Harrison Terrace
Inspection history, citations, penalties and survey trends for this long-term care facility in Indianapolis, Indiana.
- Location
- 1924 Wellesley Blvd, Indianapolis, Indiana 46219
- CMS Provider Number
- 155636
- Inspections on file
- 27
- Latest survey
- September 22, 2025
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Harrison Terrace during CMS and state inspections, most recent first.
Surveyors found that the facility was not kept clean or in good repair, with strong urine odors in multiple units, sticky and stained floors, and resident rooms with chipped door frames, damaged walls, and worn linens. Staff and residents confirmed these issues, and used gloves and dirty items were observed on the floor.
A resident with dementia and osteomyelitis, who required extensive ADL assistance, was repeatedly observed unshaved and with food and dry skin on his face and beard. Despite a care plan specifying the need for help with grooming and hygiene, staff did not ensure regular face washing or shaving, and interviews indicated the resident did not refuse these services during the observed period.
A resident with dementia and severe cognitive impairment began exhibiting new behaviors involving physical contact with peers, including grabbing other residents. Despite multiple documented incidents, medication changes, and room moves, the facility did not timely develop or implement an individualized care plan addressing these behaviors, the use of psychotropic medication, or the resident's anxiety and agitation. Direct care staff were not informed of the resident's behavioral history, and the required care planning was not completed as per facility policy.
The facility failed to maintain cleanliness in the kitchen and on the Meridian unit, affecting all residents consuming food from the kitchen and those on the unit. Observations revealed a black substance under the dishwasher and gray substance on ceiling vents. The ice machine had a black substance inside, dust, and drainage issues. The Culinary Manager and Maintenance Supervisor acknowledged the issues, but documentation of cleaning was lacking.
The facility failed to properly contain trash for all residents. During a kitchen tour, an open dumpster with visible trash bags was observed, and the surrounding area was littered with debris, medication cups, and gloves. The Culinary Manager stated that the maintenance department is responsible for the area, while the Maintenance Supervisor admitted to not regularly checking the dumpster area.
The facility's kitchen was found to have flying insects in the dishwasher and storage areas, with a red bucket of soiled rags attracting more insects. The Culinary Manager admitted the issue had persisted for two weeks. An exterminator had previously noted small flies and recommended cleaning around drains, but a later visit reported no pest activity.
A facility failed to notify a medical provider of high blood sugar readings for a resident with diabetes and dementia. Despite a care plan and physician order requiring notification for blood sugar levels over 300, multiple instances in August 2024 showed readings above this threshold without documentation of notification. The DON confirmed the absence of such documentation.
A facility failed to complete orthostatic blood pressure measurements as ordered for a resident with hypertension, who was receiving doxazosin. The order required daily checks in lying, sitting, and standing positions, but records showed only one reading per day without position indication. The Director of Nursing confirmed the expectation for complete documentation, but the facility lacked a policy on conducting these measurements.
A resident with a history of constipation and ileus did not receive effective monitoring and care for constipation. Despite physician orders for Miralax and Dulcolax, these were not administered as needed, and abdominal assessments were not performed when the resident went without a bowel movement for several days. Facility staff showed inconsistencies in monitoring bowel movements, and the facility's Bowel Elimination policy was not followed, leading to inadequate management of the resident's condition.
A resident receiving dialysis services was not provided the therapeutic diet as ordered, including the omission of ice cream and the provision of orange juice instead of cranberry juice. The CNA assisting the resident was unaware of the dietary restrictions, and the dietary staff failed to deliver the prescribed ice cream.
Failure to Maintain Clean, Odor-Free, and Well-Repaired Environment
Penalty
Summary
Surveyors observed that the facility failed to maintain a clean, odor-free, and well-repaired environment for residents, staff, and the public. During multiple tours and observations, strong urine odors were detected in the main entry, Meridian Hills Unit, and Mapleton Unit. The floors in the Meridian Hills Unit were found to be sticky, with a six-inch black spot present between the entrance and the nurse's station. The Mapleton Unit was also noted to have a persistent strong urine odor during several visits. Interviews with staff and residents confirmed the presence of these odors and described the floors as dirty and linens as worn with holes. Further inspection of resident rooms revealed additional deficiencies in the physical environment. Resident rooms had chipped and scratched door frames, scrapes and missing pieces on chair rails, and walls with missing paint. Used gloves and dirty items were found discarded on the floor, and bed linens were observed to have holes. The maintenance supervisor indicated that repairs were made on an as-needed basis, and work orders were submitted by staff or families when issues were noticed. The facility did not have a policy in place for maintaining a homelike environment.
Failure to Provide Adequate ADL Assistance for Resident with Dementia
Penalty
Summary
A deficiency occurred when a resident with diagnoses including dementia and acute osteomyelitis did not receive adequate assistance with activities of daily living (ADL), specifically related to face washing and shaving. The resident's care plan indicated a need for assistance with bathing, dressing, grooming, and hygiene, and noted impaired decision-making and a tendency to refuse some care. Despite this, multiple observations over several days found the resident unshaved, with dry, flaky skin and food debris on his face and beard. The resident was also noted to have red corners of the mouth and skin flakes on his shirt collar. Interviews with staff confirmed that the resident required extensive assistance with ADLs and was usually shaved on shower days, but there was no indication that he refused face washing or shaving during the observed period. Staff interviews revealed that while the resident sometimes refused certain aspects of care, such as deodorant or showers, he was not known to refuse face washing or shaving. Observations consistently showed the resident in an unkempt state, with visible hygiene concerns that were not addressed until a later intervention by the Director of Nursing Services. The failure to provide regular and necessary grooming and hygiene assistance as outlined in the care plan led to the identified deficiency.
Failure to Timely Develop and Implement Individualized Care Plan for Resident with Dementia and New Behavioral Symptoms
Penalty
Summary
The facility failed to timely develop and implement an individualized plan of care for a resident diagnosed with dementia who began displaying new behaviors involving physical contact with peers. Specifically, a resident with severe cognitive impairment and a history of anxiety and insomnia exhibited behaviors such as grabbing other residents in the dining area and in his room. These incidents were documented in the clinical record and included multiple room changes due to incompatibility with roommates, as well as episodes of overstimulation and confusion in common areas. Despite these documented behaviors and the initiation of new medications to address anxiety and agitation, the clinical record did not contain a care plan addressing the new behaviors, the use of psychotropic medication, or the resident's anxiety and agitation. The deficiency was further evidenced by the lack of communication and education among direct care staff regarding the resident's history of making physical contact with peers. Interviews with CNAs revealed that they were not informed about the resident's behavioral history, even after several incidents had occurred. The facility's own policy required that care plans be initiated for any problematic or distressing behavioral expression and when a resident is receiving psychotropic medication for mood or behavior. However, the care plan for the resident did not address the new behaviors, the use of lorazepam, or the risk of agitation and aggression with roommates. Additionally, the facility's interdisciplinary team (IDT) met and reviewed the resident's behaviors, but failed to ensure that a care plan was promptly developed and implemented to address the specific behavioral issues. The lack of a timely and individualized care plan resulted in continued incidents involving physical contact with peers, room changes, and increased supervision, without a documented, proactive approach to managing the resident's behavioral health needs as required by facility policy.
Facility Fails to Maintain Cleanliness in Kitchen and Ice Machine
Penalty
Summary
The facility failed to maintain cleanliness in the kitchen and on the Meridian unit, which had the potential to affect all residents consuming food from the kitchen and those residing on the Meridian unit. During observations, a black substance was found on the flooring under the dishwasher, and gray substance was noted on the ceiling vents in the food prep area. The Culinary Manager acknowledged the issue and mentioned the use of a power washer to address the black substance, but was unsure about the last cleaning of the ceiling vents. The cleaning schedules indicated regular cleaning tasks, but the Interim Administrator could not provide documentation of the last cleaning of the ceiling vents. Additionally, the ice machine on the Meridian unit was found with a black substance inside the ice bin, dust, and dried reddish droplets on its outer surfaces. A towel was placed on the floor due to drainage issues. The Maintenance Supervisor stated that the ice machine was last cleaned in July 2024 and was scheduled for quarterly maintenance. However, the machine's condition suggested more frequent cleaning might be necessary. The manufacturer's instructions recommended de-scaling and sanitizing every six months, but the current state of the machine indicated it might require more immediate attention.
Improper Trash Containment
Penalty
Summary
The facility failed to ensure proper containment of trash for all 70 residents. During a kitchen tour with the Culinary Manager, it was observed that one of the outside dumpsters had a sliding side door open, with trash bags visible inside. The area around the dumpsters and along the fence line in the parking lot was littered with paper, plastic debris, medication cups, and gloves. The Culinary Manager acknowledged that the sliding doors should be closed and stated that the maintenance department is responsible for maintaining the area around the dumpsters and the grass. An additional observation with the Maintenance Supervisor confirmed the presence of plastic bottles, paper product debris, medication cups, gloves, plastic silverware, food wrappers, and cups in the dumpster area and grass along the fence. The Maintenance Supervisor admitted that the maintenance department is responsible for the grounds but does not regularly check the area around the dumpsters.
Presence of Flying Insects in Kitchen Area
Penalty
Summary
The facility failed to maintain a pest-free kitchen environment, as evidenced by the presence of flying insects in the kitchen area. During an observation with the Culinary Manager, flying insects were noted in the dishwasher and storage areas. Additionally, a red bucket containing soiled rags was observed with flying insects on top, and when the Culinary Manager removed the rags, more insects were seen flying from the bucket. The Culinary Manager acknowledged that the insects had been present for at least two weeks and admitted that the rags should not have been left in the bucket. An exterminator service visit on 6/4/24 had previously noted small flies in the dishwasher area and recommended frequent cleaning around drains to prevent pest breeding sites. However, a subsequent exterminator visit on 8/5/24 reported no rodent or insect activity.
Failure to Notify Medical Provider of High Blood Sugar Readings
Penalty
Summary
The facility failed to notify the medical provider of blood sugar readings exceeding the specified parameters for a resident with diabetes mellitus and dementia. The care plan for the resident, dated March 15, 2021, indicated a risk for adverse effects of hyperglycemia or hypoglycemia due to glucose-lowering medication and insulin dependency. A physician order from May 20, 2021, required staff to notify the medical provider if the resident's blood sugar was greater than 300 or less than 70. Despite this, the Medication Administration Record for August 2024 showed multiple instances where the resident's blood sugar exceeded 300, specifically on August 1, 7, 10, and 11, without any documentation of the medical provider being notified. An interview with the Director of Nursing confirmed the lack of documentation for notifying the medical provider on these dates.
Failure to Complete Orthostatic Blood Pressure Measurements
Penalty
Summary
The facility failed to complete orthostatic blood pressure measurements as per the physician's order for a resident diagnosed with chronic kidney disease, generalized anxiety disorder, and hypertension. The resident was receiving doxazosin, a medication known to cause orthostatic hypotension in older adults, and there was a recommendation to consider discontinuing it. The physician's order required daily orthostatic blood pressure checks before medication administration for 14 days, with specific instructions to notify a medical professional if the systolic blood pressure was outside the specified range. However, the medication administration record showed only one blood pressure reading per day without indicating the position (lying, sitting, or standing) for several days. The clinical record lacked orthostatic blood pressure readings for certain days, and some entries were recorded as late entries. The Director of Nursing confirmed that the expectation was to perform and document blood pressure checks in all three positions, but the facility did not have a policy on conducting orthostatic blood pressures. This oversight in following the physician's order and documenting the required measurements led to the deficiency identified in the report.
Failure to Manage Constipation in Resident with History of Ileus
Penalty
Summary
The facility failed to provide effective monitoring, assessment, and care for a resident with a history of constipation, partial bowel obstruction, and ileus. Resident B, who was always incontinent of bowel and bladder, required maximum assistance for toileting. The resident had physician orders for Miralax and Dulcolax suppositories to be administered as needed for constipation, but the orders lacked specific frequency instructions. Despite a care plan indicating the need for abdominal assessments and physician notification if no bowel movement occurred after three days, these interventions were not consistently implemented. From early February to late March, Resident B experienced multiple episodes of constipation, with no bowel movements recorded for several consecutive days on multiple occasions. During these periods, the prescribed laxatives were not administered as per the physician's orders and the care plan. Additionally, there was no documentation of abdominal assessments or physician notifications when the resident went without a bowel movement for four or more days. Interviews with facility staff revealed inconsistencies in how bowel movements were monitored and reported, with some staff not counting small bowel movements in their assessments. The facility's Bowel Elimination policy outlined procedures for monitoring and addressing constipation, including administering laxatives after three days without a bowel movement and conducting abdominal assessments if no results were achieved by the fourth day. However, these procedures were not followed for Resident B, leading to a deficiency in the care provided. The lack of adherence to the policy and care plan resulted in inadequate management of the resident's constipation, as evidenced by the failure to administer prescribed medications and perform necessary assessments.
Failure to Provide Therapeutic Diet for Dialysis Resident
Penalty
Summary
The facility failed to provide a therapeutic diet as ordered for a resident receiving dialysis services, identified as Resident 31. The resident, who has diagnoses including dementia and end-stage renal disease, was observed during breakfast without the prescribed ice cream and was given orange juice instead of cranberry juice. The care plan for the resident, dated back to 2018, specified dietary restrictions including no orange juice and the inclusion of ice cream with every meal. However, during the observation, the Certified Nurse Aide (CNA) assisting the resident was unaware of these dietary requirements and allowed the resident to consume orange juice. Further investigation revealed that the dietary staff forgot to send the ice cream to the resident, as confirmed by the Culinary Manager. The Licensed Practical Nurse (LPN) on duty noted that the CNA was new to the unit and unaware of the resident's specific dietary needs. The facility's diet orders policy emphasizes the importance of providing liberalized diets tailored to each resident's medical condition, needs, and rights, but this was not adhered to in the case of Resident 31.
Latest citations in Indiana
Surveyors observed that dietary staff repeatedly worked in kitchen and meal service areas with uncovered facial hair, despite facility policy and state sanitation requirements mandating effective hair restraints. Two dietary aides with short beards or mustaches were seen walking through food preparation areas, taking food temperatures, handling food, and plating meals at steamtables in dining rooms without any facial hair coverings, while the current policy required all hair, including facial hair, to be restrained to prevent contamination.
The facility failed to consistently provide and document required bed-hold policy notices when several residents were transferred to the hospital. In multiple cases, residents with dementia, psychotic disorders, COPD, chronic respiratory failure, altered mental status, and cerebral infarction were sent out for acute changes in condition, and while transfer notes reflected physician and family notifications, they lacked documentation that the bed-hold policy was discussed with the resident or responsible party. Notices of Transfer or Discharge often indicated a copy of the bed-hold policy was sent with the resident, but the records did not show signed and dated acknowledgment by the resident or appropriate representative, including in situations where a resident had moderate cognitive impairment, short-term memory issues, or a documented need for a proxy and a financial POA authorizing an agent for health care decisions.
Surveyors found that the facility failed to provide trauma‑informed and culturally competent care by not incorporating two residents’ extensive trauma histories and specific behavioral triggers into their care plans. One resident with documented homelessness, polysubstance abuse, severe accidents with multiple fractures, viral encephalitis with coma, physical and sexual abuse, loss of family contact, and a past suicide attempt had multiple behavior‑focused care plans that referenced identifying triggers but listed none and did not mention their physical, sexual, medical, or psychosocial trauma. Another resident with TBI from being struck by a truck, an 11‑month coma, long‑term state hospital residence, alleged shooting of a parent, and diagnoses including intermittent explosive disorder and borderline personality disorder had a PASRR identifying a specific trigger and notes of inappropriate sexual behavior, yet their care plans omitted these traumatic events, the identified trigger, and the sexual behavior. Staff interviews confirmed that residents were screened for trauma, but the trauma histories and triggers were not reflected in the individualized plans of care.
A resident with schizophrenia, post‑stroke hemiparesis, and mild cognitive impairment expressed feeling down and wanting to kill himself, but staff did not document asking about a specific plan, did not notify the physician or psychiatric NP as expected, and did not develop or update a care plan addressing depression or suicidal ideation. The SSD documented offering support and initiating 15‑minute checks once, but there was no further follow‑up or documentation of interventions after subsequent suicidal statements made in a care plan meeting with the resident’s father. The DON and Administrator reported that facility policy requires immediate notification of key staff, assessment for a plan and means of self‑harm, and thorough documentation, which were not carried out or reflected in the medical record for this resident.
A resident with schizophrenia, post-stroke hemiparesis, and mild cognitive impairment verbalized suicidal ideation, but the care plan did not address depression or suicidal thoughts, and required assessments and services were not accurately or timely documented. An SSD note recorded the resident saying he wanted to kill himself and referenced 15‑minute checks and a care plan update, yet the active care plan lacked depression/suicidal ideation interventions. Multiple late-entry Social Services notes were later added, describing follow-up visits and the resident denying suicidal ideation, but the SSD later reported she did not typically ask about a suicide plan and did not personally provide individual follow-up visits as described. These practices conflicted with the facility’s policy requiring factual, first-hand, and timely documentation of assessments and services.
A resident was observed with an Albuterol inhaler on an overbed table and later reported keeping the inhaler in a nightstand drawer, with no staff present during these observations. Record review showed the resident had no cognitive impairment on the admission MDS but lacked any documented self-medication administration assessment. The DON acknowledged that the required assessment had not been completed, despite facility policy requiring staff and the practitioner to evaluate each resident’s mental and physical abilities before allowing self-administration of medications.
Surveyors found that the facility submitted inaccurate direct care staffing data to CMS through the PBJ system over multiple days in a quarter. CASPER reports showed apparent gaps in 24-hour licensed nurse coverage, low weekend staffing, and a 1-star staffing rating, while internal staffing sheets documented that licensed nurses were present and the facility was fully staffed on those days. The Administrator reported that the discrepancies were due to PBJ data entry errors, despite a facility policy requiring all PBJ entries to be accurate, auditable, and verifiable against payroll, invoices, or contracts.
Surveyors found that the facility did not provide or document required written transfer/discharge notices and bed-hold policy information for four residents who were sent to the hospital, including individuals with conditions such as dementia, CHF, chronic respiratory failure, and CKD. In each case, progress notes showed that the resident was transferred for acute issues, but the clinical records lacked evidence that written notices were given to the residents or their representatives, and in one case lacked documentation that required information was sent to the receiving provider. Facility leadership, including the ADON, DON, and Administrator, acknowledged that the records did not contain the required documentation, despite a written policy requiring such notices and information exchange.
A resident with Alzheimer’s disease and depression, previously on an antidepressant, exhibited intermittent refusals of medications and care, occasional yelling at staff, and reports of unusual perceptions, such as believing men were in or near her room. Nursing notes over several months documented these refusals and complaints but did not show that the behaviors were evaluated or recorded as dangerous, non-redirectable, or causing significant distress, nor did they document specific non-pharmacological interventions attempted or their outcomes. Despite this, a psychiatric NP later added new diagnoses of schizoaffective disorder, borderline personality disorder, and delusional disorder and ordered an antipsychotic (Seroquel) without a comprehensive evaluation in the record to support these diagnoses. The facility’s psychotropic medication policy, which requires identification and documentation of target behaviors, use of nonpharmacological interventions, and ongoing behavior monitoring, was not followed for this resident.
The facility failed to keep PASARR Level I screenings accurate and current for three residents when new mental health diagnoses and psychoactive medications were initiated. One resident’s PASARR omitted a PTSD diagnosis and an added antidepressant, despite documentation of PTSD on the MDS and care plan and a physician order for Pristiq. Another resident’s PASARR listed only depression and dementia, even after additional diagnoses such as borderline personality disorder, delusional disorder, and schizoaffective disorder were added and an antipsychotic (quetiapine) was ordered, with the MDS later reflecting psychotic disorder, schizophrenia, and depression with antipsychotic and antidepressant use. A third resident’s PASARR did not include a depression diagnosis or newly ordered escitalopram and lorazepam, although the admission MDS documented depression with antianxiety and antidepressant use. These omissions occurred despite facility policy requiring a new Level I review after significant mental status changes, including new mental health diagnoses or new psychotropic medications.
Uncovered Facial Hair During Food Preparation and Meal Service
Penalty
Summary
The deficiency involves the facility’s failure to ensure that food was served in a sanitary and safe manner in accordance with professional standards and facility policy during multiple kitchen and meal service observations. During an initial kitchen observation, two dietary aides were seen walking through the kitchen food preparation area with uncovered facial hair. One aide had facial hair above and below the lip and along the jaw line, approximately one-fourth inch in length, and the other had a mustache of similar length; neither used any facial hair covering. These observations occurred while staff were present in the kitchen area where food was stored and prepared. During subsequent observations on the same day, the same two dietary aides were again observed with uncovered facial hair while directly involved in meal preparation and service. One aide walked through the kitchen while the noon meal was being prepared and placed into a transport cart for service in the south dining room, and later was observed plating the noon meal at the steamtable in that dining room, still without a facial hair covering. The other aide walked through the kitchen while the noon meal was being prepared and placed into the steamtable for the north dining room, took food temperatures, assisted with plating meals at the steamtable, and retrieved food items and supplies from the kitchen, all while having an uncovered mustache approximately one-fourth inch in length. The Dietary Manager stated that staff hair was to be covered when in the kitchen and during meal service, and the facility’s written policy and the cited Indiana Food Establishment Sanitation Requirements both required effective hair restraints, including for facial hair, to prevent contamination of food, equipment, and utensils.
Failure to Provide and Document Bed-Hold Policy at Time of Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure that required bed-hold policy information was provided and documented for four residents transferred to the hospital. For a resident with dementia, psychotic disorder, and autistic disorder who had a BIMS score of 0 indicating severe cognitive impairment, progress notes documented physician notification and guardian notification when the resident was sent to the hospital, but there was no documentation that the bed-hold policy was provided to the responsible party. A Notice of Transfer or Discharge later indicated a copy of the bed-hold policy was sent with the resident. Another resident with COPD and chronic respiratory failure, cognitively intact with a BIMS score of 13, experienced a decline in condition and was transferred to the hospital by ambulance; progress notes documented family notification but did not document any discussion of the bed-hold policy, although a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident. A third resident with altered mental status and cerebral infarction, with a BIMS score of 10 indicating moderate cognitive impairment and documented short-term memory impairment, experienced changes in condition and was transferred to the hospital. Progress notes stated the resident was their own responsible party and that no other notification was completed, and transfer documentation did not include the bed-hold policy, although an untimed Notice of Transfer or Discharge indicated a copy of the bed-hold policy was signed by the resident. A financial power of attorney document in the record showed the resident had designated an agent to act in consent or refusal of health care. For a fourth resident with dementia and osteomyelitis, transfer documentation and a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident, and the transfer form noted the resident required a proxy for decision making. The facility’s policy required that at the time of transfer to a hospital, written notice specifying the duration of the bed-hold policy and information on return to the next available bed be provided, and that a signed and dated copy of the bed-hold notice given to the resident or representative be kept in the resident file, which was not consistently documented for these residents.
Failure to Integrate Trauma Histories and Behavioral Triggers Into Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to identify and incorporate residents’ trauma histories and specific behavioral triggers into their care plans, despite documented histories of significant trauma and behavioral health issues. For one resident, extensive social service and progress notes documented homelessness, polysubstance abuse, major depressive and anxiety disorders, chronic pain, a history of severe car accidents with multiple fractures, viral encephalitis resulting in a three‑month coma, loss of child custody, multiple divorces, physical abuse by a spouse, the death of a fiancé who was struck by a car while in a wheelchair, lack of family contact, and a past suicide attempt by Valium overdose. Additional documentation noted a history of rape by a brother at age eight and prior placement under direct supervision and 15‑minute checks related to suicidal ideation. Despite these documented traumatic events and behavioral health concerns, the resident’s care plans did not identify a history of physical trauma, sexual trauma, homelessness, substance abuse, medical trauma, or attempted suicide. For this same resident, the MDS showed no cognitive deficit and identified behaviors such as verbal aggression and rejection of care, along with diagnoses including seizure disorder, depression, chronic pain syndrome, homelessness, and anxiety disorder. Multiple care plans addressed behaviors such as drug‑seeking, pretending to have seizures for attention or medication, making false allegations, verbal aggression when unable to smoke, and a desire for intimate relationships with consenting male residents. These care plans referenced goals such as effective coping skills, seeking staff support, and compliance with the smoking policy, and they called for identification and reduction of behavioral triggers. However, none of these care plans actually listed any specific triggers. The care plan addressing the resident’s right to consensual intimate relationships focused on assessment and education regarding consent but did not integrate the resident’s extensive trauma history. Staff interviews indicated the resident had displayed sexual behaviors since admission, including an incident where the resident expressed anger at another resident for not buying a soda after engaging in sexual acts. A second resident with a documented history of traumatic brain injury (TBI), dementia, seizure disorder, borderline personality disorder, anxiety, intermittent explosive disorder, tobacco use, and other behavioral/emotional disorders was also affected by the same deficiency. Social history and progress notes documented that this resident sustained a TBI after being hit by a semi‑truck while riding a bicycle at age 18, resulting in an 11‑month coma, followed by 13 years in a state hospital and subsequent residence in a group home. Additional documentation indicated the resident allegedly shot their father at age 26 after being sworn at and had a PASRR identifying TBI, intermittent explosive disorder, and borderline personality disorder, with a specific trigger of hearing the name of the current U.S. President. Progress notes also described inappropriate sexual behavior toward staff, including touching themselves intimately during personal care and refusing to stop when redirected. Despite this, the resident’s care plans, which addressed explosive disorder and history of altercations, risk for decreased psychosocial well‑being, and refusal to bathe or shower, did not list any specific behavioral triggers, did not reference the traumatic events such as being hit by a truck or shooting their father, and did not document the inappropriate sexual behavior. The Administrator and Social Service Director acknowledged that residents were to be screened for trauma and that trauma responses and PTSD should be added to care plans, but the specific trauma histories and triggers for these two residents were not incorporated into their plans of care.
Failure to Assess and Care Plan for Resident Suicidal Ideation
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess, investigate, and care plan for a resident’s suicidal ideation in accordance with its own policy and staff expectations. The resident had diagnoses including schizophrenia, cerebral edema, and hemiparesis/hemiplegia following a cerebral infarction, and a current MDS showed mild cognitive impairment (BIMS score 12). A progress note documented that the resident told the Social Services Director (SSD) he was feeling down and wanted to kill himself; the SSD offered assistance, activities, and initiated 15‑minute checks, and the note stated the care plan was updated. However, the note did not indicate that the SSD asked whether the resident had a plan to kill himself, and there were no additional notes regarding suicidal ideation or follow‑up. Review of the current care plan showed no problem, goal, or interventions addressing depression or suicidal ideation, and progress notes over the following month contained no documentation of physician notification related to the suicidal statement. Further record and interview evidence showed that the care plan conference summary did not document interventions for suicidal ideation, and the SSD acknowledged she did not normally ask residents expressing suicidal ideation if they had a plan. The SSD reported that the resident had admission paperwork mentioning suicidal ideation related to depression after a stroke and that the resident again vocalized suicidal ideation during a care plan meeting with his father, after which emotional support was offered and the father took the resident out on a leave of absence; no further visits or follow‑up were done. The DON stated that, upon notification of suicidal verbalization, staff should assess the resident, ask if there is a plan, remove potential means of self‑harm, immediately notify the psychiatric NP, and document the occurrence, and that a detailed progress note and updated care plan were expected but not present for this resident. The Administrator similarly stated that staff should ask about a plan, document interventions, notify the physician and family, and update the care plan, and indicated the resident should have had a care plan addressing depression with suicidal ideation. The facility’s written policy required immediate notification of the DON, SSD, and physician, an interview including asking about a plan and assessing mood and means for self‑harm, and thorough documentation of mood, behavior, and all actions taken, which were not reflected in the resident’s record.
Incomplete and Inaccurate Documentation of Suicidal Ideation and Follow-Up
Penalty
Summary
The facility failed to ensure accurate, complete, and timely documentation of assessments and services for a resident who verbalized suicidal ideation. Resident 6, who had schizophrenia, cerebral edema, and right-sided hemiparesis/hemiplegia following a cerebral infarction, had a BIMS score of 12 indicating mild cognitive impairment. The resident’s admission paperwork mentioned suicidal ideation related to depression after a stroke, and a Social Services note on 3/11/2026 documented that the resident was feeling down and said he wanted to kill himself. The Social Services Director (SSD) documented that she talked with the resident, coordinated with Activities, advised the resident to contact SSD or nursing if he wanted to talk, and that the resident was scheduled for 15-minute checks and the care plan was updated. However, the current care plan initiated on 2/26/2026 did not address depression or suicidal ideation. Multiple Social Services progress notes were later entered as late entries in April, with effective dates in March, stating that the resident had no plan and no longer had suicidal ideation, that he felt much better after 1:1 time, and that he continued his daily routine and therapy. These late entries described follow-up visits and reassessments of suicidal ideation on several consecutive days, but in interviews the SSD stated she did not normally ask residents about having a plan when they verbalized suicidal ideation and did not recall any other occurrences beyond the initial event. She further indicated she did not personally provide individual follow-up visits with this resident regarding suicidal ideation, despite the late-entry notes describing such visits. The DON acknowledged that late entries had been added to address concern about suicidal verbalization, and the Administrator stated that upon suicidal statements staff should ask about a plan, notify the physician and family, and update the care plan, and that this resident should have had a care plan addressing depression with suicidal ideation. The facility’s documentation policy required factual, first-hand, timely documentation, which was not followed in this case.
Failure to Complete Required Self-Administration Assessment for Inhaler Kept at Bedside
Penalty
Summary
Surveyors identified that a resident was allowed to keep and access an Albuterol inhaler without the facility completing the required self-administration medication assessment. During an initial tour, the resident was observed sitting in a wheelchair with a handheld Albuterol inhaler on the overbed table and no staff present in the room or hallway. On a subsequent observation, the resident again was in a wheelchair and reported that the Albuterol inhaler was stored in the top drawer of the nightstand, where it was found. Review of the clinical record showed an admission MDS indicating no cognitive impairment, but there was no documentation of a self-medication administration assessment. In an interview, the DON confirmed that the resident did not have the required self-medication assessment, despite the facility’s policy stating that staff and the practitioner must assess each resident’s mental and physical abilities to determine whether self-administering medications is clinically appropriate. This failure to complete and document a self-administration medication assessment for a resident who had an Albuterol inhaler kept at bedside constituted noncompliance with the facility’s own policy and with 410 IAC 16.2-3.1-11(a).
Inaccurate PBJ Staffing Data Submission to CMS
Penalty
Summary
The deficiency involves the facility’s failure to electronically submit complete and accurate direct care staffing information to CMS through the Payroll-Based Journal (PBJ) system for 22 days in a fiscal quarter. A CASPER report review on 4/6/26 showed that, according to PBJ data, the facility did not have licensed nursing coverage 24 hours per day on multiple specific dates across three months, had low weekend staffing, and held a 1-star staffing rating. However, review of the facility’s internal staffing sheets for that quarter indicated the facility was fully staffed and had licensed nurse coverage on all of the dates in question. During an interview, the Administrator stated that the PBJ information must have contained data entry errors, as she had verified licensed staff coverage on the timesheets. The facility’s PBJ policy in effect stated that all staffing data entered into the PBJ system would be auditable and verifiable through payroll, invoices, or contracts, but the submitted PBJ data did not accurately reflect the facility’s actual licensed nurse staffing as documented on internal records. No specific residents or clinical conditions were mentioned in the report, and the deficiency centers solely on inaccurate staffing data submission rather than direct resident care events.
Failure to Provide and Document Required Transfer/Discharge and Bed-Hold Notices
Penalty
Summary
The deficiency involves the facility’s failure to provide and document required written notices of transfer/discharge and bed-hold policies, as well as required information to receiving providers, for four residents who were transferred or discharged to the hospital. For a resident with generalized anxiety disorder, major depressive disorder, and dementia, progress notes showed that the resident was sent to the hospital via 911 for chest pain, lower back pain, and shortness of breath and later returned to the facility, but the clinical record lacked documentation that a written Notice of Transfer/Discharge and the bed-hold policy were provided to the resident or representative, and lacked documentation that required information was conveyed to the receiving facility. The ADON and the Administrator both confirmed there was no documentation that these written notices were provided. For a resident with congestive heart failure and muscle weakness who was sent to the emergency room for painful urination and bloody urine, the clinical record lacked documentation that a Notice of Transfer/Discharge or bed-hold policy was given to the resident or representative, which the DON confirmed. Another resident with chronic respiratory failure and diabetes was discharged to the hospital for respiratory failure, and a resident with chronic kidney disease and dementia was discharged to the hospital, but in both cases there was no documentation that a written notice of transfer/discharge or bed-hold policy was provided to the residents or their representatives. Review of the facility’s Transfer and Discharge policy, dated 1/15/26, showed that the policy required the facility to provide written transfer/discharge notices and bed-hold information to residents and representatives and to provide specified information to receiving providers, but the records for these four residents did not contain the required documentation.
Failure to Document Target Behaviors and Non-Pharmacological Interventions Before Initiating Antipsychotic
Penalty
Summary
The deficiency involves the facility’s failure to document how a resident’s behaviors presented danger or distress to self or others, and failure to document non-pharmacological interventions attempted prior to initiating an antipsychotic medication. Resident 6 had documented diagnoses of Alzheimer’s disease, depression, and severe cognitive impairment, and was receiving sertraline for depression. A PASSAR identified only depression and dementia, and the admission MDS listed Alzheimer’s disease and depression as active diagnoses. Over several months, nursing progress notes documented that the resident intermittently reported unusual perceptions, such as believing there were men causing trouble, a man in her room, or a man wanting to marry her and yelling through the walls, but there was no documentation that these episodes caused danger to the resident or others or that they resulted in unmanageable distress. From late April through mid-July, nursing notes primarily described the resident’s frequent refusals of evening and morning medications, blood sugar checks, blood pressure checks, insulin administration, hygiene care, and showers. Staff documented that the resident sometimes yelled at staff, said “Get out!”, was visibly upset by a room move, was leery of staff and asked to see name badges, and became upset about a pillow under her head until it was removed, after which she calmed down. The notes also recorded instances where the resident believed housekeeping had not cleaned her room or that she had not received medications when she had. However, there were no progress notes or assessments indicating that these behaviors were evaluated as dangerous, non-redirectable, or causing significant distress or functional impairment, and no detailed behavior monitoring logs were present as required by facility policy. On a psychiatric NP visit for initial psychotropic medication management, new mental health diagnoses of schizoaffective disorder, borderline personality disorder, and delusional disorder were added, and Seroquel 25 mg, an antipsychotic, was ordered. The clinical record did not contain a comprehensive evaluation to support these new diagnoses, and there was no documentation of target behaviors meeting the facility’s policy criteria for psychotropic use, such as behaviors representing danger to self or others, causing distress and impairment in functional abilities, or clearly attributable to psychosis or mania. The resident’s representative reported that the resident had no prior history of mental health disorders or psychiatric hospitalization and was unaware of the new diagnoses. The facility’s own psychotropic medication policy required identification and documentation of specific target behaviors, use and documentation of nonpharmacological interventions, and ongoing monitoring of behaviors and interventions, which were not reflected in the record for this resident.
Failure to Update PASARR Screens for New Mental Health Diagnoses and Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that Preadmission Screening and Resident Review (PASARR) Level I screenings were accurate and updated when new mental health diagnoses and psychoactive medications were initiated for multiple residents. For one resident with dementia, anxiety, depression, and post-traumatic stress disorder (PTSD), the PASARR completed on admission listed anxiety, depression, and dementia with sertraline and quetiapine, but did not include the PTSD diagnosis or the antidepressant Pristiq, despite the admission MDS and care plan documenting PTSD and a subsequent physician’s order for Pristiq. For another resident with Alzheimer’s disease, borderline personality disorder, delusional disorder, schizoaffective disorder, and depression, the PASARR only reflected depression and dementia with sertraline, even though additional mental health diagnoses were added later and an antipsychotic (quetiapine) was ordered for borderline personality disorder, and the quarterly MDS documented psychotic disorder, schizophrenia, and depression with antipsychotic and antidepressant use. A third resident had diagnoses including Alzheimer’s disease, depression, anxiety disorder, irritability and anger, and nonrheumatic aortic valve stenosis. The PASARR for this resident listed dementia and anxiety with Risperdal but omitted the diagnosis of depression and the medications escitalopram and lorazepam, although physician’s orders were in place for escitalopram for depression and lorazepam for anxiety, and the admission MDS documented depression with antianxiety and antidepressant use. Interviews with the Assistant Director of Nursing confirmed that new Level I PASARR screens should have been completed when new mental health diagnoses and psychoactive medications were added, and that the PASARR for one resident, completed prior to arrival, should have included all mental health diagnoses and medications. The facility’s own policy required notification of the state mental health authority within 14 days after a significant change in mental condition and specified that a new Level I screen is required for new mental health diagnoses or newly prescribed psychotropic medications, which was not followed in these cases.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
