Lodge Of The Wabash
Inspection history, citations, penalties and survey trends for this long-term care facility in Vincennes, Indiana.
- Location
- 723 E Ramsey Rd, Vincennes, Indiana 47591
- CMS Provider Number
- 155632
- Inspections on file
- 25
- Latest survey
- March 4, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Lodge Of The Wabash during CMS and state inspections, most recent first.
Two residents with severe cognitive impairment and chronic pain conditions missed multiple doses of prescribed narcotic pain medications after full sheets of these medications went missing from the medication cart. Facility records showed discrepancies between the number of doses delivered and those accounted for, and required shift-to-shift narcotic counts were not consistently performed. As a result, the residents received alternative pain medications while the facility worked to replace the missing narcotics.
The facility failed to follow infection control practices during incontinence care and medication administration. CNAs did not change gloves or perform hand hygiene between tasks for two residents, and a nurse did not adequately sanitize hands during medication passes for several residents. These actions were contrary to the facility's policies on hand hygiene and infection control.
The facility did not have a qualified Infection Preventionist (IP) working at least part-time. The DON, who was the designated IP, was on leave, and the interim IP, the ADON, lacked infection control certification. The facility lacked documentation on hours dedicated to infection prevention, and the DON's schedule only allocated Thursdays for infection control. The IP role required specialized training beyond the initial professional degree, which the interim IP did not have.
The facility failed to maintain a sanitary and home-like environment, with issues such as dusty and broken blinds, uncovered personal items, soiled toilets, and missing paint observed in multiple areas. Refrigerator temperature logs were inconsistently maintained, and staff interviews revealed a lack of clear procedures for cleaning and maintenance tasks. The facility lacked specific policies for maintaining a homelike environment and checking refrigerator temperatures, contributing to the deficiencies.
The facility failed to provide required transfer or discharge notices to residents or their representatives for three residents who were hospitalized. Clinical records for these residents lacked the necessary documentation, and staff interviews confirmed the absence of completed paperwork. The facility's policy mandates that such notices be completed and included in the resident's clinical record, but this was not adhered to.
The facility failed to provide a bed hold policy to residents or their representatives during hospital transfers, as evidenced by the lack of completed bed hold paperwork for three residents. A resident with moderate cognitive impairment and multiple health issues was hospitalized without the necessary documentation. Similarly, another resident with severe cognitive impairment and a history of multiple hospitalizations also lacked bed hold paperwork. A third resident with several hospitalizations for various health issues did not have documented bed hold notices, despite the facility's policy requiring written notice at the time of transfer.
The facility failed to provide adequate supervision and prevent falls for two residents with severe cognitive impairments. Delays in completing fall assessments and updating care plans were noted, with some assessments completed weeks after the falls. Additionally, family notifications were not made in a timely manner, contrary to the facility's protocol.
The facility failed to provide necessary respiratory care for three residents, including not changing oxygen tubing weekly, not cleaning oxygen concentrator filters, and not ensuring portable oxygen tanks were adequately filled. A resident was found with outdated tubing and soiled filters, another with dusty concentrator filters, and a third with an empty portable oxygen tank. These deficiencies were observed despite physician orders and care plans requiring regular maintenance and checks.
The facility failed to ensure competent nurse staffing, resulting in deficiencies in medication administration and wound care. A resident did not receive an ordered expectorant due to unavailability and lack of notification to the DON. Another resident had a bandage left on for six days and a skin tear treated without a physician's order. Facility policies on medication, treatment accuracy, and skin care management were not followed.
The facility failed to provide person-centered dementia care for two residents, who were often left without engagement or meaningful activities. Despite care plans suggesting interaction and participation in activities, staff did not adhere to these plans, leaving the residents unstimulated and unsupported. Observations showed residents sitting in wheelchairs or recliners with minimal staff interaction, highlighting a deficiency in the facility's dementia care approach.
The facility failed to secure narcotic boxes in two medication carts, as observed on multiple occasions. A narcotic box in the 200 Hall cart and another in the 400 Hall cart were found unlocked. An RN confirmed that narcotic boxes should be locked when not in use, in accordance with the facility's policy requiring double-locking of Schedule 2 controlled substances.
The facility failed to accurately post nurse staffing sheets for six consecutive days. Observations showed that the sheets lacked detailed information about specific hours worked by staff, with some shifts not fully documented. The ADON confirmed that the shift nurse was responsible for filling out the sheets, and the Clinical and Quality Consultant noted the absence of a specific policy, relying instead on federal guidelines.
Failure to Safeguard Narcotic Medications Leads to Missed Pain Doses
Penalty
Summary
The facility failed to protect residents from misappropriation of their narcotic medications, resulting in two residents missing physician-ordered pain medications. For one resident with severe cognitive impairment, osteoarthritis, chronic kidney disease, and diabetes, the medication administration record showed that oxycodone was unavailable for several days, and the resident was instead given Tylenol for pain. The controlled drug record indicated that a significant number of oxycodone doses were received from the pharmacy, but the last dose was signed out several days before the medication ran out, and the delivery sheet showed more doses were delivered than were accounted for in the medication cart. Another resident, also with severe cognitive impairment and multiple serious diagnoses including malignant neoplasm, diabetes, hemiplegia, and cirrhosis, was prescribed Norco for pain. The medication administration record documented that Tylenol was given when Norco was not available. The controlled drug record and pharmacy delivery sheet indicated that more doses were delivered than were present in the medication cart, and the resident missed routine doses of their narcotic medication. Facility investigation revealed that full sheets of narcotic medications had gone missing from the medication cart, and that required shift-to-shift narcotic counts were not consistently performed or documented. Interviews with nursing staff and facility leadership confirmed that medication count sheets and narcotic medications were missing, and that the lack of consistent shift counts made it impossible to determine the exact number of missing doses. Both residents received alternative pain medication while the facility worked to obtain new orders and refills from the pharmacy. The facility's own policy required that all controlled substances be counted by two nurses at each shift change, but this procedure was not followed, contributing to the loss of medications.
Infection Control Lapses in Incontinence Care and Medication Administration
Penalty
Summary
The facility failed to adhere to proper infection control practices during incontinence care and medication administration for several residents. During incontinence care for Resident B, a CNA did not change gloves or perform hand hygiene between handling soiled and clean items. Similarly, during care for Resident F, CNAs did not sanitize their hands after removing gloves and handling various items. These lapses in protocol were observed during the transfer and cleaning of residents, where gloves were not changed, and hand hygiene was not performed as required. Additionally, during medication administration, a registered nurse did not perform adequate hand hygiene before and after administering medications to multiple residents. Observations revealed that hand lathering was performed for only 2 to 8 seconds, which is below the recommended duration. The facility's policies on hand hygiene and medication administration were not followed, as staff failed to sanitize hands before and after medication preparation and administration, contributing to the deficiency.
Inadequate Infection Preventionist Coverage
Penalty
Summary
The facility failed to ensure a qualified Infection Preventionist (IP) was working at least part-time, as required. The Director of Nursing (DON), who was designated as the IP, was on leave, and the interim IP, the Assistant Director of Nursing (ADON), lacked the necessary infection control certification. Interviews revealed that the facility did not have documentation on the hours dedicated to infection prevention, and the DON's schedule only allocated Thursdays for infection control activities. The job description for the Infection Prevention and Control Officer required specialized training and education in infection prevention and control beyond the initial professional degree, which the interim IP did not possess.
Sanitation and Maintenance Deficiencies in Facility
Penalty
Summary
The facility failed to maintain a sanitary and home-like environment across multiple areas, including three halls, a shower room, and several resident rooms. Observations revealed numerous issues such as dusty and broken blinds, uncovered personal items and linens, soiled toilets, missing paint, and baseboards that were either falling off or missing. In the shower room, there were unlabeled personal care items, cobwebs, bugs in light covers, and a toilet seat riser left uncovered on the floor. The water temperature in the sink was also noted to be significantly low at 56.6 degrees Fahrenheit. In several resident rooms, there were issues with cleanliness and maintenance. Vents were blackened and caked with dust, paint was missing, and refrigerator temperature logs were not consistently maintained. Some rooms had strong odors, debris, and spiderwebs, while others had missing or loose fixtures such as toilet paper holders and doorknob pieces. The refrigerator temperatures were often not recorded, and when they were, they showed inconsistencies, with some logs being filled out retroactively by the Housekeeping Supervisor. Interviews with staff revealed a lack of clear procedures and responsibilities for cleaning and maintenance tasks. Housekeepers and maintenance staff were reportedly short-staffed, leading to difficulties in keeping up with cleaning and repairs. The Housekeeping Supervisor was responsible for checking refrigerator temperatures, but when absent, the task was delegated without proper documentation. The Assistant Director of Nursing and other staff indicated that personal items should be labeled and stored properly, but this was not consistently practiced. The facility lacked specific policies for maintaining a homelike environment and checking refrigerator temperatures, contributing to the deficiencies observed.
Failure to Provide Transfer/Discharge Notices
Penalty
Summary
The facility failed to provide timely notification of transfer or discharge to residents or their representatives, as required by regulations. This deficiency was identified for three residents who were hospitalized. For Resident 27, the clinical records showed hospitalization from December 1 to December 5, 2024, but lacked the necessary transfer or discharge paperwork. Interviews with staff revealed that the paperwork was not retained, and the nurse responsible for the transfer did not keep a copy of the documentation. Similarly, Resident 37's records indicated multiple hospitalizations, but the transfer or discharge paperwork was missing. The Clinical and Quality Consultant was unable to locate the necessary documentation. For Resident 13, the records showed several hospitalizations, but there was no documentation of transfer or discharge notices being provided to the resident or their representative. The facility's policy required that such notices be completed, copied, and included in the resident's clinical record, but this was not done.
Failure to Provide Bed Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to provide a bed hold policy to residents or their representatives during hospital transfers, as evidenced by the lack of completed bed hold paperwork for three residents. Resident 27, who had moderate cognitive impairment and multiple health issues, was hospitalized for sepsis and weakness, but the clinical records did not contain the necessary bed hold documentation. Interviews with facility staff revealed that the paperwork was not retained or properly managed, indicating a lapse in protocol. Similarly, Resident 37, with severe cognitive impairment and a history of multiple hospitalizations for conditions such as sepsis and heart failure, also lacked bed hold paperwork in their clinical records. The Clinical and Quality Consultant confirmed the absence of this documentation. Resident 13, who had several hospitalizations for various health issues, including stroke and end-stage renal disease, also did not have documented bed hold notices. The facility's current bed hold policy, revised in 2017, mandates written notice to be provided at the time of transfer, which was not adhered to in these cases.
Failure to Prevent Falls and Update Care Plans
Penalty
Summary
The facility failed to provide adequate supervision and prevent falls for two residents, as evidenced by the lack of timely updates to fall assessments and care plans. Resident 44, who has severe cognitive impairment and requires substantial assistance, experienced multiple falls over a period of time. The clinical records for Resident 44 showed significant delays in completing fall assessments and updating care plans, with some assessments being completed weeks after the falls occurred. Additionally, the family of Resident 44 was not notified of at least one fall, which is contrary to the facility's protocol. Similarly, Resident 33, who also has severe cognitive impairment and requires substantial assistance, experienced a fall without a subsequent fall assessment or family notification. The facility's Fall Assessment and Prevention Protocol, which mandates immediate care plan updates and family notifications, was not adhered to in these cases. The Clinical and Quality Consultant confirmed that the protocol requires fall assessments to be completed within four hours and family notifications to occur on the same shift as the fall, highlighting the facility's failure to follow its own procedures.
Failure to Provide Adequate Respiratory Care
Penalty
Summary
The facility failed to provide necessary respiratory care and services in accordance with professional standards for three residents. Resident C was observed with oxygen tubing that had not been changed since 12/8/24, and the oxygen concentrator machine filter was soiled with dust and hair on multiple occasions. Despite physician orders and a COPD care plan requiring weekly changes and cleaning, these tasks were not completed as scheduled. Licensed Practical Nurse 9 confirmed that the night nurse was responsible for changing the tubing weekly, but this was not documented or executed as required. Resident D was also observed with dusty filters on the oxygen concentrator and oxygen tubing that was not changed as per the weekly schedule. The resident, who had diagnoses including COPD and was on hospice care, required continuous oxygen therapy. Despite physician orders for weekly maintenance, the necessary cleaning and tubing changes were not performed, as confirmed by Registered Nurse 3. Resident B was found using a portable oxygen tank that was nearly empty, with the arrow on the tank in the red area, indicating it was depleted. The resident, who had multiple diagnoses including advanced dementia and heart failure, was using oxygen at 4 liters per minute. The portable tank was not checked in a timely manner, leading to the resident being without adequate oxygen supply until the tank was replaced. RN 3 acknowledged that portable tanks were checked approximately two hours after being changed, but this was insufficient to ensure continuous oxygen supply for the resident.
Deficiencies in Medication Administration and Wound Care
Penalty
Summary
The facility failed to ensure competent nurse staffing necessary to provide services to meet resident rights and well-being, as evidenced by deficiencies in medication administration and wound care. For one resident, an expectorant medication, guaifenesin, was ordered but never administered due to unavailability. Despite the resident exhibiting symptoms such as coughing, the medication was not ordered by the Director of Nursing (DON) because the nurse failed to notify the DON of the medication's unavailability. Consequently, the medication was discontinued without being administered, as the resident's symptoms were deemed no longer present. In another case, a resident with severe cognitive impairment was found with a bandage on her wrist that had been left for six days following a blood draw. The staff, including Certified Nurse Aides (CNAs) and a Licensed Practical Nurse (LPN), were unaware of the reason for the bandage and failed to remove it in a timely manner. Additionally, a skin tear on the resident's wrist was treated without a physician's order, and the nurse did not notify the physician as required by facility protocol. The facility's policy mandates that all dressings require a physician's order and that any skin integrity issues should be documented and communicated to the physician. The facility's policies on medication and treatment accuracy, as well as skin care management, were not adhered to, leading to these deficiencies. The Clinical and Quality Consultant confirmed that the nurse should have checked for facility stock of the medication and notified the DON if unavailable. Furthermore, the facility's protocol for skin assessments and treatment orders was not followed, as evidenced by the lack of weekly skin assessments for all residents and the absence of a treatment order for the resident's skin tear.
Deficiency in Person-Centered Dementia Care
Penalty
Summary
The facility failed to provide person-centered dementia care for two residents, Resident 46 and Resident 47, as observed during multiple instances. Resident 46 was frequently seen sitting in a wheelchair or recliner, often with her eyes closed or weeping, and staff did not engage with her. Despite having a care plan that included engaging in conversation and encouraging participation in activities, staff were observed walking by without interaction. Resident 46's clinical record indicated severe cognitive impairment, and she had experienced multiple falls, yet there was a lack of meaningful engagement or stimulation provided by the staff. Resident 47 was similarly observed sitting in a wheelchair at the nurses' station or in the activity room, often fidgeting and attempting to get up without staff engagement. Although her care plan suggested activities like ball toss and sing-alongs, staff did not provide these or other forms of stimulation. The resident was left unsupervised at times, and staff interactions were minimal and ineffective in redirecting her behavior. Her clinical record also indicated severe cognitive impairment, and she required assistance with daily activities. The facility's dementia management policy emphasized the need for individualized care plans and meaningful stimulation to avoid boredom, yet these were not implemented effectively for the residents observed. The lack of engagement and appropriate activities for Residents 46 and 47 highlights a deficiency in the facility's approach to dementia care, as staff failed to adhere to the established care plans and policies designed to ensure the residents' well-being.
Improper Storage of Narcotics in Medication Carts
Penalty
Summary
The facility failed to ensure proper storage of medications in two of three medication carts, specifically regarding the security of narcotic boxes. On two separate occasions, the narcotic box in the 200 Hall medication cart was observed to be unlocked. Similarly, the narcotic box in the 400 Hall medication cart was also found unlocked. During an interview, a registered nurse confirmed that narcotic boxes should be locked when not in use. The facility's Controlled Substances Policy, revised in April 2021, mandates that all Schedule 2 controlled substances must be stored in double-locked areas, which was not adhered to in these instances.
Inaccurate Nurse Staffing Sheets
Penalty
Summary
The facility failed to ensure that the posted nurse staffing sheets were accurately completed and displayed daily for six consecutive days. Observations on various dates revealed that the staffing sheets were posted behind the nurse's desk with the correct date, but they lacked detailed information about the specific hours worked by each staff member. For instance, on multiple occasions, the sheets did not differentiate the hours worked by the staff, and in some cases, only the day shift information was filled out, with no details provided for the evening shift. This lack of differentiation in hours worked was consistent across all observed days. During an interview, the Assistant Director of Nursing (ADON) acknowledged that the shift nurse was responsible for filling out the posted nurse staffing upon arrival for their shift. The ADON indicated that the hours worked should be specified under the shift and schedule to differentiate who was working which hours. It was noted that if two staff members worked half shifts, they were counted as one staff member. Additionally, the Clinical and Quality Consultant mentioned that there was no specific policy for posted nurse staffing, but they followed federal guidelines.
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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