Hillcrest Village
Inspection history, citations, penalties and survey trends for this long-term care facility in Jeffersonville, Indiana.
- Location
- 203 Sparks Ave, Jeffersonville, Indiana 47130
- CMS Provider Number
- 155203
- Inspections on file
- 42
- Latest survey
- February 26, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Hillcrest Village during CMS and state inspections, most recent first.
A resident with traumatic brain injury, anoxic brain damage, schizophrenia, and quadriplegia was physically abused by a CNA during a transfer to bed. While assisting with care, the resident punched and spat on the CNA and verbally insulted her, after which the CNA, by her own account and corroborated by another CNA, became angry and struck the resident on the right side of the face multiple times with an open hand, including hitting the resident in the mouth. Subsequent assessment documented scratches to the resident’s forehead and right brow and a swollen, discolored upper lip. These actions occurred despite a facility policy that prohibits willful physical abuse such as hitting or slapping residents.
The facility did not ensure that the administration of narcotic medications was properly documented in the MARs for three residents, despite records showing the medications were given. Staff confirmed that documentation should occur at the time of administration, and facility policy requires recording in both the MAR and controlled substances inventory, but this was not followed.
Blood pressure medications were administered to two residents with hypotension despite physician orders to hold the medication for out-of-parameter systolic blood pressure readings. An LPN confirmed that medications should not be given when blood pressure is outside the specified range, but records showed multiple instances where midodrine was administered contrary to orders.
A resident with multiple health conditions requiring assistance with ADLs did not consistently receive scheduled showers. The care plan specified two showers per week, but records showed multiple instances of missing documentation, indicating showers were not provided. Interviews with the resident and staff confirmed the deficiency, with staff acknowledging that blank shower sheets meant showers were not given.
Two residents experienced delays in receiving their prescribed medications due to issues with pharmacy services and medication availability. One resident, with chronic respiratory and pain conditions, missed multiple doses of Percocet, while another resident with acute respiratory failure and other conditions faced delays in receiving scheduled antibiotics. Staff interviews highlighted that medications should not take days to arrive, yet the facility encountered significant delays despite having 24-hour pharmacy access.
A resident with hypertension and hemiparesis experienced multiple instances of elevated blood pressure readings over several months, which were not communicated to the physician as required by the facility's policy. Despite the resident's blood pressure consistently exceeding the acceptable range, the clinical record lacked evidence of physician notification. A Nurse Practitioner confirmed that such changes should have been reported immediately.
A facility failed to conduct a self-administration assessment for a resident, resulting in medications being left at the bedside without proper authorization. The resident, with a history of hypertension, hemiparesis, hemiplegia, and diabetes, was observed with morning medications on the bedside table. Interviews confirmed the absence of a self-administration assessment or physician's order, contrary to facility policy.
A resident with a history of hypertension and CVA experienced consistently high blood pressure readings without adequate follow-up or rechecks by the facility. Despite a care plan that included monitoring and medication administration, the resident frequently refused medication and called 911 due to feeling unwell. Interviews with staff revealed the resident's noncompliance with the medication regimen, and the facility failed to implement sufficient monitoring or interventions to address the resident's condition effectively.
A facility failed to accurately document medication administration for a resident with hypertension and diabetes. The MAR lacked records for metformin and hydralazine on several occasions, and a one-time clonidine order was not documented. An LPN confirmed the requirement to sign off medications on the MAR, and the DON provided a procedure document emphasizing this practice.
A resident reported an incident of verbal abuse by an LPN to another LPN, who informed the Executive Director. However, the Executive Director claimed no such report was made, and the facility failed to document or report the incident to the Indiana Department of Health as required by their policy.
A facility failed to document a resident's blood pressure before administering Clonidine, a medication for hypertension, as required by the physician's order. The resident's blood pressure was not recorded on several occasions, and there was no explanation for withholding the medication on one occasion. An LPN confirmed the necessity of documenting blood pressure when parameters are in place, highlighting a procedural lapse.
Staff-to-Resident Physical Abuse During Transfer
Penalty
Summary
The facility failed to protect a resident from staff-to-resident physical abuse when a CNA intentionally struck the resident during care. The resident involved had significant medical conditions, including traumatic brain injury, anoxic brain damage, schizophrenia, and quadriplegia, and was observed on a later date resting in a reclining high-back wheelchair, well groomed and without visible facial injuries. According to an incident report and subsequent wound assessments from the date of the event, the resident sustained a right forehead scratch measuring 2 cm by 0.1 cm, a right eyebrow scratch measuring 0.1 cm by 0.5 cm, and a swollen area of the right upper lip measuring 0.3 cm by 1.8 cm, all without depth. During a telephone interview, the CNA admitted that while assisting with transferring the resident to bed, the resident punched her in the face and spat on her multiple times, after which she became angry and smacked the resident on the right side of the face before leaving the room and self-reporting the incident to the Executive Director. Another CNA who assisted with the transfer reported that the resident cursed at and verbally insulted the first CNA, which appeared to trigger her, and that the CNA then approached and smacked the resident multiple times with an open hand on the right side of the face. The second CNA further stated that before she could intervene, the resident spat on the first CNA, who then struck the resident again in the mouth with an open hand. The Unit Manager later assessed the resident and confirmed the presence of a scratch to the forehead, a scratch near the right brow, and a swollen, discolored upper lip. These actions occurred despite the facility’s written abuse policy, which prohibits physical abuse and defines it as a willful act such as hitting or slapping a resident.
Failure to Document Narcotic Medication Administration in MARs
Penalty
Summary
The facility failed to ensure that medication administration records (MARs) accurately reflected the administration of narcotic medications for three residents. For one resident with diagnoses including anxiety, diabetes, and chronic pancreatitis, the MAR did not document the administration of prescribed Xanax and oxycodone, despite the controlled substance record indicating these medications were given on multiple occasions. Similarly, another resident with depression and rheumatoid arthritis received Tramadol as documented in the controlled substance record, but the administration was not recorded in the MAR for both March and April. A third resident with a left femur fracture and osteoarthritis was administered hydrocodone-acetaminophen, as shown in the controlled substance record, but the MAR lacked corresponding documentation. Interviews with staff confirmed that the MAR should be signed when narcotic medications are administered. The Director of Nursing provided a policy stating that administration of controlled substances must be recorded in both the MAR and the controlled substances inventory record at the time of administration. Despite this policy, the required documentation was missing from the MARs for all three residents, as observed during the review.
Failure to Hold Blood Pressure Medication per Physician Orders
Penalty
Summary
The facility failed to ensure that blood pressure medications were held according to physician-ordered parameters for two residents diagnosed with hypotension. For one resident, midodrine was ordered to be held if the systolic blood pressure (SBP) exceeded 135 mmHg or diastolic blood pressure (DBP) exceeded 85 mmHg. Despite this, the medication was administered when the resident's SBP was 142 mmHg. An LPN confirmed during interview that blood pressure medications should not be given when readings are outside the specified range. For another resident, midodrine was ordered to be held if the SBP was greater than 140 mmHg. The medication administration record showed multiple instances where midodrine was administered despite SBP readings ranging from 144 to 151 mmHg. These actions were not in accordance with the physician's orders and the residents' clinical needs as documented in their records.
Inconsistent Shower Provision for Resident
Penalty
Summary
The facility failed to consistently provide showers for Resident 84, who was reviewed for Activities of Daily Living (ADL) care. Resident 84 had multiple diagnoses, including Parkinson's disease, spinal stenosis, type 2 diabetes mellitus, and reduced mobility, which necessitated staff assistance for ADL tasks. The care plan for the resident, dated 9/6/24, specified that the resident should receive two showers per week, with partial baths in between, and assistance with other ADL tasks as needed. However, a review of the resident's shower report records revealed multiple instances in December 2024 where documentation was lacking, indicating that the resident did not receive the scheduled showers. Interviews with the resident and staff members confirmed the deficiency. The resident reported not receiving the showers as scheduled, stating she was supposed to get two showers a week but was lucky to get one. Certified Nursing Aides (CNAs) and a Licensed Practical Nurse (LPN) confirmed that the shower sheets were supposed to be checked off when showers were given, and if the sheets were blank, it meant the showers were not provided. The Director of Nursing (DON) also indicated that staff should document on the shower report sheet when a shower was given and what care was provided.
Medication Administration Delays for Two Residents
Penalty
Summary
The facility failed to ensure that two residents received their medications as ordered and in a timely manner. Resident 62, who had diagnoses including acute and chronic respiratory failure, COPD, asthma, and chronic pain, did not receive their prescribed Percocet on multiple occasions due to issues with medication availability and prior approval requirements. The resident's care plan emphasized the importance of administering pain medications as ordered, yet there were repeated instances where the medication was unavailable, and the pharmacy was notified but did not provide the medication promptly. The Director of Nursing acknowledged the challenges with obtaining prior approvals and indicated that medications should not take more than a few hours to a day to be delivered. Resident 64, diagnosed with acute respiratory failure, atrial fibrillation, cardiomegaly, type 2 diabetes, hypertension, and chronic pain, also experienced delays in receiving their scheduled antibiotic treatment. The resident's vascular access was replaced, and a scheduled dose of meropenem was administered late. Additionally, three doses of IV antibiotics were missed, and the pharmacy was informed of the need to extend the order due to these missed doses. The facility's Emergency Drug Kit did not have the correct dose available, and the reconstitution was out of stock, further delaying the administration of the medication. Interviews with facility staff, including an LPN, revealed that medications should not take days to arrive and that the facility had access to pharmacy services 24 hours a day. Despite having a backup pharmacy, the facility experienced significant delays in obtaining necessary medications, impacting the timely administration of prescribed treatments for the residents involved.
Failure to Notify Physician of Resident's Out-of-Range Blood Pressure
Penalty
Summary
The facility failed to notify the physician when a resident's blood pressure readings were outside the established parameters. Resident B, who had a history of hypertension and left-sided hemiparesis secondary to a cardiovascular accident, experienced multiple instances of elevated blood pressure readings over several months. These readings were consistently above the acceptable range set for the resident, with systolic pressures reaching as high as 200 mmHg and diastolic pressures exceeding 100 mmHg on numerous occasions. Despite these out-of-range blood pressure readings, the clinical record did not show any evidence that the physician was notified of these changes in the resident's condition. During an interview, a Nurse Practitioner confirmed that such high or low blood pressures should be considered a change in condition, warranting immediate notification to the physician. The facility's policy on resident change of condition, which mandates communication with the physician for any changes, was not adhered to in this case.
Failure to Conduct Self-Administration Assessment for Resident Medications
Penalty
Summary
The facility failed to ensure that medications for a resident, identified as Resident B, were not left at the bedside without a self-administration assessment. Resident B, who has a medical history including hypertension, left-sided hemiparesis, hemiplegia secondary to a cerebral vascular accident (CVA), and diabetes, was observed with a medication cup containing six tablets/capsules on her bedside table. These medications were scheduled to be administered between 7:00 a.m. and 11:00 a.m. and included Amlodipine, Aspirin, Clopidogrel, Metformin, Metoprolol, and Hydralazine. However, there was no documentation in the clinical record of a self-administration medication assessment or a physician's order allowing Resident B to self-administer these medications. During interviews, an LPN confirmed that Resident B did not self-administer medications and that the medications observed were her morning doses. The Director of Nursing also confirmed that Resident B did not have a medication self-administration assessment. The facility's policy on self-administration of medications, dated January 2015, requires an interdisciplinary team assessment and a physician's order for a resident to self-administer medications. This deficiency was identified during a complaint investigation related to Resident B.
Failure to Monitor and Intervene for Resident with High Blood Pressure
Penalty
Summary
The facility failed to ensure increased monitoring and interventions for a resident with consistently high blood pressure and a history of cardiovascular accident. The resident, diagnosed with hypertension and CVA with left-sided hemiparesis, had a care plan that included various interventions such as medication administration, monitoring vital signs, and notifying the physician of any changes. Despite these interventions, the resident's blood pressure readings were frequently out of the acceptable range, and there was a lack of follow-up or documented rechecks for these elevated readings. The resident often refused the prescribed hydralazine medication, believing it was too strong, and this refusal was communicated to the nurse practitioner. The resident's blood pressure remained high, leading to multiple instances where the resident called 911 due to feeling unwell. The facility's records showed numerous instances of elevated blood pressure readings without appropriate follow-up or rechecks, indicating a failure to adequately monitor and address the resident's condition. Interviews with facility staff, including an LPN and a nurse practitioner, revealed that the resident was noncompliant with the medication regimen, often refusing medications and calling emergency services instead. The nurse practitioner noted the resident's noncompliance and did not make changes to the medication regimen, considering the resident's refusals as non-compliance. Despite the resident's high blood pressure readings and frequent calls to emergency services, the facility did not implement sufficient monitoring or interventions to address the resident's condition effectively.
Medication Administration Documentation Deficiency
Penalty
Summary
The facility failed to ensure accurate documentation of medication administration for a resident diagnosed with hypertension and diabetes. The resident's care plan required the administration of metformin and hydralazine as ordered by the physician. However, the Medication Administration Record (MAR) for October 2024 lacked documentation of metformin administration on two occasions and hydralazine on multiple occasions. Additionally, a one-time order for clonidine was not documented in the MAR, indicating a failure to record the administration of this medication. During an interview, an LPN confirmed that medications should be signed out on the MAR once administered, and one-time orders should be entered and signed off in the electronic medical record. The Director of Nursing provided a document outlining the medication administration procedure, which emphasized the need for recording medication administration on the MAR after it is given. This deficiency was identified during a complaint investigation, highlighting lapses in the facility's medication administration documentation process.
Failure to Report Alleged Verbal Abuse
Penalty
Summary
The facility management failed to report an incident of alleged verbal abuse involving a resident, identified as Resident B, to the Indiana Department of Health. Resident B, who was alert and oriented, reported having multiple negative interactions with an LPN, specifically mentioning an incident where the LPN became aggressive after a request for pain medication. The LPN allegedly called Resident B a 'smart a**,' to which Resident B responded in kind. This incident was reported by Resident B to another LPN, who then informed the Executive Director (ED). However, the ED indicated that no such report was made to him, and the facility's records for June 2024 did not document this allegation of verbal abuse. The facility's policy, titled 'Abuse Prohibition, Reporting, and Investigation,' mandates that all abuse allegations must be reported to the ED immediately and to the Long-Term Care Division of the Indiana Department of Health within two hours. Despite this policy, the facility did not provide any additional information related to the incident, and the required report was not made. This deficiency was identified during a review of the facility's handling of the complaint, which was related to Complaint IN00436365.
Failure to Document Blood Pressure Before Medication Administration
Penalty
Summary
The facility failed to ensure that a resident's blood pressure was obtained prior to the administration of Clonidine, a medication prescribed for hypertension. The clinical record for Resident D, who has diagnoses including cardiovascular disease and hypertension, was reviewed. The physician's order specified that Clonidine 0.1 mg should be administered every six hours, with the condition that it should be held if the systolic blood pressure was less than 100. However, on multiple occasions in June 2024, the medication was administered without documenting the resident's blood pressure. Additionally, on June 8, 2024, the Clonidine was not administered as it was on hold, but there was no documentation explaining why the medication was withheld. During an interview, an LPN confirmed that blood pressure should have been documented and obtained prior to medication administration when parameters are in place. The Director of Nursing provided a document titled Medication Administration, which included the requirement for obtaining vital signs if necessary, indicating a procedural lapse in this instance.
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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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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