept off the floor, yet this was not adhered to in practice.
Failure to Monitor Dialysis Access Site
Penalty
Summary
The facility failed to properly assess a resident's condition for complications before and after hemodialysis treatments. Resident 49, who has end-stage renal disease and requires dialysis, reported that staff did not check her vascular access site after returning from dialysis sessions. On one occasion, the access site bled and soaked through the bandage, which the resident had to change herself using supplies in her room. Observations confirmed that the dressing on the resident's access site was not checked for bleeding after her return from dialysis. The medical record review revealed that the care plan for Resident 49 lacked specific instructions for monitoring the access site for bleeding, swelling, or abnormalities. Although there was a physician order to check the access site for bruit and thrill daily, and to assess vital signs after dialysis, these were not consistently followed. Interviews with staff, including an LPN and the DON, indicated a lack of adherence to the required checks and documentation. The facility's policy on dialysis care, which mandates monitoring the shunt site and notifying a physician of any issues, was not adequately implemented.
Failure in Behavior Monitoring and Documentation
Penalty
Summary
The facility failed to ensure proper behavior monitoring for a resident who was reviewed for unnecessary medications. The resident had multiple diagnoses, including alcoholic cirrhosis of the liver, visual hallucinations, anxiety disorder, and major depressive disorder. Despite having physician's orders to monitor behaviors such as depression, tearfulness, insomnia, and visual hallucinations every shift, the facility's records lacked documentation of any behavioral symptoms for several months. The resident's care plans indicated a risk for ineffective coping and emotional and physical distress, with interventions including medication administration and collaboration with medical and psychiatric service providers. However, pharmacy recommendations to evaluate and potentially reduce medication doses were not acted upon due to the behavior committee's assessment that the resident remained symptomatic. The physician agreed with the committee's recommendation not to reduce medication doses, but the lack of documented behavioral symptoms in the Treatment Administration Records (TAR) and progress notes suggests inadequate monitoring. Interviews with the Director of Nursing (DON) and the Social Services Director (SSD) revealed issues with the documentation process. The DON indicated that nurses needed more education on completing the TAR for resident behaviors. The SSD noted that a change in the documentation system prevented Certified Nursing Assistants (CNAs) from directly documenting behaviors, leading to a reliance on nurses who were lax in documentation. The facility's policy on behavioral assessment and monitoring was not effectively implemented, contributing to the deficiency.
Medication Administration Errors and Privacy Breach
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5 percent, resulting in an error rate of 21.43 percent for three residents. Registered Nurse (RN) 15 was observed preparing and administering medications incorrectly to two residents. For Resident 169, RN 15 crushed and administered enteric-coated ferrous sulfate and slow-release Klor-Con in applesauce, contrary to physician orders and facility guidelines that specified these medications should not be crushed. Similarly, for Resident 14, RN 15 crushed and administered enteric-coated ferrous sulfate and extended-release Myrbetriq, again violating the facility's 'do not crush' guidelines. Additionally, RN 17 was observed administering insulin to Resident 26 without priming the insulin pen, as required by the manufacturer's guidelines and the facility's standard operating procedure. The RN also failed to provide privacy during the administration by leaving the door open and not pulling the curtain. The RN admitted to not knowing the requirement to prime the insulin pen and acknowledged the oversight in providing privacy. These actions contributed to the facility's high medication error rate.
Improper Labeling of Insulin Pens
Penalty
Summary
The facility failed to ensure proper labeling of insulin pens for three residents, as observed during a survey. On the morning of December 17, 2024, three medication carts were inspected, revealing that insulin pens for three residents were not labeled with the date they were opened. Specifically, Tresiba insulin for one resident, Lantus insulin for another, and Basaglar insulin for a third resident were all missing the required opening date. Interviews with nursing staff confirmed that insulin pens should be dated when opened, and if no date is present, the pen should be discarded. The medical records of the affected residents were reviewed, revealing that each resident had a diagnosis of Type 2 diabetes, among other health conditions. The facility's policy, provided by the Director of Nursing, mandates that the expiration date be checked and the opening date be placed on multidose containers. However, this procedure was not followed, leading to the deficiency noted in the survey.
Failure to Honor Resident's Food Preferences
Penalty
Summary
The facility failed to honor the food preferences of a resident, identified as Resident 49, who had repeatedly requested not to be served vegetables. Despite these requests, vegetables continued to be included on her plate. An observation of the dietary tray slip for Resident 49 revealed that her dislike for vegetables was not documented. Interviews with facility staff indicated that the resident's preferences were supposed to be recorded and communicated to the dietary department, but this was not done effectively in this case. Resident 49 was admitted with diagnoses including end-stage renal disease, dependence on renal dialysis, and type 2 diabetes mellitus with diabetic chronic kidney disease. Her physician had ordered a controlled carbohydrate diet with specific restrictions. The resident was cognitively intact, as indicated by a quarterly Minimum Data Set assessment. The facility's policy required individual food preferences to be assessed upon admission and updated as needed, but this was not adhered to, resulting in the resident's preferences not being honored.
Improper Food Storage and Disposal Practices
Penalty
Summary
The facility failed to ensure proper food storage and disposal practices, as observed during a kitchen inspection. During the inspection, a walk-in refrigerator was found to contain a clear plastic container with corn that was dated beyond the acceptable timeframe for consumption. Additionally, a plastic bag of lettuce was found to be brown and wilted, with a delivery date from October, indicating it was expired. Three cucumbers were also found in an open and undated plastic bag, making it impossible to determine their freshness or safety for consumption. An interview with a staff member revealed that food should be labeled and disposed of after three days if opened and placed in a new container. The staff member acknowledged that the corn and lettuce should have been discarded and was unsure why they had not been. The cucumbers were also deemed necessary for disposal due to the lack of proper labeling. The facility's policy documents, provided by the Administrator, confirmed that food should be labeled and dated, and discarded if over 72 hours old or if there is no identification or date on the item.
Failure to Follow Antibiotic Stewardship Protocol
Penalty
Summary
The facility failed to adhere to its antibiotic stewardship protocol for a resident who was on long-term antibiotic therapy. The resident, who had a history of Parkinson's disease, COPD, urinary retention, and recurrent urinary tract infections, was admitted with an order for prophylactic Ampicillin 500 mg via G-tube. The medical record lacked evidence of a physician's assessment to justify the long-term use of antibiotics and did not document any education provided to the resident's responsible party regarding the implications of prolonged antibiotic use. Interviews with the Director of Nurses (DON) and the Medical Director revealed that the resident was on antibiotics due to a history of chronic urinary tract infections and a diagnosis of VRE. Despite the resident's admission with an antibiotic regimen from a previous facility, no additional urinalysis or cultures were conducted after admission to the current facility. The Medical Director acknowledged the potential resistance to penicillin and indicated plans to discontinue the antibiotic in favor of non-antibiotic measures. The facility's policy on antibiotic stewardship, which requires specific elements such as the duration of treatment, was not followed in this case.
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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