Hickory Creek At Scottsburg
Inspection history, citations, penalties and survey trends for this long-term care facility in Scottsburg, Indiana.
- Location
- 1100 N Gardner Ave, Scottsburg, Indiana 47170
- CMS Provider Number
- 155417
- Inspections on file
- 28
- Latest survey
- December 4, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Hickory Creek At Scottsburg during CMS and state inspections, most recent first.
A resident with pain and depression did not receive a scheduled Fentanyl patch because the medication was unavailable, and there was no timely notification to the pharmacy or physician. The facility did not follow its policy requiring immediate action when a medication shortage was discovered, resulting in a delay in pain management.
A resident with pain and depression received PRN Percocet on several occasions, as shown in the controlled substance record, but the medication administration record did not reflect these administrations. An LPN confirmed that both records should be signed when narcotics are given, and facility policy requires proper documentation.
A resident with a history of GI bleeding and multiple chronic conditions experienced repeated episodes of dark brown vomiting and an elevated heart rate. Despite these symptoms and the resident's request for hospital evaluation, the LPN did not notify the NP or DON for over six hours, delaying medical intervention. Facility policy required prompt communication of such changes, but this was not followed.
A QMA in a LTC facility failed to follow infection control protocols during medication administration for several residents. The QMA handled medications with bare hands and did not perform hand hygiene before or after administering medications, despite the facility's policy requiring such practices. This was observed across multiple instances involving residents with various medical conditions.
The facility failed to follow physician orders for three residents during medication administration. A resident with COPD did not receive the correct dosage of calcium carbonate and was not offered Advair Diskus. Another resident did not rinse her mouth after using Breo Ellipta and Incruse Ellipta inhalers. A third resident did not rinse and spit after using Advair HFA inhaler. The facility's policy requires adherence to medication administration guidelines, which was not followed.
A facility failed to document the administration of narcotic medications for a resident with anxiety, irritable bowel syndrome, and pain. Despite physician orders for Xanax, Viberzi, and hydrocodone-acetaminophen, the medication administration record lacked documentation, although the controlled substance record indicated administration on various dates. An LPN confirmed the requirement to sign off on administered narcotics, and the DON provided a procedure document for controlled substances.
The facility failed to address multiple resident concerns raised during Resident Council meetings over several months, including delayed call light responses, improper room cleaning, and staff using foul language. Despite promises from management to resolve these issues, residents continued to experience the same problems, indicating a lack of effective action and accountability.
The facility failed to provide meals that were palatable, appetizing, and at appropriate temperatures, affecting 30 of 31 residents. Observations revealed that food temperatures were not maintained within the required range, and residents reported dissatisfaction with the food quality and temperature. The Dietary Manager acknowledged logistical challenges in maintaining food temperatures and noted that the menu had not been updated since October.
Failure to Provide Timely Pain Medication Due to Unavailability
Penalty
Summary
The facility failed to ensure that a resident's pain medication, specifically a Fentanyl Duragesic patch, was available and administered in a timely manner. The resident, who had diagnoses including depression and pain and was assessed as cognitively intact, was care planned to receive pain medication as ordered. The medication administration record showed that the pain patch was due but not administered on the scheduled date because it was unavailable. The resident reported not having her pain patch for two days, and documentation indicated that the pharmacy was not notified until one day after the missed dose. The clinical record lacked evidence of timely notification to the physician or pharmacy regarding the unavailability of the medication. Facility policy required immediate action and notification to the pharmacy upon discovery of a medication shortage, but this procedure was not followed. Interviews with facility leadership confirmed that it was the facility's responsibility to ensure medication availability for residents.
Failure to Document PRN Narcotic Administration in MAR
Penalty
Summary
The facility failed to ensure that a resident's medication administration record (MAR) accurately reflected the administration of as needed (PRN) narcotic pain medication. Review of the clinical record for a resident with diagnoses including depression and pain showed that the physician had ordered Percocet (oxycodone-acetaminophen) 5-325 mg every 6 hours as needed for pain. Controlled substance records indicated that the medication was administered on multiple occasions across October and November, but the corresponding MARs for those months lacked documentation of these administrations. During interviews, an LPN confirmed that both the MAR and the controlled substance record should be signed when a narcotic is given, and facility policy required documentation of controlled substances in accordance with applicable law.
Failure to Timely Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to ensure timely notification of a physician following a significant change in a resident's condition. The resident, who had a complex medical history including chronic iron deficiency anemia, diabetes, schizoaffective disorder, and a history of gastrointestinal (GI) bleeding, experienced multiple episodes of vomiting dark brown emesis. On one occasion, the resident vomited a large amount of dark emesis in the early morning hours, with vital signs showing low blood pressure and elevated heart rate. Despite these symptoms and the resident's request to go to the emergency room, the nurse practitioner (NP), director of nursing (DON), and executive director (ED) were not notified until several hours later. Documentation revealed that the resident had a known history of GI bleeding and had previously been hospitalized for similar symptoms. On the date in question, the resident began vomiting at 1:56 a.m., but the NP, DON, or ED were not notified until 8:28 a.m., more than six hours after the initial episode. During this time, the resident continued to vomit and exhibited an elevated heart rate. Only after the delayed notification was the NP contacted, who then ordered the resident to be sent to the emergency room for evaluation and treatment. Interviews with facility staff confirmed that the DON was not contacted at the time of the incident, and the nurse's notes did not reflect timely communication with the appropriate clinical leadership. The facility's policy required that all changes in resident condition be promptly communicated to the physician and responsible parties, but this protocol was not followed in this instance, resulting in a delay in medical intervention for the resident.
Infection Control Breach During Medication Administration
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices during medication administration for six residents. During observations, a Qualified Medication Aide (QMA) was seen handling medications with bare hands and not performing hand hygiene before or after administering medications. This was observed across multiple instances involving different residents, each with various medical conditions such as chronic obstructive pulmonary disease (COPD), diabetes, and depression. For Resident B, the QMA was observed removing calcium carbonate tablets with bare hands and transferring them between medication cups without sanitizing her hands. Similar practices were noted for Resident C, where the QMA did not sanitize her hands before or after handling medications. The QMA's actions were inconsistent with the facility's policy, which requires hand hygiene before and after direct resident contact and prohibits touching medications with bare hands. The same QMA was observed repeating these practices with Residents E, F, G, and H. In each case, the QMA unlocked the medication cart, handled medications, and used a computer mouse without performing hand hygiene. The facility's Director of Nursing provided a document outlining the proper procedures for medication administration, which the QMA did not follow. This deficiency was related to specific complaints and highlighted a failure in adhering to established infection control protocols.
Failure to Follow Physician Orders During Medication Administration
Penalty
Summary
The facility failed to ensure physician orders were followed during medication administration for three residents. Resident B, diagnosed with chronic obstructive pulmonary disease (COPD), chronic respiratory failure, and gastroesophageal reflux disease, was supposed to receive 1,250 mg of calcium carbonate and one puff of Advair Diskus with instructions to rinse the mouth after use. However, during observation, the Qualified Medication Aide (QMA) administered only 1,000 mg of calcium carbonate and did not offer the Advair Diskus to the resident, despite the Director of Nursing indicating that the medication should have been offered even if the resident typically refused it. Resident C, with diagnoses including COPD and diabetes, was to receive Breo Ellipta and Incruse Ellipta inhalers with instructions to rinse the mouth after use. During the medication administration observation, the QMA failed to ensure the resident rinsed her mouth after using both inhalers. Similarly, Resident G, diagnosed with COPD and iron deficiency anemia, was to receive Advair HFA aerosol inhaler with instructions to rinse and spit after use. The QMA did not have the resident rinse and spit after administration. The facility's policy and procedure document, provided by the Director of Nursing, emphasized the importance of following manufacturer medication administration guidelines, which were not adhered to in these cases.
Failure to Document Narcotic Medication Administration
Penalty
Summary
The facility failed to ensure that a resident's medication administration record accurately reflected the administration of narcotic medications. Specifically, the clinical record for a resident with diagnoses including irritable bowel syndrome, anxiety, and pain was reviewed, revealing discrepancies in the documentation of medication administration. The physician's orders indicated that the resident was to receive Xanax, Viberzi, and hydrocodone-acetaminophen at specified times. However, the October 2024 controlled substance record showed that these medications were administered on various dates and times, but the corresponding medication administration record lacked documentation of these administrations. During an interview, an LPN confirmed that when a narcotic medication is administered, it should be signed off on the medication administration record. The Director of Nursing provided a document titled 'General Dose Preparation and Medication Administration,' which outlined the procedure for documenting the administration of controlled substances. This deficiency was related to complaints IN00447152 and IN00447339, indicating a failure to adhere to accepted professional standards in maintaining accurate medical records for the resident.
Facility Fails to Address Resident Concerns Over Several Months
Penalty
Summary
The facility failed to address multiple resident concerns raised during Resident Council meetings over several months. Residents reported that call lights were not being answered in a timely manner, with some waiting up to hours or even a day for assistance. Additionally, rooms were not being properly cleaned, beds were left unmade, and urinals were not emptied. Staff were observed using gloves without washing their hands, and there were complaints about staff using foul language and discussing other staff members in front of residents. Residents also reported missing clothes after being sent to the laundry and feeling rushed by housekeeping staff during meal times. Despite these concerns being raised repeatedly from August 2023 to April 2024, the facility's management failed to take effective action to resolve them. The Director of Nursing (DON) and the Director of Maintenance/Housekeeping made several promises to educate staff, monitor call light response times, and ensure deep cleaning schedules were followed, but these measures did not lead to any significant improvements. Residents continued to experience the same issues month after month, indicating a lack of follow-through and accountability from the facility's management. Interviews with residents further highlighted the severity of the issues. Residents reported waiting long periods for call lights to be answered, sometimes resulting in them having to lie in soiled briefs. There were also complaints about noise levels at night, staff not being courteous, and aides placing urinals on tabletops. The facility's failure to address these ongoing concerns demonstrates a significant deficiency in providing adequate care and maintaining a safe and respectful environment for residents.
Failure to Provide Palatable and Appropriately Tempered Meals
Penalty
Summary
The facility failed to provide meals that were palatable, appetizing, and at appropriate temperatures, affecting 30 of 31 residents. Observations on multiple dates revealed that food temperatures were not maintained within the required range. For instance, on 4/21/24, the sliced turkey was served at 124.9°F, Au gratin potatoes at 118°F, and brussels sprouts at 117.8°F, all below the required 135°F. Additionally, the banana cream pie was partially frozen at 21.3°F. Similar issues were observed on 4/25/24, with the ham salad sandwich served at 37.7°F and 30.5°F, apricots at 34.5°F, broccoli soup at 164°F, and bean salad at 32°F. Residents reported that the food was often cold, unappetizing, and of poor quality, with some indicating that they could not eat certain items due to these issues. The Dietary Manager acknowledged the complaints and mentioned logistical challenges in maintaining food temperatures, such as the lack of a plate warmer machine and the need for a suction device to handle hot plates. Interviews with residents further highlighted the dissatisfaction with the food quality and temperature. One resident mentioned that the food was often cold and inedible, while another mistook turkey for ham due to the poor quality. The Dietary Manager noted that the menu had not been updated since October and that residents had requested changes due to repetitive meals. Despite these requests, the facility's policy on food temperatures, revised in June 2023, was not adhered to, as hot foods were not consistently held at or above 135°F and cold foods at or below 41°F. The Dietary Manager expressed confusion about the palatability complaints, citing that salt and pepper were available and that residents had maintained their weight, but acknowledged the need for better equipment to maintain food temperatures.
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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