Cypress Grove Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Newburgh, Indiana.
- Location
- 4255 Medwell Dr, Newburgh, Indiana 47630
- CMS Provider Number
- 155273
- Inspections on file
- 30
- Latest survey
- April 9, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Cypress Grove Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found that the facility did not consistently provide hot foods at a palatable temperature, particularly for residents receiving in-room meal service. Multiple residents reported that cooked foods were lukewarm, sometimes cold, or not always cooked thoroughly when delivered to their rooms, and several residents at a Resident Council meeting echoed that food was not always warm during in-room dining. This occurred despite the facility’s policy and the Dietary Manager’s statement that all hot and cold food items must be served at an adequate, palatable temperature and that resident food preferences would be accommodated.
A resident with breast cancer, prescribed daily exemestane 25 mg, was found with a medication cup at the bedside containing a small white pill she could not identify. Review of the medication cart confirmed the pill was exemestane. Although the resident was documented as cognitively intact and independent for eating, the DON acknowledged there was no completed self-administration of medications assessment for this resident, despite facility policy requiring a nurse-conducted Self-Administration of Medication Assessment and approval before any resident self-administers medications.
The facility failed to ensure accurate completion of MDS assessments for two residents, leading to incorrect coding of antidepressant use and falls. For one resident with Alzheimer’s disease and major depressive disorder, the quarterly MDS indicated antidepressant use during the lookback period despite no active physician order or eMAR documentation of antidepressant administration. For another resident with dementia, the quarterly MDS coded one fall with no injury since the prior assessment, although the clinical record contained no fall documentation and the Administrator confirmed no fall occurred. The Regional Clinical Nurse reported that the MDS Coordinator had reviewed the wrong dates when coding these sections.
A resident with paraplegia and moderate cognitive impairment, dependent on staff for transfers and using a manual wheelchair, was observed alone in a courtyard sitting in direct sunlight without a drink, contrary to his care plan interventions. The resident reported being routinely left outside unattended, without a way to call staff, and not being offered sunscreen when outside. The care plan called for encouraging fluids, supplying and assisting with sunscreen, and offering assistance in and out of doors, but an RN acknowledged there was no monitoring system or set check times while the resident was outside and that there was no physician order for sunscreen available to offer.
Surveyors found that two cognitively intact residents, one with hypertension and one with dementia, did not receive showers on multiple days listed on their individualized shower schedules, despite one resident having previously filed a grievance about not getting showers and preferring showers over bed baths. Review of electronic and paper shower records showed several missed scheduled shower days for each resident, and documentation also noted that one resident refused a shower when it was offered outside his preferred time. These findings showed that staff did not consistently provide bathing on scheduled days in accordance with residents’ assessed needs, preferences, and stated rights.
Surveyors found that staff failed to accurately document a resident’s ongoing purple discoloration on the buttocks despite physician orders and a care plan requiring weekly skin assessments and documentation of abnormal findings, and despite prior hospital documentation of the discoloration. In addition, staff did not accurately document administration of calcitonin-salmon nasal spray for another resident, recording doses as given to the wrong nostril on multiple occasions, even though the DON reported the medication was being administered as ordered. These practices were inconsistent with the facility’s documentation policy requiring accurate, organized entries for skin assessments and medication administration.
A resident with COPD, obesity, and obstructive sleep apnea received ongoing O2 therapy via nasal cannula, with multiple progress notes documenting use of 2–3 LPM and staff reporting continuous oxygen use and CNA management of oxygen tanks, but no practitioner orders for oxygen application or equipment maintenance were found in the clinical record for several months. The care plan referenced administering oxygen as ordered, yet the admission MDS did not code oxygen therapy, and the DON acknowledged believing there had been an admission order while also stating the facility lacked its own oxygen therapy policy and instead followed a supplier’s policy. The deficiency was cited under 3.1-47(a)(6).
The facility failed to ensure that residents who required assistance with ADLs received showers as per their care plans. Six residents with various medical conditions and cognitive impairments experienced irregular shower schedules and incomplete documentation. Despite efforts to improve, the facility lacked an effective policy for ADL care or showers.
The facility failed to maintain a resident's dignity when a resident was observed fully exposed in bed with the door open. The resident, dependent on staff for care, was not wearing pants or an incontinence brief, and the situation was not immediately addressed by the staff present.
The facility failed to send necessary documents with a resident transferred to the hospital. The resident, with diagnoses including epilepsy and COPD, was transferred without the required transfer paperwork and bed hold policy. Interviews with staff confirmed the absence of proof that the transfer packet was sent, violating the facility's Hospital Transfer policy.
The facility failed to follow physician orders for two residents with feeding tubes, resulting in improper administration of nutritional feedings and lack of required documentation. One resident had outdated nutritional formula and improper head elevation, while another had enteral nutrition turned off without proper documentation.
The facility failed to ensure routine medications for a resident with GERD were available and dispensed according to physician's orders. Despite reordering the medications, they were not administered from May 12 through May 16 due to unavailability, and there was no documentation or follow-up actions taken to obtain them from the Emergency Drug Kit (EDK).
The facility failed to maintain accurate medical records for two residents. One resident's record incorrectly indicated participation in psychotherapy during a hospitalization, and another resident's record lacked documentation of departures and returns for medical procedures, contrary to facility guidelines.
Failure to Provide Palatable-Temperature Meals to Residents, Especially During In-Room Dining
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to reasonably accommodate resident food preferences regarding temperature of cooked foods, particularly for residents receiving meals in their rooms. In individual interviews, one resident stated the cooked food was lukewarm, another reported that cooked food was sometimes cold when it arrived to their room, and additional residents indicated that cooked food was cold at times, sometimes cold, or cold and not always cooked thoroughly when they ate in their rooms. During a Resident Council meeting, three anonymous residents also reported that food was not always warm when they ate in their rooms. The Dietary Manager stated that food must be served at an adequate temperature and with palatable taste and that resident food preferences were accommodated, and the facility’s Food Temperatures policy indicated that all hot and cold food items would be served at a palatable temperature at the time the resident receives the food. These resident reports and policy statements formed the basis for the cited deficiency under 410 IAC 16.2-3.1-3(v)(1). No additional clinical history or medical conditions for the residents involved were documented in the report.
Medication Left at Bedside Without Required Self-Administration Assessment
Penalty
Summary
Surveyors observed that a resident had a medication cup on the bedside table containing a small white round pill imprinted "111," and the resident stated she was unsure what the pill was. Review of the medication cart at that time identified the pill as exemestane 25 mg, a steroidal drug that had been ordered once daily since 10/9/23 for this resident, who had diagnoses including malignant neoplasm of the upper-inner quadrant of the left female breast. The most recent Quarterly MDS assessment indicated the resident was cognitively intact and independent for eating. During interview, the DON confirmed that the resident did not have a completed self-administration of medications assessment, despite facility policy requiring the nurse to evaluate and approve each resident who self-administers medications by completing a Self-Administration of Medication Assessment form before allowing self-administration. This failure to complete the required assessment occurred in the context of a medication being left at the bedside for the resident without documented evaluation of her ability to safely self-administer, as required by the facility’s Self Administration of Medications policy and 410 IAC 16.2-3.1-11(a).
Inaccurate MDS Coding for Medication Use and Falls
Penalty
Summary
The facility failed to ensure accurate completion of Minimum Data Set (MDS) assessments for two residents, resulting in incorrect coding of antidepressant use and falls. For one resident with diagnoses including Alzheimer’s disease and major depressive disorder, the quarterly MDS dated 3/30/26 indicated the resident received an antidepressant during the 7‑day lookback period, but the clinical record contained no active physician order for an antidepressant and the electronic Medication Administration Record showed no administration of an antidepressant during that time. For another resident with dementia, the quarterly MDS dated 3/30/26 coded one fall with no injury since the prior assessment on 12/29/25, yet the clinical record contained no documentation of a fall during that interval, and the Administrator confirmed the resident did not fall in that period. During interviews, the Regional Clinical Nurse stated that both MDS assessments dated 3/30/26 for these residents were wrong because the MDS Coordinator looked at the wrong dates for the fall and antidepressant, while the Administrator stated that the facility followed Resident Assessment Instrument (RAI) guidelines to code MDS assessments.
Failure to Implement Care Plan for Resident Outside in Courtyard
Penalty
Summary
The deficiency involves the facility’s failure to implement an existing care plan for a resident who liked to go outside in an unsecured courtyard area. During an observation, the resident was seen alone in his wheelchair in direct sunlight without a drink. In an interview shortly afterward, the resident reported that staff always left him outside unattended, that he had no way to notify staff when he was ready to return indoors, that he had not been offered sunscreen, and that he was ready to go back inside. The resident’s diagnoses included paraplegia, and his most recent Quarterly MDS showed he was moderately cognitively impaired, dependent on staff for transfers, and used a manual wheelchair for mobility. The resident’s care plan, in place since 2018, documented that he liked to go outside in an unsecured area, was not considered an elopement risk, had a BIMS score of 13, and had been educated to notify staff when outside and to remain on the sidewalk. Care plan interventions included encouraging the resident to have a drink of choice when outside, supplying sunscreen and assisting with its application when appropriate, and offering assistance in and out of doors. An RN stated there was no monitoring system or set time intervals for checking on the resident while he was outside unattended, and that staff often only told him a time limit for being outside. The RN also noted the resident was not wearing sunscreen because he often refused it previously, and the physician’s orders did not include an order for sunscreen to be available to offer. The facility’s Comprehensive Care Plan policy required periodic review and revision of care plan problems, goals, and interventions following each OBRA MDS assessment.
Failure to Provide Scheduled Showers for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide scheduled bathing for residents who required staff assistance. For one resident with hypertension who was cognitively intact and required partial staff assistance for bathing, the clinical record showed a grievance had been filed stating she was not receiving her showers or having her hair washed. The grievance also noted that staff had been educated on her preference for a shower rather than a complete bed bath. Her shower schedule, updated on 4/1/26, listed Tuesday and Friday as her shower days, yet review of electronic and paper shower documentation showed she did not receive showers on several scheduled dates between 3/9/26 and 4/9/26, specifically on 3/10/26, 3/27/26, and 3/31/26. Another resident with dementia, who was cognitively intact per the admission MDS and required staff supervision during bathing, also did not receive showers on multiple scheduled days. His shower schedule, updated on 4/1/26, indicated Wednesday and Saturday as his shower days. Review of shower documentation from 3/11/26 to 4/9/26 showed missed showers on 3/14/26, 3/18/26, and 3/25/26. Documentation further indicated that this resident refused a shower on 4/8/26 because it was offered outside of his preferred shower time. The facility’s Residents Rights policy, revised 7/2023, stated that all staff members recognize the rights of residents at all times to enable personal dignity, well-being, and proper delivery of care, but the documented missed showers demonstrated that scheduled bathing was not consistently provided as planned.
Failure to Accurately Document Skin Assessments and Medication Administration
Penalty
Summary
The facility failed to ensure accurate and timely documentation of skin assessments for one resident. During an observation of incontinence care, the resident was noted to have a large purple discoloration on both buttocks, and barrier cream was applied. The resident’s diagnoses included diabetes mellitus, hemiplegia, and a left below-knee amputation, and the MDS indicated the resident was cognitively intact and dependent on staff for several ADLs. Physician orders and the skin integrity care plan required weekly skin assessments, documentation of skin condition, and notification of the MD for abnormal findings. A hospital after-visit assessment documented a non-blanchable purple discoloration on the buttocks, but subsequent admission and weekly skin observations, including the most recent one, documented no skin discolorations. The RN and Wound Nurse later indicated the resident had purple discoloration on the buttocks since admission, but staff had not documented its presence. The facility also failed to ensure accurate documentation of medication administration for another resident receiving calcitonin-salmon nasal spray. The resident had chronic obstructive pulmonary disease and required setup assistance for eating. Physician orders directed calcitonin-salmon spray to be administered to alternating nostrils on different days. A pharmacy consult noted staff were not giving calcitonin spray as ordered and recommended staff education on proper administration. Review of the eMAR showed that staff documented administering the spray to the left nostril on some days when the order was for the right nostril, and to the right nostril on some days when the order was for the left nostril. The DON stated that staff were administering the calcitonin spray as ordered but were not documenting it correctly. The facility’s documentation policy required accurate, organized documentation of all resident information, including weekly skin and vital sign assessments and wound management entries.
Oxygen Therapy Provided Without Practitioner Orders or Facility Policy
Penalty
Summary
The facility failed to ensure a resident receiving oxygen therapy had practitioner orders for oxygen use and equipment maintenance. The resident had diagnoses including nontraumatic acute subdural hemorrhage, COPD, morbid obesity due to excess calories, and obstructive sleep apnea. An admission MDS was not coded for oxygen therapy, yet the care plan addressing potential impaired gas exchange related to COPD and sleep apnea included an approach to administer oxygen as ordered starting in mid-November. Progress notes documented multiple entries over several weeks indicating the resident was on oxygen via nasal cannula at 2–3 LPM, including notations that the resident used Bi-PAP or C-PAP and required or used oxygen. Despite this documented and ongoing use of oxygen therapy, a review of physician orders for November, December, and January revealed no orders for oxygen application or equipment maintenance in the clinical record. Staff interviews confirmed that the resident was treated as being on continuous oxygen therapy, with CNAs refilling oxygen tanks and applying oxygen when the resident was out of bed, and an LPN recalling the resident being on oxygen at admission and later believed to be weaned to C-PAP only. The DON stated she was almost certain the resident had been on continuous oxygen therapy and thought it was an admission order, and also reported that the facility did not have its own oxygen therapy policy, instead following the policy of the medical supply service. This deficiency was cited under 3.1-47(a)(6).
Failure to Provide Consistent Showers for Residents
Penalty
Summary
The facility failed to ensure that residents who required assistance with Activities of Daily Living (ADLs) received showers as per their care plans. This deficiency was identified for six out of seven residents reviewed for ADLs. The residents involved had various medical conditions and cognitive impairments, and their care plans specified the frequency and preference for showers, which were not consistently followed or documented by the staff. Resident 40, who had mild cognitive impairment and required partial to moderate assistance for bathing, reported receiving only one shower per week despite preferring three showers weekly. The Point of Care (POC) history indicated irregular shower schedules and several refusals, but no complete bed baths were documented. Similarly, Resident 46, with mild cognitive impairment and requiring substantial assistance, reported rarely receiving showers, and the POC history showed inconsistent shower records with no complete bed baths documented. Other residents, including Resident 20, Resident 12, Resident 19, and Resident 75, also experienced irregular shower schedules and incomplete documentation of showers or bed baths. The Director of Nursing (DON) acknowledged that partial bed baths were not an acceptable substitution for showers, and the Administrator admitted that the facility had been working on this issue for over a year. Despite efforts to improve documentation accuracy, the facility lacked a specific policy related to ADL care or showers, and the existing Resident Care/ADL Sheet policy was not effectively implemented.
Failure to Maintain Resident's Dignity
Penalty
Summary
The facility failed to maintain a resident's dignity for Resident 75, who was observed fully exposed in bed with the bedroom door fully open. The incident occurred on 5/17/24 at 8:58 A.M., when Resident 75 was not wearing pants, an incontinence brief, or covered with a bedsheet. A Qualified Medication Aide (QMA) was present but did not address the situation, and it was only at 9:01 A.M. that a Certified Nurses Aide (CNA) responded to the resident's call light and provided an incontinence brief. Resident 75, who was admitted with diagnoses including acute respiratory failure with hypoxia, dysphagia, pneumonitis due to inhalation of food and vomit, and sepsis, was completely dependent on staff for toileting, bathing, and transfers. The resident was also receiving nutrition through a feeding tube. During an interview, a Registered Nurse (RN) indicated that residents should not be left exposed and that CNAs should seek a nurse to pause feedings before performing incontinence care. The facility's policy on Resident's Rights, dated 11/15, was reviewed and indicated that residents should be treated with consideration, respect, and full recognition of their dignity and individuality, including privacy in treatment and care for personal needs.
Failure to Send Required Transfer Documents with Resident
Penalty
Summary
The facility failed to ensure that necessary documents were sent to the hospital upon the transfer of Resident 80. The resident, who had diagnoses including epilepsy and COPD, was transferred to the hospital for evaluation. However, the nursing progress note from the day of transfer lacked documentation of sending the required transfer paperwork and bed hold policy. The hospital records confirmed that the medical transfer paperwork was incomplete, missing critical information such as the resident's code status. Interviews with facility staff, including RN 3 and the Director of Nursing, revealed that there was no proof that the transfer packet was sent with the resident on the day of the transfer. The facility's Hospital Transfer policy mandates that pertinent information about the resident and actions taken to receive treatment at a hospital must be properly documented and copies placed in the resident's record. This policy was not followed, as evidenced by the absence of the transfer and bed hold paperwork in Resident 80's medical records.
Failure to Follow Physician Orders for Tube Feedings
Penalty
Summary
The facility failed to ensure physician orders were followed and residents' nutritional feedings were administered correctly for two residents with feeding tubes. Resident 75 was observed with a feeding pump running at 75 mL per hour, but the nutritional formula bottle was dated from the previous day, and the gauze around the feeding tube was dated two days prior. Additionally, the head of the bed was not elevated as required, and there was a discrepancy between the CNA's and RN's accounts regarding the pausing of the feeding pump during incontinence care. Resident 75's clinical record indicated multiple serious diagnoses, including acute respiratory failure and dysphagia, and required continuous feeding and specific care for the feeding tube site, which were not adhered to as per physician orders. Resident 68 was observed with enteral nutrition running at 38 mL per hour while the head of the bed was flat, contrary to physician orders. The enteral nutrition was also found to be turned off at various times without proper documentation. Resident 68's clinical record showed significant medical conditions, including spastic quadriplegic cerebral palsy and profound intellectual disabilities, and required continuous feeding with specific instructions for the head of the bed elevation and feeding schedule. The facility's records lacked documentation of the enteral nutrition being turned off outside the prescribed times, and the facility's Enteral Therapy policy was not followed as required.
Failure to Administer Routine Medications
Penalty
Summary
The facility failed to ensure that routine medications were available and dispensed according to physician's orders for a resident diagnosed with gastro-esophageal reflux disease (GERD). The resident had orders for omeprazole and pantoprazole, both medications to treat acid reflux, which were not administered from May 12 through May 16 because the drugs were unavailable. The medications had been reordered from the pharmacy on May 10, but there was no documentation in the clinical record explaining the unavailability of the medications or any follow-up actions taken by the staff to obtain them from the Emergency Drug Kit (EDK), which had the medications in stock. Licensed Practical Nurse (LPN) 7 indicated that medications usually arrived the same day and that staff should call the pharmacy if they did not. The Director of Nursing (DON) confirmed that if a medication was unavailable, it should be given from the EDK and that staff should document the unavailability and follow up with the pharmacy. However, there was no such documentation in the clinical record for the resident's omeprazole and pantoprazole. The facility's policy on reordering, changing, and discontinuing orders required staff to review transmitted re-orders for status and potential issues, which was not adhered to in this case.
Failure to Maintain Accurate Medical Records
Penalty
Summary
The facility failed to maintain accurate medical records for two residents. For Resident 14, the clinical record indicated participation in psychotherapy on a date when the resident was actually hospitalized, leading to an erroneous entry in the medical record. This discrepancy was confirmed during an interview with Social Services, who acknowledged the resident's hospitalization during the documented psychotherapy session. For Resident 75, the clinical record lacked documentation of the resident's departure and return to the facility for medical procedures on two separate days. Despite the resident being out of the building for an endoscopy and a colonoscopy, there was no record of these absences in the clinical documentation. The facility's own guidelines require accurate documentation of resident status upon leaving and returning to the facility, which was not adhered to in this case.
Latest citations in Indiana
Surveyors observed that dietary staff repeatedly worked in kitchen and meal service areas with uncovered facial hair, despite facility policy and state sanitation requirements mandating effective hair restraints. Two dietary aides with short beards or mustaches were seen walking through food preparation areas, taking food temperatures, handling food, and plating meals at steamtables in dining rooms without any facial hair coverings, while the current policy required all hair, including facial hair, to be restrained to prevent contamination.
The facility failed to consistently provide and document required bed-hold policy notices when several residents were transferred to the hospital. In multiple cases, residents with dementia, psychotic disorders, COPD, chronic respiratory failure, altered mental status, and cerebral infarction were sent out for acute changes in condition, and while transfer notes reflected physician and family notifications, they lacked documentation that the bed-hold policy was discussed with the resident or responsible party. Notices of Transfer or Discharge often indicated a copy of the bed-hold policy was sent with the resident, but the records did not show signed and dated acknowledgment by the resident or appropriate representative, including in situations where a resident had moderate cognitive impairment, short-term memory issues, or a documented need for a proxy and a financial POA authorizing an agent for health care decisions.
Surveyors found that the facility failed to provide trauma‑informed and culturally competent care by not incorporating two residents’ extensive trauma histories and specific behavioral triggers into their care plans. One resident with documented homelessness, polysubstance abuse, severe accidents with multiple fractures, viral encephalitis with coma, physical and sexual abuse, loss of family contact, and a past suicide attempt had multiple behavior‑focused care plans that referenced identifying triggers but listed none and did not mention their physical, sexual, medical, or psychosocial trauma. Another resident with TBI from being struck by a truck, an 11‑month coma, long‑term state hospital residence, alleged shooting of a parent, and diagnoses including intermittent explosive disorder and borderline personality disorder had a PASRR identifying a specific trigger and notes of inappropriate sexual behavior, yet their care plans omitted these traumatic events, the identified trigger, and the sexual behavior. Staff interviews confirmed that residents were screened for trauma, but the trauma histories and triggers were not reflected in the individualized plans of care.
A resident with schizophrenia, post‑stroke hemiparesis, and mild cognitive impairment expressed feeling down and wanting to kill himself, but staff did not document asking about a specific plan, did not notify the physician or psychiatric NP as expected, and did not develop or update a care plan addressing depression or suicidal ideation. The SSD documented offering support and initiating 15‑minute checks once, but there was no further follow‑up or documentation of interventions after subsequent suicidal statements made in a care plan meeting with the resident’s father. The DON and Administrator reported that facility policy requires immediate notification of key staff, assessment for a plan and means of self‑harm, and thorough documentation, which were not carried out or reflected in the medical record for this resident.
A resident with schizophrenia, post-stroke hemiparesis, and mild cognitive impairment verbalized suicidal ideation, but the care plan did not address depression or suicidal thoughts, and required assessments and services were not accurately or timely documented. An SSD note recorded the resident saying he wanted to kill himself and referenced 15‑minute checks and a care plan update, yet the active care plan lacked depression/suicidal ideation interventions. Multiple late-entry Social Services notes were later added, describing follow-up visits and the resident denying suicidal ideation, but the SSD later reported she did not typically ask about a suicide plan and did not personally provide individual follow-up visits as described. These practices conflicted with the facility’s policy requiring factual, first-hand, and timely documentation of assessments and services.
A resident was observed with an Albuterol inhaler on an overbed table and later reported keeping the inhaler in a nightstand drawer, with no staff present during these observations. Record review showed the resident had no cognitive impairment on the admission MDS but lacked any documented self-medication administration assessment. The DON acknowledged that the required assessment had not been completed, despite facility policy requiring staff and the practitioner to evaluate each resident’s mental and physical abilities before allowing self-administration of medications.
Surveyors found that the facility submitted inaccurate direct care staffing data to CMS through the PBJ system over multiple days in a quarter. CASPER reports showed apparent gaps in 24-hour licensed nurse coverage, low weekend staffing, and a 1-star staffing rating, while internal staffing sheets documented that licensed nurses were present and the facility was fully staffed on those days. The Administrator reported that the discrepancies were due to PBJ data entry errors, despite a facility policy requiring all PBJ entries to be accurate, auditable, and verifiable against payroll, invoices, or contracts.
Surveyors found that the facility did not provide or document required written transfer/discharge notices and bed-hold policy information for four residents who were sent to the hospital, including individuals with conditions such as dementia, CHF, chronic respiratory failure, and CKD. In each case, progress notes showed that the resident was transferred for acute issues, but the clinical records lacked evidence that written notices were given to the residents or their representatives, and in one case lacked documentation that required information was sent to the receiving provider. Facility leadership, including the ADON, DON, and Administrator, acknowledged that the records did not contain the required documentation, despite a written policy requiring such notices and information exchange.
A resident with Alzheimer’s disease and depression, previously on an antidepressant, exhibited intermittent refusals of medications and care, occasional yelling at staff, and reports of unusual perceptions, such as believing men were in or near her room. Nursing notes over several months documented these refusals and complaints but did not show that the behaviors were evaluated or recorded as dangerous, non-redirectable, or causing significant distress, nor did they document specific non-pharmacological interventions attempted or their outcomes. Despite this, a psychiatric NP later added new diagnoses of schizoaffective disorder, borderline personality disorder, and delusional disorder and ordered an antipsychotic (Seroquel) without a comprehensive evaluation in the record to support these diagnoses. The facility’s psychotropic medication policy, which requires identification and documentation of target behaviors, use of nonpharmacological interventions, and ongoing behavior monitoring, was not followed for this resident.
The facility failed to keep PASARR Level I screenings accurate and current for three residents when new mental health diagnoses and psychoactive medications were initiated. One resident’s PASARR omitted a PTSD diagnosis and an added antidepressant, despite documentation of PTSD on the MDS and care plan and a physician order for Pristiq. Another resident’s PASARR listed only depression and dementia, even after additional diagnoses such as borderline personality disorder, delusional disorder, and schizoaffective disorder were added and an antipsychotic (quetiapine) was ordered, with the MDS later reflecting psychotic disorder, schizophrenia, and depression with antipsychotic and antidepressant use. A third resident’s PASARR did not include a depression diagnosis or newly ordered escitalopram and lorazepam, although the admission MDS documented depression with antianxiety and antidepressant use. These omissions occurred despite facility policy requiring a new Level I review after significant mental status changes, including new mental health diagnoses or new psychotropic medications.
Uncovered Facial Hair During Food Preparation and Meal Service
Penalty
Summary
The deficiency involves the facility’s failure to ensure that food was served in a sanitary and safe manner in accordance with professional standards and facility policy during multiple kitchen and meal service observations. During an initial kitchen observation, two dietary aides were seen walking through the kitchen food preparation area with uncovered facial hair. One aide had facial hair above and below the lip and along the jaw line, approximately one-fourth inch in length, and the other had a mustache of similar length; neither used any facial hair covering. These observations occurred while staff were present in the kitchen area where food was stored and prepared. During subsequent observations on the same day, the same two dietary aides were again observed with uncovered facial hair while directly involved in meal preparation and service. One aide walked through the kitchen while the noon meal was being prepared and placed into a transport cart for service in the south dining room, and later was observed plating the noon meal at the steamtable in that dining room, still without a facial hair covering. The other aide walked through the kitchen while the noon meal was being prepared and placed into the steamtable for the north dining room, took food temperatures, assisted with plating meals at the steamtable, and retrieved food items and supplies from the kitchen, all while having an uncovered mustache approximately one-fourth inch in length. The Dietary Manager stated that staff hair was to be covered when in the kitchen and during meal service, and the facility’s written policy and the cited Indiana Food Establishment Sanitation Requirements both required effective hair restraints, including for facial hair, to prevent contamination of food, equipment, and utensils.
Failure to Provide and Document Bed-Hold Policy at Time of Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure that required bed-hold policy information was provided and documented for four residents transferred to the hospital. For a resident with dementia, psychotic disorder, and autistic disorder who had a BIMS score of 0 indicating severe cognitive impairment, progress notes documented physician notification and guardian notification when the resident was sent to the hospital, but there was no documentation that the bed-hold policy was provided to the responsible party. A Notice of Transfer or Discharge later indicated a copy of the bed-hold policy was sent with the resident. Another resident with COPD and chronic respiratory failure, cognitively intact with a BIMS score of 13, experienced a decline in condition and was transferred to the hospital by ambulance; progress notes documented family notification but did not document any discussion of the bed-hold policy, although a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident. A third resident with altered mental status and cerebral infarction, with a BIMS score of 10 indicating moderate cognitive impairment and documented short-term memory impairment, experienced changes in condition and was transferred to the hospital. Progress notes stated the resident was their own responsible party and that no other notification was completed, and transfer documentation did not include the bed-hold policy, although an untimed Notice of Transfer or Discharge indicated a copy of the bed-hold policy was signed by the resident. A financial power of attorney document in the record showed the resident had designated an agent to act in consent or refusal of health care. For a fourth resident with dementia and osteomyelitis, transfer documentation and a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident, and the transfer form noted the resident required a proxy for decision making. The facility’s policy required that at the time of transfer to a hospital, written notice specifying the duration of the bed-hold policy and information on return to the next available bed be provided, and that a signed and dated copy of the bed-hold notice given to the resident or representative be kept in the resident file, which was not consistently documented for these residents.
Failure to Integrate Trauma Histories and Behavioral Triggers Into Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to identify and incorporate residents’ trauma histories and specific behavioral triggers into their care plans, despite documented histories of significant trauma and behavioral health issues. For one resident, extensive social service and progress notes documented homelessness, polysubstance abuse, major depressive and anxiety disorders, chronic pain, a history of severe car accidents with multiple fractures, viral encephalitis resulting in a three‑month coma, loss of child custody, multiple divorces, physical abuse by a spouse, the death of a fiancé who was struck by a car while in a wheelchair, lack of family contact, and a past suicide attempt by Valium overdose. Additional documentation noted a history of rape by a brother at age eight and prior placement under direct supervision and 15‑minute checks related to suicidal ideation. Despite these documented traumatic events and behavioral health concerns, the resident’s care plans did not identify a history of physical trauma, sexual trauma, homelessness, substance abuse, medical trauma, or attempted suicide. For this same resident, the MDS showed no cognitive deficit and identified behaviors such as verbal aggression and rejection of care, along with diagnoses including seizure disorder, depression, chronic pain syndrome, homelessness, and anxiety disorder. Multiple care plans addressed behaviors such as drug‑seeking, pretending to have seizures for attention or medication, making false allegations, verbal aggression when unable to smoke, and a desire for intimate relationships with consenting male residents. These care plans referenced goals such as effective coping skills, seeking staff support, and compliance with the smoking policy, and they called for identification and reduction of behavioral triggers. However, none of these care plans actually listed any specific triggers. The care plan addressing the resident’s right to consensual intimate relationships focused on assessment and education regarding consent but did not integrate the resident’s extensive trauma history. Staff interviews indicated the resident had displayed sexual behaviors since admission, including an incident where the resident expressed anger at another resident for not buying a soda after engaging in sexual acts. A second resident with a documented history of traumatic brain injury (TBI), dementia, seizure disorder, borderline personality disorder, anxiety, intermittent explosive disorder, tobacco use, and other behavioral/emotional disorders was also affected by the same deficiency. Social history and progress notes documented that this resident sustained a TBI after being hit by a semi‑truck while riding a bicycle at age 18, resulting in an 11‑month coma, followed by 13 years in a state hospital and subsequent residence in a group home. Additional documentation indicated the resident allegedly shot their father at age 26 after being sworn at and had a PASRR identifying TBI, intermittent explosive disorder, and borderline personality disorder, with a specific trigger of hearing the name of the current U.S. President. Progress notes also described inappropriate sexual behavior toward staff, including touching themselves intimately during personal care and refusing to stop when redirected. Despite this, the resident’s care plans, which addressed explosive disorder and history of altercations, risk for decreased psychosocial well‑being, and refusal to bathe or shower, did not list any specific behavioral triggers, did not reference the traumatic events such as being hit by a truck or shooting their father, and did not document the inappropriate sexual behavior. The Administrator and Social Service Director acknowledged that residents were to be screened for trauma and that trauma responses and PTSD should be added to care plans, but the specific trauma histories and triggers for these two residents were not incorporated into their plans of care.
Failure to Assess and Care Plan for Resident Suicidal Ideation
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess, investigate, and care plan for a resident’s suicidal ideation in accordance with its own policy and staff expectations. The resident had diagnoses including schizophrenia, cerebral edema, and hemiparesis/hemiplegia following a cerebral infarction, and a current MDS showed mild cognitive impairment (BIMS score 12). A progress note documented that the resident told the Social Services Director (SSD) he was feeling down and wanted to kill himself; the SSD offered assistance, activities, and initiated 15‑minute checks, and the note stated the care plan was updated. However, the note did not indicate that the SSD asked whether the resident had a plan to kill himself, and there were no additional notes regarding suicidal ideation or follow‑up. Review of the current care plan showed no problem, goal, or interventions addressing depression or suicidal ideation, and progress notes over the following month contained no documentation of physician notification related to the suicidal statement. Further record and interview evidence showed that the care plan conference summary did not document interventions for suicidal ideation, and the SSD acknowledged she did not normally ask residents expressing suicidal ideation if they had a plan. The SSD reported that the resident had admission paperwork mentioning suicidal ideation related to depression after a stroke and that the resident again vocalized suicidal ideation during a care plan meeting with his father, after which emotional support was offered and the father took the resident out on a leave of absence; no further visits or follow‑up were done. The DON stated that, upon notification of suicidal verbalization, staff should assess the resident, ask if there is a plan, remove potential means of self‑harm, immediately notify the psychiatric NP, and document the occurrence, and that a detailed progress note and updated care plan were expected but not present for this resident. The Administrator similarly stated that staff should ask about a plan, document interventions, notify the physician and family, and update the care plan, and indicated the resident should have had a care plan addressing depression with suicidal ideation. The facility’s written policy required immediate notification of the DON, SSD, and physician, an interview including asking about a plan and assessing mood and means for self‑harm, and thorough documentation of mood, behavior, and all actions taken, which were not reflected in the resident’s record.
Incomplete and Inaccurate Documentation of Suicidal Ideation and Follow-Up
Penalty
Summary
The facility failed to ensure accurate, complete, and timely documentation of assessments and services for a resident who verbalized suicidal ideation. Resident 6, who had schizophrenia, cerebral edema, and right-sided hemiparesis/hemiplegia following a cerebral infarction, had a BIMS score of 12 indicating mild cognitive impairment. The resident’s admission paperwork mentioned suicidal ideation related to depression after a stroke, and a Social Services note on 3/11/2026 documented that the resident was feeling down and said he wanted to kill himself. The Social Services Director (SSD) documented that she talked with the resident, coordinated with Activities, advised the resident to contact SSD or nursing if he wanted to talk, and that the resident was scheduled for 15-minute checks and the care plan was updated. However, the current care plan initiated on 2/26/2026 did not address depression or suicidal ideation. Multiple Social Services progress notes were later entered as late entries in April, with effective dates in March, stating that the resident had no plan and no longer had suicidal ideation, that he felt much better after 1:1 time, and that he continued his daily routine and therapy. These late entries described follow-up visits and reassessments of suicidal ideation on several consecutive days, but in interviews the SSD stated she did not normally ask residents about having a plan when they verbalized suicidal ideation and did not recall any other occurrences beyond the initial event. She further indicated she did not personally provide individual follow-up visits with this resident regarding suicidal ideation, despite the late-entry notes describing such visits. The DON acknowledged that late entries had been added to address concern about suicidal verbalization, and the Administrator stated that upon suicidal statements staff should ask about a plan, notify the physician and family, and update the care plan, and that this resident should have had a care plan addressing depression with suicidal ideation. The facility’s documentation policy required factual, first-hand, timely documentation, which was not followed in this case.
Failure to Complete Required Self-Administration Assessment for Inhaler Kept at Bedside
Penalty
Summary
Surveyors identified that a resident was allowed to keep and access an Albuterol inhaler without the facility completing the required self-administration medication assessment. During an initial tour, the resident was observed sitting in a wheelchair with a handheld Albuterol inhaler on the overbed table and no staff present in the room or hallway. On a subsequent observation, the resident again was in a wheelchair and reported that the Albuterol inhaler was stored in the top drawer of the nightstand, where it was found. Review of the clinical record showed an admission MDS indicating no cognitive impairment, but there was no documentation of a self-medication administration assessment. In an interview, the DON confirmed that the resident did not have the required self-medication assessment, despite the facility’s policy stating that staff and the practitioner must assess each resident’s mental and physical abilities to determine whether self-administering medications is clinically appropriate. This failure to complete and document a self-administration medication assessment for a resident who had an Albuterol inhaler kept at bedside constituted noncompliance with the facility’s own policy and with 410 IAC 16.2-3.1-11(a).
Inaccurate PBJ Staffing Data Submission to CMS
Penalty
Summary
The deficiency involves the facility’s failure to electronically submit complete and accurate direct care staffing information to CMS through the Payroll-Based Journal (PBJ) system for 22 days in a fiscal quarter. A CASPER report review on 4/6/26 showed that, according to PBJ data, the facility did not have licensed nursing coverage 24 hours per day on multiple specific dates across three months, had low weekend staffing, and held a 1-star staffing rating. However, review of the facility’s internal staffing sheets for that quarter indicated the facility was fully staffed and had licensed nurse coverage on all of the dates in question. During an interview, the Administrator stated that the PBJ information must have contained data entry errors, as she had verified licensed staff coverage on the timesheets. The facility’s PBJ policy in effect stated that all staffing data entered into the PBJ system would be auditable and verifiable through payroll, invoices, or contracts, but the submitted PBJ data did not accurately reflect the facility’s actual licensed nurse staffing as documented on internal records. No specific residents or clinical conditions were mentioned in the report, and the deficiency centers solely on inaccurate staffing data submission rather than direct resident care events.
Failure to Provide and Document Required Transfer/Discharge and Bed-Hold Notices
Penalty
Summary
The deficiency involves the facility’s failure to provide and document required written notices of transfer/discharge and bed-hold policies, as well as required information to receiving providers, for four residents who were transferred or discharged to the hospital. For a resident with generalized anxiety disorder, major depressive disorder, and dementia, progress notes showed that the resident was sent to the hospital via 911 for chest pain, lower back pain, and shortness of breath and later returned to the facility, but the clinical record lacked documentation that a written Notice of Transfer/Discharge and the bed-hold policy were provided to the resident or representative, and lacked documentation that required information was conveyed to the receiving facility. The ADON and the Administrator both confirmed there was no documentation that these written notices were provided. For a resident with congestive heart failure and muscle weakness who was sent to the emergency room for painful urination and bloody urine, the clinical record lacked documentation that a Notice of Transfer/Discharge or bed-hold policy was given to the resident or representative, which the DON confirmed. Another resident with chronic respiratory failure and diabetes was discharged to the hospital for respiratory failure, and a resident with chronic kidney disease and dementia was discharged to the hospital, but in both cases there was no documentation that a written notice of transfer/discharge or bed-hold policy was provided to the residents or their representatives. Review of the facility’s Transfer and Discharge policy, dated 1/15/26, showed that the policy required the facility to provide written transfer/discharge notices and bed-hold information to residents and representatives and to provide specified information to receiving providers, but the records for these four residents did not contain the required documentation.
Failure to Document Target Behaviors and Non-Pharmacological Interventions Before Initiating Antipsychotic
Penalty
Summary
The deficiency involves the facility’s failure to document how a resident’s behaviors presented danger or distress to self or others, and failure to document non-pharmacological interventions attempted prior to initiating an antipsychotic medication. Resident 6 had documented diagnoses of Alzheimer’s disease, depression, and severe cognitive impairment, and was receiving sertraline for depression. A PASSAR identified only depression and dementia, and the admission MDS listed Alzheimer’s disease and depression as active diagnoses. Over several months, nursing progress notes documented that the resident intermittently reported unusual perceptions, such as believing there were men causing trouble, a man in her room, or a man wanting to marry her and yelling through the walls, but there was no documentation that these episodes caused danger to the resident or others or that they resulted in unmanageable distress. From late April through mid-July, nursing notes primarily described the resident’s frequent refusals of evening and morning medications, blood sugar checks, blood pressure checks, insulin administration, hygiene care, and showers. Staff documented that the resident sometimes yelled at staff, said “Get out!”, was visibly upset by a room move, was leery of staff and asked to see name badges, and became upset about a pillow under her head until it was removed, after which she calmed down. The notes also recorded instances where the resident believed housekeeping had not cleaned her room or that she had not received medications when she had. However, there were no progress notes or assessments indicating that these behaviors were evaluated as dangerous, non-redirectable, or causing significant distress or functional impairment, and no detailed behavior monitoring logs were present as required by facility policy. On a psychiatric NP visit for initial psychotropic medication management, new mental health diagnoses of schizoaffective disorder, borderline personality disorder, and delusional disorder were added, and Seroquel 25 mg, an antipsychotic, was ordered. The clinical record did not contain a comprehensive evaluation to support these new diagnoses, and there was no documentation of target behaviors meeting the facility’s policy criteria for psychotropic use, such as behaviors representing danger to self or others, causing distress and impairment in functional abilities, or clearly attributable to psychosis or mania. The resident’s representative reported that the resident had no prior history of mental health disorders or psychiatric hospitalization and was unaware of the new diagnoses. The facility’s own psychotropic medication policy required identification and documentation of specific target behaviors, use and documentation of nonpharmacological interventions, and ongoing monitoring of behaviors and interventions, which were not reflected in the record for this resident.
Failure to Update PASARR Screens for New Mental Health Diagnoses and Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that Preadmission Screening and Resident Review (PASARR) Level I screenings were accurate and updated when new mental health diagnoses and psychoactive medications were initiated for multiple residents. For one resident with dementia, anxiety, depression, and post-traumatic stress disorder (PTSD), the PASARR completed on admission listed anxiety, depression, and dementia with sertraline and quetiapine, but did not include the PTSD diagnosis or the antidepressant Pristiq, despite the admission MDS and care plan documenting PTSD and a subsequent physician’s order for Pristiq. For another resident with Alzheimer’s disease, borderline personality disorder, delusional disorder, schizoaffective disorder, and depression, the PASARR only reflected depression and dementia with sertraline, even though additional mental health diagnoses were added later and an antipsychotic (quetiapine) was ordered for borderline personality disorder, and the quarterly MDS documented psychotic disorder, schizophrenia, and depression with antipsychotic and antidepressant use. A third resident had diagnoses including Alzheimer’s disease, depression, anxiety disorder, irritability and anger, and nonrheumatic aortic valve stenosis. The PASARR for this resident listed dementia and anxiety with Risperdal but omitted the diagnosis of depression and the medications escitalopram and lorazepam, although physician’s orders were in place for escitalopram for depression and lorazepam for anxiety, and the admission MDS documented depression with antianxiety and antidepressant use. Interviews with the Assistant Director of Nursing confirmed that new Level I PASARR screens should have been completed when new mental health diagnoses and psychoactive medications were added, and that the PASARR for one resident, completed prior to arrival, should have included all mental health diagnoses and medications. The facility’s own policy required notification of the state mental health authority within 14 days after a significant change in mental condition and specified that a new Level I screen is required for new mental health diagnoses or newly prescribed psychotropic medications, which was not followed in these cases.
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