Envive Of Sullivan
Inspection history, citations, penalties and survey trends for this long-term care facility in Sullivan, Indiana.
- Location
- 325 W Northwood Dr, Sullivan, Indiana 47882
- CMS Provider Number
- 155468
- Inspections on file
- 27
- Latest survey
- September 29, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Envive Of Sullivan during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple diagnoses had changes to her medication regimen, including an increased dose of Risperdal and a new order for vitamin D3, but there was no documentation that her representative was notified as required. The DON confirmed the lack of notification after reviewing the medical record, and a family member reported ongoing communication issues regarding changes in care.
The facility did not ensure proper documentation or timely implementation of interventions following falls for two residents with severe cognitive impairments and fall risks. Multiple falls were not promptly or thoroughly documented in the medical record, and required assessments and care plan updates were missing. Interviews revealed that key fall-related documentation was kept in internal systems not accessible to all staff, contrary to facility policy.
The facility did not assign a qualified IP nurse separate from the DON to oversee infection prevention and antibiotic stewardship programs. Infection surveillance and antibiotic tracking were not completed for several months, with the DON solely responsible for these duties and unaware of the requirement for a separate, trained IP nurse. This affected all residents in the facility.
The facility did not consistently track infections or antibiotic use and failed to ensure required TB testing was completed for multiple residents. Medical records showed missing documentation for second TB tests, unread test results, and lapses in annual TB testing. Infection surveillance and antibiotic tracking were not conducted for several months, despite facility policy requiring these measures.
A resident with severe cognitive impairment and multiple mental health diagnoses was prescribed Risperidone and other psychotropic medications. Despite care plans requiring monitoring for side effects, documentation showed that the last AIMS assessment was completed several months prior, with no evidence of the required quarterly assessments. Staff interviews confirmed the expectation for quarterly AIMS assessments, but the DON could not locate recent documentation.
The facility did not update or implement care plans for two residents, including one who continued to have outdated care plan entries for IV antibiotics and another who lacked a pain management care plan despite frequent opioid use. Additionally, care plan meetings were not conducted or documented quarterly for a resident with severe cognitive impairment, and the family was not invited to participate as required.
Two residents who required staff assistance for ADLs, including personal hygiene, were not consistently provided help with shaving. Both residents were observed with untrimmed facial hair and expressed a preference to be clean-shaven, while staff and documentation failed to show that shaving was regularly offered or performed as required by facility policy.
A resident with a history of Parkinson's disease, diabetes, shortness of breath, and COPD had physician orders for nightly oxygen and weekly tubing changes, but observations showed the oxygen tubing was not changed or dated as required. The resident reported not receiving oxygen, and the medical record lacked a care plan for oxygen use, despite documentation indicating oxygen administration. Facility policy requiring weekly changes of oxygen equipment was not followed.
A resident with severe cognitive impairment received doxycycline for pneumonia beyond the prescribed seven-day course because the stop date was not correctly entered into the system, leading to continued administration and additional doses being taken from the Emergency Drug Kit. The DON confirmed the error, which was inconsistent with facility policy requiring clear antibiotic order durations.
Surveyors found that medications, including multi-use vials and insulin pens, were not properly labeled with open dates and expired medications such as hepatitis B vaccines were not disposed of as required. An LPN and the DON confirmed that facility policy and professional standards were not followed, affecting two residents with diabetes who had undated insulin pens on their medication carts.
The facility failed to maintain 24-hour licensed nurse coverage, resulting in two residents falling during a shift without a nurse present. The DON attempted to cover the shift but was absent at times, leaving QMAs to manage alone. Resident W, with a history of falls, suffered a significant drop in oxygen levels after a fall, requiring hospital transfer. Resident T, with an anoxic brain injury, also fell and sustained minor injuries.
A resident with polyneuropathy did not receive pregabalin as prescribed due to delays in obtaining a new prescription. The facility's staff made multiple attempts to contact the physician and pharmacy, but the medication was unavailable for several days, leading to increased pain and hospitalization. Communication issues and a change in Medical Directors contributed to the deficiency.
The facility failed to serve food at a safe and appetizing temperature, as residents reported receiving cold meals in their rooms. A test tray revealed that food items were below the required temperature of 135 degrees Fahrenheit, contrary to the facility's policy. The Dietary Manager confirmed the deficiency in food temperature.
The facility failed to maintain temperature logs for the walk-in refrigerator and freezer for several days in April. The housekeeping supervisor and dietary aide were unaware of the lapses, despite a policy requiring twice-daily checks.
The facility failed to properly administer inhaled medication to a resident, resulting in a medication error rate of 6.67%. An LPN did not follow the required procedure of allowing a waiting period and mouth rinsing between administering Advair and Spiriva inhalers, contrary to physician orders and facility policy.
The facility failed to properly dispose of expired medications in the medication storage room. An RN was unaware of the policy, and both the Administrator and President of Clinical Operations confirmed the medications were expired and should have been discarded according to facility policy.
The facility failed to document wound treatments for a resident with severe cognitive deficit and multiple medical conditions, leading to a deep tissue injury that progressed to a stage 3 pressure ulcer. The treatment administration records lacked documentation of several physician-ordered treatments, and the DON confirmed that without signatures, there was no way to ensure treatments were completed.
The facility failed to ensure accurate staffing sheets were posted daily for three out of five days during the recertification survey. The staffing sheets were dated correctly but lacked documentation of the total number and actual hours worked by licensed and unlicensed nursing staff. The DON was unaware of the inaccuracies and indicated that the night shift nurse was responsible for posting the sheets.
Failure to Notify Resident Representative of New Medication Orders
Penalty
Summary
The facility failed to notify a resident's representative of new medication orders, as required by policy. A resident with severe cognitive impairment, Alzheimer's disease, and major depressive disorder with psychotic symptoms had changes to her medication regimen, including an increase in Risperdal dosage and the addition of vitamin D3. Documentation in the resident's record did not show that the representative was informed of these new orders. Progress notes specifically lacked evidence of notification following both the Risperdal dosage change and the initiation of vitamin D3. Interviews with the resident's family member revealed ongoing issues with communication from the facility regarding changes in the resident's care. The DON confirmed, after reviewing the 24-hour report and medical record, that there was no documentation of notification to the resident's representative for the medication changes. Facility policy requires that residents and their representatives be informed of changes in health status and treatment, but this was not followed in these instances.
Failure to Document and Implement Interventions After Resident Falls
Penalty
Summary
The facility failed to ensure proper documentation and implementation of interventions following falls for two residents with significant cognitive impairments and fall risks. For one resident with moderate dementia, diabetes, and atrial fibrillation, multiple falls occurred over a period of several months. The medical record lacked timely documentation of these falls, including missing fall assessments, skin and pain assessments, and progress notes detailing the circumstances of the incidents. In several instances, there was a delay of several days before any interdisciplinary team (IDT) notes were entered, and there was no evidence that new interventions were added to the care plan after repeated falls. Additionally, family notification was not documented for at least one fall. For another resident with Alzheimer's disease and a cognitive communication deficit, an unwitnessed fall was not properly documented in the progress notes, and the change in condition evaluation did not include details about the fall or any interventions to prevent recurrence. The only documentation of the fall was found in a risk management incident report, which was not part of the resident's official medical record and was not visible to all staff. The IDT note, completed several days after the fall, mentioned the resident's shoes were too big and that a new pair would be obtained, but there was no documentation of immediate interventions or assessments in the medical record. Interviews with the LPN and DON revealed that staff were expected to complete fall assessments, skin and pain assessments, and notify the DON, physician, and family immediately after a fall. However, the DON was unaware that the fall risk management assessment and risk management incident reports were not part of the official medical record and not accessible to all staff. The facility's own falls protocol required detailed assessment and documentation after a fall, but this was not consistently followed for the residents reviewed.
Failure to Designate Qualified Infection Preventionist and Complete Infection Surveillance
Penalty
Summary
The facility failed to designate a qualified Infection Preventionist (IP) nurse, other than the Director of Nursing (DON), to oversee the infection prevention and antibiotic stewardship programs. Record review showed that antibiotic tracking and infection surveillance were not completed for a seven-month period. During an interview, the DON stated she began working at the facility in December 2024 and was solely responsible for infection tracking, TB testing, surveillance, and the antibiotic stewardship program. She acknowledged she was unaware that the DON could not serve as the IP nurse and that an additional nurse with infection preventionist training was required for the role. Facility documentation indicated that both a full-time DON and a full-time IP nurse were designated, but in practice, only the DON was fulfilling these responsibilities. Policies provided by the administrator outlined that the IP nurse or designated infection control personnel should conduct ongoing surveillance, gather and interpret infection data, and coordinate the infection prevention program. However, these duties were not being carried out as required, as evidenced by the lack of infection surveillance and antibiotic tracking during the specified period. This deficiency had the potential to affect all 38 residents in the facility.
Failure to Track Infections, Antibiotic Use, and Complete Required TB Testing
Penalty
Summary
The facility failed to ensure proper implementation of its infection prevention and control program, specifically in tracking infections, antibiotic use, and conducting required tuberculin (TB) testing for residents. Review of medical records revealed that several residents did not have evidence of a second TB test administered within the required timeframe after admission, and in some cases, there was no documentation of TB test results being read or of annual TB testing being completed. The Director of Nursing, who also served as the Infection Preventionist, acknowledged responsibility for overseeing immunizations and TB testing, and confirmed that two initial TB tests are required upon admission unless contraindicated. Additionally, the facility's infection control program lacked documentation of antibiotic tracking or infection surveillance for a period of several months, specifically from May to November of the previous year. Although the facility had policies in place requiring ongoing surveillance for healthcare-associated infections and routine tracking of antibiotic use, these procedures were not followed during the specified period. The DON indicated that infection tracking began only after her employment started in December, leaving a gap in compliance with infection control protocols.
Failure to Complete Required AIMS Assessments for Resident on Psychotropic Medication
Penalty
Summary
A deficiency was identified when the facility failed to ensure that AIMS (Abnormal Involuntary Movement Scale) assessments were completed as required for a resident receiving psychotropic medications. Record review showed that a resident with diagnoses including Alzheimer's disease, anxiety disorder, and major depressive disorder was prescribed Risperidone and other psychotropic medications. The resident's care plans included interventions to monitor for side effects and effectiveness of these medications, as well as to consult with pharmacy and medical staff regarding ongoing need. Despite these interventions, documentation revealed that the last AIMS assessment for this resident was completed in July 2024, with no evidence of subsequent quarterly assessments as required by facility policy. Interviews with staff confirmed that AIMS assessments should be completed on admission and every three months, but the DON was unable to locate any documentation of assessments after July 2024. The facility's policy also recommended quarterly AIMS assessments for residents on psychotropic medications.
Failure to Update and Implement Care Plans and Conduct Care Plan Meetings
Penalty
Summary
The facility failed to ensure that care plans were updated and implemented in accordance with regulatory requirements for multiple residents. For one resident with a history of unspecified mild dementia with psychotic disturbance, a care plan indicated the presence of a venous access device and administration of IV antibiotics for a urinary tract infection due to ESBL. However, after the completion of the antibiotic course and removal of the IV access, the care plan was not updated to reflect these changes. Additionally, both quarterly and annual MDS assessments lacked documentation of antibiotic administration or IV access during the relevant periods, despite clear evidence from progress notes and resident interviews that these interventions had occurred and subsequently ended. Another resident, who experienced frequent pain and was prescribed as-needed opioid pain medication, did not have a care plan implemented for pain management or opioid use, despite regular administration of the medication and frequent complaints of pain interfering with activities of daily living. The DON and MDS coordinator were unaware of the absence of a pain management care plan, even though the resident had been receiving pain medication consistently since admission. The facility also failed to conduct and document quarterly care plan meetings for a resident with severe cognitive impairment. The resident's daughter reported never being invited to a care plan meeting, and the record lacked documentation of such meetings prior to a specific date. The Social Service Director acknowledged not inviting the family due to missing contact information and was unaware of previous documentation practices. The Administrator confirmed the absence of documentation verifying that care plan meetings were held as required.
Failure to Provide Assistance with Shaving for Dependent Residents
Penalty
Summary
The facility failed to provide necessary assistance with shaving for two residents who were unable to perform this activity of daily living (ADL) independently. One resident, who had severe cognitive impairment and required substantial to maximal staff assistance with personal hygiene, was repeatedly observed with untrimmed beard and mustache growth over several days. The resident expressed a preference to be shaved at least once a week and indicated that staff did not ask if he wanted to be shaved during showers. Documentation in the resident's record did not indicate any refusal of shaving care, and shower sheets lacked consistent documentation of shaving or offers to shave, except for one instance. Another resident, who had mild cognitive impairment and required extensive assistance with ADL care due to Parkinson's disease and other medical conditions, was observed with oily, disheveled hair and extensive facial hair. The resident stated a preference for being clean-shaven and confirmed he had not been shaved. Staff interviews confirmed that shaving was expected to occur on shower days, but records did not consistently reflect that shaving was provided or offered. The facility's policy required appropriate support and assistance with hygiene, including grooming, for residents unable to perform ADLs independently.
Failure to Change and Date Oxygen Equipment per Policy
Penalty
Summary
The facility failed to ensure that oxygen equipment was changed and dated according to its own policy for a resident with orders for supplemental oxygen. Observations revealed that the oxygen tubing in the resident's room was stored in a bag dated over a month prior, and interviews with the resident confirmed that she was not receiving oxygen at any time, including at night. Despite this, the medication administration record indicated that oxygen was being administered nightly. An LPN stated that oxygen tubing was supposed to be changed weekly, but acknowledged the resident did not use oxygen often. The Director of Nursing later confirmed that the oxygen order was discontinued because the resident was not using oxygen, and the tubing and storage bag had not been changed as required, due to being overlooked. The resident in question had a medical history including Parkinson's disease, diabetes mellitus, shortness of breath, and COPD, and had a physician's order for oxygen at night for shortness of breath, with instructions to change the tubing weekly and as needed. The medical record lacked a care plan related to oxygen use, despite documentation that the resident was cognitively intact and had received oxygen during a recent assessment period. Facility policy required oxygen cannula and tubing to be changed every seven days or as needed, which was not followed in this case.
Antibiotic Administered Beyond Prescribed Duration Due to Order Entry Error
Penalty
Summary
A resident with severe cognitive impairment was prescribed doxycycline 100 mg twice daily for seven days to treat a pneumonia identified by chest x-ray. The physician's order, dated 5/12/25, specified the duration of therapy as seven days. However, the medication was administered from the evening of 5/12/25 through the evening of 5/27/25, exceeding the prescribed duration. Review of the pharmacy delivery log confirmed that 14 tablets were initially delivered, but additional doses were obtained from the Emergency Drug Kit on multiple occasions after the original supply was exhausted. The Director of Nursing confirmed that the antibiotic was not discontinued as ordered because the stop date was included only in the text of the order and not entered correctly into the system, resulting in continued administration beyond the intended stop date. Facility policy required prescribers to provide complete antibiotic orders, including start and stop dates or number of days of therapy.
Failure to Properly Label and Dispose of Medications
Penalty
Summary
The facility failed to ensure proper labeling and timely disposal of medications in accordance with professional standards and facility policy. During observation of the medication storage room, an undated multi-use vial of Aplisol was found, and staff interviews confirmed that the vial should have been dated upon opening and discarded after 30 days. Additionally, three prefilled syringes of hepatitis B vaccine with an expiration date that had already passed were found in the storage room, and staff acknowledged these should have been discarded. Facility policy requires regular review and removal of expired medications, but this was not followed. Further deficiencies were identified on two medication carts. An insulin pen injector for a resident with Type 2 diabetes was found without an open date, and the LPN confirmed that insulin pens should be dated when opened and are only good for 28 days after opening. Another cart contained two insulin pen injectors for a different resident, also without open dates, and the LPN was unable to determine how long they had been open. Both residents had physician orders for Glargine insulin, and the facility's policy requires medications with shortened expiration dates to be labeled with the date opened and the initials of the nurse, which was not done.
Failure to Ensure 24-Hour Licensed Nurse Coverage
Penalty
Summary
The facility failed to ensure a licensed nurse was on duty 24 hours a day, specifically on a day shift when two residents fell. On the day in question, an agency nurse did not show up for the scheduled shift, leaving the facility without a licensed nurse from 6:00 a.m. to 6:00 p.m. The Director of Nursing (DON) attempted to cover the shift by administering insulin and checking on residents, but had to leave the facility at times, leaving the Qualified Medication Aides (QMAs) to manage without a licensed nurse present. This lack of coverage was contrary to the facility's policy, which required a licensed nurse to be on duty at all times. During this period, two residents, identified as Residents W and T, experienced falls. Resident W, who had a history of falling and required substantial assistance with transfers, fell in his room and suffered a skin tear. His condition deteriorated, with oxygen levels dropping significantly, necessitating a hospital transfer. Resident T, who had an anoxic brain injury and dementia, also fell and sustained minor injuries. The DON was present for part of the shift but could not provide continuous coverage, and there was no documentation of the exact hours worked due to the DON's salaried status.
Failure to Timely Reorder Medications for Resident
Penalty
Summary
The facility failed to ensure timely reordering of medications, resulting in a deficiency in pharmaceutical services for one resident. Resident D, who was cognitively intact and diagnosed with unspecified polyneuropathy, had a care plan that included administering medications as ordered. However, the Medication Administration Record (MAR) indicated that pregabalin, a nerve pain medication, was unavailable for administration on several occasions in December 2024 and January 2025. The deficiency arose from a series of communication failures and delays in obtaining a new prescription for pregabalin. The facility's staff left messages with the physician and attempted to contact the pharmacy, but the physician did not return calls, and a new prescription was required. The Director of Nursing (DON) and other staff members made multiple attempts to resolve the issue, including contacting the hospital for an on-call physician, but were unsuccessful. As a result, Resident D missed doses of pregabalin from 12/25/24 to 12/30/24 and again from 1/8/25 to 1/11/25. The lack of pregabalin led to Resident D experiencing increased pain and ultimately being hospitalized. The resident reported not feeling well for several days, with generalized pain and high blood pressure, and the hospital records indicated that the resident had been without pregabalin for over a week. Interviews with facility staff revealed issues with obtaining narcotic medications due to a change in Medical Directors and the requirement for prescription authorization to access the Emergency Drug Kit (EDK).
Deficiency in Food Temperature and Palatability
Penalty
Summary
The facility failed to ensure that food served to residents was at a safe and appetizing temperature, as evidenced by interviews, observations, and record reviews. During confidential interviews, residents reported that meals served in their rooms were often cold. Specifically, Resident C, Resident F, and Resident E indicated that their meals were sometimes or often served cold, affecting the palatability of the food. On a specific date, the Dietary Manager measured the temperatures of a test tray and found that the fried potatoes, cooked broccoli, and BBQ sandwich were below the required temperature of 135 degrees Fahrenheit, with readings of 128 F, 118 F, and 128 F, respectively. The facility's policy on food temperatures, dated January 2023, mandates that hot foods be held at or above 135 degrees Fahrenheit to prevent foodborne illness and ensure palatability at the time of service.
Failure to Maintain Temperature Logs for Refrigeration and Freezing Units
Penalty
Summary
The facility failed to maintain refrigerator and freezer temperature logs for several days in April. During an initial kitchen tour, it was observed that the temperature logs for the walk-in refrigerator and freezer were incomplete. Specifically, the refrigerator log lacked documentation for five days, and the freezer log lacked documentation for two days. The housekeeping supervisor, who was filling in as the cook, was unaware of why the logs were incomplete and why the refrigerator log was not in its usual place. The dietary aide also did not know why the logs were not completed, although he understood that temperatures should be checked and documented daily. The dietary manager later provided a policy document indicating that refrigerator and freezer temperatures should be checked at least twice daily. Despite this policy, the logs were not maintained as required. The failure to document these temperatures was confirmed through interviews with the housekeeping supervisor and dietary aide, who both expressed uncertainty about the lapses in documentation.
Improper Administration of Inhaled Medication
Penalty
Summary
The facility failed to ensure proper administration of inhaled medication during a medication administration pass for one resident, resulting in a medication error rate of 6.67%. During an observation, an LPN administered an Advair inhaler to a resident and immediately followed it with a Spiriva inhaler without allowing the resident to rinse and spit after the first inhaler or wait several minutes between the two medications. This was contrary to the physician's orders and the facility's policy, which required a waiting period and mouth rinsing to prevent complications such as thrush. The resident's medical record indicated diagnoses of emphysema and unspecified asthma, with specific physician orders for the administration of Advair and Spiriva. Interviews with nursing staff and the President of Clinical Operations confirmed that the proper procedure was not followed. The facility's policy documents also supported the need for a waiting period and mouth rinsing after inhaler use. The failure to adhere to these guidelines led to the identified deficiency.
Expired Medications Not Properly Disposed
Penalty
Summary
The facility failed to ensure expired medications were disposed of properly in the medication storage room. During an observation, an opened multi-use vial of Aplisol solution with an open date of 2/27/24 and an opened multi-use vial of flu vaccine solution with an open date of 11/2/23 were found. Registered Nurse (RN) 9 was unaware of the facility policy regarding the duration for which the medication was good once opened but acknowledged that they needed to be discarded. The Administrator and the President of Clinical Operations confirmed that the medications were expired and should have been discarded. The facility policy indicated that Aplisol vials should be discarded 30 days after initial use and flu vaccine vials should be discarded 28 days after initial use.
Failure to Document Wound Treatments for Resident
Penalty
Summary
The facility failed to ensure the documentation of wound treatments for a resident with severe cognitive deficit and multiple medical conditions, including type 2 diabetes mellitus, heart failure, and end-stage renal disease. The resident was at risk for pressure ulcers and had a care plan in place to address this risk. However, the treatment administration records (TAR) lacked documentation of several physician-ordered treatments, including weekly skin assessments, floating heels while in bed, turning/repositioning every 2 hours, and applying triad paste to the buttocks. Specific dates where documentation was missing include 3/27/24 and 4/4/24. Additionally, the resident developed a deep tissue injury on the left buttocks, which was later restaged to a stage 3 pressure ulcer. Despite new treatment orders being provided, the TAR still lacked documentation of the treatments being completed as ordered. During an interview, the Director of Nursing (DON) confirmed that the TAR should always be signed off when treatments are completed, and without a signature, there was no way to ensure the treatments were carried out. The facility's policy on medication administration and general guidelines also emphasized the importance of documenting treatments in the TAR.
Failure to Post Accurate Daily Staffing Sheets
Penalty
Summary
The facility failed to ensure accurate staffing sheets were posted daily for three out of five days during the recertification survey. On multiple occasions, the staffing sheets posted on the wall across from the nurses' station were dated correctly but lacked documentation of the total number and the actual hours worked by licensed and unlicensed nursing staff. Specifically, on 4/15/24, 4/16/24, and 4/19/24, the staffing sheets were incomplete. During an interview, the Director of Nursing (DON) indicated she was unaware that the staffing sheets were not completed accurately and mentioned that the night shift nurse was responsible for ensuring the sheets were posted and completed accurately. The DON provided a document titled 'Posting Direct Care Daily Staffing Numbers,' revised in August 2022, which indicated that the number of licensed nurses and unlicensed nursing personnel directly responsible for resident care should be posted in a prominent location at the beginning of each shift. The policy also required the actual time worked during that shift for each category and type of nursing staff to be documented. Despite this policy, the facility did not adhere to these requirements, leading to the identified deficiency.
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.
