Envive Of Huntington
Inspection history, citations, penalties and survey trends for this long-term care facility in Huntington, Indiana.
- Location
- 850 Ash St, Huntington, Indiana 46750
- CMS Provider Number
- 155531
- Inspections on file
- 36
- Latest survey
- March 20, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Envive Of Huntington during CMS and state inspections, most recent first.
A resident with vascular dementia, hearing impairment, and dependence on staff for personal care and toileting was subjected to undignified treatment by a CNA. Multiple staff reported hearing the CNA speak in a loud, angry tone and tell the resident to stop using the call light because staff were busy and had other residents to care for. Staff also reported that the CNA stated she would not change or toilet the resident, and another CNA ultimately responded to the call light and assisted the resident to the bathroom. The facility’s abuse policy defined such deprivation of necessary care and failure to acknowledge requests for assistance as abuse.
A resident in COVID-19 isolation was the subject of multiple staff reports that a CNA yelled at her, used an angry tone, told her not to keep using the call light because staff were busy, and stated she would not take the resident to the bathroom. Another CNA later assisted the resident to the bathroom after hearing this exchange outside the closed door. The facility’s initial incident report to the State Agency described the situation mainly as the CNA raising her voice so the resident could hear through PPE and advising her not to use the call light unless needed, and it omitted the allegation that the CNA threatened to withhold toileting care, resulting in a failure to timely and accurately report the full abuse and neglect allegations.
The facility posted photographs of two residents on social media without obtaining the required written consent as outlined in facility policy. One resident with cognitive impairment and another who was cognitively intact were both pictured in online posts, but neither had a signed social media release form in their records. Staff and administration confirmed the absence of proper consent, despite the facility's policy mandating explicit written approval before releasing resident images for such purposes.
Staff transferred a resident with Parkinson's disease and mobility impairment without using a gait belt or assistive device, contrary to facility policy and the resident's care plan. Both CNAs involved acknowledged the omission, and nursing leadership confirmed that a gait belt was required for such transfers.
A CNA provided incontinence care to a resident with Parkinson's disease and, without removing gloves or performing hand hygiene, touched the resident's call light and bed controls before discarding gloves. Interviews with staff and review of facility policy confirmed that gloves should have been removed and hand hygiene performed before touching environmental surfaces, resulting in a breach of infection control practices.
A facility failed to notify the Ombudsman of a resident's multiple hospital transfers due to serious medical conditions, including diabetic ketoacidosis and hypertension. The Social Services Director misunderstood notification requirements, and the facility lacked a policy for Ombudsman notification.
The facility failed to update care plans for two residents, leading to discrepancies in dialysis scheduling and lack of documented management for a pressure injury. One resident's care plan did not align with actual dialysis days, while another resident's care plan was not updated to include interventions for a pressure ulcer upon returning from the hospital. Staff interviews confirmed that care plans should be updated with significant changes, but this was not done in these cases.
A resident with multiple health conditions received incorrect administration of Midodrine due to improperly written medication orders. The orders instructed staff to hold the medication based on incorrect blood pressure parameters, leading to administration when the resident's systolic blood pressure was above the specified threshold. Interviews with the DON and NP confirmed the error in the medication order, which was not properly reviewed and signed electronically.
A facility failed to follow physician orders for administering an anti-hypotensive medication to a resident with a history of liver disease and hypertension. The medication was given despite the resident's blood pressure being outside the prescribed parameters, and there were multiple instances where the medication was held without proper documentation of vital signs. Staff interviews revealed inconsistencies in documentation practices.
A facility failed to ensure a resident did not receive antipsychotic medication without proper indication. The resident, with a history of bipolar disorder and other mental health issues, was receiving antipsychotic medication despite inconsistent documentation of a psychotic disorder. Care plans included monitoring for side effects, but the resident exhibited behaviors not clearly linked to medication use. Staff interviews indicated the resident's tearfulness was often random, suggesting inadequate justification for the medication.
A resident was subjected to inappropriate and sexually-toned conversations by an employee, DE5, through Facebook Private Messenger. Despite the resident reporting the issue to the Social Services Director, no action was taken by the previous administration to investigate or address the situation. The new administrator discovered the issue through an anonymous tip, leading to an investigation and the suspension of DE5. The facility failed to adhere to its policies on abuse and social media use, leaving the resident unprotected.
A facility failed to report an allegation of sexual abuse involving a resident and a dietary employee. The resident reported inappropriate messaging to the Social Services Director, but no action was taken. The Dietary Manager was also aware and informed the previous administrator, who dismissed the concerns. The issue was not addressed until a new administrator received an anonymous tip and suspended the employee. Facility policies on abuse reporting and investigation were not followed.
A facility failed to promptly investigate allegations of inappropriate messaging between a resident and a dietary employee. Despite the resident's report to the Social Services Director and the Dietary Manager's awareness, no action was taken by the previous administrator. The situation was only addressed months later by a new administrator following an anonymous tip, leading to the employee's suspension.
The facility failed to ensure proper hand hygiene was performed by staff before and after resident contact. A Restorative Aide and the Activities Director were observed assisting residents without performing hand hygiene, despite acknowledging the requirement and having hand sanitizer available. The DON and Nurse Consultant confirmed the expectation for staff to follow hand hygiene protocols.
Failure to Treat Resident With Dignity and Respect When Requesting Assistance
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was treated with dignity and respect when requesting assistance. The resident had vascular dementia, was cognitively intact per the most recent MDS, was hard of hearing, and required assistance with personal care, transfers, and mobility using a walker and wheelchair. Her care plan included interventions to allow adequate time for responses, minimize environmental stimuli, and provide clear, simple instructions due to impaired communication and psychosocial wellbeing concerns related to negative interactions with others. On the day of the incident, staff in the activity area heard a staff member speaking in a very loud and angry tone. The Activity Director and Activity Assistant reported hearing a CNA tell the resident that she could not keep pushing her call light if she did not need something because there were other people to take care of and the CNA did not have time to keep coming into her room. When they looked to see where the yelling was coming from, they saw the CNA exiting the resident’s room, which was in isolation for COVID-19. Another staff member later reported that the same CNA also told the resident that she would not change her because she was too busy. Additional staff interviews corroborated that the CNA told the resident to stop putting on her call light and stated she was not going to take the resident to the bathroom. One CNA reported standing outside the closed door and hearing the CNA tell the resident to stop using the call light and that she would not take her to the bathroom; when the resident turned on her call light again, this CNA assisted her to the bathroom. The resident’s roommate confirmed that the CNA told the resident not to turn on her call light unless she needed something. The facility’s abuse policy defined abuse to include deprivation of goods and services necessary to maintain physical, mental, and psychosocial well-being, including when staff have the knowledge and ability to provide care but choose not to do so or fail to acknowledge a resident’s request for assistance, resulting in care deficits.
Failure to Timely and Accurately Report Allegations of Verbal Abuse and Neglect
Penalty
Summary
The deficiency involves the facility’s failure to timely and accurately report allegations of verbal abuse and neglect involving one resident. On a specific date, the Activity Director heard someone yelling loudly while in the activity room and heard a staff member state that the resident could not keep pushing the call light unless something was needed because there were other people to care for. When the Activity Director stepped out, she saw a CNA exiting the resident’s room. A similar account was documented by the Activity Assistant, who heard an aide using a very loud and angry tone and heard the aide tell the resident not to keep pushing the call light if she did not need something, because there were other people to take care of and there was no time to keep coming into the room. These observations were reported to the Administrator. The Administrator and DON later entered the resident’s room, donning PPE due to the resident being in COVID-19 isolation, and questioned the resident about any trouble with staff. The resident reported that the CNA had told her she could not turn on her call light because staff were busy, but stated she did not feel abused. The resident’s roommate also reported that the CNA told the resident not to turn on her call light unless she needed something and denied that the resident needed to use the restroom at that time. Another CNA reported that, while standing outside the resident’s closed door, she heard the CNA tell the resident to stop putting her call light on and that she was not going to take her to the bathroom; this CNA later assisted the resident to the bathroom after the call light was turned on again. Despite these multiple staff reports and statements describing yelling, an angry tone, and a statement that the CNA would not toilet the resident, the facility’s initial incident report and follow-up documentation characterized the event primarily as the CNA raising her voice because the resident could not hear through PPE and telling the resident not to turn on the call light unless she needed something. The incident report did not include the allegation that the CNA threatened to withhold services, specifically refusing to toilet the resident. The facility’s policy required immediate reporting of abuse allegations to the Administrator and authorities within two hours and removal of any accused employee from resident contact during investigation, but the CNA continued to work after the initial allegation, and the allegation of refusal to toilet the resident was not accurately reflected in the initial report to the State Agency.
Failure to Obtain Written Consent Before Posting Resident Photos on Social Media
Penalty
Summary
The facility failed to protect resident dignity and rights by not obtaining written consent, as required by facility policy, before posting photographs of two residents on social media platforms. For one resident with dementia, depression, and mild cognitive impairment, a photograph was posted during an arts and crafts activity, but the only consent on file was for photographs intended for medical records and activities, not for social media use. The resident was aware of the photos being taken and posted but had not provided explicit written consent for social media release. For another resident, who was cognitively intact and had diagnoses including diabetes, bipolar disorder, and heart failure, photographs were posted online showing the resident at a lake during a meal, but there was no signed photography or video consent release form in the admission packet. Interviews with the Administrator confirmed that neither resident had a signed social media release form on file, and the Director of Nursing verified that both residents appeared in the facility's social media posts. The facility's current policy explicitly requires written consent from the resident or representative before images or recordings are taken or released for any purpose other than specific exceptions, such as investigations or emergencies. The lack of proper written consent prior to posting these images constituted a failure to honor the residents' rights to dignity and self-determination.
Failure to Use Assistive Device During Resident Transfer
Penalty
Summary
Staff failed to follow facility policy regarding the use of assistive devices during the transfer of a physically dependent resident diagnosed with Parkinson's disease, muscle weakness, tremors, and difficulty walking. The resident was documented as cognitively intact but had upper and lower extremity impairment on one side and required extensive assistance from two staff members for transfers. The care plan specified that transfers required two staff and that a mechanical lift could be used as needed. However, during observed transfers, two CNAs moved the resident between a recliner and bed without using a gait belt or any assistive device, instead lifting the resident by placing their arms under the resident's armpits and cueing the resident to move his feet. Both CNAs acknowledged during interviews that they should have used a gait belt for the transfer, and this was confirmed by an RN and the DON, who stated that a gait belt was required for this resident during transfers. The facility's policy on safe lifting and movement of residents required staff to incorporate resident safety and to be trained in the use of manual and mechanical lifting devices. The failure to use a gait belt or assistive device during the transfer was directly observed and confirmed by staff interviews, constituting a failure to implement the facility's policy for safe resident transfers.
Failure to Follow Infection Control Protocols During Incontinence Care
Penalty
Summary
A deficiency was identified when a certified nursing assistant (CNA) failed to follow proper infection control practices during incontinence care for a resident diagnosed with Parkinson's disease, diabetes, muscle weakness, and tremors. The resident was cognitively intact but dependent on staff for toileting due to upper and lower extremity impairment on one side. During an observed care episode, the CNA washed her hands and donned gloves before providing incontinence care for a small bowel movement. After completing the care and redressing the resident, the CNA, still wearing the same gloves, touched the resident's call light and bed controls before removing her gloves and performing hand hygiene. Interviews with the CNA, a registered nurse (RN), and the director of nursing (DON) confirmed that gloves should have been removed and hand hygiene performed before touching any items in the resident's environment after providing incontinence care. The facility's current hand hygiene policy also required all personnel to follow handwashing procedures to prevent the spread of infections. The failure to remove gloves and perform hand hygiene before touching environmental surfaces constituted a breach of infection control protocols.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to provide timely notification to the Office of the State Long-Term Care Ombudsman regarding the transfer or discharge of a resident, specifically Resident 21, who was hospitalized multiple times throughout the year. Resident 21's clinical record indicated several hospitalizations due to serious medical conditions, including diabetic ketoacidosis, refusal of dialysis and medications, hypertension, hyperglycemia, and hyperkalemia. Despite these transfers, the facility did not notify the Ombudsman for the months of March, May, October, and December 2024. The Social Services Director indicated that a monthly report of transfers and discharges was typically sent to the Ombudsman via email. However, the facility's system did not notify her of hospitalizations if a resident was on bed-hold status, leading to a misunderstanding that notification was only necessary if a resident's return was not anticipated. Additionally, the facility lacked a policy addressing the notification of the Ombudsman, as confirmed by the Administrator during an interview.
Failure to Update Care Plans for Dialysis and Pressure Injury Management
Penalty
Summary
The facility failed to review and revise care plan interventions for dialysis management for Resident 21. The resident's clinical record indicated a discrepancy between the scheduled dialysis days and the care plan. The care plan, initiated on March 7, 2024, stated that the resident was to attend dialysis on Tuesday, Thursday, and Saturday, while physician orders and staff interviews confirmed that dialysis was scheduled for Monday, Wednesday, and Friday. This inconsistency was not addressed in the care plan, leading to a lack of alignment between the resident's care plan and actual treatment schedule. For Resident 27, the facility did not update the care plan to include the management of a pressure injury upon the resident's return from the hospital. The resident was admitted with an unstageable pressure ulcer on the left buttock, but the care plan was not revised to reflect this condition or to include goals and interventions for wound management. Despite the presence of a pressure injury and the need for specific interventions, the care plan remained unchanged until January 17, 2025, several months after the resident's return from the hospital. Interviews with facility staff, including the DON and Social Services, revealed that care plans were expected to be updated when there was a significant change in a resident's condition or upon readmission from a hospital stay. However, this protocol was not followed for Resident 27, resulting in a lack of documented care strategies for the pressure injury. The facility's policy required care plans to be reviewed and updated in response to significant changes, but this was not adhered to in the cases of Residents 21 and 27.
Incorrect Administration of Anti-Hypotensive Medication
Penalty
Summary
The facility failed to ensure that an anti-hypotensive medication, Midodrine, was ordered and administered correctly for a resident with multiple health conditions, including anoxic brain damage, type 1 diabetes mellitus, end-stage renal disease, bipolar disorder, and hypertension. The resident's medication orders were incorrectly written, leading to the administration of Midodrine 2.5 mg when the resident's systolic blood pressure was 126 mmHg, contrary to the order to hold the medication if the systolic blood pressure was greater than 120 mmHg. Interviews with the Director of Nursing (DON) and a Nurse Practitioner (NP) revealed that the medication order for Midodrine 5 mg was also incorrectly written, instructing staff to hold the medication if the systolic blood pressure was less than 120 mmHg, instead of greater than 120 mmHg. This error was acknowledged by the NP, who admitted to the oversight in reviewing and signing the electronic orders. The incorrect orders led to the improper administration of the medication, potentially affecting the resident's blood pressure management.
Failure to Follow Physician Orders for Anti-Hypotensive Medication Administration
Penalty
Summary
The facility failed to adhere to physician orders regarding the administration of an anti-hypotensive medication for a resident. The resident, who had a history of alcoholic cirrhosis of the liver, muscle weakness, dysphagia, essential hypertension, and alcoholic polyneuropathy, was prescribed midodrine 10 mg to be taken twice daily for decreased blood pressure, with instructions to hold the medication if blood pressure exceeded 120/80 mmHg. However, on December 28, 2024, the medication was administered despite the resident's blood pressure being 148/89, which was outside the prescribed parameters. Further review of the January 2025 Medication Administration Record (MAR) revealed that the medication was held on several occasions without documentation of the resident's blood pressure in the MAR, vital signs tab, or progress notes. Interviews with facility staff, including a QMA, RN, LPN, and the DON, indicated inconsistencies in documenting vital signs and medication administration. The facility's policy on administering medications required adherence to prescriber orders, including any specified time frames, which was not followed in this instance.
Failure to Justify Antipsychotic Medication Use
Penalty
Summary
The facility failed to ensure that a resident did not receive antipsychotic medication without proper indication related to targeted behavior expressions and mental health diagnoses. The resident in question, who had a history of bipolar disorder, mild intellectual disabilities, paranoid personality disorder, delusional disorder, and major depressive disorder, was receiving antipsychotic medication. However, the resident's quarterly Minimum Data Set (MDS) assessments initially indicated no psychotic disorder, which later changed to indicate a psychotic disorder other than schizophrenia. The care plans for the resident included the use of antipsychotic and anti-anxiety medications, with interventions to monitor and document side effects and effectiveness. Despite these interventions, the resident exhibited behaviors such as tearfulness, withdrawal, agitation, and restlessness, which were not consistently linked to the use of the medications. The facility's policy required that residents only receive antipsychotic medications when necessary to treat specific conditions, but the documentation and observations did not clearly support the continued use of these medications for the resident. Interviews with staff members revealed that the resident's understanding of conversations varied, and she could become tearful and upset easily. The resident's tearfulness was often random and not prompted by specific events, suggesting that the use of psychotropic medications may not have been adequately justified. The facility's failure to ensure that the resident did not receive unnecessary antipsychotic medication without clear indication and documentation of targeted behaviors and mental health diagnoses led to the deficiency.
Failure to Protect Resident from Sexual Abuse by Employee
Penalty
Summary
The facility failed to protect a resident from sexual abuse perpetrated by an employee, identified as DE5, who engaged in inappropriate and sexually-toned conversations with Resident B. The interactions began as friendly exchanges on Facebook Private Messenger but escalated to flirty and inappropriate messages, including DE5 sending pictures of herself in pajamas and messages indicating she was wearing only a bra and panties. Resident B, who was cognitively intact, reported feeling uncomfortable with the nature of the conversations and ended the relationship, but not before informing the Social Services Director (SSD) about the situation. Despite Resident B's report to the SSD, no further action was taken by the facility's previous administration to investigate or address the issue. The SSD advised Resident B to stop messaging DE5 but did not document the incident or follow up with the resident. The Dietary Manager (DM) was also aware of the inappropriate messaging and reported it to the previous administrator, who dismissed the concerns, stating that action could only be taken if there was evidence of sexual activity. No documentation or investigation was conducted by the previous administration regarding the allegations. The issue came to light when the new administrator received an anonymous call about the inappropriate relationship and initiated an investigation. The investigation confirmed the inappropriate nature of the messages, leading to the suspension of DE5. The facility's policies on abuse and social media use were not adhered to, as the previous administration failed to report or investigate the allegations, leaving Resident B unprotected from potential abuse.
Failure to Report Allegation of Sexual Abuse
Penalty
Summary
The facility failed to report an allegation of sexual abuse to the Indiana Department of Health when the concern was initially identified for a resident. The issue began when the resident, identified as Resident B, reported to the Social Services Director (SSD) that a Dietary Employee (DE5) was engaging in inappropriate messaging with him via Facebook Private Messenger. The messages included flirty content and photos, with one message indicating the employee was in her bra and panties. Despite Resident B informing the SSD about the situation, no further action was taken by the SSD or the previous administrator to investigate or report the incident. The Dietary Manager (DM) was also aware of the inappropriate messaging and had informed the previous administrator about the situation. However, the previous administrator dismissed the concerns, stating that the facility could not take action unless there was evidence of sexual activity. The DM did not document any of the reports or take further action to address the issue. The inappropriate messaging continued until the new administrator received an anonymous call about the relationship and initiated an investigation, which led to the suspension of DE5. The facility's policies on abuse and neglect require immediate reporting of such allegations to the state licensing agency and a thorough investigation. However, these procedures were not followed by the previous administration, resulting in a failure to report the incident in a timely manner. The lack of documentation and follow-up by the SSD and DM further contributed to the deficiency, as the situation was not addressed until months later when the new administrator took action.
Delayed Investigation of Staff-Resident Misconduct
Penalty
Summary
The facility failed to conduct a timely and thorough investigation into allegations of sexual misconduct involving a staff member and a resident. Resident B reported to the Social Services Director (SSD) that a dietary employee, DE5, was engaging in inappropriate messaging with him via Facebook Private Messenger. Despite Resident B's disclosure in May, the SSD only advised him to stop messaging DE5 and did not document the incident or follow up. The Dietary Manager (DM) was also aware of the situation and reported it to the previous administrator, who took no documented action. The inappropriate relationship continued, with DE5 sending messages and photos that crossed professional boundaries. DE5 admitted to sending a photo of herself in pajamas and a message indicating she was in her bra and panties. Despite being aware of the situation, the previous administrator did not initiate an investigation or document any actions taken. It was not until an anonymous call in September that the new administrator became aware of the situation and began an investigation, suspending DE5 and collecting evidence from Resident B. The facility's policies on abuse and neglect require immediate reporting and thorough investigation of such allegations, which were not followed in this case. The lack of documentation and follow-up by the previous administrator and other staff members resulted in a significant delay in addressing the allegations, leaving the resident without proper support and the staff member without appropriate oversight.
Failure to Perform Hand Hygiene Before and After Resident Contact
Penalty
Summary
The facility failed to ensure proper hand hygiene was performed by staff before and after moments of resident contact. During a random observation, a Restorative Aide was seen assisting a resident in a wheelchair and adjusting his foot pedals without performing hand hygiene after exiting the resident's room. The Restorative Aide admitted to sometimes delaying hand hygiene until she returned to her work room, especially if she encountered another resident needing therapy. Similarly, the Activities Director was observed assisting a resident with oxygen tubing and then distributing crafting supplies to other residents without performing hand hygiene before or after these activities. The Activities Director acknowledged that she was supposed to perform hand hygiene before and after entering a resident's room but did not always do so, despite having hand sanitizer available in her pocket and work room. The Director of Nursing (DON) and Nurse Consultant confirmed that staff were expected to perform hand hygiene before and after entering resident rooms where care was performed. The facility's current policy, dated February 2022, also stipulated that healthcare workers should use hand hygiene before and after direct physical contact with residents. These observations and interviews indicate a failure to adhere to the facility's hand hygiene policy, potentially compromising infection prevention and control measures.
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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