Harrison Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Corydon, Indiana.
- Location
- 150 Beechmont Dr, Corydon, Indiana 47112
- CMS Provider Number
- 155657
- Inspections on file
- 58
- Latest survey
- January 29, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Harrison Healthcare Center during CMS and state inspections, most recent first.
A resident with hypertension received metoprolol on multiple occasions when their systolic blood pressure was below the physician-ordered threshold, contrary to medication administration parameters. Staff interviews and record review confirmed that the medication was administered outside of prescribed guidelines, despite facility policy requiring adherence to provider orders.
A resident with an indwelling catheter and a history of acute kidney failure and uropathy did not have catheter care documented during several night shifts, despite a care plan and facility policy requiring such care every shift. Staff interviews confirmed the expectation for regular catheter care, and the deficiency was identified due to missing documentation for the specified period.
A resident receiving nebulizer treatments did not have required respiratory assessments documented before and after treatments, and the nebulizer equipment was not replaced weekly as per facility policy. The nebulizer mouthpiece was observed to be undated and unbagged at the bedside, and staff interviews confirmed these lapses in care.
A resident with pain management needs received Oxycodone IR 5 mg as documented on the controlled drug administration record, but the medication administration record (MAR) did not reflect these administrations. Staff interviews confirmed that both records should be signed when narcotics are given, and facility policy requires medications to be charted when administered. This resulted in incomplete documentation of narcotic administration.
The facility failed to maintain oxygen concentrator filters for five residents, leading to deficiencies in respiratory care. Observations showed filters were covered with a white powdery substance, and records indicated inconsistencies in cleaning schedules. Staff interviews revealed lapses in the cleaning process, contributing to the deficiencies.
The facility failed to maintain resident dignity by not covering a resident's catheter bag, making urine visible from the hallway, and an LPN spoke disrespectfully to a resident during an assessment. The facility's policy on resident rights was not followed, leading to deficiencies in maintaining dignity and respect.
A resident requiring long-term IgG infusions due to poor venous access experienced a significant delay in scheduling a port placement. Despite a physician's order and a referral made in August, the appointment was not secured, leading to the continued use of midlines, one of which showed signs of infection. Interviews revealed confusion over insurance and primary physician details, contributing to the delay. The facility's staff acknowledged the issue, indicating it should not have taken months to address.
A resident with diabetes and other health conditions received insulin despite a physician's order to withhold it if blood sugar was below 150. The facility's records showed multiple instances of insulin administration when the resident's blood sugar was below this threshold. An LPN confirmed that insulin should be administered per physician's parameters, and the facility's policy emphasized adherence to prescribed medication orders.
The facility failed to follow physician's orders for two residents requiring laboratory services. One resident, with multiple diagnoses, did not have several required tests documented over several months. Another resident on Warfarin did not have timely INR monitoring, and the physician was not notified of results as required. The DON confirmed these lapses in following the facility's policies.
The facility failed to maintain a safe and homelike environment, with issues such as mold from air conditioning leaks and unclean filters in several rooms. The Maintenance Director admitted to delays in addressing these issues, and the DON confirmed that air conditioning filters were not cleaned monthly as required by policy.
A facility failed to monitor a resident's chole drain and did not adhere to medication parameters for several residents. A resident with a chole drain had no documented monitoring, and the drain was found missing. Additionally, medications were administered to residents despite blood pressure and pulse readings not meeting prescribed parameters, and documentation of vital signs was lacking before administering medication.
The facility failed to maintain a sanitary environment in two hallways. On the 300 Hallway, issues included towels and a bath blanket on the floor, a commode with a strong stool odor, and an out-of-order bathroom. Debris and a shop vac were also noted. On the 200 Hallway, bed linens were on the floor, and a commode was not properly emptied. A CNA confirmed improper handling of soiled linens and commode checks.
The facility failed to bag respiratory equipment for three residents, including a resident with a tracheostomy and two residents using nebulizers, despite physician orders and infection control protocols. An LPN confirmed the need for bagging to prevent germs.
Failure to Follow Blood Pressure Medication Parameters
Penalty
Summary
The facility failed to follow physician-ordered medication administration parameters for a resident diagnosed with hypertension. The physician's order specified that metoprolol 25 mg should be administered twice daily but held if the resident's systolic blood pressure (SBP) was less than 120. Despite this order, medication administration records showed that metoprolol was given on multiple occasions when the resident's SBP was below the prescribed threshold, with recorded SBP values ranging from 94 to 119 at the time of administration. Interviews confirmed that staff were aware that medications should not be administered if a resident's blood pressure was outside of ordered parameters. The facility's policy on medication administration also required medications to be given only as prescribed by the provider. The failure to adhere to these parameters was identified through record review and staff interviews, and the deficiency was cited in relation to a specific complaint.
Failure to Provide and Document Catheter Care Every Shift
Penalty
Summary
A resident with diagnoses including acute kidney failure and obstructive and reflux uropathy had an indwelling catheter and a care plan directing staff to provide catheter care every shift. Review of the resident's clinical record showed a lack of documentation for indwelling catheter care during the night shift from June 11 through June 13, 2025. Interviews with staff confirmed that catheter care was expected to be provided every shift, and the facility's policy required catheter care at least twice daily for residents with indwelling catheters. The deficiency was identified due to the absence of documented catheter care for the specified period.
Failure to Complete Respiratory Assessments and Replace Nebulizer Equipment Weekly
Penalty
Summary
The facility failed to ensure that respiratory assessments were completed for a resident receiving nebulizer treatments and did not replace respiratory equipment on a weekly basis as required. Observation revealed that a nebulizer machine at the resident's bedside had a handheld mouthpiece that was neither bagged nor dated. Record review showed that the resident, who had diagnoses including anxiety and cough, was receiving Duoneb Solution via nebulizer twice daily per physician order. However, there was no documentation in the clinical record of respiratory assessments being performed before and after the treatments, nor was there evidence of weekly replacement of the nebulizer tubing, chamber, and mouthpiece. Interviews with staff confirmed that the nebulizer tubing should be dated and bagged when not in use and that equipment was to be replaced weekly. The DON acknowledged that respiratory assessments were expected to be completed before and after treatments to assess effectiveness, but confirmed that such assessments were not in place for this resident. Facility policy required collection of respiratory data pre- and post-treatment, but this was not documented in the resident's record.
Failure to Accurately Document Narcotic Administration on MAR
Penalty
Summary
The facility failed to ensure that a resident's medication administration record (MAR) accurately reflected the administration of narcotic pain medication. Specifically, for a resident with diagnoses including right upper arm pain and low back pain, the July and August medication administration records did not document the administration of Oxycodone IR 5 mg, despite the controlled drug administration record indicating that the medication was given on multiple occasions. The MAR lacked documentation for the administration of the resident's medication from July through early August, even though the controlled drug record showed the medication was dispensed at those times. Interviews with staff confirmed that both the controlled drug administration record and the MAR should be signed by the nurse when administering routine or as-needed narcotic pain medication. The facility's policy, as provided by the Director of Nursing, states that medications will be charted when given and narcotics will be signed out when administered. The failure to document the administration of narcotic medication on the MAR was identified during a review of the clinical record and confirmed through staff interviews.
Deficient Maintenance of Oxygen Concentrator Filters
Penalty
Summary
The facility failed to ensure proper maintenance of oxygen concentrator filters for five residents, leading to deficiencies in respiratory care. Observations revealed that the filters of these residents' oxygen concentrators were either heavily or moderately covered with a white powdery substance. This issue was noted during multiple observations, including one where a resident's filter was 100% covered and pushed against the outer wall of the room. The facility's Director of Nursing confirmed the condition of the filters during an observation. The records of the affected residents showed that they had various respiratory and cardiac conditions, such as COPD, emphysema, heart failure, and anxiety disorders, which necessitated the use of oxygen therapy. Physician orders indicated that the filters should be cleaned weekly and as needed, but documentation in the Treatment Administration Records (TAR) showed inconsistencies in the cleaning schedule. For instance, one resident's filter was last cleaned several days before the observation, and another resident's TAR lacked documentation for filter cleaning altogether. Interviews with facility staff revealed lapses in the cleaning process. The Patient Resident Scheduler responsible for cleaning the filters admitted to being behind schedule and missing the cleaning of one resident's filter. She also acknowledged that the buildup of the white powdery substance could occur quickly, especially if the filters were wet when replaced. The facility's policy on oxygen concentrator maintenance was not consistently followed, contributing to the observed deficiencies in respiratory care.
Failure to Maintain Resident Dignity and Respect
Penalty
Summary
The facility failed to respect the dignity of residents by not ensuring that the urine side of an indwelling catheter bag was not visible to those passing by a resident's room. Resident 283's catheter bag was observed multiple times over several days hanging off the side of the bed without a dignity cover, making the urine visible from the hallway. Despite a physician's order and care plan indicating the need for a privacy bag, staff interviews revealed that the catheter bag was not covered, and staff were aware of the requirement to use dignity covers but failed to implement it. Additionally, the facility did not ensure that staff spoke to residents in a dignified manner. An incident involving Resident 34 occurred when an LPN, responding to a reported change in condition, entered the resident's room and startled her. The resident became combative, and the LPN responded by yelling at her to "shut up," which was confirmed by multiple staff members. The resident's care plan included interventions for behavior management, but the LPN's response was inappropriate and disrespectful. The facility's policy on resident rights emphasizes treating residents with dignity and respect, including speaking respectfully and providing privacy. However, the observations and interviews indicate that these policies were not followed, leading to deficiencies in maintaining the dignity and respect of the residents involved.
Delay in Scheduling Port Placement for Resident Requiring IV Therapy
Penalty
Summary
The facility failed to ensure a timely appointment was scheduled for the placement of a port for a resident requiring intravenous therapy. The resident, who was cognitively intact and diagnosed with conditions such as immobility syndrome and chronic inflammatory demyelinating polyneuritis, required long-term IgG infusions due to poor venous access. Despite a physician's order dated 10/30/24 for a referral to a surgeon for port placement, the appointment was not scheduled promptly. The resident had a midline placed in the right arm, which later showed signs of infection, necessitating its removal. The resident expressed concern over the delay in port placement, which was initially referred by her family physician in August, but the referral may have been ignored. Interviews with facility staff revealed confusion and delays related to the resident's insurance and primary physician, contributing to the scheduling issue. The facility's scheduler and business office manager were involved in the process, but the appointment for port placement was not secured. The Director of Nursing and the Regional Director of Clinical Operations acknowledged the delay, with the latter indicating that it should not have taken months to schedule the appointment. The deficiency highlights a lapse in the facility's process for managing referrals and scheduling necessary medical procedures for residents.
Failure to Follow Insulin Administration Parameters
Penalty
Summary
The facility failed to adhere to a physician's order regarding insulin administration for a resident with diabetes, hypertension, congestive heart failure, and cognitive communication deficit. The physician's order specified that insulin should be withheld if the resident's blood sugar was below 150. However, the resident received insulin on multiple occasions when their blood sugar was below this threshold, as documented in the Electronic Administration Record/Electronic Treatment Administration Record (EMAR/ETAR) for October, November, and December 2024. This included instances where the blood sugar levels were as low as 101, 106, and 132, among others. During an interview, an LPN confirmed that insulin administration should follow the physician's parameters and that any deviations should be reported to a medical provider. The facility's policy on medication administration, which was provided by the Administrator in Training, emphasized administering medication only as prescribed and observing the five rights of medication administration. Despite these guidelines, the facility did not comply with the physician's order, leading to the administration of insulin outside the specified parameters.
Failure to Follow Physician's Orders for Laboratory Services
Penalty
Summary
The facility failed to follow physician's orders for obtaining laboratory services for two residents. Resident 25, who was moderately cognitively impaired and had multiple diagnoses including seizures and hypertension, had a physician's order for several laboratory tests to be conducted every three months starting in July 2024. However, the resident's record lacked documentation of several required tests in July and October 2024, and an Oxcarbazepine level in November 2024. The LPN indicated that the nurse was responsible for inputting lab orders into the lab courier system, but the Director of Nursing confirmed that the labs were not completed as ordered. Resident 14, who was cognitively intact and had diagnoses including atrial fibrillation and heart failure, was on Warfarin and required regular INR monitoring. A new order for daily Warfarin was made on November 8, 2024, with a recheck of INR scheduled for November 15, 2024. However, the INR was not drawn until November 22, 2024, and there was no indication that the physician was notified of the result or that a new INR order was placed until December 13, 2024. The facility's policy required communication between the facility and the physician for INR monitoring, but this was not followed, as confirmed by the DON.
Deficiencies in Room Maintenance and Air Conditioning Filter Cleaning
Penalty
Summary
The facility failed to maintain a safe and homelike environment for residents, as evidenced by issues with air conditioning units and room conditions in several observed rooms. In one instance, wallpaper was buckled and peeling due to a water leak from an air conditioning unit, which had caused mold growth on the wall. The Maintenance Director acknowledged the mold issue, stating that the wall had been cut out and replaced after a leak from the air conditioner. However, the leak had persisted for months, requiring staff to use blankets and a bath pan to manage the water. The dark black substance observed on the wall was identified as mold, which the Maintenance Director planned to clean with bleach. Additionally, the facility did not adhere to its policy of cleaning air conditioning filters monthly. Observations revealed that several air conditioning filters were either missing or covered in dust, with the Maintenance Director admitting that the filters on one hallway had not been cleaned since July. The Director of Nursing confirmed that the filters were supposed to be cleaned monthly, as per facility policy. This failure to maintain clean air conditioning filters and address water leaks promptly compromised the safety and comfort of the residents' living environment.
Failure to Monitor Chole Drain and Adhere to Medication Parameters
Penalty
Summary
The facility failed to ensure proper monitoring and care for a resident with a chole drain. Resident B, who was admitted with a chole drain due to acute cholecystitis and sepsis, had no documented monitoring of the drain from the time of admission until it was discovered missing by a nurse practitioner. The Director of Nursing acknowledged that staff should have been monitoring the resident's drain. Additionally, the facility did not adhere to medication administration parameters for several residents. Resident B received Metoprolol Succinate ER despite having a systolic blood pressure below the prescribed threshold. Similarly, Resident C was administered Midodrine HCl even when their systolic blood pressure exceeded the limit set by the physician's order. Resident D received Hydralazine and Metoprolol Tartrate despite having blood pressure and pulse readings below the specified parameters. Resident E's medication administration records lacked documentation of blood pressure readings prior to administering Carvedilol on multiple occasions. The facility's policy requires recording pertinent information, such as blood pressure and apical pulse, before medication administration, which was not followed in these instances.
Sanitation Deficiencies in Facility Hallways
Penalty
Summary
The facility failed to maintain a sanitary environment in two of the three hallways observed, specifically the 200 and 300 Hallways. On the 300 Hallway, multiple issues were noted, including towels and a bath blanket on the floor under the heating and air unit in one room, and a bedside commode with a dried, speckled brown substance that emitted a strong odor of stool. Additionally, the bathroom in this room was out of order. Another room on the same hallway had towels on the floor, a strong urine odor, a puddle of water, and a brown substance on the toilet seat and floor. The piping from the toilet was removed and lying on the floor, and the trash can was out of reach and without a trash bag. Debris such as an empty chocolate milk container and snack wrappers were also observed on the floor. A shop vac was left in the hallway, and a can of air freshener, considered a chemical, was improperly left in a resident's room. On the 200 Hallway, bed linens were found on the floor at the end of a bed, and a bedside commode was observed with urine and toilet paper, a quarter full. A CNA indicated that soiled linens should not be on the floor and should be bagged and placed in the dirty linen container, and that bedside commodes should be checked and emptied every two hours. The facility's policy on infection control practices for laundry/linen was provided, indicating that resident safety is a primary consideration. These observations were related to a complaint investigation.
Failure to Bag Respiratory Equipment
Penalty
Summary
The facility failed to ensure that respiratory equipment was properly bagged when not in use for three residents who required respiratory care. Resident C, who had a tracheostomy, was observed with a yankauer suctioning tool lying directly on the nightstand without being bagged. This was despite a physician's order indicating the need for regular suctioning. An LPN confirmed that respiratory equipment should be bagged to prevent germs and infection. Similarly, Resident D, diagnosed with congestive heart failure and asthma, had a nebulizer machine with tubing attached to a handheld nebulizer lying on a recliner without being bagged. Resident E, with chronic obstructive pulmonary disease and chronic respiratory failure, also had a nebulizer machine with tubing attached to a handheld nebulizer in bed, not in use or bagged. Both residents had physician's orders for nebulizer treatments, yet the equipment was not stored according to infection control protocols.
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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