Evansville Protestant Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Evansville, Indiana.
- Location
- 3701 Washington Ave, Evansville, Indiana 47714
- CMS Provider Number
- 155768
- Inspections on file
- 21
- Latest survey
- April 22, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Evansville Protestant Home during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple comorbidities experienced repeated falls, including two with major injuries, due to the facility's failure to consistently update care plans and implement new fall prevention interventions after each incident. Despite changes in the resident's condition and increased fall risk, care plan revisions and follow-up actions were delayed or incomplete, and some interventions discussed by the IDT were not promptly added to the care plan.
The facility did not ensure the Dietary Manager had the required certification or was enrolled in a state-approved food service management course, as confirmed by interviews and employee file review. The Dietitian was aware of this but did not increase oversight, and the facility lacked a written policy on dietary manager qualifications.
Surveyors found that food items in the dietary area were not stored or labeled according to professional standards, including open and undated produce, outdated and molded items, and food stored directly on the floor. These practices did not comply with facility policy requiring proper labeling, dating, and storage above the floor.
The facility did not ensure timely physician notification for two residents: one with a catheter-associated UTI and new symptoms, and another receiving antianxiety medication for whom pharmacy recommendations to decrease dosage were not addressed. Documentation was lacking for physician notification regarding lab results, changes in condition, and pharmacy suggestions, and the medical director was not informed when the primary provider was unresponsive.
The facility did not create or implement care plans for several residents receiving high-risk medications, including antibiotics, opioids, anticoagulants, antipsychotics, antianxiety agents, antidepressants, and anticonvulsants. This deficiency was identified for three residents with complex medical conditions and medication regimens, and staff interviews confirmed the absence of required care plans to address medication monitoring and related risks.
A resident with chronic kidney disease and recent significant weight loss did not receive the prescribed daily ice cream supplement as outlined in their care plan. Despite documentation and meal tickets indicating the supplement was required, observations showed the resident did not receive it, and the dietary manager's list did not include the resident for this supplement.
A resident with a suprapubic catheter and history of chronic UTIs experienced delays in diagnosis and treatment due to lapses in communication, incomplete documentation, and lack of a specific care plan for UTI prevention. The facility did not have a written policy for UTI management, and staff failed to promptly act on lab results and physician orders, resulting in delayed antibiotic administration and insufficient monitoring of catheter-related complications.
A resident with severe cognitive impairment and dementia was admitted and did not receive a documented physician assessment as required. Review of the clinical record and confirmation by the DON showed no evidence of a physician visit or assessment since admission, despite facility policy mandating timely medical assessments.
A resident with an anxiety disorder received pharmacy recommendations on two occasions to decrease the dosage of an antianxiety medication, but there was no documentation that these recommendations were acted upon or addressed by the prescriber or Medical Director, despite facility policy requiring timely response and documentation.
A resident with an indwelling catheter and urine retention did not have their catheter change accurately documented according to physician orders. Documentation indicated a QMA performed the change, but the QMA denied doing so, and a nurse later completed the procedure after the scheduled date. Facility policy required complete and accurate medical record documentation.
Two residents with wounds did not receive proper infection control measures during wound care, as staff failed to use required gowns and EBP signage was missing or not followed. In both cases, RNs performed wound care without appropriate PPE, and one resident was not identified for EBP despite having an open wound, contrary to facility policy.
Failure to Revise Care Plans and Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to revise care plans and implement appropriate interventions to reduce the risk of falls for a resident with severe cognitive impairment and multiple comorbidities, resulting in repeated falls with major injuries. The resident experienced four falls over a three-month period, two of which resulted in fractures requiring hospitalization and a significant decline in activities of daily living (ADLs). Despite the resident's changing condition and increased fall risk, care plans were not consistently updated with new interventions following each incident, and some interventions discussed by the interdisciplinary team (IDT) were not promptly added to the care plan. After the first fall, the only intervention added was fluorescent tape to the walker, and the resident was still assessed as low risk for falls. Following subsequent falls, the resident's risk status was updated to high, but care plan revisions and implementation of new interventions were delayed or incomplete. For example, after the second fall, which resulted in pelvic fractures, the care plan was not updated with new interventions, and there was a lack of timely follow-up with the physician regarding the resident's ongoing pain and mobility decline. Documentation also showed gaps in communication and follow-up on diagnostic results, such as x-rays and urinalysis, and the IDT did not consistently meet to reassess and address the resident's needs after each fall. Observations and interviews revealed that some interventions, such as the concave mattress, were not added to the care plan until days after being discussed, and visual cues like fluorescent tape were not always present as required. The facility's own policies required ongoing assessment, documentation, and revision of care plans when goals were not achieved or when there was a significant change in the resident's condition. However, these procedures were not consistently followed, contributing to the resident's repeated falls and injuries.
Dietary Manager Lacked Required Certification
Penalty
Summary
The facility failed to ensure that the Dietary Manager met the required qualifications for the position. The Dietary Manager confirmed during an interview that she did not possess a dietary manager certification and had not enrolled in a certification program. The Dietitian was aware of the Dietary Manager's lack of certification but did not increase her oversight or visits, maintaining her current schedule of being in the facility once a week. Review of the Dietary Manager's employee file showed that the job description, signed by the manager, required completion of a state-approved food service management course or current enrollment in such a program, which had not occurred. Additionally, the Administrator stated there was no written policy regarding the qualifications for the dietary manager, and that the facility's practice was to follow state regulations.
Improper Food Storage and Labeling in Dietary Area
Penalty
Summary
Surveyors observed multiple failures in the facility's dietary area to store and label food according to professional standards. During a kitchen walkthrough, an open bag of mixed vegetables without a date, a chunk of ham dated over a month prior, a carton of molded strawberries, and containers of bran mixture and banana cake with outdated preparation labels were found in the walk-in refrigerator. In the dry storage room, rice crispy treats and a box of sandwich crackers were stored directly on the floor. In the walk-in freezer, a bag of pepperonis was double-bagged with conflicting dates on the inner and outer bags. The facility's policy requires food to be stored at least six inches above the floor, properly covered, labeled, and dated, with leftovers used within seven days or discarded, but these standards were not met in the observed instances.
Failure to Notify Physician of Significant Changes and Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure timely and appropriate physician notification regarding significant changes in condition and laboratory results for two residents. For one resident with a history of malignant neoplasm of the bladder and an indwelling suprapubic catheter, there were multiple instances where the clinical record lacked documentation of physician notification. These included situations where lab results were not obtained, the resident experienced new symptoms such as abdominal pain, pain at the catheter site, and redness at the catheter insertion site, and when the medical provider was unresponsive to facility attempts at contact. Additionally, there was no evidence that the medical director was notified when the primary physician or post-acute care provider did not respond to urgent communications regarding the resident's condition and lab findings. For another resident with an anxiety disorder who was receiving antianxiety medication, the facility did not document any action or physician notification in response to pharmacy recommendations to decrease the medication dosage. Pharmacy recommendations were made on two separate occasions, but there was no evidence that the attending physician or medical director was contacted to accept or decline these recommendations. Interviews confirmed that the medical director was not made aware of the lack of response from the attending physician, despite facility policy requiring follow-up in such cases. Facility policies required that recommendations from the consultant pharmacist be acted upon and documented, and that nursing staff notify the physician of acute changes in condition. However, the records reviewed showed that these protocols were not consistently followed, resulting in missed or delayed physician notifications for significant clinical changes and pharmacy recommendations for both residents.
Failure to Develop Care Plans for High-Risk Medications
Penalty
Summary
The facility failed to develop and implement comprehensive care plans addressing high-risk medications for three residents. For one resident with diagnoses including Fournier Gangrene, prostate cancer, and chronic pain syndrome, the clinical record showed the use of both an antibiotic (daptomycin) and an opioid (oxycodone), but there were no care plans in place for pain management or antibiotic monitoring. The resident was cognitively intact and dependent on staff for several activities of daily living. Another resident with congestive heart failure was receiving an anticoagulant (Eliquis) but did not have a care plan identifying interventions to monitor for side effects such as bleeding. Although the resident's care plan mentioned the use of Eliquis to prevent embolism, it did not address the specific risks associated with anticoagulant therapy. The resident was cognitively intact and required varying levels of assistance with daily activities. A third resident with Alzheimer's disease, anxiety, depression, and spinal stenosis was prescribed multiple high-risk medications, including antipsychotics, antianxiety agents, antidepressants, anticonvulsants, and opioids. Despite the complexity of the medication regimen and the resident's moderate cognitive impairment, the care plan did not address the use of these medications, the underlying disease processes, or interventions to monitor for side effects. Interviews with facility staff confirmed that care plans for high-risk medications were not in place for these residents.
Failure to Implement Care Plan for Nutritional Supplement
Penalty
Summary
A deficiency occurred when the facility failed to implement a resident's care plan related to nutrition. The resident, who had chronic kidney disease and was cognitively intact, experienced an unplanned weight loss of 5% or more in the last month. The care plan, updated after a significant change assessment, included providing daily ice cream to increase calorie intake due to recent weight loss. However, on multiple occasions, the resident did not receive the prescribed ice cream with lunch, as observed in both the dining room and in her room. The lunch ticket indicated that ice cream should have been included, but it was missing from the tray. Further review revealed that the dietary manager's list of residents receiving supplemental foods did not include this resident for the ice cream supplement, despite it being part of the care plan. The facility's policy required care plans to be reviewed and revised as needed, but the failure to ensure the care plan was followed resulted in the resident not receiving the intended nutritional intervention.
Delayed UTI Treatment and Inadequate Catheter Care Documentation
Penalty
Summary
The facility failed to ensure timely treatment of a urinary tract infection (UTI) for a resident with an indwelling suprapubic catheter. The resident, who had a diagnosis of malignant neoplasm of the bladder and was moderately cognitively impaired, experienced multiple episodes of UTI. Documentation revealed delays in obtaining and acting upon laboratory results, as well as lapses in communication with medical providers. For example, after a urine culture was collected in the emergency department, the final results were available within two days, but the resident did not begin antibiotic treatment until several days later. The clinical record did not show that staff directly contacted the hospital laboratory to expedite culture results, and there were repeated notes of difficulty reaching the physician or post-acute care line. Additionally, the resident experienced recurring issues with catheter care, including episodes of purple urine bag syndrome, blood in the urine, and pain at the catheter site. There were periods where no progress notes or observations were documented regarding the resident's catheter, pain, or UTI monitoring, particularly following reports of catheter occlusion and pain. In one instance, a contaminated urine specimen delayed diagnosis and treatment, and a subsequent order for antibiotics was not initiated promptly despite the resident exhibiting increased confusion and lethargy. The facility also lacked a care plan specifically addressing the resident's frequent UTIs and prevention strategies, such as promoting hand hygiene, despite documentation that the resident frequently handled his catheter tubing. Interviews with the DON and Administrator confirmed the absence of a written policy for UTI management, and the only protocols provided were general in nature, not specific to UTI prevention or timely intervention. These deficiencies contributed to delays in diagnosis and treatment of UTIs for the resident.
Lack of Physician Assessment for Newly Admitted Resident
Penalty
Summary
The facility failed to ensure that a resident was assessed by a physician since admission, as required. Resident 22, who was admitted with diagnoses including dementia and was noted to be severely cognitively impaired and in need of partial assistance for toileting and bathing, did not have any documented physician assessment in the clinical record following admission. This was confirmed through review of the resident's clinical record, which lacked physician assessments, progress notes, or related documentation, and was further corroborated by the DON, who was unable to locate any physician assessment for the resident. The facility's policy requires timely medical assessments by a physician in accordance with OBRA regulations, but this was not followed for this resident.
Failure to Act on Pharmacy Recommendations for Medication Regimen Review
Penalty
Summary
The facility failed to ensure that pharmacy recommendations regarding a resident's medication regimen were acted upon and documented as required. Specifically, a resident with an anxiety disorder, who was receiving buspirone for anxiety, had two separate pharmacy recommendations to decrease the medication dosage from 10 mg once a day to 5 mg once a day. These recommendations, dated over a month apart, lacked documentation showing that they were either accepted, acted upon, or rejected by the prescriber or facility staff. The resident's physician, who did not visit the facility, did not respond to the pharmacy recommendations, and the process for escalating unaddressed recommendations to the Medical Director was not followed, as there was no evidence the Medical Director accepted or declined the recommendations. Facility policy required that pharmacy recommendations be acted upon and documented by staff or the prescriber, with further escalation to the Medical Director if the prescriber did not respond within 30 days. Despite this policy, there was no documentation of any action taken in response to the pharmacy's suggestions for this resident. Interviews confirmed that the established process for handling unaddressed pharmacy recommendations was not followed, resulting in a lack of timely and appropriate response to the consultant pharmacist's input regarding the resident's medication therapy.
Failure to Accurately Document Catheter Change
Penalty
Summary
The facility failed to ensure accurate documentation of a catheter change for one resident with an indwelling catheter and a diagnosis of urine retention. The resident was cognitively intact and required maximal assistance for activities of daily living. Physician orders specified that the resident's Foley catheter was to be changed monthly, with a specific schedule outlined. Documentation provided by the Director of Nursing indicated that a Qualified Medication Aide (QMA) had performed the catheter change on a specified date; however, during an interview, the QMA denied performing the procedure and suggested that a nurse may have documented the task under her username. Further review of nursing progress notes revealed that the catheter change was not completed as scheduled, and a Registered Nurse subsequently performed the change several days later. Facility policy required that documentation in the medical record be objective, complete, and accurate.
Failure to Implement Enhanced Barrier Precautions and PPE During Wound Care
Penalty
Summary
The facility failed to implement proper infection control practices related to Enhanced Barrier Precautions (EBP) and Personal Protective Equipment (PPE) during wound care for two residents. In the first instance, a resident with severe cognitive impairment and a stage 4 pressure wound on the coccyx was observed receiving wound care from two registered nurses who did not wear gowns as required by the EBP protocol, despite signage indicating the need for such precautions. One of the nurses acknowledged forgetting to don the gown prior to performing wound care. In the second instance, another resident with an ulcer on the right buttock was not listed as being on EBP, and there was no EBP signage or documentation indicating the need for EBP in the care plan or physician orders. During wound care, two registered nurses were observed not wearing gowns, and the necessary EBP signage and PPE were not present. The Director of Nursing and Infection Preventionist later confirmed that the resident should have been on EBP and that staff should have used gowns and gloves during wound care.
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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