Heritage Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in West Lafayette, Indiana.
- Location
- 3401 Soldiers Home Rd, West Lafayette, Indiana 47906
- CMS Provider Number
- 155402
- Inspections on file
- 24
- Latest survey
- February 18, 2026
- Citations (last 12 mo.)
- 20
Citation history
Health deficiencies cited at Heritage Healthcare during CMS and state inspections, most recent first.
A resident with multiple medical conditions, including diabetes, a femur fracture, CKD, and a non-traumatic subarachnoid hemorrhage, had PRN oxycodone ordered for pain. During a narcotic count between two RNs, two oxycodone cards and corresponding narcotic log sheets were present, but at the next shift’s count one oxycodone card and its log sheet were missing. One RN reported the resident had needed pain medication overnight and then left without signing the narcotic count. The DON later confirmed the card and log sheet were missing, with only the card top found in the disposal box and the pharmacy verifying that five oxycodone tablets were unaccounted for, while the resident did not recall receiving a pain pill at the reported time.
A resident, who was cognitively intact, was moved to a smaller room without being given the option to remain in his original room after completing rehabilitation therapy. The new room lacked adequate bathroom facilities, and the resident was not informed of his right to refuse the transfer. The Executive Director later acknowledged that the resident should have been given a choice.
The facility failed to properly store and label medications across four medication carts, leading to deficiencies. Observations revealed oral medications mixed with topical ones, cleaning supplies stored with medications, and expired or unlabeled medications. Interviews with QMAs highlighted a lack of awareness regarding proper storage practices, indicating systemic issues with medication management.
A facility failed to thoroughly investigate allegations of a CNA working while impaired, potentially affecting residents' well-being. Resident B reported concerns about the CNA's behavior, including smelling alcohol and inappropriate proximity. The investigation lacked comprehensive staff interviews, resident statements, and documentation of emotional impact. The facility's policy requires thorough evidence collection, but the investigation was incomplete and delayed.
A facility failed to submit a discharge MDS assessment for a resident, resulting in a delay of over 120 days since the last assessment. The resident had multiple medical conditions, and while the admission MDS was submitted, the discharge assessment remained pending. The MDS Coordinator admitted the oversight, and the Administrator confirmed reliance on the RAI manual without a specific facility policy.
A facility failed to resubmit a PASARR for a resident after a new mental health diagnosis and medication were added. The resident, initially evaluated with no mental health issues, was later diagnosed with mild major depressive disorder and prescribed sertraline. Despite these changes, the facility did not complete another PASARR, as required by their policy. The oversight was acknowledged by the Social Services Director.
A resident with multiple pressure ulcers was not turned every two hours as ordered, particularly during evening and night shifts. Despite a care plan and physician's order, CNA task records showed missing documentation of required repositioning. The resident expressed concerns about the lack of consistent care, and facility staff acknowledged the issue but lacked a specific policy to prevent pressure ulcers.
A resident with end-stage renal disease and other health conditions missed a dialysis session due to the facility's failure to arrange transportation, resulting in hospitalization for fluid overload and respiratory failure. The facility was responsible for transportation arrangements but failed to inform the resident until the last minute, leading to severe health complications.
A facility failed to follow proper procedures before using bed rails for a resident who used them for mobility assistance. The facility did not obtain a physician's order, conduct a side rail assessment, or secure signed consent. Additionally, no alternatives were documented, and the care plan did not include the use of side rails. The facility's policy requires these steps to prevent safety hazards, but they were not followed.
A facility failed to conduct an annual gradual dose reduction (GDR) for a resident's anti-depressant and antipsychotic medications. The resident, who was observed to be in good spirits and engaged, had not had a GDR for bupropion since 2020 due to COVID-19, and no further recommendations were made until 2024. Similarly, the last GDR for olanzapine was in 2023, with no subsequent recommendations. The facility's administrator acknowledged the oversight, noting the absence of pharmacy requests for GDRs during monthly reviews.
The facility failed to notify physicians of high blood glucose levels for two residents and did not provide a Broda chair for a hospice resident as ordered. One resident had multiple blood sugar readings over 400 without physician notification, while another had similar readings with only one notification. Additionally, a hospice resident did not receive a Broda chair due to missed approval, despite it being ordered upon hospice admission.
The facility failed to follow physician's orders for indwelling urinary catheters for two residents. One resident's catheter was not changed as needed, leading to improper management of hematuria without physician notification. Another resident's catheter was not secured, resulting in leakage and dislodgement. The facility's policy on catheter management was not adhered to, contributing to these deficiencies.
Misappropriation of Resident Narcotic Medication
Penalty
Summary
The facility failed to protect a resident from misappropriation of property when a card of oxycodone and its corresponding narcotic log sheet went missing from the medication supply. RN 2 reported that during the narcotic count at 10:00 p.m., there were two narcotic cards and log sheets for the resident’s oxycodone. When RN 2 returned for her next shift at 6:00 a.m. and completed another narcotic count with RN 3, one oxycodone card and its narcotic log sheet for the resident were no longer present. RN 3 stated that the resident had required pain medication during the night and then left the facility without signing to indicate the narcotic count was completed and accurate. The DON’s review confirmed that the medication card and documentation sheet for the resident’s oxycodone were missing, with only the top of the narcotic card found in the medication disposal box and no pills present. The pharmacy verified that a card containing five oxycodone tablets for the resident was missing. The resident, who had diagnoses including diabetes mellitus, a fracture of the lower end of the left femur, chronic kidney disease, and non-traumatic subarachnoid hemorrhage, had an order for oxycodone HCL IR 5 mg every 6 hours as needed for pain and reported not being aware of the missing medications or recalling receiving a pain pill at 2:00 a.m. on the date in question. These findings supported that the resident’s narcotic medications were not kept free from potential theft or wrongful use by an employee.
Resident's Right to Refuse Room Transfer Not Upheld
Penalty
Summary
The facility failed to protect a resident's right to refuse a non-requested room transfer, resulting in a deficiency. Resident C, who was cognitively intact with a BIMS score of 13 out of 15, was moved from his original room after completing rehabilitation therapy. Despite not experiencing a change in payor source, the resident was transferred to a smaller room without being given the option to remain in his initial room, which better accommodated his needs. The new room lacked adequate bathroom facilities, forcing the resident to use a bedside commode. Interviews with the resident and staff revealed that the resident was upset about the move and was not provided a choice to stay in his original room. The Executive Director acknowledged that the resident should have been given the option to remain in his previous room or be moved to a different room within the facility. This oversight was identified during a complaint investigation, highlighting the facility's failure to ensure the resident's rights were upheld.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications across four medication carts, leading to several deficiencies. During observations, it was noted that oral medications were not separated from topical medications and eye drops, and cleaning supplies were stored alongside medications. Specifically, medication cart 1 contained unlabeled medication cups and a nebulizer machine, while cart 2 had ear wax removal drops improperly stored next to oral tablets and sanitizer wipes next to oral medications. Additionally, cart 3 had oral medications stored next to eye drops without a divider, and cart 4 contained expired glucose gel. The facility's policy on medication storage and expiration was not adhered to, as evidenced by the presence of expired and improperly labeled medications. Opened medications were not dated, and over-the-counter medications lacked necessary labeling information. Interviews with Qualified Medical Assistants (QMAs) revealed a lack of awareness regarding proper storage practices, such as the need to store ointments in treatment carts and the correct expiration period for eye drops. These observations indicate a systemic issue with medication management within the facility.
Failure to Investigate Allegations of Impaired Staff
Penalty
Summary
The facility failed to thoroughly investigate allegations of a staff member, CNA 12, working while impaired, which potentially affected residents' physical or emotional well-being. The incident was initially reported through social media by Resident B, who expressed concerns about a male staff member's behavior, including smelling alcohol on his breath and inappropriate proximity. The facility's investigation did not include the allegation of inappropriate touching, and the investigation documents lacked comprehensive staff interviews and resident statements. The investigation was delayed, with the full investigation requested multiple times before being provided. Staff statements indicated that CNA 12 exhibited signs of impairment, such as slurred speech and difficulty walking, and admitted to drinking on the job. However, the investigation did not document the emotional impact on Resident B or include a psychosocial assessment. Additionally, the facility's investigation did not clarify the number of residents CNA 12 interacted with or the extent of their care. The facility's policy on abuse investigations requires thorough evidence collection and interviews with all relevant parties, but the investigation lacked completeness. The incident was not reported until it was posted on social media, and the facility did not document any follow-up with Resident B by social services. The investigation did not include a review of the psychiatric Nurse Practitioner's notes, which indicated Resident B's increased depression due to her mother's passing, nor did it provide emotional support or counseling to the resident during the investigation.
Failure to Submit Discharge MDS Assessment
Penalty
Summary
The facility failed to submit a discharge Minimum Data Set (MDS) assessment for a resident upon discharge, resulting in a delay of more than 120 days since the last submitted assessment. The resident, who had a range of medical conditions including hypo-osmolality, hyponatremia, alcohol abuse, pneumonia, cystitis, dysphagia, and protein calorie nutrition, was admitted with an MDS assessment dated and submitted on 2/9/24. However, the discharge MDS assessment dated 5/1/24 was pending and not submitted. During interviews, the MDS Coordinator acknowledged that the discharge assessment should have been completed and submitted, and the Administrator noted that the facility used the RAI manual but did not have a specific facility policy in place.
Failure to Resubmit PASARR After New Mental Health Diagnosis
Penalty
Summary
The facility failed to resubmit a PASARR (Preadmission Screening and Resident Review) for a resident after a new mental health diagnosis and medication were added. Resident 70, who was initially evaluated with no mental health diagnosis or medications, was later diagnosed with mild major depressive disorder on February 2, 2024, and prescribed sertraline, an antidepressant, on February 3, 2024. Despite these changes, the facility did not complete another PASARR for the resident, as confirmed by the Social Services Director during an interview. The facility's current policy on PASARR, reviewed on September 25, 2023, states that any resident with a newly evident or possible serious mental disorder must be referred for review. However, this policy was not followed in the case of Resident 70, as the additional diagnosis and medication were not addressed with a new PASARR. The oversight was acknowledged by the Social Services Director, who indicated that the resident should have undergone another PASARR, but it was missed.
Failure to Reposition Resident Every Two Hours
Penalty
Summary
The facility failed to adhere to a physician's order to turn and reposition a resident every two hours to promote healing and prevent future pressure injuries. The resident, who was paralyzed from the waist down and had limited mobility, had multiple diagnoses including stage 3 and 4 pressure ulcers. Despite a care plan initiated to address these needs, the facility did not consistently perform the required turning and repositioning, as evidenced by missing documentation in the CNA task records over several days. The resident expressed concerns during interviews, indicating that she was not turned every two hours as required, particularly during evening and night shifts. She reported having to use her call light to request assistance, which was contrary to her preference of being woken up every two hours to be turned. The resident had chronic pressure wounds and emphasized the importance of regular turning to prevent new wounds and promote healing. Interviews with facility staff, including the Social Services Director and the DON, revealed that the issue of not turning the resident every two hours was known and had been discussed in care plan meetings. The DON acknowledged the ongoing concern and had attempted to address it by re-educating CNAs. However, the facility lacked a specific policy for preventing pressure ulcers or routine turning of residents, which contributed to the deficiency.
Failure to Provide Dialysis Transportation Leads to Hospitalization
Penalty
Summary
The facility failed to ensure transportation was available for a resident requiring dialysis, leading to a hospitalization. Resident 18, who has a medical history including dependence on renal dialysis, type 2 diabetes mellitus, end-stage renal disease, congestive heart failure, and amputations, was unable to attend a scheduled dialysis session due to a transportation issue. The facility did not inform the resident of the lack of transportation until the last minute, resulting in the resident missing dialysis on a Saturday. The absence of transportation led to the resident experiencing severe health issues, including fluid overload, pulmonary edema, congestive heart failure, and acute respiratory failure with hypoxia. The resident had to call 911 due to difficulty breathing and was subsequently hospitalized. The facility's agreement with the dialysis provider indicated that the facility was responsible for arranging suitable transportation, but a miscommunication led to the failure to secure transportation on the required day.
Failure to Follow Procedures for Bed Rail Use
Penalty
Summary
The facility failed to ensure proper procedures were followed before the use of bed rails for a resident, identified as Resident D, who was reviewed for accident hazards. The resident used the side rails for mobility assistance while in bed, as observed during multiple instances. However, the facility did not obtain a physician's order for the use of the side rails, nor did they conduct a side rail assessment. Additionally, there was no signed consent for the use of the side rails, and the facility did not document any appropriate alternatives attempted prior to the installation of the side rails. The care plan for Resident D also did not include the use of the side rails. The facility's policy on the safe and effective use of bed rails, which was last revised in December 2022, requires an assessment for risk of entrapment, a review of risks and benefits with the resident or their representative, and informed consent prior to the installation of bed rails. The policy also mandates documentation of alternatives to bed rail use and how these alternatives did not meet the resident's assessed needs. Despite these requirements, the facility did not adhere to these procedures, as indicated by the Administrator's admission that they missed obtaining an order or assessment for the use of the side rails and that they obtained blanket consent from all residents, regardless of their need for side rails.
Failure to Conduct Annual Gradual Dose Reduction for Psychotropic Medications
Penalty
Summary
The facility failed to conduct an annual gradual dose reduction (GDR) for an anti-depressant and an antipsychotic medication for a resident, identified as Resident J, who was reviewed for unnecessary medications. Despite the resident's positive demeanor and engagement during observations, the facility did not address the need for a GDR for bupropion, an anti-depressant prescribed since 2020, and olanzapine, an antipsychotic prescribed in 2023. The last GDR for bupropion was contraindicated in March 2020 due to COVID-19 circumstances, and no further GDR recommendations were made between June 2023 and July 2024. Similarly, the last GDR for olanzapine was conducted in April 2023, with no subsequent recommendations made. The facility's administrator acknowledged the oversight, indicating that no GDR requests from the pharmacy were found during monthly reviews for bupropion, and the last GDR for olanzapine was in April 2023. The administrator admitted that the contraindication for bupropion was not revisited since the initial decision in 2020. The facility's policy on unnecessary medication, last reviewed in August 2023, emphasizes the importance of ensuring medications are necessary for treating the resident's assessed condition and supports the use of GDR to manage symptoms with the lowest effective dose or discontinuation if possible.
Failure to Notify Physician and Provide Ordered Equipment
Penalty
Summary
The facility failed to notify the physician of blood glucose levels that exceeded the parameters set by the physician for three residents. Resident L had multiple instances of blood sugar readings over 400, with values reaching as high as 531, yet there were no records of the physician being notified of these elevated levels. This oversight was confirmed by the facility's administrator, who acknowledged the absence of any call-outs to the physician regarding these high blood sugar readings. Similarly, Resident C experienced blood sugar levels in the 400 and 500 range, but the facility only notified the physician once, despite multiple readings exceeding the threshold of 400. The resident's family member expressed concern over the lack of intervention, such as adjusting insulin, to address these high readings. The clinical records corroborated that the physician was only informed of the elevated blood sugar on one occasion, despite several instances of high readings. Additionally, the facility did not follow up on a hospice order for a Broda chair for Resident 136, who was on hospice care and had a history of hemiplegia and hemiparesis. The resident was observed lying in bed on multiple occasions without the Broda chair, which was ordered upon admission to hospice. The hospice RN confirmed that the chair was expected to be provided, but due to changes in hospice leadership, the approval was missed. This lack of coordination resulted in the resident not receiving the necessary equipment to support her mobility and comfort needs.
Failure to Follow Physician's Orders for Indwelling Catheters
Penalty
Summary
The facility failed to follow physician's orders for indwelling urinary catheters for two residents, Resident C and Resident H. Resident C's family member reported that the resident's catheter needed to be changed on the day of discharge, but the staff did not comply. The clinical record showed that Resident C had obstructive uropathy and an indwelling urinary catheter, with orders to change the catheter for infection, obstruction, or when the closed system was compromised. On one occasion, Resident C experienced hematuria, and the catheter was improperly managed without notifying the physician. The Director of Nursing indicated that the facility did not notify the physician unless there was a significant amount of blood. Resident H was observed with a Foley catheter in a dignity bag, and the clinical record indicated issues with catheter leakage and dislodgement. The catheter was not secured to prevent pulling or dislodgement, and there was no documentation of a device used to secure the catheter. The facility's policy required the catheter to be anchored to prevent tension, which was not adhered to in Resident H's case. These deficiencies were related to a complaint investigation.
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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