Cumberland Trace Health & Living Community
Inspection history, citations, penalties and survey trends for this long-term care facility in Plainfield, Indiana.
- Location
- 1925 Reeves Road, Plainfield, Indiana 46168
- CMS Provider Number
- 155836
- Inspections on file
- 35
- Latest survey
- May 23, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Cumberland Trace Health & Living Community during CMS and state inspections, most recent first.
The facility failed to prevent accidents and implement appropriate interventions for residents at risk for falls, resulting in injuries such as fractures and head lacerations. Additionally, several residents were found with medications at their bedside without proper orders or self-administration assessments, despite cognitive impairment and facility policy requiring staff supervision during medication administration.
A resident with a recent hip replacement and multiple fractures was admitted for rehabilitation and required assistance for all ADLs. The facility failed to follow wound management policies, did not document or clarify wound care orders, and left the surgical incision uncovered while the resident was placed in adult briefs and not consistently toileted. When signs of infection developed, there was insufficient documentation of wound assessment, physician notification, or appropriate wound care interventions. The resident's wound became infected, leading to hospital readmission and surgical intervention.
Surveyors found that several medications, including inhalers and sprays, were not properly labeled with resident names or dates of opening on multiple medication carts and in a medication storage room. A vial of tuberculosis testing serum was also missing an open date. Facility policy requires dating and timely disposal of such medications, but this was not consistently done.
A resident with significant medical conditions, including heart failure and Alzheimer's disease, did not have an advance directive (code status) order in their record, despite documentation in their profile and care plan indicating a desire for CPR. The DON confirmed the omission, which was not consistent with facility policy requiring care plans to reflect residents' documented treatment preferences.
The facility did not ensure accurate MDS assessments for two residents: one with dementia had falls inaccurately documented in the MDS compared to clinical notes, and another with muscle weakness and UTIs was recorded as frequently incontinent in the MDS despite documentation and staff interviews indicating she was usually continent. The facility lacked a specific policy for MDS assessments and followed the RAI manual.
Two residents did not have complete or current care plans addressing their specific needs: one lacked a care plan for CPR preferences despite a physician's order and personal wishes, and another did not have an active care plan for a history of UTIs despite multiple documented episodes and a hospital diagnosis. The absence of these care plans was confirmed through record review and staff interviews.
A resident's PICC line was dressed with a split gauze under a transparent tegaderm, covering the insertion site and preventing visual assessment, contrary to facility policy requiring the site to remain visible.
A resident experienced significant psychosocial harm due to the facility's failure to address ongoing concerns about her roommate's disruptive behavior. Despite being aware of the issue, the staff did not provide effective interventions, leading to the resident's decline in mental and physical health.
A resident was left without a call device for several hours after a bed bath, despite her care plan indicating the need for it to be within reach due to physical limitations and risk of falls. Staff interviews confirmed the oversight, and the facility lacked a specific policy on call device accessibility.
A facility failed to ensure timely assessment and treatment of a resident's new open areas on the skin. Despite the resident having multiple diagnoses, including a stage 4 pressure ulcer, there was a lack of documentation and timely intervention for a new stage 2 pressure ulcer. The facility's Skin Assessment Policy was not followed, leading to a gap in care and documentation.
The facility failed to follow physician orders for oxygen administration and storage of oxygen equipment for two residents. One resident was found with a nasal cannula connected to an oxygen tank set at 0, causing shortness of breath, while another resident had undated oxygen tubing and a humidifier bottle. Staff interviews confirmed that CNAs were not authorized to adjust oxygen flow, and facility policies required dating and labeling of oxygen equipment, which were not followed.
Failure to Prevent Accidents and Ensure Medication Safety
Penalty
Summary
The facility failed to prevent accidents and implement appropriate interventions for residents at risk for falls and injury. One resident with a history of falls and a care plan requiring bilateral side rails was moved to a new room without the side rails or alternative interventions in place. This resident subsequently rolled out of bed, sustained a head laceration and a humeral head fracture, and required orthopedic evaluation. Documentation showed that the need for side rails or other interventions was not reassessed or implemented after the room change, despite the resident's known fall risk and previous similar incidents. Two additional residents with repeated falls and injuries did not have new interventions implemented or documented after their respective falls. One resident fell in the hallway while seeking assistance and sustained a right hip fracture, but the care plan was not updated with new interventions addressing the root cause. Another resident was found on the floor in his bathroom and later diagnosed with a right femoral neck fracture, yet the record lacked documentation of interdisciplinary team follow-up or new interventions to prevent future falls. The facility's fall prevention policy requires root cause analysis and new intervention strategies after each fall, but this was not followed for these residents. The facility also failed to prevent potential accidents related to medication safety. Multiple residents were found with medications at their bedside without orders or assessments for self-administration. One resident had topical medication on the nightstand, another had an inhaler and an over-the-counter medication without an order, and two residents with cognitive impairment had pills accessible in their rooms. Records lacked up-to-date self-administration assessments for these residents, and facility policy requires that staff remain with residents to ensure medications are taken as prescribed. These lapses created the potential for medication errors and harm.
Failure to Provide Appropriate Wound Care and Monitoring Resulting in Infection
Penalty
Summary
A resident with a recent total right hip replacement and additional non-operable fractures was admitted to the facility for rehabilitation. Upon admission, the resident was dependent for bed mobility and required assistance for all activities of daily living. The hospital discharge documentation indicated the surgical incision was healing well, and the resident had previously used a PureWick device and bedside commode to keep the incision clean and dry. However, at the facility, the resident was placed in adult briefs, the surgical incision was left uncovered, and staff did not consistently assist the resident to the toilet, resulting in prolonged periods in soiled briefs. The resident expressed concerns about wound infection risk and requested toileting assistance, but her preferences were not accommodated due to her transfer needs. The facility's records lacked initial and ongoing assessments and descriptions of the surgical incision site, as well as documentation of treatment orders or physician clarification for wound care. Although care plans referenced the surgical incision and the need to provide treatment per physician order, there were no specific interventions or precautions documented to protect the wound from contamination. When drainage and signs of infection developed at the incision site, there was insufficient documentation of physician notification, wound assessment, or implementation of appropriate wound care, such as covering the draining wound. Progress notes indicated ongoing drainage, foul odor, and infection, but lacked detailed wound descriptions and timely communication with the physician. Despite the resident's increasing symptoms and the development of a wound infection, the facility did not document the initiation of appropriate wound care interventions or consistent monitoring. The resident's condition worsened, leading to a hospital readmission where the wound was found to be infected with multiple bacteria, requiring surgical intervention. Facility policies required prompt assessment, documentation, and physician notification for changes in condition, as well as enhanced barrier precautions for wounds, but these were not followed, resulting in actual harm to the resident.
Failure to Properly Label and Date Medications
Penalty
Summary
Surveyors observed that drugs and biologicals in the facility were not consistently labeled and dated according to professional standards. On multiple medication carts and in a medication storage room, several medications, including albuterol inhalers, fluticasone sprays, and a vial of Aplisol, were found either without resident names, without dates indicating when they were opened, or both. Specifically, some inhalers were labeled only with a resident's name and lacked an open date, while others had neither a name nor a date. The Aplisol vial in the medication room was missing an open date despite being received from the pharmacy months prior. The facility's policy requires that multi-dose vials and certain medications be dated when opened and discarded within 28 days, but this was not followed in the observed instances.
Failure to Implement Advance Directive Order
Penalty
Summary
The facility failed to implement an advance directive (code status) order for a resident with multiple diagnoses, including heart failure, weakness, type 2 diabetes mellitus, and Alzheimer's disease. Upon review, the resident's record did not contain an order for an advance directive, despite documentation in the resident's profile and care plan indicating a desire to receive cardiopulmonary resuscitation (CPR). This omission was confirmed during an interview with the Director of Nursing, who acknowledged that the order had been missed. Facility policy requires that each resident's plan of care be consistent with their documented treatment preferences and/or advance directive.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure accurate Minimum Data Set (MDS) assessments for two residents. For one resident with Alzheimer's disease and dementia, documentation showed two separate incidents where the resident was found sitting on the floor, one of which involved complaints of right foot pain. Progress notes and interdisciplinary team documentation indicated no injuries were observed at the time of the falls, and subsequent notes confirmed no new wounds or injuries. However, the most recent MDS assessment inaccurately recorded the number and type of falls, indicating no falls without injury and one fall with injury, which did not align with the clinical documentation. For another resident with muscle weakness, tremors, and a history of urinary tract infections, there were inconsistencies between the resident's self-report, staff interviews, and progress notes regarding her continence status. While the resident and staff described her as usually continent with occasional incontinence, the most recent MDS assessment documented her as frequently incontinent of both bladder and bowel. The facility did not have a specific policy for MDS assessments and reported following the Resident Assessment Instrument (RAI) manual.
Failure to Implement and Maintain Resident Care Plans for Advanced Directives and UTI History
Penalty
Summary
The facility failed to develop and implement complete care plans for two residents, resulting in deficiencies related to care plan implementation. One resident with diagnoses including sleep apnea, heart failure, hypertension, and high cholesterol had a physician's order and personal preference for cardiopulmonary resuscitation (CPR), but there was no care plan in place reflecting this advanced directive. The Director of Nursing confirmed the absence of the care plan during an interview. Another resident with a history of type 2 diabetes and pneumonia experienced multiple episodes of pain, burning with urination, and abdominal discomfort, which were documented in progress notes. Despite a positive urine dip test and subsequent hospital diagnosis of cystitis and pyelonephritis, the resident's record did not contain a current care plan addressing UTIs or a history of UTIs. A discontinued care plan was provided, but there was no documentation of an active care plan at the time of the events.
Improper PICC Line Dressing Prevents Site Assessment
Penalty
Summary
The facility failed to ensure proper dressing of a Peripherally Inserted Central Catheter (PICC) line for one resident. On observation, the resident's PICC line was covered with a clear tegaderm dressing and a 2 by 2 split gauze placed directly over the catheter and insertion site, which prevented assessment of the skin around the insertion site. The dressing was dated and initialed, but the facility's own procedure guide specifies that the insertion site should not be covered by anything other than the transparent dressing, and the site must remain visible for assessment. The improper application of the split gauze under the transparent dressing directly contradicted facility policy and prevented visual inspection of the insertion site.
Failure to Address Resident's Concerns About Roommate
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 83, was treated with respect and dignity, leading to significant psychosocial harm. Resident 83 had ongoing concerns about her roommate, Resident 30, who frequently yelled out for help, especially during the night. This behavior disrupted Resident 83's sleep, causing her to become more irritable, tearful, and isolated. Despite the staff being aware of the issue, no effective interventions were provided to address Resident 83's concerns, leading to a decline in her mental and physical health, including increased medication and weight loss. Resident 83's medical records indicated that she had a history of mild cognitive impairment, major depressive disorder, and a new diagnosis of insomnia. Before the arrival of her new roommate, Resident 83 was described as a happy and social individual. However, after Resident 30 moved in, her condition deteriorated. She began to sleep through meals, skip activities, and experience disorienting dreams. The facility's staff, including the Director of Nursing and Unit Manager, acknowledged that Resident 30's behavior was problematic and had been ongoing since at least March 2024. The facility's policies and procedures for room transfers were not adequately followed. Resident 83 was not notified about the new roommate, and there was no documentation of a meet-and-greet or psychosocial follow-up. The Social Services Director admitted that she could not remember if she had informed Resident 83 about the new roommate. The facility's failure to address Resident 83's concerns and provide appropriate interventions led to her significant decline in well-being, highlighting a deficiency in respecting and ensuring the dignity and self-determination of residents.
Failure to Ensure Call Device Within Reach
Penalty
Summary
The facility failed to ensure that a call device was within reach for a resident, leading to the resident being unable to call for assistance for several hours. On the day of the incident, the resident was observed calling out for help from her wheelchair, with the call light out of reach on her bed. The resident reported that she had been without her call light since her bed bath earlier that morning, and staff had not provided it to her when they brought her lunch. The resident's care plan indicated that she required assistance with toileting and that the call light should be kept within reach due to her physical limitations and risk of falls. Interviews with staff revealed that the call light was likely left in the bed after the bed bath, and subsequent staff who delivered lunch did not ensure it was within reach. The resident's medical history included muscle weakness, unsteadiness on feet, pressure ulcers, and other conditions that necessitated the availability of a call light for her safety and well-being. The facility did not have a specific policy related to call devices being within reach, but it was considered a standard of care. The deficiency was confirmed by the Regional Clinical Specialist and the Administrator during their interviews.
Failure to Ensure Timely Assessment and Treatment of Pressure Ulcer
Penalty
Summary
The facility failed to ensure timely assessment and treatment of a resident's new open areas on the skin. Resident 93, who had multiple diagnoses including a stage 4 pressure ulcer, local infection of the skin, and dementia, was observed with a note from family indicating the need for specific care measures. Despite this, there was a lack of documentation and timely intervention for a new stage 2 pressure ulcer that developed on the resident's right buttock and coccyx. The initial discovery of the new open area was noted on 11/15/23, but there was no documentation of progress notes, physician notification, or wound care between 11/15/23 and 11/20/23. It was only on 11/20/23 that the wound team classified the wound as unstageable and provided measurements and care instructions. The comprehensive care plan was initiated on the same day, indicating the need for specific interventions to manage the stage 4 pressure ulcer on the sacrum. The facility's Skin Assessment Policy, provided by the Administrator, outlined the required actions for new skin conditions, including notifying the physician, obtaining treatment orders, applying initial treatment, notifying the family, and documenting these actions in the medical record. However, these steps were not followed in the case of Resident 93, leading to a gap in care and documentation for the new pressure ulcer. The Regional Clinical Specialist confirmed that no additional documentation related to the wound was found for the period between 11/15/23 and 11/20/23, highlighting a failure to adhere to the facility's policy and ensure timely and appropriate care for the resident's pressure ulcer.
Failure to Follow Physician Orders for Oxygen Administration
Penalty
Summary
The facility failed to follow physician orders for oxygen administration and storage of oxygen equipment for two residents. In the first case, a resident was observed with a nasal cannula connected to an oxygen tank that was not providing oxygen, as the liter flow dial was set at 0. The resident had been experiencing shortness of breath and had turned on the call light for assistance. A CNA had placed the nasal cannula on the resident but was not authorized to adjust the oxygen flow. Licensed Practical Nurses (LPNs) later adjusted the oxygen flow but did not assess the resident's oxygen level or overall condition at the time of observation. The resident's medical history included acute and chronic respiratory failure, COPD, and other conditions requiring careful oxygen management. Physician orders specified oxygen titration to maintain oxygen saturation above 90% and regular changes of oxygen equipment, which were not followed in this instance. In the second case, another resident was observed with undated oxygen tubing and a humidifier bottle on multiple occasions. The resident's oxygen was administered via nasal cannula at varying flow rates, but the equipment was not dated as required by facility policy. Interviews with staff confirmed that oxygen equipment should be dated each time it is changed, but this was not done. The resident's medical history included chronic congestive heart failure, COPD, and other conditions necessitating continuous oxygen therapy. Physician orders included specific instructions for changing and dating oxygen equipment weekly and as needed, which were not adhered to. The facility's policies on medication administration and oxygen administration were reviewed and indicated that medications, including oxygen, must be administered as prescribed and in a timely manner. The policies also required dating and labeling of oxygen equipment. The failure to follow these policies and physician orders resulted in deficiencies in the care provided to the residents, as observed and documented by the surveyors.
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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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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