Envive Of Indianapolis
Inspection history, citations, penalties and survey trends for this long-term care facility in Indianapolis, Indiana.
- Location
- 45 Beachway Dr, Indianapolis, Indiana 46224
- CMS Provider Number
- 155077
- Inspections on file
- 41
- Latest survey
- March 4, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Envive Of Indianapolis during CMS and state inspections, most recent first.
A resident with hemiplegia, a right AKA, and behavioral diagnoses requiring two-person assistance for transfers and showers was left in a shower room while one CNA sought additional help and another CNA remained at the doorway. The resident became upset, began banging and yelling, and a verbal altercation ensued between the resident and the CNA at the door. Multiple nurses reported hearing both the resident and the CNA yelling and cursing at each other from the shower room and later at the nurse’s station, while one CNA reported only hearing the resident’s racially charged and profane insults and seeing him spray the CNA with the shower head. In interviews, the resident stated that the CNA entered the shower room, yelled at him, cursed and called him names, and later yelled at him again at the nurse’s station. The facility’s investigation, under its abuse and neglect protocol that includes verbal abuse, substantiated that the CNA verbally abused the resident.
A facility did not complete a thorough investigation after a resident reported being struck by another resident following a disagreement in the smoking area. The affected resident, who had a history of stroke and amputation, reported pain and ongoing discomfort, but the investigation was limited to statements from the involved parties and an LPN who did not witness the event. No additional staff or resident interviews were conducted, and the Administrator was unaware of the ongoing psychosocial concerns.
A resident with diabetes and neuropathy sustained a full thickness burn to the left foot during wound care when an LPN failed to properly check water temperature and left the resident unattended. The burn was not promptly or thoroughly assessed, and documentation was incomplete. The resident's condition worsened, resulting in hospitalization and surgical intervention for the burn.
A resident with diabetes and neuropathy, who required staff assistance for foot care, sustained a full-thickness burn after an LPN prepared a basin of water for a foot soak, failed to verify the water temperature after filling the basin, and left the resident unattended. The resident, experiencing numbness, placed his foot in the hot water and developed a severe burn, ultimately requiring surgical intervention.
A facility failed to document the reasons for discharging a resident with multiple behavioral issues and did not allow the resident to appeal the discharge. The resident, who had antisocial personality disorder and other conditions, was not permitted to return after a hospital stay. The facility did not provide a discharge assessment or a 30-day notice, and there was a lack of communication with the resident's family and the ombudsman.
A facility failed to allow a resident to return after hospitalization, violating the resident's rights. The resident, with multiple mental health diagnoses, was transferred to a hospital after calling 911. The facility cited safety concerns due to the resident's behavior, including aggression and property damage, but lacked documentation justifying the denial of return. The decision was made without a discharge assessment, and the resident's mother was not informed of the reasons.
The facility did not update its Facility Assessment Tool to reflect current resident needs, affecting 102 residents. The tool lacked details on psychiatric care providers and their availability, and failed to address infection control and accident hazards. This oversight could impact the facility's ability to provide adequate care.
The facility failed to accurately code the MDS for four residents requiring Level II PASRR, as identified during a record review. Despite having Level II PASRRs, the MDS assessments for these residents did not reflect this requirement, contradicting their care plans. The MDS Coordinator, new to the facility, could not explain the discrepancies, which were against the facility's policy that mandates consistency between MDS assessments and care plans.
The facility failed to ensure symptomatic staff were tested or wore masks, and staff did not use PPE during high-contact care for residents requiring Enhanced Barrier Precautions (EBP). Staff members worked while ill without masks, and PPE was not available for residents with chronic wounds and indwelling devices, such as a resident with necrotizing fasciitis and another with a urinary catheter. This non-compliance with infection control protocols risked spreading infections.
The facility failed to maintain accurate Smoking Safety assessments and lacked clear policies for smokers, affecting 30 residents. A resident sustained facial burns from smoking with oxygen, and others were found smoking unsafely. Records lacked documentation of safety evaluations and care plan revisions.
A facility failed to update a resident's advance directive wishes in her medical record. The resident, with conditions including dementia and schizoaffective disorder, had changed her Physician Scope of Treatment (POST) form to Do Not Resuscitate (DNR) from a full code status. However, her physician orders and care plans were not updated to reflect this change. The Social Service Director confirmed the oversight, which was against the facility's policy requiring updates to be documented in the resident's medical record and plan of care.
A resident with hemiplegia, cerebral infarction, and major depressive disorder was not provided with adequate one-on-one activities as per her care plan. Despite expressing a desire to participate in activities, she was visited infrequently by activity staff, who did not leave her with activities to engage in. Records indicated insufficient visits, and the facility lacked a specific policy for one-on-one activities.
A resident with multiple diagnoses requested to be sent to the hospital, but the facility failed to assess and prepare him for transfer. There was no documentation of vital signs, patient condition, or notification to the nurse or physician. Discrepancies were found in the Leave of Absence log and Transfer-to-the-Hospital form, and the resident's care plans did not address his history of calling 911 or inconsistent use of the LOA policy.
A resident with hemiplegia and dementia developed new pressure ulcers due to the facility's failure to provide necessary treatments and services. Despite recommendations for a low air loss mattress, the resident developed a new stage 2 pressure ulcer. The facility's policy required at-risk individuals to be placed on appropriate support surfaces, which was not followed, leading to this deficiency.
A resident with COPD and schizophrenia did not receive necessary toenail care despite having an active physician's order for podiatry services. Observations showed the resident's toenails were long and discolored, and he reported having to rip them off due to lack of care. The facility's policies on nail care and ADLs were not followed, as the resident was not scheduled for the next podiatry visit.
A resident experienced an 11.26% weight loss over two months, and the facility failed to evaluate and address the nutritional status adequately. Despite the resident's significant weight loss and existing medical conditions, there were no active orders for nutritional supplements, and the care plan lacked new interventions. The Registered Dietician noted the need for reweight verification, but there was no documentation of physician notification or assessment of the weight discrepancy.
A facility failed to document pre and post dialysis assessments for a resident with ESRD receiving dialysis from an outside facility. The resident's medical records lacked documentation for multiple dates, despite a care plan requiring such assessments. The Vice President of Clinical Services admitted that the assessments could not be located, and the dialysis center's paperwork was only obtained upon request.
The facility failed to date and manage medications properly, with observations revealing undated Tubersol in the A wing medication room and insulin pens on medication carts lacking opening dates. An LPN noted a vial of Amikacin was opened without a date. The facility's policy requires multi-dose vials to be dated and discarded within 28 days, which was not followed.
A facility failed to maintain accurate medical records for a resident with schizoaffective disorder and mobility issues. After the resident experienced a fall, the facility was supposed to implement 15-minute safety checks for 72 hours. However, they could not provide documentation proving these checks were completed, violating their policy on Falls and Fall Risk Management.
A resident's privacy was compromised during incontinent care when staff left the door open, exposing her to passersby. Despite the presence of an RN and a CNA, the resident's bare bottom and wounds were visible from the hallway. The resident, who has spina-bifida and anxiety, expressed discomfort with the lack of privacy, which contradicted her care plan emphasizing dignity and respect.
The facility failed to install call light devices with pull cords in 16 out of 60 residents' bathrooms, as identified through interviews and observations. Resident B and Resident C reported issues with the absence of pull cords and call light devices, respectively. An environmental tour confirmed these deficiencies, which were not identified during weekly staff reviews, despite the facility's policy requiring operational and accessible call lights.
The facility failed to protect a resident's right to smoke, affecting one resident with multiple diagnoses. Despite being offered a smoking cessation aid, the resident reported not receiving it. The care plan was later updated to allow supervised smoking.
Failure to Protect a Resident From Verbal Abuse During Shower Care
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from verbal abuse by a CNA during a shower episode. A resident with hemiplegia, hemiparesis following a cerebral infarction, a right above-knee amputation, intermittent explosive disorder, PTSD, and adjustment disorder was care planned as dependent on staff for transfers and bathing, used an electric wheelchair, and required care in pairs due to extensive attention-seeking behaviors and making false statements and accusations. On the day of the incident, the resident was in the shower room receiving care from two CNAs for transfer and showering, consistent with his need for two-person assistance. After the shower was completed, one CNA left to obtain a male staff member to assist with the transfer, and the other CNA (CNA 6) was positioned outside the shower room door to provide oversight and privacy. While the resident remained in the shower room, he became upset and began banging and yelling. Multiple staff witness statements and interviews indicated that a verbal altercation then occurred between the resident and CNA 6. Nurse witnesses reported hearing loud voices and both the resident and CNA 6 yelling and cursing at each other from the shower room, but did not see any physical altercation. One nurse supervisor reported that when she approached, she heard yelling and cursing from both the resident and CNA 6, and that CNA 6 ran out of the shower room stating the resident had hit her. When the supervisor and charge nurse spoke privately with the resident, he admitted he had been cursing at the CNA and stated she was cursing back at him, and that she lunged at him in a threatening manner "like a boxer," though he denied that anyone was hit. Additional staff accounts described the resident directing racially charged and profane insults toward CNA 6, including references to her "fat black African" appearance, and spraying her with the shower head. One CNA stated she did not hear CNA 6 engage verbally with the resident at that time, while another RN reported hearing both the resident and CNA 6 "cussing each other out" in the shower room and later again at the nurse’s station. In his own interview, the resident stated that CNA 6 came into the shower room and started yelling at him, cursing and calling him names, and that he yelled back and told her to get out. He reported that when he later passed the nurse’s station, CNA 6 again began to yell at him and he yelled back until another CNA intervened. The facility’s abuse and neglect protocol defined abuse as including verbal abuse that causes physical harm, pain, or mental anguish, and the internal investigation concluded that CNA 6 had engaged in verbal abuse of the resident during this incident.
Failure to Thoroughly Investigate Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to conduct a thorough investigation following a resident-to-resident allegation of abuse involving two cognitively intact residents. The incident occurred in the smoking area, where a disagreement led to one resident making physical contact with the other's cheek. The affected resident reported moderate pain and was assessed by nursing staff, who found no visible injuries. Both residents were separated, and notifications were made to the physician, DON, Administrator, and resident representatives. However, the investigation documentation included only a written statement from an LPN who did not witness the event and a summary of brief interviews with the involved residents. The resident who was struck reported feeling embarrassed and uncomfortable after the incident, noting swelling on his face and a sense of unease around the other resident. He also expressed that staff did not address his feelings privately and that he continued to feel uncomfortable, choosing to smoke in his truck to avoid further misunderstandings. Despite these ongoing concerns, the Administrator was unaware of the resident's discomfort and did not interview other residents or staff who may have witnessed the incident or had relevant information. The facility's policy required all accidents or incidents to be investigated and reported to the Administrator, but the investigation was limited to statements from the involved residents and a non-witnessing LPN. No additional interviews or broader inquiry were conducted to fully assess the circumstances or psychosocial impact. The lack of a comprehensive investigation did not meet the facility's policy or regulatory expectations for handling resident-to-resident abuse allegations.
Failure to Provide Timely Assessment and Treatment of Burn Injury
Penalty
Summary
A resident with a history of diabetes mellitus type II and degenerative disease of the nervous system sustained a full thickness burn to the left foot during wound care. The incident occurred when a nurse prepared a basin of water for the resident to soak his foot prior to applying a treatment for an unrelated skin condition. The nurse checked the water temperature by hand but did not use a thermometer or recheck the temperature after filling the basin. The resident, who had decreased sensation in his feet due to diabetes, initially reported the water felt too hot and removed his foot. The nurse, after assuring the resident the water was not too hot, left the room to gather supplies, instructing the resident to wait. However, the resident placed his foot back in the water, and when the nurse returned several minutes later, a blister had formed on the top of his foot. Following the incident, documentation in the clinical record was incomplete. There was a lack of timely and thorough assessment and description of the burn wound, particularly on the day after the incident. Progress notes indicated the wound worsened over the next two days, with blisters, sloughing, copious drainage, and increased pain. The nurse practitioner did not remove the dressing or fully assess the wound during follow-up visits, and the physician was not immediately involved in the assessment. The resident's pain escalated, and the wound was eventually described as a third-degree burn with significant tissue damage. Due to the severity of the injury and inadequate initial assessment and intervention, the resident required emergency transfer to an acute care burn unit. Hospital records confirmed a full thickness scald burn, necessitating two surgical procedures for debridement and skin grafting. The facility's documentation and care planning did not accurately reflect the burn injury or the subsequent hospitalization, and staff interviews revealed lapses in communication, assessment, and documentation following the incident.
Resident Sustains Full-Thickness Burn Due to Improper Foot Soak and Inadequate Supervision
Penalty
Summary
A resident with a history of diabetes mellitus, neuropathy, and a diabetic foot ulcer required partial to moderate staff assistance for lower body dressing and footwear. The resident's care plan included an intervention to avoid exposure to extreme heat or cold. During a scheduled wound care session, an LPN prepared a basin of water for the resident to soak his foot, intending to clean the area before treatment. The LPN checked the water temperature by hand while filling the basin but did not verify the temperature after the basin was filled. The resident initially expressed that the water felt hot and removed his foot, but the LPN reassured him and left the room to retrieve supplies, instructing him to wait. While the LPN was out of the room for approximately five minutes, the resident placed his foot back into the basin. Upon the LPN's return, a blister had developed on the top of the resident's left foot. The resident, who experienced frequent numbness in his feet due to neuropathy, did not realize the water remained too hot. Subsequent nursing assessments documented the development of blisters, sloughing, copious drainage, and significant pain. The resident later described the pain as excruciating, and the wound was observed to be a third-degree burn with yellow slough, redness, and matted toes. The incident resulted in the resident being transferred to an acute care burn unit, where he was diagnosed with a full-thickness scald burn to the left foot and underwent two surgical procedures for debridement and skin grafting. Interviews with facility staff confirmed that soaking the resident's foot was not part of the wound care orders and that the LPN should not have left the resident unattended with the basin of water. The lack of proper supervision and failure to ensure safe water temperature directly led to the resident sustaining a serious burn injury.
Failure to Document and Allow Appeal for Resident Discharge
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident D, was able to appeal a facility-initiated discharge and did not document the reasons for the discharge. Resident D, who had multiple diagnoses including antisocial personality disorder, bipolar disorder, and traumatic brain injury, was not allowed to return to the facility after a hospital stay. The facility did not provide documentation of why the resident was discharged or how he posed a danger to himself or others, nor did they honor his right to return pending an appeal. Resident D had a history of aggressive and inappropriate behaviors, including throwing his colostomy bag at staff, making false allegations, and being non-compliant with care. Despite these behaviors, the facility did not document specific incidents that justified the denial of his readmission. The Executive Director acknowledged that the resident's admission documentation did not indicate such behaviors, and there was no clear documentation of the resident's current condition at the hospital. Interviews with the Social Services Director and the Executive Director revealed concerns about the safety of other residents and staff due to Resident D's behaviors. However, the facility did not complete a discharge assessment or provide a 30-day notice of intent to discharge, as required. The ombudsman and Resident D's mother were also unaware of the specific reasons for the discharge, highlighting a lack of communication and documentation regarding the facility's decision.
Facility Fails to Allow Resident Return Post-Hospitalization
Penalty
Summary
The facility failed to adhere to its policy by not allowing a resident to return after hospitalization, which was a violation of the resident's rights. Resident D, who had multiple diagnoses including antisocial personality disorder, bipolar disorder, and traumatic brain injury, was transferred to a hospital after calling 911. The facility did not document any specific incidents that justified the denial of his return, nor did it provide evidence that the resident was a danger to himself or others. The facility's decision was based on concerns about the resident's behavior, which included throwing a colostomy bag at staff, hitting a staff member, and causing property damage. Interviews with facility staff revealed that the decision not to readmit Resident D was made by the company due to safety concerns for other residents and staff. The Executive Director acknowledged that the resident's admission documentation did not indicate such behaviors, and there was no discharge assessment completed. The ombudsman confirmed witnessing the resident's behavior and advised the facility to issue a 30-day notice of intent to discharge. The resident's mother was unaware of the reasons for the denial of readmission and expressed concern about his belongings.
Failure to Update Facility Assessment Tool
Penalty
Summary
The facility failed to update its Facility Assessment Tool in a timely manner to accurately reflect the specific nursing needs, care, and treatment services for its resident population. During the survey, it was found that the Facility Assessment Tool provided by the Administrator was outdated, with the most recent assessment dated November 2024 containing identical information to the previous year's assessment. This oversight meant that the data did not accurately reflect the current population and resident needs, potentially affecting all 102 residents receiving care in the facility. The assessment tool failed to document critical information regarding the facility's ability to manage mental health and behavioral needs. It did not specify the psychiatric provider, their availability, or how residents' needs for psychiatric services were determined. Additionally, the tool lacked details on the staff members or contracted providers responsible for behavioral and mental health care, including their availability and the extent of services provided. Furthermore, during a QAPI interview, it was noted that concerns related to infection control practices and accident hazards, such as resident smoking procedures, had not been identified or discussed, indicating a gap in the facility's risk management processes.
Inaccurate MDS Coding for Level II PASRR
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for four residents who required a Level II Pre-admission Screening and Resident Review (PASRR). The discrepancies were identified during a record review and interview process. Resident 52, diagnosed with schizophrenia, muscle weakness, and hyperlipidemia, had a Level II PASRR dated August 8, 2023, but his MDS assessment dated April 4, 2024, incorrectly indicated he did not require a Level II PASRR. Similarly, Resident 49, with diagnoses including schizophrenia and bipolar disorder, had a Level II PASRR dated August 11, 2022, but his MDS did not reflect this requirement. Resident 9, diagnosed with multiple psychiatric disorders, had a Level II PASRR dated September 12, 2023, yet his MDS failed to indicate the need for Level II. Lastly, Resident 14, with various mood and anxiety disorders, had a Level II PASRR dated March 7, 2024, but his MDS did not reflect this requirement. The MDS Coordinator, during an interview, admitted to being new to the facility and was unable to explain the inaccuracies in the coding of Level II PASRRs. The facility's policy on Resident Assessments, provided by the Vice President of Clinical Services, stated that information in the MDS assessments should consistently reflect the information in progress notes, care plans, and resident observations/interviews. However, the MDS assessments for these residents did not align with their care plans, which indicated the need for Level II PASRRs, highlighting a significant deficiency in the facility's assessment process.
Inadequate Infection Control and PPE Use
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, as evidenced by staff members who were symptomatic with illness not being tested or wearing source control measures to prevent the spread of infection. Several staff members, including the former Regional Nurse Consultant, the Memory Care Coordinator, and the Corporate Business Office Manager, were observed working while exhibiting symptoms of illness such as coughing, sneezing, and hoarseness, without wearing masks. The facility's policy required staff with symptoms of contagious illnesses to follow CDC guidelines, including wearing well-fitted source control and not reporting to work when ill, but this was not adhered to. Additionally, the facility did not ensure that staff donned personal protective equipment (PPE) while providing high-contact care to residents requiring Enhanced Barrier Precautions (EBP). Observations revealed that staff members, including registered nurses and certified nursing assistants, did not wear PPE while performing tasks such as wound care and hygiene assistance for residents with chronic wounds and indwelling medical devices. The facility's policy required PPE to be available and used for such residents to prevent the transmission of multi-drug-resistant organisms, but PPE was not readily available outside or inside the residents' rooms. Specific residents, such as Resident B and Resident D, who had conditions necessitating EBP, were not provided with the required precautions. Resident B had a history of necrotizing fasciitis, open wounds, and indwelling medical devices, while Resident D had chronic wounds and a urinary catheter. Despite their needs, staff did not use PPE during care, and EBP signs and equipment were not consistently present in their rooms. This lack of adherence to infection control protocols had the potential to affect multiple residents requiring EBP.
Deficient Smoking Safety Practices in Facility
Penalty
Summary
The facility failed to ensure that residents who chose to smoke had accurate and current Smoking Safety assessments and interventions. The facility also lacked clear, concise, and consistent policies and procedures for independent versus supervised smokers, and the storage and accountability of smoking materials. This deficiency had the potential to affect 30 of 56 residents reviewed for smoking. The report highlights several incidents where residents were found smoking unsafely, including Resident E, who sustained facial burns after lighting a cigarette while wearing oxygen. Resident E, a long-term care resident with multiple psychiatric and cognitive diagnoses, was involved in a serious incident where he lit a cigarette in a transport vehicle, causing burns to his face. Despite this incident, Resident E continued to obtain smoking materials and attempted to smoke, even while using oxygen. The facility's records lacked documentation of a comprehensive Smoking Safety evaluation or a revised care plan to address Resident E's unsafe smoking behaviors and his ability to adhere to the Leave of Absence policy. Other residents, such as Resident 6 and Resident 80, also demonstrated unsafe smoking behaviors. Resident 6 was found smoking in his room multiple times, and his care plan lacked revisions to address his non-compliance with the smoking policy. Resident 80 was witnessed with his hair on fire from a cigarette, yet the facility did not complete a Smoking Safety evaluation after the incident. Additionally, several residents refused to sign the Smoking Policy, and their records lacked individualized plans to address their refusal and ensure their safety.
Failure to Update Resident's Advance Directive Wishes
Penalty
Summary
The facility failed to update a resident's advance directive wishes in her medical record, leading to a deficiency. Resident 53, a long-term care resident with diagnoses including dementia, schizoaffective disorder, and peripheral vascular disease, had an original Physician Scope of Treatment (POST) form dated 10/2/23 indicating a full code status. However, an updated POST form dated 7/20/24 showed that the resident wished to change her status to Do Not Resuscitate (DNR). Despite this change, the resident's physician orders still reflected a full code status and had not been revised to align with the updated POST form. Additionally, Resident 53's comprehensive care plans, which included a care plan dated 10/4/23, indicated she wished to be a full code and were not updated to reflect her new DNR status after the POST form was changed. During an interview, the Social Service Director confirmed that the physician order and care plan had not been updated as required. The facility's policy on advance directives, revised in February 2024, mandates that the Director of Nursing Services or designee notify the attending physician of any changes in advance directives to ensure appropriate documentation in the resident's medical record and plan of care.
Failure to Provide Adequate One-on-One Activities for Resident
Penalty
Summary
The facility failed to provide an ongoing program of one-on-one activities for a resident who was reviewed for activities. The resident, who had diagnoses including hemiplegia, cerebral infarction, and major depressive disorder, expressed a desire to participate in activities but was unable to do so due to pain when using a wheelchair. Despite being on a one-on-one activity schedule, the resident reported that activity staff would visit infrequently and not leave any activities for her to engage in, resulting in her spending most of her time in bed watching TV. The resident's care plan, dated December 2023, indicated that she should receive one-on-one activities as desired and tolerated. However, records showed that the resident was visited only 10 times in December, 7 times in January, and 5 times in the first half of February. An activity aide confirmed that there was a weekly schedule for residents unable to leave their rooms and that staff should visit these residents daily, recording any refusals and attempting revisits. Despite a request, the facility did not provide a specific policy for one-on-one activities, only a policy related to activity evaluation.
Failure to Assess and Document Resident Transfer to Hospital
Penalty
Summary
The facility failed to ensure that a resident who requested to be sent to the hospital was properly assessed and prepared for transfer. Resident E, a long-term care resident with multiple diagnoses including schizoaffective disorder, bipolar disorder, and dependence on supplemental oxygen, expressed a desire to go to the hospital. However, there was no documentation indicating that a nurse assessed the resident or prepared him for the transfer. The record also lacked documentation of vital signs, patient condition, or the reason for the hospital request. Furthermore, there was no evidence that the nurse or physician was notified of the resident's transfer to the hospital. The facility's records showed discrepancies in the documentation of Resident E's transfer. The Leave of Absence (LOA) log did not reflect that Resident E signed out to smoke or go to the hospital on the specified dates. Additionally, the Transfer-to-the-Hospital form was completed hours after the resident had already arrived at the hospital. Resident E's care plans did not address his history of calling 911 himself or his inconsistent use of the LOA policy. The facility's policy on discharging residents was not followed, as there was no transfer summary or telephone report to the receiving facility, and the resident's condition at discharge was not documented.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatments and services to promote the healing of a pressure ulcer and prevent new pressure ulcers from developing for a resident. The resident, who had diagnoses including hemiplegia and dementia, was observed with pressure ulcers on his body. A skin and wound note from December 12, 2024, indicated the presence of an abscess on the back of the resident's left thigh, an unstageable pressure ulcer on the right buttock, and a stage 3 pressure ulcer on the back of the right thigh. Treatment recommendations included the need for a low air loss (LAL) mattress. Despite having an active order for a LAL mattress dated December 20, 2024, the resident developed a new stage 2 pressure ulcer on the left buttock by December 19, 2024. The facility's policy on support surfaces, dated August 2024, indicated that individuals at risk for developing pressure ulcers should be placed on a redistribution support surface. The failure to implement the recommended support surface contributed to the development of a new pressure ulcer, indicating a deficiency in the facility's care for the resident.
Failure to Provide Podiatry Services for a Resident
Penalty
Summary
The facility failed to provide necessary toenail care for Resident 66, who was observed with long, rough, thick, and discolored toenails. Despite having an active physician's order for podiatry services, the resident reported that podiatry had not yet attended to him, and he had previously resorted to ripping his toenails off due to the lack of care. Observations on two separate occasions confirmed that the resident's nails remained untrimmed, and he continued to express dissatisfaction with the lack of podiatry services. Resident 66, a long-term care resident with chronic obstructive pulmonary disorder (COPD) and schizophrenia, had been recommended for a podiatry consult by a Nurse Practitioner (NP) due to thickened toenails and foot pain. However, despite being placed on the podiatry list, the resident was not scheduled for the next podiatry visit. The facility's policies on nail care and activities of daily living (ADLs) emphasize the importance of maintaining personal hygiene, yet these were not adhered to in the case of Resident 66.
Failure to Address Resident's Nutritional Needs
Penalty
Summary
The facility failed to adequately evaluate and address the nutritional status of a resident, resulting in an 11.26% weight loss over two months. The resident, who had diagnoses including hemiplegia, major depressive disorder, dementia, and obsessive-compulsive disorder, was observed to have sores and reported uncertainty about their origin. Despite a significant weight loss from 231 pounds to 205 pounds, there were no active physician orders for nutritional supplements, and the resident's care plan did not reflect any new interventions to address the weight loss. The facility's records showed repeated notes from the Registered Dietician (RD) requesting a reweight to verify the weight loss, citing the use of a new scale as a potential factor. However, there was no documentation that the weight discrepancy was assessed by the dietician or that the physician was notified of the weight loss. Additionally, the resident's record lacked documentation of new care plan interventions to address his weight loss or his frequent refusals to be weighed. The facility's policy required staff to report significant weight changes to the physician, which was not adhered to in this case.
Failure to Document Dialysis Assessments for a Resident
Penalty
Summary
The facility failed to complete pre and post dialysis assessments for a resident who required dialysis services from an outside facility. The resident, identified as Resident 79, had a medical history that included diabetes mellitus type 2, heart failure, end-stage renal disease (ESRD), muscle weakness, and anxiety disorder. The review of Resident 79's medical records revealed a lack of documentation for pre-dialysis assessments on multiple dates spanning from November 2024 to January 2025. Similarly, post-dialysis assessments were also missing for several dates within the same timeframe. A comprehensive care plan dated July 2024 indicated that Resident 79 required hemodialysis due to ESRD and specified that appropriate assessments should be completed before and after dialysis sessions. During an interview, the Vice President of Clinical Services (VPCS) acknowledged that the pre and post assessments completed by the facility staff could not be located, and the paperwork from the dialysis center was not obtained until requested. The facility's policy on dialysis monitoring, dated November 2022, required vital signs to be obtained following dialysis treatment and assessments of the fistula and catheter sites for any signs of complications, which were not documented in the resident's medical record.
Medication Management Deficiency
Penalty
Summary
The facility failed to properly date and manage medications with time limitations, as well as remove expired medications from use. During an observation, a bottle of Tubersol in the A wing medication room refrigerator was found without a date indicating when it was opened. Additionally, an insulin pen on the A wing front cart, belonging to a resident, was dated but not within the appropriate time frame. Another insulin pen on the B wing front cart, belonging to a different resident, lacked an opening date. Furthermore, a vial of Amikacin on the B wing back cart, belonging to another resident, was opened without a date, although an LPN indicated it was opened that morning. The facility's policy requires multi-dose vials to be dated and discarded within 28 days unless otherwise specified by the manufacturer, which was not adhered to in these instances.
Failure to Document Safety Checks for Resident After Fall
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, identified as Resident 3, who was reviewed for medical record accuracy. Resident 3, a long-term care resident with diagnoses including schizoaffective disorder, unsteadiness on feet, and difficulty in walking, was observed yelling nonsensical things in her room. An Interdisciplinary Team note indicated that Resident 3 had a fall on January 7, 2025, and the intervention was to implement 15-minute safety checks for 72 hours to reduce falls and increase safety. However, the facility could not provide documentation proving that these 15-minute safety checks were completed for the specified duration. The facility's policy on Falls and Fall Risk Management required staff to monitor and document each resident's response to interventions intended to reduce falling or the risks of falling.
Failure to Ensure Resident Privacy During Care
Penalty
Summary
The facility failed to ensure a resident's right to privacy during incontinent care, as observed on February 7, 2025. Resident B was seen from the hallway through her open door while receiving care in bed. The privacy curtain was not closed, and her bare bottom and several wounds were visible. Registered Nurse (RN) 6 and Certified Nursing Assistant (CNA) 22 were present, with CNA 22 removing a brief from under the resident. During this time, two unidentified male residents walked past the open door, and a housekeeper briefly entered the doorway before being redirected by RN 6. RN 6 later acknowledged that the door should have been closed, attributing the oversight to an aide leaving to get a hoyer lift and forgetting to close the door. Resident B, a long-term care resident with diagnoses including spina-bifida, borderline intellectual functioning, and anxiety, expressed discomfort with the situation, noting that staff often left doors open, which bothered her due to her modesty and religious beliefs. Her comprehensive care plan emphasized the need for dignity and respect, aligning with the facility's policy on dignity, which mandates that residents be treated with respect and privacy during personal care and treatment procedures. This incident was related to a complaint identified as IN00451140.
Deficiency in Call Light Devices in Residents' Bathrooms
Penalty
Summary
The facility failed to ensure that call light devices with pull cords were installed in the residents' bathrooms, affecting 16 out of 60 bathrooms reviewed. Specifically, 7 bathrooms lacked a call light device entirely, while 9 bathrooms had call light devices without pull cords. This deficiency was identified through interviews, observations, and record reviews. During an interview, Resident B expressed concern about the absence of a pull cord on the bathroom call light, which would prevent him from calling for assistance if he fell. Similarly, Resident C reported that her bathroom lacked a call light device altogether. An environmental tour conducted with the Executive Director (ED) and Maintenance Director confirmed the absence of call light devices and pull cords in several residents' bathrooms. The ED acknowledged that all residents' bathrooms should have a call light switch and a pull cord for staff assistance. Despite ongoing renovations, the facility's policy mandates that call lights be accessible and functional at all times, yet the weekly reviews by staff failed to identify these deficiencies. The facility's policy, dated August 2024, outlines the importance of ensuring call lights are operational and accessible to residents, but this was not adhered to in the identified cases.
Failure to Protect Resident's Right to Smoke
Penalty
Summary
The facility failed to protect a resident's right to smoke cigarettes, which affected one of the four residents reviewed for smoking. Resident B, who has multiple diagnoses including cerebral palsy, paraplegia, obstructive sleep apnea, and nicotine dependence, expressed frustration over not being allowed to smoke. He was observed in the lounge preparing to call the state due to his dissatisfaction. The resident's care plan, dated 8/11/22, indicated that his smoking privileges had been suspended due to unsafe smoking behavior, specifically nodding off during a smoke break. Despite being offered a smoking cessation aid, Resident B reported that he never received the gum he requested to help him quit smoking. The Vice President of Clinical Services (VPCS) confirmed that there was no order placed for the smoking cessation aid. A new smoking assessment was completed, and Resident B's care plan was updated to allow him to smoke under supervision with a smoking apron. The facility's policies on resident rights and smoking were reviewed, indicating that residents should be supported in exercising their rights and that a designated smoking area should be established. This deficiency relates to Complaint IN00429920.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
