Envive Of River City
Inspection history, citations, penalties and survey trends for this long-term care facility in Evansville, Indiana.
- Location
- 909 North First Ave, Evansville, Indiana 47710
- CMS Provider Number
- 155520
- Inspections on file
- 18
- Latest survey
- January 7, 2026
- Citations (last 12 mo.)
- 23
Citation history
Health deficiencies cited at Envive Of River City during CMS and state inspections, most recent first.
The facility failed to follow physician orders for medication administration and implement fall prevention interventions for two residents. A resident with hypertension received medication without proper blood pressure monitoring, and non-slip strips were not placed in the shower as required. Another resident experienced a fall-related incident without new interventions being documented. The facility's policies on medication administration and care plans were not adhered to.
The facility failed to administer insulin according to professional standards, with insulin given late and by unqualified staff. A QMA administered insulin without certification, and there was a lack of nursing staff to administer insulin on time, leading to delays for several residents. Facility policies on medication administration and staffing were not followed, resulting in these deficiencies.
The facility failed to notify the physician and guardian when two residents left independently. One resident, with a court-appointed guardian, left multiple times without notification, despite a physician's order requiring guardian approval. Another resident, dependent on staff, left without the physician being informed. Facility policies on leave of absence and elopement were not followed, leading to these deficiencies.
A resident admitted with osteomyelitis and multiple wounds did not have necessary physician orders for their PICC line, wound care, and enhanced barrier precautions. A nurse administered vancomycin without donning a gown, and the clinical record lacked orders for saline flushes, PICC line management, and wound vac care. The DON confirmed these orders should have been in place upon admission.
The facility failed to ensure accurate MDS assessments for residents with specific medical conditions and incidents. A resident with PTSD and IV access was inaccurately assessed, and two residents with falls were not properly documented in their MDS assessments. The DON confirmed these omissions, indicating a failure to accurately reflect the residents' conditions and incidents.
A facility failed to establish a baseline care plan for a resident with multiple wounds and a wound vac, essential for infection control. The resident was admitted with osteomyelitis and had wounds on the gluteal folds, coccyx, and left toe, but the clinical record lacked care plans for these wounds. Observations and interviews indicated that care plans were not updated immediately upon admission, contrary to the facility's policy.
The facility failed to update care plans for two residents after significant incidents. One resident experienced multiple falls without care plan revisions, while another was involved in a methamphetamine incident and was at risk of elopement, yet her care plan was not updated. The facility's policies required care plans to be individualized and revised as conditions changed, but this was not followed.
A resident with PTSD and Borderline Personality Disorder did not receive necessary mental health services due to incorrect preadmission screening and billing issues with the contracted provider. Despite expressing a need for mental health support and showing signs of mild depression, the facility failed to arrange alternative services, impacting the resident's quality of life.
A facility failed to adhere to its policy of limiting PRN antianxiety medication to 14 days for a resident with generalized anxiety disorder. The resident was prescribed diazepam without an end date and received it on multiple occasions over a period exceeding 14 days. The facility's policy requires PRN psychotropic medications to have a 14-day stop date and be reviewed by a physician, which was not followed in this case.
The facility failed to properly label and store medications on a medication cart, with loose pills found and multi-dose containers lacking opening dates. The DON incorrectly stated that dating was unnecessary for certain medications, contrary to the facility's policy requiring opened multi-dose vials to be dated and discarded within 28 days.
The facility failed to prepare puree food correctly for two residents on altered diets. A dietary staff member was unsure of recipe conversions, and the Administrator provided incorrect conversions. The staff member used these incorrect measurements, resulting in improperly prepared puree food, which was then stored in a temperature holding area.
The facility failed to maintain complete and accurate documentation for residents, particularly in cases of elopement and falls. A resident with a court-appointed guardian left the facility multiple times without proper documentation, while another resident's leave of absence records lacked necessary details. Additionally, a resident with a history of falls had incomplete neurological checks documented. The facility's policies on documentation were not followed in these instances.
A facility failed to implement enhanced barrier precautions for a resident with a PICC line and multiple wounds, as observed when an RN administered vancomycin without donning a gown. The resident, diagnosed with osteomyelitis, had no orders for EBP in their clinical record, despite the facility's policy requiring PPE to prevent the spread of multi-drug resistant organisms.
The facility did not designate a certified Infection Preventionist (IP) who dedicates at least part-time hours to the role. The DON, responsible for the infection prevention and control program, could only allocate about 8 hours per week to this role while working full-time as the DON. The facility's program required a designated clinical team member to monitor and manage infection control activities.
The facility failed to post accurate nurse staffing information, omitting actual hours worked by RNs, LPNs, and CNAs for three days. Observations showed that the posted sheets did not specify actual shift hours, and the Administrator confirmed the inability to determine actual hours worked. This was contrary to the facility's policy requiring the recording of actual time worked.
Failure to Follow Physician Orders and Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to follow physician orders for medication administration and implement care plan interventions for residents at risk of falls. Resident D, who was admitted with diagnoses including essential hypertension and orthostatic hypotension, had specific physician orders to hold lisinopril if systolic blood pressure was less than 110. However, the medication was administered without obtaining blood pressure readings on multiple occasions, and it was given even when the systolic blood pressure was below the specified threshold on several dates. Additionally, non-slip strips, which were part of the fall prevention interventions for Resident D, were not observed in the shower room where the resident resided. Resident B, with a history of transient ischemic attack and flaccid hemiplegia, experienced an incident where they were found sliding out of their chair and lowered to the floor. Despite this incident, no new interventions were documented in the clinical record to address the risk of falls. The Director of Nursing acknowledged that a new intervention should have been implemented following the incident. The facility's policies on medication administration and care plans emphasize the importance of administering medications as prescribed and developing comprehensive, person-centered care plans with measurable objectives. However, these policies were not adhered to, as evidenced by the failure to follow blood pressure parameters for medication administration and the lack of implementation of fall prevention interventions for the residents involved.
Insulin Administration Deficiencies
Penalty
Summary
The facility failed to ensure insulin was administered in accordance with professional standards for five residents with type 2 diabetes mellitus. Insulin was administered late and by unqualified staff. For instance, Resident 18 received insulin from a Qualified Medication Aide (QMA) who was not certified to administer insulin. The Director of Nursing (DON) confirmed that QMAs were not allowed to administer insulin, indicating a breach in protocol. Additionally, there was a lack of nursing staff available to administer insulin at the scheduled times. On a specific day, there were no nurses present from 6:00 A.M. to 9:40 A.M., resulting in delayed administration of insulin for several residents, including Residents 1, 17, 11, and 8. The Registered Nurse (RN) on duty began their shift at 9:40 A.M., which was after the scheduled time for insulin administration. The facility's policies required medications to be administered within one hour of the scheduled time and documented accurately. However, the documentation was inaccurate, as evidenced by the QMA's incorrect documentation of insulin administration. The facility's policies also mandated that licensed nurses be available 24/7, which was not adhered to, leading to the deficiencies observed.
Failure to Notify Physician and Guardian of Resident Elopement
Penalty
Summary
The facility failed to notify the physician and resident representative when two residents left the facility independently, which was a requirement for their care. Resident 22, who had diagnoses including schizophrenia and stimulant dependence, was admitted with a court-appointed guardian. Despite being assessed as low risk for elopement, the resident's clinical record lacked a care plan related to the guardian or elopement risk. The resident signed out of the facility multiple times without the guardian or physician being notified, contrary to the physician's order that required guardian approval for leaving the facility. The Director of Nursing (DON) acknowledged that the former administrator had allowed the resident to leave without proper approval, and there was no documentation of the guardian's changing permissions. Resident 75, who was cognitively intact but dependent on staff for various activities, also left the facility independently without the physician being notified. The resident's clinical record included a physician's order allowing leave of absence with a responsible party as needed, but the order was not modified to reflect the resident's independent departures. The facility's policies required a sign-out log and notification of the physician and legal representative upon the resident's return, but these procedures were not followed. The facility's policies, including those for leave of absence, wandering and elopement, and adult guardianship, were not adhered to, resulting in a lack of proper documentation and notification. The DON and Administrator provided these policies during the survey, but the deficiencies in following them led to the failure to notify the necessary parties when the residents left the facility independently.
Lack of Admission Orders for Resident's PICC Line and Wound Care
Penalty
Summary
The facility failed to ensure that a resident had the necessary physician orders upon admission for the management of their medical needs, including a PICC line, wound care, and enhanced barrier precautions. On observation, a registered nurse was seen administering vancomycin to the resident without donning a gown, despite a sign indicating enhanced barrier precautions. The nurse flushed the resident's PICC line and administered the medication without documented orders for saline flushes or the PICC line itself. Additionally, a wound vac was observed on the resident's coccyx, but there were no orders for its management or for wound care. The resident, who was admitted with a diagnosis of osteomyelitis, had several wounds and a PICC line for intravenous antibiotics. The clinical record lacked essential orders for the resident's immediate care needs, such as saline flushes for the PICC line, wound vac management, and enhanced barrier precautions. The Director of Nursing acknowledged that these orders should have been in place upon admission, as per the facility's policy, which requires immediate care orders to be provided by a physician or other qualified healthcare professional.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to ensure accurate Minimum Data Set (MDS) assessments for residents with specific medical conditions and incidents. Resident 21, who was admitted with diagnoses including osteomyelitis and PTSD, was inaccurately assessed in the MDS dated 9/25/24, which failed to reflect the presence of PTSD and intravenous access, despite the care plan indicating IV medication administration. The Director of Nursing (DON) confirmed that the MDS should have included these details. Additionally, the facility did not accurately document falls for two residents. Resident 10, who required substantial assistance for daily activities, experienced an unwitnessed fall resulting in a hospital transfer, which was not recorded in the MDS assessment dated 9/27/24. Similarly, Resident 2, with a history of falls and cognitive impairment, had an unwitnessed fall on 7/19/24 that was not documented in the MDS assessment dated 9/13/24. The DON acknowledged these omissions, indicating a failure to accurately reflect the residents' conditions and incidents in the MDS assessments.
Failure to Establish Baseline Care Plan for Wound Management
Penalty
Summary
The facility failed to ensure that a baseline care plan was in place for a resident with multiple wounds and a wound vac, which is crucial for infection control. The resident, identified as Resident 225, was admitted with a diagnosis of osteomyelitis and had a power injection catheter in the right chest, along with wounds on the left gluteal fold, right gluteal fold, coccyx, and left toe. Despite these conditions, the clinical record lacked baseline care plans for all four documented wounds and the management of the wound vac. Observations and interviews revealed that the care plans were not updated immediately upon admission, as required by the facility's policy for comprehensive, person-centered care plans.
Failure to Update Care Plans After Incidents
Penalty
Summary
The facility failed to revise care plans for two residents following significant incidents. Resident 2, who had a history of repeated falls and cognitive impairment, experienced multiple unwitnessed falls on different occasions. Despite these incidents, the care plan was not updated with new interventions to address the falls. The Director of Nursing acknowledged that care plans should be updated after each fall, but this was not done for Resident 2. Resident 22, diagnosed with schizophrenia and stimulant dependence, was involved in an incident where methamphetamine was found in her possession. The care plan was not updated following this incident, nor was it revised to reflect her risk of elopement, despite her inclusion in the facility's elopement binder. The Director of Nursing confirmed that residents at risk of elopement should have corresponding care plans, and the Regional Support noted the absence of a substance abuse policy, which had been retired without replacement. The facility's policies required care plans to be individualized and updated as residents' conditions changed, but this was not adhered to in these cases.
Failure to Provide Mental Health Services for Resident with PTSD
Penalty
Summary
The facility failed to provide necessary social services to address the mental and psychosocial needs of a resident with a history of PTSD and Borderline Personality Disorder. The resident, who was admitted with these diagnoses, expressed anxiety and a desire for mental health services, which were not provided. The facility's Social Service Director acknowledged that the preadmission screening was completed incorrectly by the hospital and should have been reviewed and corrected upon admission. Despite the resident's indication of mild depression on the PHQ-9 Questionnaire, no mental health services were arranged due to billing issues with the contracted behavioral health company. The resident's care plan included a risk for ineffective coping due to past experiences, yet the facility did not take appropriate steps to ensure mental health services were provided. The Social Service Director admitted that the facility would have to cover the cost of services since the contracted provider could not bill the resident's insurance, but no alternative providers were contacted. This oversight resulted in the resident not receiving the necessary mental health support to achieve the highest possible quality of life, as required by the facility's standards.
Failure to Limit PRN Antianxiety Medication to 14 Days
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary medications, specifically regarding the use of PRN antianxiety medication. Resident 18, who was diagnosed with generalized anxiety disorder and had no cognitive impairment, was prescribed diazepam, an antianxiety medication, to be taken as needed every 8 hours. The order, dated 8/28/24, did not include an end date, and the resident received the medication on multiple occasions from 8/28/24 to 10/9/24. The facility's policy, as confirmed by the Director of Nursing, requires that PRN orders for psychotropic medications have a stop date of 14 days and be reviewed by a physician every 14 days for continuance. However, this policy was not followed in the case of Resident 18, leading to the deficiency.
Medication Labeling and Storage Deficiency
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications on one of the two medication carts observed. During an observation on the 100 hall medication cart, surveyors found an oblong maroon colored pill and a small round white pill that were loose and not properly stored. Additionally, two dropper bottles of medication were found without patient labels, and two open bottles of multi-dose medications lacked a date indicating when they had been opened. The Director of Nursing (DON) incorrectly stated that multi-dose medications like Miralax did not require the date of opening to be written on them. The facility's Medication Labeling and Storage policy, provided by the Administrator, indicated that multi-dose vials should be dated when opened and discarded within 28 days unless otherwise specified by the manufacturer.
Incorrect Puree Food Preparation for Residents
Penalty
Summary
The facility failed to ensure that food was correctly prepared for two residents who required puree-altered diets. During an observation, a dietary staff member was preparing puree foods but was unsure of the conversion from a recipe designed for 15 servings to 5 servings. The Administrator provided handwritten conversions, which were later found to be incorrect. The dietary staff member proceeded to prepare the puree using these incorrect conversions, resulting in the wrong amounts of ham, apple juice, and food thickener being used. The puree was then stored in a temperature holding area. This incident was noted during an interview with the Administrator, who acknowledged the error in the conversions.
Incomplete Documentation for Resident Elopement and Falls
Penalty
Summary
The facility failed to ensure complete and accurate documentation for residents, particularly in cases of elopement and falls. Resident 22, diagnosed with schizophrenia and stimulant dependence, was identified as being at low risk for elopement but was listed in the elopement binder as at risk. Despite having a court-appointed guardian and a physician order restricting her from leaving the facility without approval, Resident 22 signed herself out multiple times without proper documentation of who she left with, expected return time, instructions provided, or medications sent. The Social Services Director acknowledged that the resident was supposed to check in but failed to document these occurrences. Resident 21, with diagnoses including osteomyelitis and PTSD, was cognitively intact and independent in certain activities. However, the facility's documentation for his leave of absence was incomplete, lacking records of medications sent, return times, and signatures of facility representatives. Additionally, there was no physician order authorizing independent leave of absence, despite the resident being listed in the elopement binder. Resident 2, with a history of repeated falls and mild cognitive impairment, had incomplete neurological checks following falls. The facility's documentation showed missing entries for required neuro checks after two separate falls. The Director of Nursing confirmed that neuro checks should be completed and documented, even if done late. The facility's policies on leave of absence and documentation emphasized the need for complete and accurate records, which were not adhered to in these cases.
Failure to Implement Enhanced Barrier Precautions for Resident with PICC Line
Penalty
Summary
The facility failed to ensure that a resident with a PICC line and multiple wounds was provided with enhanced barrier precautions (EBP) as required for infection control. During an observation, a registered nurse (RN) was seen preparing and administering vancomycin to the resident without donning a gown, despite a sign on the door indicating the need for EBP. The RN flushed the resident's PICC line and connected the medication without using the necessary protective equipment. The resident had a wound vac on the coccyx and was diagnosed with osteomyelitis, indicating a high risk for infection. A review of the resident's clinical record showed no orders for enhanced barrier precautions or transmission-based precautions related to the resident's wounds and PICC line. The care plans included various instructions for managing the resident's venous access device and monitoring for signs of infection, but did not address the need for EBP. The Director of Nursing later confirmed that staff should wear personal protective equipment when providing care to residents, aligning with the facility's policy on enhanced barrier precautions to prevent the spread of multi-drug resistant organisms.
Failure to Designate a Dedicated Infection Preventionist
Penalty
Summary
The facility failed to ensure the designation of a certified Infection Preventionist (IP) who dedicates at least part-time hours to the role. The Director of Nursing (DON) was responsible for the infection prevention and control program but was only able to dedicate approximately 8 hours per week to this role, despite working full-time as the DON. The DON held an IP certification dated November 14, 2021. The job description for the Infection Preventionist Nurse indicated that the IP provides assistance to the DON when needed. The facility's Infection Prevention and Control Program, dated August 2022, required a designated clinical team member to monitor the program, perform surveillance, and manage infection control activities.
Inaccurate Nurse Staffing Information Posting
Penalty
Summary
The facility failed to post accurate nurse staffing information, specifically the actual hours worked by licensed and unlicensed nursing staff responsible for resident care, for three out of four days during the annual survey period. On 10/8/24, an observation revealed that the posted nurse staffing data sheet did not specify the actual hours of shifts for RNs, LPNs, and CNAs. The sheet inaccurately indicated that a CNA worked 4 hours during the evening shift without specifying the actual hours worked. Further review of staffing sheets for 10/8/24, 10/9/24, and 10/10/24 confirmed that none reflected the actual hours worked. The Administrator admitted the facility did not have an evening shift and could not determine the actual hours worked from the posted sheets. The facility's policy, dated 8/2024, required that the actual time worked be recorded, which was not adhered to.
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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