Harbour Manor Health & Living Community
Inspection history, citations, penalties and survey trends for this long-term care facility in Noblesville, Indiana.
- Location
- 1667 Sheridan Rd, Noblesville, Indiana 46060
- CMS Provider Number
- 155381
- Inspections on file
- 35
- Latest survey
- February 13, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Harbour Manor Health & Living Community during CMS and state inspections, most recent first.
A resident with multiple medical conditions, including post-surgical hip fracture, cognitive impairment, incontinence, and unilateral lower extremity impairment, was admitted and did not have a 72-hour care plan meeting or baseline person-centered care plan completed within the required timeframe. The initial care conference occurred nine days after admission. Staff interviews showed that social services typically contacted representatives 24–48 hours after admission and did not routinely document unsuccessful contact attempts, and that the care conference for this resident was delayed to accommodate the representative’s schedule. This practice did not align with facility policy requiring a baseline care plan within 48 hours of admission and completion of key care planning elements by the initial IDT care conference.
A cognitively impaired resident with a history of falls and poor safety awareness was transported by a facility driver to an orthopedic office for a follow-up visit, based on hospital discharge orders and facility-entered appointment information that had been changed and not clearly communicated. The driver left the resident at the office without a caregiver, despite office records indicating the resident should be accompanied, and did not notify the facility when informed there was no current appointment. The resident, who arrived confused and agitated, remained unsupervised at the office for an extended period until the facility was contacted, and staff later acknowledged a communication breakdown, lack of discussion of transportation arrangements at care conference, and absence of a transportation policy.
Staff failed to accurately document controlled substance administration and inventory for multiple residents, resulting in mismatches between the controlled medication binder and blister card counts for medications such as pregabalin, hydrocodone-acetaminophen, tramadol, lorazepam, and clonazepam. An LPN acknowledged not recording that morning’s controlled medication doses, and subsequent review showed each affected resident’s binder count was one pill higher than the actual blister card count. The residents involved had complex medical conditions, including cognitive impairment, seizure disorder, Parkinson’s disease, cardiovascular disease, COPD, diabetes, and chronic pain, and facility leadership confirmed that this practice did not follow the policy requiring immediate documentation of controlled drug administration and remaining doses.
A resident with severe cognitive impairment and a history of combative behavior was physically restrained by an RN, who held the resident's hands and attempted to administer oral medications while the resident screamed and resisted. The incident, witnessed by a CNA, involved the resident spitting out the medication and applesauce, and was reported as staff-to-resident abuse due to the RN's failure to respect the resident's refusal and escalating the situation.
A CNA did not intervene when witnessing an RN attempt to administer medication to a severely cognitively impaired resident who became combative, resulting in the resident being restrained and distressed. The CNA, present for one-to-one observation, did not act to protect the resident, which was contrary to the facility's abuse prevention policy.
A resident with multiple medical conditions and a history of making false accusations required care to be provided by two staff members, as documented in the care plan and CNA assignment sheet. However, a CNA provided care alone, contrary to the care plan intervention, which was confirmed by the DON and other staff during interviews.
The facility failed to ensure proper narcotic count reconciliation for the Rehab 1 medication cart, missing required documentation on several dates. Staff interviews confirmed the absence of necessary signatures and count numbers, posing a potential risk for drug diversion. Despite frequent education on narcotic reconciliation, the facility's policy was not followed, leaving the facility unable to verify if any narcotics were missing.
A resident reported that the Activities Director yelled at her, causing humiliation and distress. Despite the incident being reported to the Physical Therapy staff and allegedly to the Director of Nursing, no investigation was conducted, and the facility's policy on reporting abuse was not followed.
The facility failed to report allegations of sexual abuse involving a resident to law enforcement and adult protection agencies. Despite the resident's report and the facility's policy requiring such notifications, the facility did not contact the police, citing the family's request as the reason. However, a family member later indicated that they did not request the police not to be called.
Failure to Complete Timely Baseline Care Plan and Initial Care Conference
Penalty
Summary
The deficiency involves the facility’s failure to initiate and conduct a 72-hour care plan meeting and develop a person-centered baseline care plan within the required timeframe following a resident’s admission. The resident, who had diagnoses including a right femur neck fracture post-surgical repair, cognitive symptoms following a cerebrovascular accident, repeated falls, hypertension, conversion disorder with seizures or convulsions, osteoporosis, and chronic pain, was admitted on an identified date. The admission MDS showed moderate cognitive impairment, wheelchair use for mobility, frequent urinary incontinence, occasional bowel incontinence, and impairment of one lower extremity. The clinical record lacked documentation that a 72-hour care plan meeting was initiated or conducted within the required timeframe, and the initial care conference did not occur until nine days after admission. Interviews with staff revealed that the Social Service Director typically called resident representatives 24 to 48 hours after admission to set up a care conference and generally did not document unsuccessful attempts to reach representatives. The Admission Coordinator reported leaving a voicemail for the resident’s representative on the first available business day after admission due to a holiday, and the Transitional Care Nurse acknowledged that the care conference for this resident was delayed to accommodate the representative’s schedule, who wanted to be present. The facility’s policy required development of a person-centered baseline care plan within 48 hours of admission, including medications, dietary instructions, services, treatments, and pertinent updates by the date of the initial IDT care conference, but this was not completed as required for this resident.
Failure to Supervise Cognitively Impaired Resident During Off-Site Appointment Transport
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and protection from accident hazards for a cognitively impaired resident during transport to an outside orthopedic appointment. The resident had diagnoses including a right femur neck fracture post-surgical repair, cognitive impairment following cerebrovascular disease, repeated falls, conversion disorder with seizures, osteoporosis, and chronic pain. The most recent MDS showed moderate cognitive impairment, wheelchair use, incontinence, and lower extremity impairment. Progress notes documented multiple recent falls, with root causes identified as poor safety awareness and confusion, and a physician note described the resident as confused and a poor historian. Hospital discharge orders included a follow-up orthopedic appointment, and the facility entered an appointment order; however, there were conflicting orders and a discontinued date that indicated a change in the appointment. On the day of the incident, the resident was transported by the facility’s transportation driver to the orthopedic office for what was believed to be a scheduled appointment. The orthopedic office reported that the resident arrived confused and agitated, without a current appointment, and that the office chart specified the resident should be accompanied by a caregiver. The driver left the resident at the office and went to get something to eat, did not confirm the appointment with the facility, and did not notify the facility when informed there was no appointment. The resident remained at the office unsupervised for approximately 2.5 hours until the facility was contacted and the resident was picked up. Facility staff, including the Unit Manager and Clinical Support Consultant, acknowledged a communication breakdown regarding the cancelled appointment, that the resident was not safe to be unsupervised due to periods of confusion, that transportation arrangements were not discussed at the initial care conference, and that the facility had no policy related to transportation or conduct for resident transport.
Failure to Accurately Document Controlled Substance Administration and Inventory
Penalty
Summary
The deficiency involves the facility’s failure to accurately document controlled substance administration on individual narcotic record sheets in accordance with its policy. During an observation of a medication cart serving 18 residents, an LPN stated she had not documented the controlled medications administered that morning in the controlled medication binder. Review of the binder and comparison with blister card counts for six residents showed consistent discrepancies: for each resident, the number of pills recorded as remaining in the controlled medication binder was one higher than the actual number of pills remaining in the blister card. This included pregabalin and hydrocodone-acetaminophen for one resident, tramadol for two residents, lorazepam for one resident, hydrocodone-acetaminophen for another resident, and clonazepam and pregabalin for a sixth resident. The residents involved had various medical conditions, including severe cognitive impairment, seizure disorder, depression, Parkinson’s disease, coronary artery disease, cerebrovascular accident history, anemia, hypertension, chronic obstructive pulmonary disease, neurogenic bladder, hyperlipidemia, type 2 diabetes mellitus, pain, and cardiomyopathy. Interviews with the Unit Manager and DON confirmed that the expectation and written policy required nurses to document controlled drug administration immediately after dosing, including date, time, dose, nurse signature, and remaining doses. The observed discrepancies and the LPN’s admission that she had not documented the morning controlled medication administrations demonstrated noncompliance with the facility’s controlled substance management policy.
Resident Physically Restrained and Forced Medication Administration by RN
Penalty
Summary
A deficiency occurred when a registered nurse (RN) physically restrained the hands of a severely cognitively impaired resident and attempted to administer oral medications while the resident was screaming and resisting. The resident, who had diagnoses including encephalopathy, memory deficit, and a history of combative behaviors, was under one-to-one observation due to unsafe and combative actions. During the medication administration, the resident became combative, yelled, and refused the medication, but the RN continued to attempt administration, resulting in the resident spitting out the medication and applesauce. A certified nursing assistant (CNA) witnessed the incident and reported that the RN escalated the situation instead of stopping the attempt. The incident was documented in the resident's clinical record and reported to facility leadership. The facility's policy on abuse prevention emphasizes maintaining an abuse-free environment and ensuring staff are knowledgeable about individual resident care needs, including rotating staff for residents with challenging behaviors. The actions of the RN in physically restraining the resident and forcing medication administration were identified as staff-to-resident abuse, as they did not respect the resident's right to refuse care and contributed to the resident's distress.
Failure to Intervene During Observed Resident Abuse
Penalty
Summary
A staff member (CNA) failed to intervene when witnessing another staff member (RN) attempting to administer medication to a severely cognitively impaired resident who became combative during the process. The RN sat on the resident's bed, held the resident's hands, and placed medication in the resident's mouth while the resident was screaming and subsequently spat out the medication and applesauce. The CNA, who was providing one-to-one observation for the resident at the time, did not intervene or attempt to protect the resident, later stating that the incident happened too quickly for her to act. The resident involved had significant medical conditions, including encephalopathy, anemia, hypertension, cerebrovascular disease, dysphagia, stage 4 chronic kidney disease, pain, and memory deficit, and was assessed as severely cognitively impaired. The facility's policy required any individual observing or suspecting resident abuse to promptly report the incident after ensuring the resident's safety. However, the CNA did not take immediate action to protect the resident during the incident, resulting in a failure to implement the facility's abuse prevention policy.
Failure to Follow Care Plan for Paired Staff During Resident Care
Penalty
Summary
The facility failed to follow a care plan intervention for a resident who required care to be provided by staff in pairs due to a history of making false accusations against staff members. On the night shift of 12/26/24, the resident, who was cognitively intact and had multiple medical diagnoses including multiple sclerosis, diabetes with polyneuropathy, depressive disorder, and dysphagia, reported to staff that a CNA had touched him inappropriately during incontinence care. The resident's care plan, updated on 4/28/23, specifically required that care be provided by two staff members at all times, an intervention that was also listed on the CNA Assignment Sheet and confirmed by other CNAs during interviews. Despite this documented intervention, the DON confirmed that the CNA provided care to the resident alone while another CNA was in the hallway, thus not adhering to the care plan requirement. The CNA involved did not indicate in their written statement whether another staff member was present during care. This failure to follow the care plan intervention was identified during interviews and record reviews, and was cited as a deficiency related to the facility's obligation to implement and follow individualized care plans.
Failure to Reconcile Narcotic Counts on Rehab 1 Cart
Penalty
Summary
The facility failed to ensure proper shift-to-shift narcotic count reconciliation for one of the medication carts, specifically the Rehab 1 cart. During an observation, it was found that the Nurse Narcotic Sign in/out Sheet lacked reconciliation numbers for controlled medications on several dates. Interviews with staff, including LPNs and the Rehab Unit Manager, confirmed that the required signatures and count numbers were missing for October 17, 18, 19, and 20, 2024. This omission was identified as a potential opportunity for drug diversion, as the absence of count verification made it impossible to determine if any narcotics were missing. The facility's policy on Controlled Substance Reconciliation mandates that the quantity of controlled substances and the number of accompanying count sheets be verified at the end of each nursing shift. Despite frequent education provided to staff regarding the importance of complete narcotic reconciliation, the required documentation was not completed as per policy. The Director of Nursing acknowledged the deficiency, noting the lack of count numbers on the Nurse Narcotic Sign in/out Sheets for the specified dates, which left the facility unable to ascertain if drug diversion had occurred.
Failure to Investigate Allegation of Verbal Abuse
Penalty
Summary
The facility failed to complete an investigation of an allegation of verbal abuse involving Resident D. During an interview, Resident D reported that the Activities Director (AD) yelled at her loudly, accusing her of rejecting another resident from sitting at her table. This incident left Resident D feeling humiliated, embarrassed, and hurt, causing her to cry for several days. Despite this, the AD did not follow up with Resident D or apologize. Resident D, who has diagnoses including major depressive disorder and morbid obesity, was cognitively intact and able to communicate effectively, as indicated by her quarterly Minimum Data Set (MDS) assessment. Physical Therapy staff (PT) 2 reported that Resident D was extremely upset when she recounted the incident and that PT 2 had informed her supervisor, who then reported it to the Director of Nursing (DON). However, during an interview, the DON indicated she was unaware of the allegation. The facility's policy requires immediate reporting of any alleged mistreatment, neglect, or abuse to the Indiana Department of Health, but this procedure was not followed in this case.
Failure to Report Allegations of Sexual Abuse
Penalty
Summary
The facility failed to report allegations of sexual abuse involving a resident to law enforcement and adult protection agencies. The incident involved Resident B, who reported an allegation of staff-to-resident sexual abuse during incontinent care by CNA 1. The facility's investigation into the allegation lacked documentation of notification to law enforcement or adult protection agencies. Despite the resident's report and the facility's policy requiring such notifications, the facility did not contact the police, citing the family's request as the reason. However, a family member later indicated that they did not request the police not to be called. Interviews with the Administrator, Director of Nursing, and Corporate Consultant confirmed that law enforcement was not notified. The facility's current policy, dated 10/14/2014, mandates reporting any reasonable suspicion of a crime against a resident to local law enforcement and state agencies within 24 hours. The failure to report the incident as required by the policy resulted in a deficiency citation related to Complaint IN00428301.
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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