Columbia Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Evansville, Indiana.
- Location
- 621 W Columbia St, Evansville, Indiana 47710
- CMS Provider Number
- 155224
- Inspections on file
- 38
- Latest survey
- November 13, 2025
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Columbia Healthcare Center during CMS and state inspections, most recent first.
A resident with a pressure ulcer and multiple comorbidities did not receive antibiotics and wound care as ordered by the physician, with missing documentation for several medication doses and treatments. Staff interviews revealed confusion about care plan requirements, and the resident was not consistently included on the assignment form for turning and repositioning, despite physician orders.
Several residents who required staff assistance for ADLs did not consistently receive scheduled showers or complete bed baths, with some going weeks without bathing and their preferences for timing and frequency not being honored. Observations included residents with unkempt hair and direct complaints about missed showers, while documentation and staff interviews confirmed lapses in both care delivery and record-keeping.
The facility was found to have significant cleanliness issues, including dust and dirt build-up in multiple halls, unclean linen closets, and improperly stored urinals in a shared bathroom. Shower rooms were not maintained, with discolored grout and broken tiles observed. A strong urine odor was present in various areas, and residents expressed concerns about inadequate housekeeping. The facility's housekeeping policy was not effectively implemented, leading to these unsanitary conditions.
The facility failed to ensure complete and accurate documentation for four residents' medication administration records. Insulin and nebulizer treatments were not properly documented, and the facility lacked a nebulizer treatment documentation policy. Staffing issues during the evening shift contributed to incomplete documentation.
A facility failed to follow its nebulizer treatment protocol for a resident, resulting in the resident being found unresponsive during the treatment. The RN left the resident unattended to contact a nurse practitioner, and required assessments were not documented. CPR was initiated, and the resident was transported to the hospital. The facility lacked a formal nebulizer treatment policy, although nurses received skills check-offs during orientation.
A resident with diabetes experienced dangerously high blood glucose levels, leading to diabetic ketoacidosis (DKA) and emergency hospitalization. The facility failed to document physician notifications and follow-up actions, despite critical readings and symptoms. Communication and documentation inconsistencies were noted, including the use of undocumented text messages.
The facility failed to ensure medications were properly dated, labeled, and not expired across multiple medication and treatment carts. Observations revealed insulin vials, nasal saline, sterile water, Betadine, and other medications were missing open dates, labels, or were expired. Non-medical items were found in medication carts, and interviews confirmed the need for proper labeling and dating.
A facility failed to notify a physician of a resident's critical blood glucose levels, which were outside the specified parameters. Despite a lab report indicating a critical level, there was no documented follow-up with the physician as required by the facility's policy. This deficiency highlights a lapse in communication and adherence to established protocols for managing changes in a resident's condition.
A facility failed to implement a care plan for a resident with frequent UTIs and multidrug-resistant organisms. The resident reported that improper cleaning by staff led to the infections. The DON acknowledged the absence of a care plan, which was required by the facility's policy to address the resident's needs, including ESBL colonization and recurrent UTIs.
A resident developed avoidable pressure ulcers due to the facility's failure to monitor skin under a knee immobilizer. Despite a care plan requiring weekly skin assessments, the facility did not conduct these assessments, resulting in two unstageable pressure wounds. The facility's policy to prevent pressure ulcers was not followed, as confirmed by the DON.
A resident with cancer diagnoses did not receive appropriate pain management before wound care. Despite requesting pain medication, the RN proceeded with the treatment, causing the resident to express pain. The facility's pain management policy was not adhered to, as the medication was not given time to take effect before continuing the procedure.
A facility failed to administer medications according to standards, resulting in a 7.69% error rate. An LPN did not prime insulin pens before administering Glargine and Lispro Insulin to a resident with diabetes and systemic lupus erythematosus. The LPN was unaware of the priming requirement, as indicated in the Humalog Kwik Pen instructions provided by the administrator.
A resident with diabetes mellitus experienced critically high blood glucose levels, but the LTC facility failed to document insulin administration and physician notifications as required. The DON admitted to lapses in documentation, and interviews revealed inconsistencies in communication and record-keeping practices, leading to incomplete records for the resident's insulin management.
The facility failed to follow infection control practices during care for three residents. A CNA did not sanitize hands or change gloves after handling soiled items for a resident with dementia. Another resident, who was cognitively intact and had frequent UTIs, received care from staff who did not sanitize hands between tasks. A resident with a stage 4 pressure ulcer did not receive proper enhanced barrier precautions during wound care, as the LPN did not wear a gown despite facility policy requiring it.
A resident with multiple health issues was discharged home without the arrangement of home health services and without completing necessary documentation. The resident left the facility with her husband before being evaluated by the hospice company, which later did not accept her. The facility did not follow its policy on discharge against medical advice and failed to notify outside agencies about the resident's safety concerns.
The facility failed to ensure dignity and timely care for three residents, leading to significant delays in assistance and disrespectful treatment. Residents reported waiting hours for care, being talked down to, and experiencing neglect despite their medical conditions requiring substantial assistance.
Failure to Follow Physician Orders for Pressure Ulcer Care and Antibiotic Administration
Penalty
Summary
A resident with diagnoses including type 2 diabetes mellitus and gout, and with a history of a right heel pressure ulcer and osteomyelitis, did not receive care and treatment as ordered by the physician. The resident's care plan required turning and repositioning every 2 hours and administration of antibiotics for a right heel infection. However, documentation was missing for several doses of prescribed antibiotics (Clindamycin and Cephalexin) and wound treatments on specific dates. The medication administration record (MAR) and treatment administration record (TAR) lacked evidence that these orders were carried out as scheduled. Additionally, the resident was not consistently included on the CNA assignment form for turning and repositioning, despite the care plan directive. Interviews with staff revealed inconsistencies in understanding and implementing the resident's care plan. A CNA stated the resident was not listed as needing to be turned and repositioned every 2 hours, while the DON confirmed that such interventions were required and should have been documented. The DON also indicated that staff should have attempted to wake the resident for treatments, and that MAR and TAR entries should not have been left blank. The facility did not have a specific policy related to following physician's orders, though the Assistant Administrator stated it was their practice to do so.
Failure to Provide Scheduled Showers and ADL Assistance
Penalty
Summary
The facility failed to ensure that residents who were dependent on staff for activities of daily living (ADLs), specifically bathing, received showers or complete bed baths as scheduled. Multiple residents reported or were observed to have gone extended periods without showers, despite care plans and preferences indicating the need for assistance with bathing at least twice per week, with partial baths in between. Documentation and interviews revealed that showers were missed on several scheduled days for seven out of eight residents reviewed, and in some cases, residents' preferences for shower timing and frequency were not honored. Residents affected included those with cognitive impairments such as Alzheimer's disease and dementia, as well as those with physical limitations like quadriplegia and major depressive disorder. Observations included residents with unbrushed, greasy, or oily hair, and direct complaints from residents about not receiving showers for up to two or three weeks. Clinical records and care plans consistently documented the need for staff assistance with bathing, and residents' preferences for shower frequency and timing were noted but not consistently followed. Review of the facility's documentation systems, including Point of Care (POC) charting and shower sheets, showed gaps where showers or bed baths were neither provided nor documented as refused. Staff interviews confirmed that information was sometimes not transferred correctly between documentation systems, and that reattempts or alternative shower times were not always offered when a resident initially refused care. The facility's policy on resident rights emphasized dignity, respect, and honoring resident schedules, but these standards were not met in practice for the residents reviewed.
Facility Fails to Maintain Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe and sanitary environment over the course of a two-day survey. Observations revealed a significant build-up of dust and dirt along the base of room doors and fire doors in multiple halls, including the 1200, 1400, 1500, 2100, 2200, and 2400 halls. Additionally, the fire doors leading to the second-floor dining room were also found to have dust and dirt accumulation. The facility's linen closets were not properly cleaned, with one closet on the 1100 hall containing a safety razor on the floor, and another on the 2500 hall having debris, trash, and gloves on the floor. The facility's policy indicated that floors should be swept and mopped daily, but this was not adhered to, as evidenced by the observations. The survey also identified issues with the cleanliness and maintenance of shower rooms. The 2500 hall shower room had discolored grout, a cracked tile, and a build-up of dust and dirt, while the 2100 hall shower room had broken window blind strings and a cracked tile. Furthermore, there were concerns about the improper storage of urinals in a shared bathroom, where two uncovered urinals were found on the floor near the commode. A resident expressed concerns about the lack of housekeeping on weekends and the poor quality of cleaning in their room and bathroom. Throughout the survey, a strong urine odor was detected in various areas of the facility, including the 1100 hall, the first and second floors, and the lobby by the front entrance. The facility's housekeeping policy outlined specific cleaning procedures, including sweeping and mopping under beds, corners, and edges, as well as wiping down walls and cove bases on designated days. However, these procedures were not effectively implemented, contributing to the unsanitary conditions observed during the survey.
Incomplete Documentation of Medication Administration
Penalty
Summary
The facility failed to ensure complete and accurate documentation for four out of eight resident records reviewed. For Resident C, the Medication Administration Record (MAR) lacked documentation indicating whether insulin doses were administered on specific dates. The Director of Nursing (DON) was unable to confirm if the insulin was given as ordered due to the absence of documentation. Resident U's electronic medication administration record (eMAR) also lacked documentation for blood sugar results and insulin administration on a particular date. Resident M's eMAR was missing documentation for insulin administration and blood sugar results on two consecutive days. Similarly, Resident O's eMAR lacked documentation for the administration of ipratropium bromide and pre and post-nebulizer assessments on multiple occasions. The facility did not have a nebulizer treatment documentation policy, although nurses received skills check-off during orientation. An anonymous interview revealed that the facility was often understaffed during the evening shift, leading to incomplete documentation. The facility's current Medication Administration policy, revised in July 2023, requires that medication administration be recorded on the MAR/eMAR or TAR after being given. This deficiency relates to a complaint identified as IN00449174, highlighting the facility's failure to maintain accurate and complete medical records in accordance with accepted professional standards.
Failure to Follow Nebulizer Treatment Protocol
Penalty
Summary
The facility failed to adhere to its nebulizer treatment policy for a resident who had recently been discharged from the hospital. The resident, identified as Resident D, was not assessed prior to receiving a nebulizer treatment, and facility staff did not remain at the bedside during the treatment. This lapse in protocol resulted in Resident D being found unresponsive, without respirations or a pulse, during the treatment. Cardiopulmonary resuscitation (CPR) was initiated, and emergency medical technicians (EMTs) were called, leading to the resident's transport to the hospital. The incident occurred when a Registered Nurse (RN) left the room to contact a nurse practitioner, leaving the resident unattended during the nebulizer treatment. The facility's documentation was incomplete, lacking records of the required pre-treatment assessments, including pulse, respirations, and breath sounds. The Director of Nursing (DON) confirmed that assessments should have been completed and documented by a nurse before, during, and after each treatment. Additionally, the facility did not have a formal nebulizer treatment policy, although nurses received skills check-offs during orientation. The deficiency was related to a complaint investigation.
Failure to Manage Elevated Blood Glucose Levels
Penalty
Summary
The facility failed to provide effective services for treating elevated blood glucose levels for a resident with diabetes mellitus, leading to a life-threatening condition known as diabetic ketoacidosis (DKA). The resident's blood glucose levels were significantly elevated on multiple occasions, with readings as high as 490 mg/dL and later exceeding 600 mg/dL. Despite these critical levels, there was a lack of documentation indicating that the physician was notified or that appropriate follow-up actions were taken by the facility staff. On several occasions, the facility's records lacked documentation of physician responses or follow-up actions between the initial high blood glucose reading and subsequent critical levels. The resident's condition deteriorated, showing symptoms such as increased heart rate, refusal to eat or drink, and excessive urination. Despite these signs, there was no documented evidence of timely communication with the physician or adjustments to the resident's insulin regimen. The facility's policies required such notifications and documentation, but these were not adhered to. The resident eventually became unresponsive, with a blood glucose level of 742 mg/dL, and was admitted to the hospital's intensive care unit for DKA treatment. Interviews with the Director of Nursing and the Nurse Practitioner revealed inconsistencies in communication and documentation practices, including the use of text messages that were not part of the clinical record. The facility's failure to document and act on critical blood glucose levels resulted in the resident's emergency hospitalization.
Medication Labeling and Expiration Deficiencies
Penalty
Summary
The facility failed to ensure that medications and biologicals were properly dated, labeled, and not expired across multiple medication and treatment carts. Observations revealed that insulin vials and pens, nasal saline, liquid protein, sterile water, Betadine, and various other medications were either missing open dates, labels, or were expired. For instance, insulin vials and pens in the 1500 Hall Medication Cart lacked open dates and labels, while a bottle of nasal saline was expired. Similarly, the 1400 Hall Medication Cart contained a bottle of sterile water past its expiration date, and the First Floor Treatment Cart had an opened bottle of Betadine without an open date. Further observations in the Memory Care Unit's medication cart revealed non-medical items such as jewelry, alongside medications like Clonidine and MiraLAX that were not properly labeled. The ,d+[DATE] Hall Medication Cart contained an opened bottle of Nitroglycerin without a date, and the 2500 Medication Cart had multiple opened bottles of MiraLAX with no open dates. The Second Floor Treatment Cart was found with various medications, including Nystatin powder and antifungal cream, lacking labels or open dates, and some items were expired. Interviews with nursing staff confirmed that medications should be labeled and dated, and the Director of Nursing indicated that stock medications require labeling once opened.
Failure to Notify Physician of Critical Blood Glucose Levels
Penalty
Summary
The facility failed to notify the physician of blood glucose levels outside of the specified parameters for a resident with diabetes mellitus. The resident's clinical record indicated that the resident was not assessed for cognitive impairment and received insulin regularly. Physician orders required notification if blood glucose levels were below 60 mg/dL or above 400 mg/dL. On a specific date, the resident's blood glucose level was recorded as greater than 600 mg/dL, but the physician was not notified as required by the facility's policy. Further documentation revealed that a critical blood glucose level of 526 mg/dL was reported by the lab, but there was a lack of follow-up with the physician between the time the lab called and the following morning. The facility's policy required that changes in a resident's condition be communicated to the physician and family, with appropriate and timely intervention. However, the clinical record lacked documentation of such communication and follow-up, indicating a deficiency in adhering to the facility's policies.
Failure to Implement Care Plan for Resident with Recurrent UTIs
Penalty
Summary
The facility failed to implement a care plan for a resident, identified as Resident 85, who experienced frequent urinary tract infections (UTIs) with multidrug-resistant organisms. On October 25, 2024, Resident 85 reported that the frequent UTIs were due to improper cleaning by the staff. A review of the clinical record on October 28, 2024, revealed that Resident 85 had several diagnoses, including a urinary tract infection, and required substantial assistance with personal hygiene. The resident was also noted to be incontinent of bowel and bladder, had a primary diagnosis of COPD, and had been on antibiotics and isolation precautions due to an intravenous catheter and colonization with ESBL. The Director of Nursing (DON) acknowledged on November 1, 2024, that there should have been an ongoing care plan addressing the recurrent UTIs and ESBL colonization in Resident 85's urine. The facility's policy, as provided by the Administrator, mandates that each resident should have a comprehensive, person-centered care plan developed and implemented based on the Resident Assessment Instrument process. This care plan should include measurable goals and resident-specific interventions to promote the resident's highest level of functioning. However, the facility did not adhere to this policy for Resident 85, resulting in a deficiency.
Failure to Monitor Skin Under Immobilizer Leads to Pressure Ulcers
Penalty
Summary
The facility failed to prevent the development of an avoidable pressure ulcer in a resident, identified as Resident 89, by not adequately monitoring the skin condition under a knee immobilizer. Resident 89, who was cognitively intact and fully dependent on staff for transfers, returned from a hospital stay with a knee immobilizer due to a fracture. Despite having a care plan that required weekly skin assessments, the facility did not conduct these assessments during several weeks when the immobilizer was in place. This lack of monitoring led to the development of two unstageable pressure wounds on the resident's right lateral calf, which were attributed to the knee immobilizer. The clinical record review revealed that there were no documented skin assessments during critical periods when the immobilizer was used, specifically from mid-June to late July. The facility's policy on skin management aimed to prevent pressure ulcers by evaluating residents' clinical conditions and implementing necessary interventions. However, the facility did not adhere to this policy, as evidenced by the absence of skin assessments and the subsequent development of pressure injuries. The Director of Nursing confirmed the lack of skin assessments during the missing weeks, highlighting a failure in the facility's monitoring and evaluation processes.
Failure to Administer Pain Management Before Wound Care
Penalty
Summary
The facility failed to provide appropriate pain management for Resident 104, who was observed during wound care. Resident 104, diagnosed with malignant neoplasm of lymph nodes and squamous cell carcinoma, was cognitively intact and dependent on staff for transfers and personal care. The resident's care plan included offering non-pharmacological interventions and administering medications as ordered. However, during an observation, RN 12 began wound care without administering pain medication, despite Resident 104's request for it. The resident expressed pain and requested medication multiple times during the procedure. RN 12 continued the wound care without repositioning the resident or postponing the treatment to allow the pain medication to take effect. Another nurse, RN 10, was called to provide the medication, which was administered during the procedure, but not given time to work before continuing the wound care. The facility's policy on pain management, which emphasizes individualized care and alternative pain relief techniques, was not followed. Resident 104 reported not receiving routine pain medications and that staff did not allow time for pain medication to take effect before wound treatments.
Medication Administration Errors Due to Lack of Priming Insulin Pens
Penalty
Summary
The facility failed to ensure medications were administered according to manufacturer and professional standards for one of five residents observed during a medication pass. Specifically, two medication errors were observed during 26 opportunities for error, resulting in a 7.69% error rate. The errors involved a resident with diagnoses including diabetes mellitus and systemic lupus erythematosus. During a medication administration, an LPN prepared Glargine Insulin and Lispro Insulin but did not prime the two insulin injection pens with two units prior to administering. The LPN indicated she was unaware of the need to prime the insulin prior to administration. The facility's administrator provided a patient information insert for the Humalog Kwik Pen, which stated that priming ensures the pen is ready and removes air that may collect in the cartridge during normal use.
Incomplete Documentation of Insulin Administration
Penalty
Summary
The facility failed to ensure complete and accurate documentation for a resident with diabetes mellitus who was receiving insulin. The resident's clinical record indicated that they were not assessed for cognitive impairment and received insulin over a seven-day period. However, there was a lack of documentation regarding the physician's response or follow-up actions taken by the facility staff when the resident's blood glucose levels were critically high on multiple occasions. On several instances, the resident's blood glucose levels exceeded 500 mg/dL, yet there was no documentation of insulin administration or physician notification as required by the facility's policies. The Director of Nursing (DON) acknowledged that the nurse did not document the notification to the Nurse Practitioner (NP), the new order, or the insulin administration amount in the progress notes. Additionally, there was confusion regarding whether the 8 A.M. dose of insulin was administered on a specific date, as the Licensed Practical Nurse (LPN) could not recall the details. Interviews with the facility's staff, including the Administrator and NP, revealed inconsistencies in communication and documentation practices. The NP indicated that she was not contacted regarding the resident's elevated blood glucose levels on certain dates and was unable to find records of rechecked blood glucose levels. The facility's policies required documentation of medication administration and communication of orders, but these were not adhered to, leading to incomplete records for the resident's insulin management.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to ensure proper infection control practices during incontinence and wound care for three residents. In the case of Resident 64, a CNA did not sanitize hands or change gloves after touching soiled items and then proceeded to touch the resident's remote and bedside table. Resident 64 was not cognitively intact and required substantial assistance with personal hygiene. For Resident 85, who was cognitively intact and had a history of urinary tract infections, a QMA did not wash or sanitize hands after changing gloves during peri care, and a CNA did not change gloves or sanitize hands after handling a soiled bedpan. Resident 86, who had a stage 4 pressure ulcer and required enhanced barrier precautions, did not receive proper care as the LPN performing wound care did not wear a gown, despite the presence of a sign indicating the need for enhanced barrier precautions. The facility's infection preventionist confirmed that residents with wounds should automatically be placed on enhanced barrier precautions, which include wearing a gown and gloves during high-contact care activities. The facility's policy on enhanced barrier precautions was not followed, contributing to the deficiency.
Failure to Implement Proper Discharge Process
Penalty
Summary
The facility failed to ensure the proper implementation of the discharge process for a resident who was unable to care for herself. Resident B, who had multiple diagnoses including COPD, major depressive disorder, anxiety, chronic pain, history of falls, weakness, and unsteadiness on feet, was discharged home without the arrangement of home health services and without completing the necessary documentation according to the facility's discharge policy. The resident's hospital notes prior to admission to the facility indicated significant concerns about her safety and stability, both socially and mentally, and recommended an in-depth Adult Protective Services (APS) investigation into her well-being. The resident's care plan required assistance with activities of daily living and noted a risk for falls. Despite this, the resident was discharged home with an order for hospice services without confirmation of acceptance from the hospice company. The discharge summary for Resident B was completed but lacked a signature from the resident or a representative, rendering it invalid. The facility's social service staff indicated that the resident was alert and oriented but chose to leave the facility without a transition of care being completed. The record lacked documentation of the exact time or date the resident left the facility and did not include any education provided about leaving against medical advice (AMA). Interviews with facility staff revealed that the resident left the facility with her husband before being evaluated by the hospice company, which later did not accept her. The facility did not contact APS regarding the resident's return home, despite the significant concerns noted in her hospital records. The facility's policy on discharge against medical advice was not followed, as there was no documentation of the options offered, risks explained, or information given to the resident. Additionally, no AMA observation was completed in the resident's record, and the facility failed to notify outside agencies about the resident's safety and well-being concerns.
Failure to Ensure Dignity and Timely Care for Residents
Penalty
Summary
The facility failed to ensure dignity for three residents, leading to significant delays in care and disrespectful treatment. Resident B reported waiting two hours for care after turning on their call light, only for staff to turn off the light and leave without providing assistance. Resident B's medical history includes hemiplegia and muscle weakness, necessitating extensive assistance with toileting. The care plan indicated the need for assistance due to these conditions, but the facility did not adhere to it. Resident D also experienced neglect, having waited over two hours to be changed despite multiple requests. The resident's medical history includes hemiplegia and contractures, requiring substantial assistance with toileting. Despite a grievance being filed, the issue persisted, and Resident D reported being talked down to and labeled as the worst patient for frequently using the call light. This indicates a pattern of disrespect and neglect from the staff. Resident C faced similar issues, including delays in receiving medications, water, and assistance with toileting. The resident's medical history includes heart failure and COPD, requiring moderate assistance with daily activities. Despite filing multiple grievances, the resident continued to experience long wait times for care. An anonymous interview also revealed that a nurse had derogatorily referred to residents as druggies when administering pain medication. These incidents collectively highlight a failure to provide timely and respectful care to the residents.
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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