Majestic Care Of Connersville
Inspection history, citations, penalties and survey trends for this long-term care facility in Connersville, Indiana.
- Location
- 1029 E 5th Street, Connersville, Indiana 47331
- CMS Provider Number
- 155491
- Inspections on file
- 49
- Latest survey
- October 29, 2025
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Majestic Care Of Connersville during CMS and state inspections, most recent first.
A male resident with severe cognitive impairment and a history of sexually inappropriate behavior was reported and observed to have inappropriately touched female residents on multiple occasions, including during smoke breaks and while assisting with wheelchairs. Staff and other residents reported these incidents, but there was a lack of thorough documentation, investigation, and consistent staff awareness regarding the reasons for increased supervision. The facility did not fully implement its abuse prevention policy, resulting in residents experiencing anxiety and fear.
The facility did not thoroughly investigate or ensure protection following multiple allegations of sexual abuse involving a resident with severe cognitive impairment and two other residents with moderate cognitive impairment. Despite reports and witness accounts of inappropriate touching during smoke breaks, the facility failed to interview all involved parties or document the reasons for safety interventions, resulting in repeated incidents and ongoing distress for the affected residents.
Two residents with cognitive impairments were involved in an incident where one resident was alleged to have sexually acted out toward another. Despite staff awareness and facility policy requiring notification, the DON and Administrator did not report the abuse allegation to the state health department, and there was a lack of documentation regarding the incident and follow-up with the affected resident.
A resident with severe cognitive impairment and dementia repeatedly engaged in sexually inappropriate behaviors toward female residents, including inappropriate touching. Staff documentation and communication about these behaviors were inconsistent, and some staff were unaware of the resident's history. Other residents reported distress and fear, and incidents were not always thoroughly investigated or documented, resulting in a failure to provide individualized interventions and protect residents.
A resident with severe cognitive impairment and a history of constipation did not receive PRN laxatives as ordered due to inaccurate EMR documentation and lack of staff follow-up. The EMR failed to generate alerts for no bowel movement, and staff did not notify the physician or administer PRN medications, resulting in a failure to provide care according to physician orders.
The facility failed to maintain the kitchen door in the west building, allowing rodents to enter. Despite monthly pest control visits, the door lacked a proper seal and was often propped open by staff, leading to an ongoing mouse problem. The issue affected 42 residents, with multiple mice caught in traps over several months. Staff interviews and pest control reports highlighted the need for door repairs, which had not been effectively addressed.
The facility failed to maintain a homelike environment for several residents, as observed during a survey. A resident's room was bare with a broken clock, while another expressed dissatisfaction with the lack of personal items. Additional issues included broken blinds, malfunctioning lights, and bathroom damage. The facility's policy emphasizes a homelike environment, which was not upheld.
The facility failed to administer medications and treatments as ordered for several residents. A resident with renal disease did not receive prescribed Midodrine before dialysis, and another with heart failure experienced unreported weight gains, leading to unadjusted medication. A resident's gastrointestinal tube removal was delayed due to incomplete orders, and another resident did not have compression stockings applied as required.
The facility failed to provide accessible fluids to three residents, leading to a deficiency in hydration care. A resident with a history of urinary tract infections had fluids placed out of reach, while another resident was observed without fluids multiple times. A third resident reported receiving only one cup of ice water a day. The facility's hydration policy was not followed, as fluids were not consistently available to these residents.
A facility failed to provide a resident with in-room self-initiated activities, despite the resident's preference for independent activities and a care plan emphasizing their importance. The resident, who had multiple medical conditions, was observed lying in bed without access to activities like music or reading materials. The facility's policy required an ongoing activity program, but the responsibility to ensure activities were available was not met.
A facility failed to maintain proper hygiene standards for a resident's urinary catheter, as the drainage bag and tubing were observed in contact with the floor. The resident, who required extensive assistance and had an indwelling catheter for obstructive uropathy, was at risk for infection due to this oversight. A CNA confirmed the issue and was unaware of how to prevent it, despite the facility's policy requiring adherence to standard practices.
A resident with chronic pain syndrome did not receive four doses of prescribed tramadol over two days, leading to elevated pain levels. The facility's medication records confirmed the missed doses, and there was a lack of documented pain assessments during this period, contrary to the facility's pain management policy.
A resident with osteoarthritis and end-stage renal disease did not have a timely follow-up for a CT scan appointment. Despite a physician's order and referral sent to a local provider, there was no documentation of a scheduled appointment or follow-up actions. The DON confirmed that the process involved contacting the provider, but a diagnosis code needed for scheduling was not provided until later, delaying the appointment.
A resident, who was cognitively intact and had multiple health conditions, was observed to have no teeth and expressed difficulty eating due to the lack of dentures. The resident had not seen a dentist since impressions were made in June 2023, as the dentures were not completed due to a lack of communication from the POA. Social Services did not follow up adequately, resulting in the resident being without dentures.
A facility failed to document treatments and enteral feeding for a resident with complex medical needs, including chronic respiratory failure and quadriplegia. The May 2024 TAR showed missing documentation for various wound care treatments and g-tube feeding, which were neither recorded as completed nor refused. The Corporate Director of Respiratory confirmed these omissions, highlighting a breach in the facility's documentation policy.
Failure to Protect Residents from Sexual Abuse by a Cognitively Impaired Resident
Penalty
Summary
The facility failed to protect residents from sexual abuse, specifically involving a male resident with severe cognitive impairment and a history of sexually inappropriate behaviors. This resident, diagnosed with vascular dementia, depression, and anxiety, was observed and reported to have inappropriately touched female residents on multiple occasions. Documentation shows that the resident was found with his hand inside a female resident's shirt, physically moving his hand around her breast, and was later reported to have touched another female resident's chest during a smoke break. Despite these incidents, there was a lack of clear documentation and follow-up regarding the behaviors that led to increased monitoring, and staff were often unaware of the reasons for the interventions being implemented. Interviews with staff and residents revealed that the incidents were witnessed by other residents, who reported the behaviors to nursing staff. One female resident expressed anxiety and fear following the incidents, stating she was uncomfortable and worried about her safety at night. Another female resident described similar inappropriate contact and indicated that such behaviors had occurred repeatedly, particularly during transitions from the smoking area. Despite these reports, there was no evidence that management conducted thorough interviews or investigations with all involved parties, including witnesses and victims. The facility's documentation and response to the allegations were inconsistent. Staff members, including nurses and CNAs, were often unaware of the specific reasons for increased supervision or 15-minute checks. The Director of Nursing and Administrator acknowledged receiving reports of inappropriate behavior but did not ensure comprehensive documentation or investigation. The facility's policy on abuse prevention required identification, correction, and intervention in situations where abuse was likely, as well as protection of residents, but these measures were not fully implemented in response to the incidents described.
Failure to Investigate and Protect Residents from Repeated Sexual Abuse Allegations
Penalty
Summary
The facility failed to conduct a thorough investigation and ensure protection from further allegations of sexual abuse involving three residents. Resident C, who had diagnoses including vascular dementia, depression, and severe cognitive impairment, was placed on 15-minute safety checks for sexually acting out, but there was no documentation explaining the behaviors that led to this intervention. On two separate occasions, Resident C was reported to have inappropriately touched female residents during or after smoke breaks. Despite these reports, the facility did not complete comprehensive interviews or investigations with all involved residents and witnesses. Resident B, who was moderately cognitively impaired and had a history of anxiety and depression, reported being touched inappropriately by Resident C while being wheeled inside after a smoke break. Another resident witnessed the incident and corroborated the report. Resident B expressed feeling uncomfortable, upset, and fearful that Resident C might enter her room at night. Similarly, Resident G, also moderately cognitively impaired, reported that Resident C had touched her inappropriately on more than one occasion and that she had informed staff, but could not recall their names. Resident G stated that these behaviors continued to occur, particularly during transitions from the smoking area, and that management had not interviewed her about the incidents. Interviews with staff, including the DON, LPN, and RN, revealed uncertainty about the reasons for Resident C's monitoring and a lack of follow-up on the initial and subsequent allegations. The facility's abuse policy required a thorough investigation, including interviews with all involved parties and witnesses, but this was not completed. The lack of comprehensive investigation and failure to ensure resident protection resulted in repeated incidents and ongoing anxiety and fear among the affected residents.
Failure to Report Sexual Abuse Allegations to State Authorities
Penalty
Summary
The facility failed to report an allegation of sexual abuse to the Indiana Department of Health (IDOH) involving two residents. Resident C, who had diagnoses including vascular dementia and was severely cognitively impaired, was placed on 15-minute safety checks for sexually acting out, but there was no documentation in the clinical record explaining the behaviors that led to this intervention. Staff, including a registered nurse and the Director of Nursing (DON), were unable to provide documentation or clear details about the incident, and the DON confirmed that the incident was not reported to IDOH. The Administrator was also aware of the allegation via text from the DON but did not report it to the state agency. Resident G, who had moderate cognitive impairment and diagnoses including diabetes and anxiety, reported that Resident C had inappropriately touched her while she was in her wheelchair. Resident G stated she informed several staff members but could not recall their names, and indicated that similar behaviors had occurred previously. The DON had not spoken with Resident G about the event, and there was no evidence that the required abuse reporting policy was followed. The facility's own policy required the Administrator to notify IDOH in the event of an abuse allegation, which was not done in these cases.
Failure to Implement Individualized Interventions for Sexually Inappropriate Behaviors in Dementia Resident
Penalty
Summary
The facility failed to implement individualized interventions for a resident with dementia who exhibited sexually inappropriate behaviors towards female residents. One resident, diagnosed with vascular dementia and severe cognitive impairment, was documented on multiple occasions to have inappropriately touched female residents, including incidents where he placed his hand inside a female resident's shirt and touched her breast, and another where he touched a female resident's chest while returning from a smoke break. Despite these incidents, documentation in the clinical record was inconsistent, with gaps in recording the behaviors that prompted safety checks and a lack of clear communication to staff regarding the resident's history of sexually inappropriate actions. Interviews with staff revealed uncertainty and lack of awareness about the reasons for safety checks and the resident's behavioral history. Some staff members were unaware of the resident's sexually inappropriate behaviors, and the Kardex did not contain alerts or documentation about these behaviors. The care plan did include some interventions, such as supervision during smoke breaks and one-on-one supervision, but these were not consistently communicated or documented in a way that ensured all staff were informed and able to implement them effectively. Other residents reported feeling uncomfortable, upset, and fearful as a result of the inappropriate behaviors, and there was evidence that incidents were not always thoroughly investigated or followed up with the affected residents. The facility's dementia care policy required individualized care plans and ongoing monitoring of interventions, but the observed deficiencies indicated a failure to consistently identify, document, and address the resident's sexually inappropriate behaviors, as well as to protect other residents from further incidents.
Failure to Document and Address Resident Constipation per Physician Orders
Penalty
Summary
The facility failed to ensure accurate documentation and appropriate follow-through regarding a resident's lack of bowel movements, which resulted in not administering physician-ordered PRN medications for constipation. The resident in question had multiple diagnoses, including unspecified dementia, COPD, a recent hip fracture, and a history of constipation. He was severely cognitively impaired, non-ambulatory, and dependent on staff for all activities of daily living. After returning from a hospital stay, he was prescribed routine stool softeners and had PRN orders for additional laxatives if no bowel movement occurred within three days. However, the electronic medical record (EMR) did not accurately reflect the absence of bowel movements, as staff selected 'Response Not Required' instead of 'No bowel movement,' and no alert was generated to notify staff of the issue. During the period in question, there was no documentation in the progress notes regarding the lack of stooling, nor was the physician or nurse practitioner notified of the resident's constipation. As a result, the PRN medications ordered for constipation were not administered. The DON confirmed that the facility did not have a specific bowel protocol policy and that the EMR system failed to alert staff to the resident's condition. The resident did not display symptoms of abdominal discomfort during this time, but the lack of accurate documentation and follow-up led to a failure to provide care as ordered.
Rodent Entry Due to Faulty Kitchen Door
Penalty
Summary
The facility failed to maintain the entry door into the main kitchen of the west building, which resulted in rodents entering the building. This deficiency was observed during a survey where mice traps were set in both the west and east kitchens. The Dietary Manager confirmed that a pest control company serviced the facility monthly, but there was an ongoing issue with mice in the west building. The kitchen door to the outside was observed to be shut but lacked a proper seal, allowing rodents to enter. Additionally, staff were found to prop the door open with a brick, as the door would lock when closed, making it difficult for dietary staff to re-enter. Interviews with various staff members, including an LPN and the Pest Control Technician, revealed that the problem had been ongoing, with mice sightings reported in resident rooms and traps catching multiple mice over several months. The Maintenance Director acknowledged attempts to fix the door but stated it needed replacement. Pest control reports from May to September indicated repeated recommendations to keep the door shut or fix it to prevent pest entry, yet the door was often found slightly open or propped open. The facility's pest control policy aimed to eradicate and contain rodents, but the deficiency persisted, affecting the 42 residents in the west building.
Failure to Maintain a Homelike Environment for Residents
Penalty
Summary
The facility failed to provide a homelike environment for several residents, as observed during a survey. Resident 18's room was noted to be bare, lacking personal belongings and pictures, with a broken clock on the wall. Despite the care plan indicating the need for a homelike environment, these conditions persisted over multiple observations. Similarly, Resident 1's room was devoid of personal items, and the resident expressed dissatisfaction with the room's lack of homeliness. The Social Service Director acknowledged the issue, noting that it was the responsibility of Social Services, Nursing, and Marketing to ensure a homelike environment. Additional deficiencies were observed in the rooms of other residents. Resident 75 reported broken blinds that had not been repaired, while Resident 38 experienced issues with malfunctioning lights, which had been reported to staff but remained unfixed. Resident 64's bathroom had unmatched paint and holes in the drywall. The facility administrator was unaware of these issues until the survey and committed to addressing them. The facility's policy on resident rights emphasizes the importance of a safe, clean, comfortable, and homelike environment, which was not upheld in these instances.
Medication and Treatment Administration Failures
Penalty
Summary
The facility failed to administer medications as ordered for Resident 52, who had diagnoses including end-stage renal disease and hypotension. The resident required hemodialysis three times a week, with a physician's order to administer Midodrine before dialysis sessions. However, the medication was not administered on two occasions, and there was no documentation of blood pressure readings on non-dialysis days to justify the non-administration of as-needed Midodrine. The Director of Nursing was unsure of the correct orders and acknowledged the lack of blood pressure monitoring. Resident 64, diagnosed with congestive heart failure and edema, experienced significant weight gains that were not reported to the physician as required. The resident's care plan included daily weight monitoring and notification of the physician for weight gains over three pounds in a day. Despite several instances of weight gain exceeding this threshold, there was no evidence of physician notification, and a verbal order to increase the dosage of Metolazone was not implemented. Resident 45 had a physician's order for the removal of a gastrointestinal tube, which was not followed through due to incomplete information in the initial order. The facility failed to ensure the order was processed correctly, resulting in a delay. Additionally, Resident 14, who required compression stockings for edema, did not have them applied as ordered. The resident reported discomfort due to swelling, and observations confirmed the absence of compression stockings, despite documentation indicating they were administered.
Failure to Provide Accessible Fluids to Residents
Penalty
Summary
The facility failed to provide fresh fluids and keep fluids within reach for three residents, leading to a deficiency in hydration care. Resident 54 was observed multiple times without water or any fluids within reach, despite having a history of urinary tract infections and being ordered thin liquids. Observations revealed that the resident's fluids were either absent or placed across the room, out of reach, on several occasions. Similarly, Resident 18 was observed without any fluids available in the room on multiple occasions, despite being ordered thin liquids. Resident 1 was also found without fluids in her room during observations, and she reported receiving only one cup of ice water a day. The facility's hydration policy, which mandates the provision and encouragement of bedside fluids, was not adhered to, as evidenced by the lack of fluids available to these residents.
Failure to Provide In-Room Activities for Resident
Penalty
Summary
The facility failed to provide in-room self-initiated activities for a resident who was observed lying in bed, awake, and staring at the ceiling on multiple occasions. The resident's television was unplugged, and there were no available activities such as music, books, magazines, puzzles, or a daily chronicle. The resident expressed dissatisfaction with her room and indicated a preference for staying to herself rather than participating in group activities. Despite being cognitively intact and having a care plan that emphasized the importance of independent activities, the resident was not provided with the necessary resources to engage in such activities. The resident's medical history included Parkinson's disease, chronic obstructive pulmonary disease, dementia, diabetes, atherosclerotic heart disease, major depressive disorder, paranoid personality disorder, and conversion disorder with seizures. The facility's activity policy stated that an ongoing activity program should support residents' choices and interests, yet the responsibility to ensure the resident had self-initiated activities available was not fulfilled. The Activity Director acknowledged that it was the Activity Aides' responsibility to provide these activities, highlighting a lapse in the implementation of the facility's policy.
Failure to Maintain Catheter Hygiene Standards
Penalty
Summary
The facility failed to ensure that a resident's urinary catheter drainage bag and tubing remained free of contact with the floor, which is a standard practice to prevent infection. Resident 33, who was mildly cognitively impaired and required extensive assistance for toileting needs, had an indwelling urinary catheter due to obstructive uropathy. Observations on two separate occasions revealed that the catheter tubing and drainage bag were in contact with the floor, which poses a risk for infection. During an interview, a Certified Nursing Assistant (CNA) confirmed that the catheter bag was contacting the floor and admitted to not knowing how to prevent this. The Regional Nurse Consultant also confirmed that keeping the catheter tubing and drainage bag off the floor is the current standard of practice. The facility's policy on the appropriate use of indwelling catheters aligns with this standard, indicating a failure in adherence to the policy.
Failure to Administer and Assess Pain Medication
Penalty
Summary
The facility failed to routinely assess and administer narcotic pain medication for a resident with chronic pain. Resident 12, who was cognitively intact and diagnosed with chronic pain syndrome, was supposed to receive tramadol 50 mg three times a day and Tylenol 650 mg every six hours for pain management. However, the resident did not receive four doses of tramadol over two days, which led to elevated pain levels, although it did not prevent her from performing her usual routine. The resident and her family member reported that the facility staff mentioned an outage as the reason for the missed medication. The facility's July 2024 medication administration record confirmed the missed doses of tramadol, while Tylenol was administered as ordered. Additionally, there was a lack of documented pain assessments between the evening of 7/18/2024 and the morning of 7/20/2024, despite the facility's pain management policy requiring residents receiving routine pain medications to be assessed each shift. This oversight in pain management and documentation contributed to the deficiency identified during the survey.
Failure to Timely Schedule CT Scan for Resident
Penalty
Summary
The facility failed to timely follow up on scheduling a CT scan for a resident with skin conditions, identified as Resident 52. The resident's clinical record was reviewed, revealing diagnoses of osteoarthritis and end-stage renal disease. A physician's order for a CT scan of the spine without contrast was issued on 7/10/24, including the cervical, lumbar, and thoracic spine, with a referral sent to a local hospital provider. However, there was no documentation in the clinical record indicating that an appointment was scheduled or any follow-up actions were taken after the referral was sent. An interview with the Director of Nursing (DON) revealed that the process for scheduling CT scans involved calling the local provider and sending the order, after which the provider would respond with an appointment or request additional information. Despite the staff's initial call to schedule the appointment, there was no verification of follow-up until the DON contacted the provider on 7/26/24. The provider indicated they needed a diagnosis code to proceed, which was not provided until the day of the interview, delaying the scheduling of the CT scan for Resident 52.
Failure to Provide Routine Dental Services
Penalty
Summary
The facility failed to ensure a resident received routine dental services, as evidenced by the case of a resident who was observed to have no upper or lower teeth and expressed difficulty eating due to the lack of dentures. The resident, who was cognitively intact and had multiple diagnoses including Parkinsonism, COPD, dementia, and diabetes, had not seen a dentist since June 2023. At that time, impressions for dentures were made, but the dentures were not completed because the dentist did not receive communication from the resident's Power of Attorney (POA). Social Services, responsible for following up with the POA and dentist, had not ensured the completion of the dental services, resulting in the resident being without dentures for an extended period.
Failure to Document Treatments and Enteral Feeding
Penalty
Summary
The facility failed to properly document treatments and enteral feeding for Resident C, who has complex medical conditions including chronic respiratory failure with hypoxia, quadriplegia, and dependence on a ventilator. The Treatment Administration Record (TAR) for May 2024 showed multiple instances where treatments were neither documented as completed nor refused. These treatments included the application of Dakins solution to the buttocks, wound care for the right lateral foot, right lateral leg, right elbow, coccyx, and buttocks, as well as enteral feeding via a gastrostomy tube. The Corporate Director of Respiratory confirmed the lack of documentation during an interview. The facility's documentation policy requires accurate and timely records of residents' experiences, which was not adhered to in this case. The absence of documentation for specific dates and shifts indicates a significant lapse in maintaining accurate medical records for Resident C, as required by professional standards.
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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