Majestic Care Of Avon
Inspection history, citations, penalties and survey trends for this long-term care facility in Avon, Indiana.
- Location
- 445 S County Road 525 E, Avon, Indiana 46123
- CMS Provider Number
- 155338
- Inspections on file
- 35
- Latest survey
- September 24, 2025
- Citations (last 12 mo.)
- 20
Citation history
Health deficiencies cited at Majestic Care Of Avon during CMS and state inspections, most recent first.
A CNA was observed passing lunch trays alone, and food temperatures on the 600 hall were found to be below required standards, with items such as chicken and vegetables measured well under the facility's policy for hot food holding. Fourteen residents receiving room tray service were potentially affected.
A resident with multiple medical conditions, including weight loss, was not served her physician-ordered diet, which required double portions and a magic cup at lunch. The omission was observed and confirmed by a CNA, who subsequently provided the missing items.
The facility failed to address ongoing Resident Council Grievance concerns about call light wait and response times, affecting 5 of 82 residents. Despite repeated complaints documented in meeting minutes, the issue persisted, with residents experiencing long wait times and accidents. Interviews revealed that grievance responses were inconsistent, and the facility's policy on prompt grievance resolution was not effectively implemented.
The facility failed to enforce its non-smoking policy, allowing residents with various health conditions to smoke on the premises and keep smoking materials in their rooms. Despite being a non-smoking facility, residents were observed smoking on the grounds, and some admitted to storing cigarettes and lighters in their rooms. The facility lacked smoking assessments for these residents, contributing to the deficiency.
The facility failed to label and date medications when opened and did not remove expired medications from use, as observed in three medication carts and one refrigerator. Medications for several residents, including inhalers, insulin pens, and nasal sprays, were found without opening dates or were expired. Additionally, a vial of tuberculin and a bottle of aplisol in the medication room refrigerators were improperly dated or expired.
A facility failed to complete necessary assessments for a resident self-administering medications. The resident had fluticasone nasal spray, carboxymethylcellulose eye drops, and metronidazole lotion in her room, but the facility's documentation was incomplete. The Medication Self-Administration Safety Screen and care plan lacked proper assessments and specific listings for these medications, contrary to the facility's policy requiring interdisciplinary team assessments.
A resident with Alzheimer's in the Memory Care unit fell and fractured her hip after being found in another resident's bed. The fall was not accurately coded in the MDS assessments, initially marked as no falls and later not indicating the fracture. The facility's policy on accurate assessment was not followed.
The facility failed to provide sufficient licensed nurse coverage on weekends, affecting all 82 residents. The CASPER report highlighted staffing concerns in the second quarter of 2024. A review of the May 2024 schedule showed a downward trend in licensed staff per-patient-per-day (PPD), with several days not meeting the minimum required PPD. The Executive Director acknowledged the issue and noted that leadership staff were mainly scheduled for weekdays, suggesting a potential rearrangement to cover weekends. The Facility Assessment Tool indicated the required minimum PPD, which was not met.
The facility failed to provide appropriate assessments and person-centered care for two residents with dementia who wished to have a relationship. Despite family approval, the care plans and assessments did not reflect the residents' preferences and behaviors, leading to a deficiency in care.
The facility failed to provide person-centered care, supervision, and engaging activities in the secured memory care unit, leading to multiple resident-to-resident altercations and injuries. Residents frequently wandered into each other's rooms, causing distress and physical altercations. The facility lacked adequate supervision and activities to redirect residents, especially during the night shift.
A facility failed to protect a non-verbal, cognitively impaired resident from abuse. A video showed a CNA hitting the resident during care while a QMA did not intervene. Family members, watching live through a web camera, reported the incident. Interviews and records revealed the resident's cognitive impairments and the facility's ongoing abuse investigation.
The facility failed to ensure staff immediately reported witnessed abuse by another staff member to a resident. During care, a CNA hit a resident, and the QMA did not intervene or report the incident immediately. The Administrator received reports later in the morning, but the QMA did not follow the facility's policy for immediate reporting.
Failure to Serve Food at Safe Temperatures
Penalty
Summary
During a lunch service observation, a CNA was found to be passing trays alone on the 600 hall. Temperatures of the food items on the lunch trays were checked and found to be below the facility's required holding temperature of greater than 135 degrees Fahrenheit, with chicken measured at 122 degrees, mashed potatoes at 122.7 degrees, and mixed vegetables at 117 degrees. The facility's policy, provided by the Executive Director, specifies that hot foods must be held at appropriate temperatures, with poultry and stuffed foods requiring a minimum of 165 degrees Fahrenheit and all foods held above 135 degrees Fahrenheit. Fourteen residents who had their trays delivered to their rooms on the 600 hall were potentially affected by this deficiency.
Failure to Provide Prescribed Therapeutic Diet to Resident
Penalty
Summary
A deficiency occurred when a resident with diagnoses including weakness, hypertension, and weight loss did not receive her prescribed diet as ordered by the physician. The resident's orders specified a regular diet with ground meat, double portions, and a magic cup at lunch. During observation, the resident was served lunch without the double portions or the magic cup. This was confirmed by a CNA, who then retrieved the missing items. No facility policy was provided at the time of the survey exit.
Failure to Address Call Light Response Concerns
Penalty
Summary
The facility failed to address Resident Council Grievance concerns regarding call light wait and response times in a timely and effective manner. This issue affected 5 of 82 residents who attended the Resident Council Meeting and complained on behalf of all 82 residents residing in the facility. The Executive Director (ED) was unable to locate Resident Council Minutes from October 2023 through February 2024, but provided minutes from March 2024 to July 2024. These minutes consistently documented complaints about overnight staff not responding to call lights for 1-2 hours and staff using phones during resident care. Despite these ongoing complaints, the facility did not effectively resolve the issue, as evidenced by repeated grievances and lack of improvement in call light response times. Interviews with residents and staff revealed that the problem persisted, with residents experiencing long wait times for assistance, leading to accidents in their briefs. The Activity Director (AD) confirmed that call light response times and inappropriate phone use by staff were major concerns. Although grievance forms were submitted, responses were inconsistent, and some grievances related to call light issues were not addressed. The Assistant Director of Nursing (ADON) reported conducting night shift observations without finding concerns, and staff had been educated multiple times. However, the facility's policy on grievances, which mandates prompt resolution efforts, was not effectively implemented, resulting in ongoing resident dissatisfaction.
Non-Smoking Policy Violation in LTC Facility
Penalty
Summary
The facility failed to adhere to its non-smoking policy, allowing residents who had not been assessed for smoking to smoke on the premises and keep smoking materials in their rooms. This deficiency was observed in six residents, all of whom had various medical conditions that could be exacerbated by smoking. Despite the facility's policy stating it was a non-smoking environment, residents were found smoking on the grounds, and some admitted to keeping cigarettes and lighters in their rooms. Resident 6, who had chronic obstructive pulmonary disease (COPD) and other health issues, was observed smoking in the parking lot. His care plan indicated he was a smoker and should comply with the facility's smoking policy, but there was no documentation of a smoking assessment in his records. Similarly, Resident 22, with schizoaffective disorder and COPD, kept cigarettes in her room, contrary to the policy. Resident 7, who also had COPD, admitted to smoking on the facility grounds and keeping smoking materials in his car. Other residents, such as Resident 67 with schizophrenia and dementia, and Resident 77 with dementia and PTSD, were also found to be non-compliant with the smoking policy. They kept smoking materials in their rooms and smoked on the premises. Resident 26, with dementia and anxiety, was observed smoking with the help of another resident, despite having a behavioral contract prohibiting smoking on facility grounds. The facility's Executive Director and staff acknowledged the lack of smoking assessments and the failure to enforce the non-smoking policy, contributing to the deficiency.
Medication Labeling and Expiration Deficiencies
Penalty
Summary
The facility failed to properly label and date medications when opened and did not remove expired medications from use, as observed in three of five medication carts and one of two refrigerators. On the 600 hall medication cart, an albuterol inhaler and a trelegy ellipta inhaler for a resident, as well as a fluticasone nasal spray for another resident, were found without dates indicating when they were opened. On the 700 hall medication cart, expired Humalog insulin pens for two residents and a glargine insulin pen for another resident were found, along with a carboxymethyl solution without an opening date. On the 800 hall medication cart, insulin pens and a nasal spray for two residents were also found without opening dates. Additionally, the medication room refrigerators on the 600, 700, and 800 halls contained a vial of tuberculin that had expired and a bottle of aplisol with an unclear date. These observations indicate a failure to adhere to the facility's policy of ensuring medications are stored according to manufacturer's recommendations, which includes proper labeling, dating, and removal of expired medications.
Failure to Complete Resident Self-Administration Assessments
Penalty
Summary
The facility failed to ensure that resident assessments were completed for a resident who self-administers medications. Resident 15 was observed to have medications in her room, including fluticasone nasal spray, carboxymethylcellulose eye drops, and metronidazole lotion. The physician's orders allowed Resident 15 to self-administer these medications, but the facility's documentation was incomplete. The Medication Self-Administration Safety Screen dated 1/3/24 only assessed the fluticasone nasal spray, while the eye drops and topical creams were not considered applicable. Furthermore, the resident's electronic medical record lacked documentation of quarterly self-administration assessments for all three medications. A new Medication Self-Administration Safety Screen dated 8/5/24 assessed only the carboxymethylcellulose eye drops, omitting the fluticasone and metronidazole. The medication care plan dated 4/4/24 indicated that Resident 15 could self-administer eye medication and face cream, but did not specifically list the metronidazole lotion. During an interview, Resident 15 mentioned that the facility staff had taken away her rosacea medication, which she had previously been allowed to keep in her room. The facility's policy on self-administration of medications requires an interdisciplinary team assessment, which was not adequately documented in this case.
Inaccurate MDS Coding for Resident Fall
Penalty
Summary
The facility failed to accurately code falls on the Minimum Data Set (MDS) for a resident in the Memory Care unit. The resident, who had Alzheimer's disease, experienced a fall on her right hip after being found in another resident's bed and was escorted back to her room. This incident resulted in an acute, impacted, nondisplaced right subcapital femoral neck fracture, which required surgical repair. However, the significant change MDS assessment initially indicated no falls since admission or prior assessment, and a subsequent assessment failed to note the fracture resulting from the fall. The facility's policy on accurate assessment, effective at the time, was not adhered to, as the resident's status was not accurately reflected in the MDS assessments.
Insufficient Weekend Nursing Staff Coverage
Penalty
Summary
The facility failed to ensure sufficient licensed nurse coverage on weekends during one of the four quarters reviewed, potentially affecting all 82 residents. The CASPER report indicated staffing concerns were triggered in the second quarter of 2024 due to low weekend staffing. Upon reviewing the licensed nursing schedule for May 2024, it was found that the licensed staff per-patient-per-day (PPD) trended down throughout the month, with several days not meeting the minimum required PPD. Specific days, including Thursdays and weekends, showed PPDs below the minimum threshold, with the lowest being 0.19 on a Sunday. During an interview, the Executive Director (ED) acknowledged the staffing issues and noted that leadership staff, such as the Medical Records Coordinator and the Assistant Director of Nursing, were primarily scheduled for weekday office hours. The ED suggested that some of these hours could be rearranged to cover weekends. The Facility Assessment Tool, dated May 20, 2024, indicated the required minimum PPD for RNs and LPNs, which was not met according to the schedule review. The ED confirmed that the Facility Assessment Tool served as the policy for staffing requirements.
Deficiency in Person-Centered Care for Residents with Dementia
Penalty
Summary
The facility failed to ensure that two cognitively impaired residents, who wished to have a relationship and resided on the secured memory care unit, had appropriate assessments, ongoing supervision, and person-centered goals and interventions. The report highlights that the facility did not adequately document or revise care plans to reflect the residents' preferences and behaviors, particularly regarding their relationship. This lack of documentation and revision in care plans contributed to the deficiency. Resident 53, who was severely cognitively impaired with a BIMS score of 3 out of 15, had a history of wandering and seeking affection from male residents. Despite her family's approval of her relationship with Resident 55, the facility did not update her care plan to include her preference for companionship with him. Additionally, her behavioral assessments lacked documentation of her seeking affection, and her activity assessments did not reflect her meaningful relationship with Resident 55. Resident 55, who was moderately cognitively impaired with a BIMS score of 10 out of 15, also had a care plan that did not address his relationship with Resident 53. His behavioral assessments did not document his feelings towards her, and his activity assessments lacked information about his preference for companionship. The facility's failure to incorporate these aspects into their care plans and assessments resulted in a deficiency in providing person-centered care for these residents.
Failure to Provide Person-Centered Care and Supervision in Memory Care Unit
Penalty
Summary
The facility failed to ensure the secured memory care unit provided person-centered care, supervision, and engaging activities to prevent resident-to-resident altercations and/or accidents. This deficiency affected all 30 residents in the secured memory care unit. Observations, interviews, and record reviews revealed that residents frequently wandered into each other's rooms, leading to altercations and injuries. For instance, Resident L, who had a history of verbal and physical aggression, pushed Resident B, causing him to fall and sustain severe head injuries. Resident B had been agitated and wandering the halls, and staff attempts to put him to bed only increased his agitation. The facility lacked adequate supervision and activities to redirect residents, especially during the night shift when the activity room was closed and no materials for redirection were available. Resident L's family member reported that she had experienced a decline in cognitive abilities and an increase in aggression, leading to her transfer to the facility. Despite being placed in a room near the activity room, Resident L was frequently disturbed by other residents wandering into her room, which agitated her further. The facility's attempts to use a Velcro stop-sign to prevent other residents from entering her room were ineffective. Resident L's care plan lacked person-centered interventions to address her history of aggression and need for personal space. The facility also failed to provide adequate supervision and engaging activities for other residents, leading to multiple resident-to-resident altercations. For example, Resident EE wandered into Resident GG's room, resulting in an altercation where Resident EE sustained an abrasion. Similarly, Resident X wandered into Resident M's room, leading to an altercation where Resident X sustained a skin tear and bruising. Observations during the survey period showed continuous unsafe and unsupervised wandering by several residents, with no staff intervention or redirection. The care plans for these residents lacked person-centered, specialized interventions for dementia care and intrusive wandering.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to ensure a non-verbal, cognitively impaired resident was free from abuse. During the survey, a video provided by the family showed Qualified Medication Aide (QMA) 11 and Certified Nurse Aide (CNA) 12 providing incontinence care to Resident B. The video captured CNA 12 hitting Resident B on the left arm and upper abdomen with both open hands and yelling at the resident. QMA 11 did not intervene to stop the abuse and did not reposition Resident B's legs or reassure her during the incident. Family members, who were watching the care live through a web camera, voiced their concerns to the staff during the incident. The facility's grievance log indicated that a grievance was filed by the family on the same day, and an abuse investigation was ongoing. Interviews with staff and family members revealed that Resident B had a history of cognitive impairment and required assistance with activities of daily living. QMA 11 and CNA 12 were providing care when the incident occurred. QMA 11 admitted to witnessing CNA 12 hit Resident B and reported the incident to the oncoming nurse. Family members had previously installed a web camera in Resident B's room due to concerns about her care. The family provided the video evidence to the facility and filed a grievance. The facility's Director of Nursing (DON) confirmed that the abuse prevention policy was in place, which included training staff to manage residents' verbal or physical aggression and monitoring staff behavior. Resident B's medical records indicated diagnoses of Pick's disease, general anxiety disorder, depression, and psychotic disorder with delusions. The care plans for Resident B included interventions for cognitive impairment, impulsivity, and communication difficulties. The records lacked documentation of the incident, and focused charting on the day of the incident did not indicate any signs of emotional distress or changes in Resident B's condition. The facility's policy emphasized the residents' right to be free from abuse and the importance of staff training and monitoring to prevent such incidents.
Failure to Immediately Report and Intervene in Resident Abuse
Penalty
Summary
The facility failed to ensure staff immediately reported to the Administrator witnessed abuse by another staff member to a resident. The incident involved Resident B, who was being cared for by a Qualified Medication Aide (QMA) and a Certified Nurse Aide (CNA). During the care, the CNA hit Resident B on the left arm and upper abdomen, and yelled at the resident. The QMA did not intervene or stop the abuse and did not reposition Resident B's legs or reassure her. The incident was witnessed by Resident B's family members through a web camera, who voiced their concerns during the event. The QMA attempted to call the Administrator but did not receive a response and did not make further attempts to report the incident immediately. The Administrator received multiple calls reporting the abuse allegation later in the morning from other staff members and Resident B's family. The QMA provided a handwritten statement the following day, indicating she had called the Administrator but did not receive a response. The Administrator's call log showed no missed calls from the QMA. The facility's policy required immediate reporting of abuse to the Administrator or the Director of Nursing (DON) if the Administrator was unavailable. The QMA did not follow up with additional calls or notify the DON as required by the policy. Resident B's medical records indicated she had diagnoses including Pick's disease, general anxiety disorder, depression, and psychotic disorder with delusions. The resident had adequate hearing and vision, was not comatose, and sometimes understood others. The facility's policy on abuse prevention emphasized the importance of immediate reporting of any suspected abuse to facility management. The failure to report the abuse immediately and the lack of intervention during the incident led to the deficiency cited in the report.
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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