Golden Years Homestead
Inspection history, citations, penalties and survey trends for this long-term care facility in Fort Wayne, Indiana.
- Location
- 3136 Goeglein Rd, Fort Wayne, Indiana 46815
- CMS Provider Number
- 155755
- Inspections on file
- 35
- Latest survey
- November 7, 2025
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Golden Years Homestead during CMS and state inspections, most recent first.
A resident with multiple comorbidities was prescribed several pain medications, including a new order for morphine, without documented monitoring for adverse side effects or consistent notification of the POA regarding medication changes. Despite facility policy requiring monitoring, there was no documentation of such monitoring after opioid administration, and the resident was later found deceased.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
A resident with epilepsy and dementia did not receive a newly ordered anti-seizure medication for several days after a neurology appointment, while the previous medication was continued without a valid order due to a delay in transcribing and acting on new physician orders. The error was discovered several days later, resulting in delayed administration of the correct medication.
A resident with cognitive and behavioral health diagnoses engaged in inappropriate touching of two other residents, but the facility failed to document the behaviors, update care plans with specific interventions, or implement prevention strategies. Staff interviews revealed inconsistent communication and lack of follow-up, and the social services team was not consistently notified. The affected female resident, who was severely cognitively impaired, had no care plan updates or interventions added after the incident.
The facility did not maintain complete and accurate medical records for two residents after an incident of inappropriate touching. Documentation failed to specify the behaviors, affected individuals, interventions taken, or evidence of required safety checks. Records also lacked details on physician or family notification, immediate assessments, and implementation of safety measures, contrary to facility policy.
The facility failed to ensure medications were properly dated when opened and destroyed when expired, as observed in two medication carts. An LPN found a Trelegy inhaler without an open date, and a QMA found Nystatin and Lidocaine solutions without open dates. Insulin medications for two residents were expired but still present in the cart. Record reviews showed discrepancies in medication management, with some medications lacking open dates and others being expired yet administered.
A resident with severe cognitive decline was abused by a QMA, who pushed the resident against a wall and later across a hallway, causing a fall. The incident was captured on video, showing the QMA's aggressive actions. Despite the resident's care plan addressing cognitive loss and agitation, the abuse occurred in a secured memory care unit. The facility's abuse policy was reviewed, and disciplinary action was taken against the QMA.
A resident with PTSD related to childhood abuse experienced fear due to a male peer entering her room uninvited. Despite reporting the incidents, the facility did not initially implement effective interventions to prevent these occurrences. The resident's care plan lacked trauma-specific goals and interventions, and the facility's trauma-informed care policy was not adequately followed.
The facility failed to maintain infection control measures for oxygen tank tubing for two residents. Oxygen tanks were found on the floor with tubing wrapped around a handrail outside the beauty shop, lacking covers or dates. One resident had COPD with an acute exacerbation, and another was dependent on supplemental oxygen. The DON confirmed the absence of a current facility policy.
The facility failed to report an injury of unknown origin for a resident with dementia. The resident was observed with facial swelling and discoloration on two separate occasions, but no investigation or follow-up was conducted. The DON admitted that the injuries were not reported to the appropriate authorities as required by facility policy.
The facility failed to notify the physician and family timely of a significant change in condition for a resident with Alzheimer's dementia and a recent C. Diff colitis infection. Despite family members reporting symptoms of pain, lethargy, and diarrhea, the facility did not document any assessment or notification to the physician or NP, leading to the resident's hospitalization.
Failure to Monitor for Opioid Side Effects After Dose Increase
Penalty
Summary
The facility failed to monitor for adverse side effects of opioid medications following an increased dose for a resident admitted for rehabilitation after a right hip fracture. The resident had multiple diagnoses, including Parkinson's disease, diabetes mellitus, depression, and stage 3 chronic kidney disease. The resident was prescribed several pain medications, including hydrocodone-acetaminophen, naproxen, oxycodone-acetaminophen, and later, morphine sulfate extended-release. There were no documented orders to monitor for side effects of these pain medications, despite the addition of morphine and the resident's complex medical history. Medication administration records showed frequent administration of multiple pain medications, including the new morphine order. Nursing notes indicated that the resident's power of attorney (POA) and family were not notified of the medication changes, despite facility policy and the resident's moderate cognitive impairment. The POA reported not being informed about the new morphine order and requested that the medication be held, but the resident received the morphine as ordered. Documentation of monitoring for adverse effects was lacking, and there were no notes or assessments between the last pain assessment and the time the resident was found deceased. Interviews with staff revealed inconsistent practices regarding notification of the POA and monitoring for side effects after opioid administration. While some staff stated that monitoring and notification were standard practice, there was no documentation to support that these actions were taken in this case. The facility's policy required monitoring for adverse side effects, but this was not documented or consistently performed for the resident after the opioid dose increase.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Follow Physician Orders for Medication Changes
Penalty
Summary
A resident with diagnoses of epilepsy with partial seizures and dementia returned from a neurologist appointment with new physician orders to discontinue Levetiracetam and begin Lacosamide for seizure management. The nurse on duty was responsible for reviewing the progress note, transcribing the new orders onto the physician order form and Medication Administration Record (MAR), and notifying the pharmacy. However, the order to discontinue Levetiracetam and start Lacosamide was not promptly transcribed onto the MAR, resulting in Lacosamide not being administered for several days after the order was written. During this period, Levetiracetam continued to be administered to the resident without a valid physician order, as the discontinuation order was not recognized or acted upon. The error was only identified several days later, after which the medication administration was corrected. The facility did not have a written policy for following physician orders, but nurses were expected to follow such orders as part of their nursing practice.
Failure to Identify and Address Inappropriate Resident Behaviors
Penalty
Summary
The facility failed to identify, document, and implement prevention interventions for inappropriate touching behaviors exhibited by a resident towards other residents. Specifically, a male resident with diagnoses including Parkinson's, dementia, anxiety, and depression, was observed on multiple occasions engaging in inappropriate physical contact with female residents, including hand holding, rubbing shoulders, and placing his hand up another resident's pant leg. Despite these incidents, there was no documentation of specific interventions to prevent recurrence or protect the residents involved, and the care plan lacked details on the types of behaviors to monitor, frequency of monitoring, or behavioral clues to observe. The records show that the resident's care plan was not updated to reflect the inappropriate behaviors or to provide clear guidance to staff on how to address or prevent such incidents. The care plan also did not specify how the resident expressed depression or anxiety, nor did it include interventions tailored to the observed behaviors. Staff interviews revealed that while some staff were aware of the incidents, there was inconsistent communication and documentation regarding the behaviors, and the social services department was not consistently notified or involved in follow-up. Additionally, behavior monitoring flowsheets did not include inappropriate touching as a targeted behavior, and there was no evidence that the psychiatric nurse practitioner was informed of the specific incidents. The female resident involved, who had severe cognitive impairment and was dependent on staff for all activities of daily living, was unable to recall the incident and showed no signs of distress during subsequent assessments. However, her care plan was not updated to address the incident or to include interventions to prevent further occurrences. The facility's policy required close monitoring and individualized care planning for behavioral health issues, but this was not followed in practice, as evidenced by the lack of documentation, care plan updates, and specific interventions after the incidents.
Failure to Maintain Complete and Accurate Medical Records After Resident-to-Resident Incident
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents following incidents of inappropriate touching. For one resident with diagnoses including Parkinson's, dementia, anxiety, and depression, interdisciplinary notes referenced inappropriate behavior but did not specify the nature of the behaviors, who was affected, or what interventions were implemented. There was also no documentation that the resident was placed on 15-minute checks as ordered, nor was there evidence that these checks were completed after the care plan was updated. Additionally, a psychiatric nurse practitioner's note did not reflect awareness of the incident or changes in medication related to observed behaviors. For the second resident, who had Lewy body dementia with psychotic disturbance, major depressive disorder, and anxiety, the records did not document the incident of inappropriate touching, notification to the physician or family, or immediate skin assessment to check for injury. There was also no documentation of how the resident was kept safe following the incident or how interventions were implemented to prevent further occurrences. The hospice visit note referenced the incident but did not specify how the other resident was restricted from entering rooms. Neither resident's clinical record included documentation that the DON and Unit Manager had reviewed the incident to confirm no sexual contact occurred, nor did the records indicate that families were notified or that interventions were put in place to ensure resident safety. The facility's policy requires timely and accurate documentation of all assessments, observations, and services, but this was not followed in these cases.
Medication Management Deficiencies
Penalty
Summary
The facility failed to ensure medications were properly dated when opened and destroyed when expired, as observed in two of four medication carts. During an observation, a Trelegy inhaler for a resident was found without a box and no open date, which was acknowledged by an LPN as incorrect. Another observation revealed an open bottle of Nystatin without an open date for a different resident, and a bottle of Lidocaine solution also lacked an open date. Additionally, insulin medications for two residents were found with open dates but had expired, yet were still present in the medication cart. Record reviews for the involved residents showed discrepancies in medication management. One resident with chronic pulmonary disease had a physician's order for Trelegy inhalation, but the medication lacked an open date. Another resident with Alzheimer's disease had no active orders for the Nystatin found. A resident with chronic obstructive pulmonary disease had Lidocaine solution administered without an open date. Two residents with type 2 diabetes mellitus had insulin medications with open dates but expired, yet they were still administered. The facility's medication storage policy, provided by the Director of Nursing, emphasized proper storage and management of medications, which was not adhered to in these instances.
Resident Abuse by Qualified Medication Assistant
Penalty
Summary
The facility failed to protect a resident, identified as Resident 26, from abuse by a Qualified Medication Assistant (QMA 6). Resident 26, who has severe cognitive decline due to dementia, was involved in an incident where QMA 6 pushed him against a wall and later across the hallway, causing him to fall. This incident was captured on video footage, which showed QMA 6's aggressive actions towards Resident 26, who was left on the ground after the altercation. The incident occurred in a secured memory care unit, and another staff member present did not intervene. Resident 26's medical history includes dementia, depression, and muscle weakness, with a Brief Interview for Mental Status score indicating severe cognitive decline. His care plan highlighted cognitive loss and a tendency to become agitated, with interventions to ensure safety and calm communication. Despite these interventions, the incident with QMA 6 occurred, and the behavior sheet for September 2024 showed missing documentation and recorded instances of aggression and anxiety. The Director of Nursing (DON) expressed disbelief upon reviewing the footage, and the Human Resources department noted a gap in the video recordings. Statements from QMA 6 and other staff were collected as part of the investigation. The facility's policy on abuse, neglect, and exploitation was reviewed, which defines abuse as the willful infliction of injury or intimidation resulting in harm or mental anguish. The report indicates that disciplinary action was taken against QMA 6.
Failure to Implement Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to implement interventions to prevent feelings of fear for a resident diagnosed with PTSD related to childhood abuse. The resident expressed feeling overwhelmed since her husband's passing and was triggered by a male peer entering her room uninvited, especially at night. Despite the resident's repeated reports of the peer's unwanted presence, the facility did not initially implement measures such as placing stop signs on the door or other deterrents. The resident requested to lock her door for safety but was denied due to safety concerns. Eventually, the peer was moved to another room, which stopped the visits, but no other solutions were offered to the resident. The resident's care plan, dated June 2024, addressed mood disorders but did not include trauma-specific problems, goals, or interventions. A subsequent care plan in September 2024 included a problem of trauma but lacked specific interventions or triggers. The facility's policy on Trauma Informed Care emphasized minimizing triggers and ensuring emotional and physical safety, but these measures were not effectively implemented for the resident. The resident's records showed no documentation of behaviors related to her trauma, and a trauma questionnaire was not dated, indicating a lack of thorough assessment and response to her trauma-related needs.
Infection Control Deficiency in Oxygen Tank Management
Penalty
Summary
The facility failed to maintain proper infection control measures for oxygen tank tubing for two residents. During an observation, two oxygen tanks were found on the floor in the hallway, with their tubing wrapped around a handrail outside the beauty shop. The tubing lacked covers, bags, or dates indicating when they were placed. Resident 16, diagnosed with chronic obstructive pulmonary disease (COPD), had a physician order for 2 liters per minute of nasal oxygen every shift due to an acute exacerbation. Similarly, Resident 247, dependent on supplemental oxygen, had a physician order for 2 liters per minute of nasal oxygen every shift for COPD. The Director of Nursing (DON) confirmed that residents would leave their oxygen tanks outside the beauty shop and acknowledged the absence of a current facility policy regarding this practice.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for Resident D, who had a diagnosis of dementia with behavioral disturbance. On two separate occasions, the resident was observed with swelling and discoloration on the right side of her face. The first incident was noted on 2/23/24, and the second on 3/23/24. Despite these observations, there was no documentation or investigation into the cause of the injuries, their effect on the resident, or any follow-up for resolution. The resident's family had taken her to the ER for evaluation and treatment after the first incident, but the facility did not report the injuries to the appropriate authorities as required by their policy. In an interview, the DON indicated that staff had assumed the resident had fallen and gotten herself back up in both incidents, although there were no witnesses or reports of falls. The facility's policy mandates reporting all allegations of abuse, neglect, exploitation, or mistreatment, including injuries of unknown sources, immediately to the Administrator and other appropriate agencies. The DON admitted that neither she nor the Administrator reported the injuries, even though the resident was unable to explain how they occurred, and the injuries were suspicious due to their location on the face/head.
Failure to Notify Physician and Family of Significant Change in Condition
Penalty
Summary
The facility failed to notify the physician and family timely of a significant change in condition for Resident D. The resident, who had been admitted following hospitalization for C. Diff colitis, experienced right-sided pain, lethargy, and diarrhea. Despite family members reporting these symptoms to the staff on multiple occasions, the facility did not document any assessment or notification to the physician or nurse practitioner. The resident's condition worsened, and she was eventually hospitalized after the family insisted on her being sent to the hospital for evaluation. Resident D's medical history included Alzheimer's dementia and a recent C. Diff colitis infection. The resident had completed a course of antibiotics and was awaiting discharge. On multiple visits, family members observed the resident in pain and reported it to the staff, who allegedly placed her on the NP list for the next visit. However, there was no documentation of the NP being informed or assessing the resident's pain. The resident was later found lethargic and in a fetal position, with an isolation cart outside her room due to diarrhea, but the family and physician were not notified. Interviews with staff revealed that there was a lack of communication and documentation regarding the resident's symptoms and condition. The QMA and LPN involved did not recall specific details or actions taken to address the resident's complaints. The DON confirmed that there was no documentation of the NP or family being notified about the resident's loose stools and isolation. The facility's policy on notification of changes was not followed, leading to a delay in addressing the resident's significant change in condition.
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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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.
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