Majestic Care Of Goshen
Inspection history, citations, penalties and survey trends for this long-term care facility in Goshen, Indiana.
- Location
- 2400 College Ave, Goshen, Indiana 46528
- CMS Provider Number
- 155689
- Inspections on file
- 38
- Latest survey
- February 3, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Majestic Care Of Goshen during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple comorbidities experienced two separate incidents in which other residents entered her room and engaged in inappropriate and intrusive behavior, including exposure, physical contact, and getting into bed with her while undressed. The resident’s responsible party reported both incidents to facility leadership via email and the facility had an abuse policy requiring immediate reporting of alleged violations to the Administrator and the Department of Health within defined time frames. However, the prior administrator did not submit required reports for these allegations, and the current administrator later acknowledged he had assumed they had been reported when they had not, resulting in a failure to timely report suspected abuse as required.
A resident with severe cognitive impairment and multiple comorbidities had a care plan including video monitoring and a STOP sign at her doorway. A male resident entered her room on more than one occasion, including an incident captured on family-installed cameras where he approached her bed while she slept, opened his robe, and ultimately sat on her chest and shoulder, causing her to cry out in pain before staff removed him. The resident’s representative reported this allegation to the Administrator by email, but the facility did not complete a thorough abuse investigation as required by its policy to investigate all alleged violations reported by residents or relatives.
Two cognitively intact residents who required substantial assistance with bathing did not receive scheduled twice-weekly showers as care planned and per facility policy. One resident with a femur fracture, cerebral palsy, and bipolar disorder received only a few documented showers despite a set Tuesday/Friday schedule, and the spouse reported repeated complaints to staff and disputed claims that the resident had refused showers, with no refusal documentation found. Another resident with neuromuscular bladder dysfunction, BPH, stroke, and anxiety reported going weeks without a shower and being told by staff they would provide one only if they could "fit it in," and he declined to sign a shower refusal sheet because he had not refused. Record reviews showed minimal shower documentation and no recorded refusals, while an LPN and the DON described expectations that showers and any refusals be documented according to the facility’s shower policy.
Surveyors found that the facility failed to follow physician orders for medication administration for a resident with exocrine pancreatic insufficiency and hypertension, including giving pancrelipase at times not aligned with meals, missing multiple doses without notifying the provider, and administering metoprolol despite heart rates below ordered hold parameters. In addition, the facility did not ensure a neurologist appointment was scheduled for a cognitively intact resident with multiple sclerosis and trigeminal neuralgia, despite a physician order, repeated resident requests, a grievance stating prior unmet requests, and documentation of severe pain, while the transportation director reported no appointments had been scheduled or completed for this resident.
A resident with a chronic Foley catheter and multiple comorbidities experienced inadequate monitoring and care when an order to record urinary output each shift was discontinued and staff did not continue to obtain or document outputs. Over subsequent days, the resident reported severe penile pain and pus at the meatus, and staff noted ongoing pain, abnormal drainage, and later fever, shaking, and gray discoloration before sending the resident to the hospital. In the ED, the Foley was found displaced with the balloon in the penile shaft, and the resident was diagnosed with a UTI and early sepsis related to a displaced catheter, while the facility’s own policy required ongoing catheter care and monitoring for catheter-associated UTI.
The facility did not ensure catheter care and urinary output documentation were completed as ordered for three residents with indwelling catheters. Review of records showed multiple shifts with missing documentation, and staff interviews confirmed there was no way to verify care was provided when documentation was absent. Family and resident interviews raised concerns about catheter care and urinary tract infections.
The facility failed to maintain sanitary conditions in the kitchen, affecting food safety for all 101 residents. Observations revealed improperly sealed food items in the freezer and a lack of open dates on dry storage items. Additionally, kitchen utensils and equipment were found with dried food and grease, despite being stored as clean. The Dietary Manager acknowledged these issues, which were contrary to the facility's sanitation policies.
The facility failed to follow infection control practices, including improper glove use and handwashing during resident care, and did not adhere to Enhanced Barrier Precautions for residents with wounds and catheters. Additionally, an illness outbreak was not reported to the State Department of Health, and medication was handled without gloves. These deficiencies potentially affected all residents.
The facility failed to notify physicians of abnormal conditions for residents, including elevated blood glucose levels and insulin refusals for two residents with diabetes, and new skin issues for another resident. Despite care plans and policies requiring physician notification, documentation was lacking, and staff interviews confirmed the deficiencies.
The facility failed to resolve resident grievances regarding long call light response times and incomplete shower schedules. Residents reported ineffective alternative alert methods and inconsistent grievance handling. Grievance forms were not accessible for anonymous submission, and the facility's grievance policy was inadequately implemented.
A facility failed to update a Level One PASARR assessment for a resident who received a new diagnosis of psychotic disorder with delusions and was prescribed antipsychotic medications. The initial PASARR form did not accurately reflect the resident's current mental health status or medications, and a new assessment was not conducted as required by facility policy.
A resident with multiple health conditions developed a stage 3 pressure ulcer due to the facility's failure to implement timely preventative measures. Despite being at risk for pressure sores, the resident's care plan interventions, such as turning and repositioning and the use of a prevalon boot, were not consistently documented or implemented. The facility delayed obtaining the recommended boot, and staff interviews confirmed the resident did not receive it until weeks after the recommendation.
A resident with nephrostomy tubes did not receive appropriate dressing changes, as staff were unfamiliar with the procedure and there were no physician orders specifying the frequency of changes. Observations showed dirty dressings, and an RN confirmed that daily changes were necessary, highlighting a deficiency in catheter care.
The facility failed to schedule timely specialty appointments for two residents, leading to a deficiency. A resident with a history of cervical cancer waited over eleven weeks for a gynecological oncology appointment after a mass was found in her uterus. Another resident with chronic kidney disease and anemia had no documented specialty referrals scheduled despite physician orders. The facility's policy on change in condition and physician notification was not effectively followed.
The facility failed to document clinical contraindications for declining gradual dose reductions (GDR) for two residents. One resident, with multiple diagnoses including PTSD, was on Haloperidol and Trazadone, while another resident with anxiety and depression was on Alprazolam PRN. Despite pharmacy recommendations to reduce dosages or evaluate the need for continued medication use, the facility did not provide adequate documentation to justify the decisions to maintain current dosages. The Director of Nursing acknowledged the lack of documentation, which was contrary to the facility's policy on managing unnecessary drugs.
The facility was found deficient in medication storage and labeling practices. Observations revealed unlabeled and improperly stored medications, including loose pills and topical creams stored with oral medications. Staff interviews confirmed these practices were against facility policy, and a policy on labeling was not provided during the survey.
A resident with diabetes and a stage 3 pressure ulcer did not receive timely laboratory testing as ordered by their physician. The facility failed to conduct a Hemoglobin A1c test and delayed other tests ordered by a wound center, despite having a policy for prompt action and communication. Interviews with staff revealed lapses in executing lab orders, even though the lab visited the facility regularly.
Two residents in the facility did not receive adequate bathing and oral care as per their care plans. One resident with quadriplegia reported not receiving scheduled showers and had difficulty shaving, while another resident with cervical spina bifida did not receive showers on preferred days, affecting her social activities. The facility's policy on ADLs was not followed, despite previous concerns raised by the Resident Council.
A resident with Alzheimer's and dementia, identified as high risk for falls, experienced multiple falls due to the facility's failure to implement a prescribed non-slip pad on her wheelchair. Despite a care plan update following a previous fall, the intervention was not in place, leading to further incidents and family concern.
The facility failed to manage urinary catheters properly for three residents, leading to deficiencies in catheter care and documentation. A resident with multiple health issues was found with a full catheter collection meter, and staff failed to document urine output as required. Another resident expressed concerns about infrequent catheter emptying, with records showing multiple instances of undocumented output. The facility's policy on catheter care was not followed, resulting in these deficiencies.
A resident with a history of fractures and chronic conditions was not administered prescribed stool softener upon admission to the facility, leading to constipation. The facility failed to input physician's orders into the EMR, delaying medication administration. The bowel movement protocol was not initiated, and a required assessment was not completed, causing the resident discomfort.
A facility failed to provide timely care to prevent a pressure wound for a resident admitted with a right femur fracture and other conditions. The resident, who was severely cognitively impaired and at risk for skin breakdown, did not receive a skin assessment upon admission. A pressure wound was later identified, which was not documented by the hospital at discharge. Delays in entering physician's orders into the EMR and implementing a pressure-reducing mattress contributed to the deficiency.
A resident with severe cognitive impairment and multiple fractures experienced unmanaged pain due to the facility's failure to conduct a pain assessment and administer pain medication upon admission. Despite hospital orders for pain management, the resident did not receive medication until over 16 hours after the last hospital dose, as the facility did not enter physician's orders into the EMR or utilize the Pyxis system. This oversight led to a significant delay in pain relief and was contrary to the facility's policies.
A resident with specific medical needs and preferences for showering was not accommodated by the facility, missing 11 out of 26 scheduled showers. The resident's care plan indicated a preference for showers on Mondays, Thursdays, and Saturdays, but the facility altered the schedule, affecting her social participation. Resident Council Minutes also noted similar concerns from other residents.
A facility failed to develop a comprehensive care plan for a resident with a urostomy, as required by its policies. The resident, who was cognitively intact and required significant assistance, reported that their urostomy bag was not emptied regularly. Despite a physician's order to empty the bag every shift, the care plan lacked specific interventions for urostomy care, management, or monitoring, leading to a deficiency identified during a complaint investigation.
The facility failed to provide scheduled showers for several residents, including those with cognitive impairments and physical disabilities, leading to a deficiency in resident rights. Residents missed numerous scheduled showers, with no refusals documented, indicating a systemic issue in adhering to care plans and personal preferences. Complaints were noted in Resident Council minutes, and the facility's policy on resident showers was not followed.
A facility failed to provide proper urostomy care for a resident, resulting in the urostomy bag not being emptied regularly. The resident, who required substantial assistance due to conditions like spina bifida and paraplegia, reported that her catheter bag was often not emptied during the day shift. The issue arose after a new medical director was hired, and the necessary urostomy orders were not entered into the EMR system, leading to a lack of documentation and compliance with care standards.
The facility failed to conduct follow-up assessments for UTIs in three residents, leading to inadequate documentation and management of symptoms. One resident was discharged to the hospital with hematuria, another showed increased confusion and refused medication, and the third experienced confusion and falls. Despite care plans outlining necessary interventions, these were not properly executed or documented.
Failure to Timely Report Multiple Allegations of Resident Abuse
Penalty
Summary
The facility failed to timely report two separate allegations of abuse involving a cognitively impaired resident, Resident C, in accordance with its abuse, mistreatment, neglect, and exploitation policy. Resident C had diagnoses including Alzheimer's disease, dementia, seizures, weakness, and depression, with a quarterly MDS showing severe cognitive impairment and dependence on substantial assistance for most ADLs. Her care plan noted a preference for video recording in her room and a STOP sign across the door frame, with interventions to protect privacy. On one occasion, an incident report (Facility Incident #236) was submitted for an event in which a male resident entered Resident C's room and sat on her bed; however, the facility's later review revealed that an earlier, more serious incident involving the same resident entering her room, exposing himself, and sitting on her chest and shoulder had been reported by the responsible party via email but was not reported to the State Agency as required. The record further showed that another incident (Facility Incident #254) involving a different resident, Resident D, climbing into bed with Resident C after undressing and wiping her genital area with Resident C's blanket was also not reported to the State Agency at the time it occurred. The responsible party had emailed the previous administrator about this event as well, but no report was filed until months later, when the current Administrator became aware that the prior incident had never been reported. The facility’s abuse policy required that all alleged violations reported by residents, relatives, or care plan members be immediately reported to the Administrator and to the Department of Health within specified time frames (2 hours for alleged abuse and no later than 24 hours for all other allegations). The Administrator acknowledged awareness of the allegations from September and October and stated he had assumed the previous administrator had reported them, but they had not been reported in accordance with the policy and regulatory requirements.
Failure to Investigate Alleged Resident-to-Resident Abuse
Penalty
Summary
The deficiency involves the facility’s failure to follow its abuse investigation policy after an allegation of abuse involving a cognitively impaired resident. Resident C had diagnoses including Alzheimer’s disease, dementia, seizures, weakness, and depression, and required substantial assistance with most activities of daily living. Her care plan documented a preference for video recording in her room and a STOP sign across the door frame, with interventions to protect privacy. On one reported incident date, a male resident entered her room and sat on her bed; the facility’s incident report documented that Resident C reported no physical contact and that a head‑to‑toe assessment showed no findings. However, Resident C’s responsible party later provided an email describing an earlier incident captured on family-installed room cameras in which the same male resident entered Resident C’s room while she was asleep, attempted to sit on the bed, opened and closed his robe, and then sat in a chair. The email further described that the male resident then moved back to the bed, sat on the bed, and then sat directly on Resident C’s chest and left shoulder, causing her to groan and call out in pain, before he sat on the floor next to the bed and fell asleep until staff found him and escorted him out. This allegation was reported by the responsible party to the previous Administrator via email as a follow-up to an incident she had already reported. The current Administrator later acknowledged awareness of this abuse allegation and that a thorough investigation had not been completed by the previous Administrator. The facility’s written policy required that all alleged violations reported by residents or relatives be immediately reported to the Administrator and the Department of Health and that, once notified, an investigation of the alleged violation be conducted. Surveyors determined that the facility failed to implement this policy by not conducting a thorough investigation into the abuse allegation involving Resident C.
Failure to Provide Scheduled Showers and Document Bathing Care
Penalty
Summary
The facility failed to provide scheduled showers and assistance with activities of daily living for two residents who required substantial assistance with bathing. One resident with diagnoses including intertrochanteric fracture of the right femur, cerebral palsy, and bipolar disorder was cognitively intact and care planned to receive showers twice weekly, on Tuesdays and Fridays, with the goal of having daily care needs met. From admission through discharge, this resident received only three documented showers despite the schedule, and there was no documentation in the medical record of any shower refusals. The resident’s wife reported she had raised concerns with the facility about missed showers and was told the resident had signed refusal documentation, but she stated he would not have continued to request showers if he had refused them. She further reported that the social worker attempted to convince the resident he had signed refusal paperwork, but the alleged refusal documentation could not be located. The Interim Director of Nursing later indicated that shower sheets were not used during the relevant month and that showers and refusals should have been documented in the medical record and nursing progress notes. Another cognitively intact resident with diagnoses including neuromuscular dysfunction of the bladder, benign prostatic hypertrophy, cerebrovascular accident, and anxiety disorder was also care planned to receive showers twice weekly on second shift, on Tuesdays and Fridays, with a goal of having daily care needs met. This resident reported he was supposed to receive showers on that schedule but had not had a shower in a while, stating that when he requested a shower, staff responded that they would provide one “if we can fit you in,” and that he had gone weeks without a shower. He also reported that the Director of Nursing asked if he had been refusing showers and that he refused to sign a shower sheet because he had not refused. Record review showed only one documented shower during the review period, with several shower sheets completed but no documentation of any refusals in the medical record. An LPN stated that residents should receive showers twice weekly and that refusals should be documented with a resident signature on a shower sheet and in nursing progress notes. The facility’s shower policy stated that residents would be provided showers per request or facility schedule protocols and based on resident safety.
Failure to Follow Medication Orders and Arrange Specialist Consultation
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders for medication administration for one resident and to schedule a specialized physician appointment for another resident. For Resident C, who had diagnoses including exocrine pancreatic insufficiency, cerebral palsy, and type 2 diabetes mellitus and was cognitively intact, hospital discharge instructions ordered pancrelipase (Creon) 36,000 units three times daily with meals and snacks. A physician’s order dated 8/29/2025 directed Creon 36,000–114,000 units one capsule three times daily for exocrine pancreatic insufficiency, but the MAR for late August and early September showed the medication was administered at 6:00 A.M., 2:00 P.M., and 6:00 P.M., which were outside the facility’s scheduled mealtimes. The MAR also showed multiple missed doses on specific dates and times, with no evidence that the physician or nurse practitioner was notified of these missed administrations. A care plan conference note documented that the family had concerns about ensuring the resident received medications before every meal. Additionally, a physician’s order for metoprolol succinate ER 25 mg daily included parameters to hold the medication for systolic blood pressure less than 100 mmHg and heart rate less than 60 bpm, yet the MAR showed the medication was administered on two dates when the resident’s heart rate was below 60 bpm. For Resident E, who had diagnoses including trigeminal neuralgia and multiple sclerosis and was cognitively intact, the facility failed to ensure a neurological consultation was scheduled as ordered. A physician’s order dated 8/10/2025 directed that a neurological consultation be scheduled. The resident reported having asked staff for over two months to make an appointment with her neurologist due to new symptoms related to multiple sclerosis, and she stated the facility would not make the appointment. A grievance form submitted by the resident on 10/9/2025 requested an appointment with a neurologist and noted a previous request without follow-up; the grievance response stated an appointment had been made, but there was no evidence an appointment was actually scheduled. A nurse practitioner’s note documented that the resident was experiencing uncontrollable trigeminal neuralgia, was screaming out in pain especially in the evenings, had requested to return to her neurologist, and that a referral had already been ordered and the facility was working on setting up the appointment. The transportation director later reported that all outside appointments were to be scheduled through her, that she had not transported this resident to any appointments, and that she had not scheduled any appointments for the resident.
Failure to Monitor Foley Catheter Output and Respond to Catheter-Related Symptoms
Penalty
Summary
The deficiency involves the facility’s failure to ensure appropriate monitoring and care of an indwelling urinary catheter for one resident. The resident had diagnoses including neuromuscular dysfunction of the bladder, benign prostatic hypertrophy, cerebrovascular accident, and anxiety disorder, and had a chronic Foley catheter with substantial assistance needed for toileting and hygiene. A physician’s order had directed staff to monitor urinary catheter output every shift, but this order was discontinued in mid-December, and nursing staff did not continue to obtain or document urinary outputs each shift. An LPN later indicated it was unclear why the order had been discontinued and why staff had not monitored urinary output as expected. The facility’s own catheter policy required ongoing care, monitoring of the resident’s response to catheter use, and monitoring for changes in condition related to potential catheter-associated UTIs. In the days following discontinuation of the urinary output order, nursing notes documented that the resident complained of penile pain, with pus coming from the head of the penis, and requested removal of the Foley catheter. Staff documented severe pain throughout the evening, treated with Tylenol and lubricant applied to the penis. The next day, the Foley catheter was changed and a urine sample was obtained via clean catch through the new catheter. The following day, the resident was found with an elevated temperature, shaking, gray discoloration of hands and lips, pain with the Foley catheter, and white drainage from the penis around the catheter, leading to a verbal order to send him to the hospital. In the emergency room, the Foley catheter was found displaced with the balloon in the penile shaft, and the resident was diagnosed with a UTI and early sepsis with borderline shock related to a UTI due to the displaced Foley catheter. The resident and his sister reported that the catheter had been dislodged or incorrectly placed, with bloody and purulent urine in the tubing and another catheter being inserted, and that he had recently been hospitalized for sepsis.
Failure to Document and Complete Catheter Care as Ordered
Penalty
Summary
The facility failed to ensure that catheter care and documentation of urinary output were completed as ordered for three residents with indwelling catheters. For one resident with obstructive and reflux uropathy, physician orders required catheter care and output documentation every shift, but review of the Medication Administration Record (MAR) revealed multiple shifts across three months with missing documentation. Nursing notes confirmed the resident experienced urinary tract infections during this period, and there was no additional documentation to verify catheter care or output. Another resident with neuromuscular dysfunction of the bladder also had orders for output documentation every shift, but the MAR showed several shifts without documentation, and no other records were available. A third resident with similar diagnoses had orders for catheter care and output documentation every shift, but the MAR again showed multiple shifts with missing entries and no other supporting documentation. Interviews with staff, including a unit manager, RN, and the DON, confirmed that there was no other documentation available to verify that catheter care or output documentation was completed as ordered for these residents. The RN and DON both stated that catheter care was performed each shift and that output was documented on the MAR, but acknowledged that when documentation was missing, there was no way to confirm the care was provided. Family and resident interviews also indicated concerns about catheter care and a history of urinary tract infections. Facility policy required catheter care to be completed as ordered to prevent infection, but the lack of documentation indicated noncompliance with these requirements.
Sanitation Deficiencies in Kitchen Affecting Food Safety
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, which had the potential to affect all 101 residents receiving food from this kitchen. During a kitchen tour, it was observed that several food items in the walk-in freezer, including bags of green beans, corn, sausage patties, and eggs, were not sealed appropriately. Additionally, a bag of cream soup base in the dry storage area was found without an open date. The Dietician confirmed that these items should have been sealed properly and labeled with an open date. Further inspection revealed unsanitary conditions with kitchen equipment and utensils. A can opener, spatula, measuring cup, knife, and measuring spoon, all stored as clean, were found with dried food and grease on them. The utensils drawer also had dried food on the bottom. The Dietary Manager acknowledged that the kitchen utensils and drawer should have been cleaned. The facility's policies on kitchen sanitation and labeling and dating guidelines were provided, indicating that the Dietary Manager is responsible for ensuring safe food handling practices and regular inspections.
Infection Control and Reporting Deficiencies
Penalty
Summary
The facility failed to adhere to proper infection control practices, particularly in the use of gloves and handwashing during perineal and catheter care for several residents. Certified Nursing Assistants (CNAs) were observed not changing gloves or washing hands between tasks, such as after cleaning a resident's perineal area and before applying a clean brief. This was noted during care for multiple residents, including those with catheters and nephrostomy tubes, where CNAs continued to handle clean items and resident belongings without changing gloves or performing hand hygiene. Additionally, the facility did not follow its policy on Enhanced Barrier Precautions (EBP) for residents with wounds and catheters. Observations revealed that residents who required EBP were not placed in isolation, and there was a lack of signage and personal protective equipment (PPE) to indicate EBP status. This was evident in the care of residents with pressure ulcers and other wounds, where staff failed to use appropriate PPE or follow isolation protocols. The facility also neglected to report an outbreak of illness to the State Department of Health. Despite multiple residents experiencing symptoms such as nausea, vomiting, and diarrhea, the cases were not reported as required. The facility's infection surveillance report was incomplete, missing several affected residents. Furthermore, during medication administration, a Registered Nurse (RN) was observed handling medication without gloves, contrary to the facility's policy. These deficiencies potentially impacted all residents in the facility.
Failure to Notify Physician of Abnormal Conditions
Penalty
Summary
The facility failed to notify the physician of abnormal blood sugar levels and insulin refusals for two residents with diabetes. Resident 4 had multiple instances of blood glucose levels exceeding 400 mg/dl, as per the physician's order, but there was no documentation indicating that the physician was notified. Interviews with the RN and the Administrator confirmed the lack of documentation regarding the elevated blood glucose levels. Resident 5 had new skin issues that were not documented or reported to the physician. The resident's family noticed discoloration on the resident's arm, but there was no explanation provided. An LPN was unaware of the skin issues, and the facility's records lacked documentation of the abnormal skin findings. The Director of Nursing acknowledged that a new skin evaluation should have been completed and the physician notified, but this was not done. Resident 96, who had multiple health conditions including diabetes, refused insulin medication numerous times over several months. The facility's records did not show that the physician or nurse practitioner was notified of these refusals, despite the resident's care plan indicating that the physician should be notified as needed. Interviews with facility staff revealed that there was no documentation of communication with the physician regarding the resident's refusals, and the Director of Nursing confirmed that a conversation with the physician should have occurred due to the excessive refusals.
Inadequate Response to Resident Grievances on Call Light and Shower Issues
Penalty
Summary
The facility failed to adequately address grievances raised by residents regarding long call light response times and incomplete shower schedules. During a resident/surveyor meeting, several residents expressed that their grievances, although acknowledged, remained unresolved. Residents reported that call lights were not illuminating outside their rooms, and alternative methods such as bells and whistles were provided, which were ineffective. Some residents, including one who was left on the toilet for 30-45 minutes, indicated that the best way to receive assistance was to physically find a staff member. The review of Resident Council Meeting Notes from February to December 2024 revealed ongoing concerns about call light response times and shower schedules. Despite documented responses and attempts to address these issues, such as hiring a shower aide and revamping shower schedules, residents continued to report inconsistencies and unresolved grievances. The facility's responses often lacked follow-through, and some responses were undated or not provided at all. Additionally, the facility failed to provide residents with accessible and anonymous grievance forms. Residents were unaware of where to find these forms, and they were not placed in a location that allowed for anonymous submission. Interviews with facility staff revealed that grievance forms were kept in locations not easily accessible to residents, particularly those who were wheelchair-bound. The facility's grievance policy outlined the need for a grievance official to oversee the process, but the implementation of this policy was inadequate, leading to unresolved grievances and dissatisfaction among residents.
Failure to Update PASARR Assessment for Resident with New Mental Health Diagnosis
Penalty
Summary
The facility failed to ensure that a Level One PASARR assessment was completed accurately for a resident and did not update the Level 1 review when there was a significant change in the resident's condition. The resident, who had diagnoses including depression, anxiety, PTSD, and dementia, was given a new diagnosis of psychotic disorder with delusions. Despite this change and the addition of antipsychotic medications such as Haloperidol, the facility did not conduct a new Level 1 PASARR assessment as required. The initial PASARR form from 2020 did not reflect the resident's current mental health status or medications accurately, as it only listed Ativan and Trazadone, omitting the newly prescribed antipsychotic medications. The facility's policy mandates that any resident exhibiting a newly evident or possible serious mental disorder should be referred for a Level II resident review. However, this was not done, as confirmed by the Social Service Staff during an interview, who acknowledged that another Level 1 should have been completed following the new mental health diagnosis and medication orders.
Failure to Implement Timely Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to implement timely preventative measures to prevent the development of pressure ulcers for a resident, identified as Resident 96. The resident had multiple diagnoses, including diabetes mellitus type 2, chronic kidney disease, and legal blindness, which increased her risk for skin breakdown. Despite a Braden Scale assessment indicating a risk for pressure sores, no further assessments were documented after June 2024. The care plan for Resident 96 included interventions such as turning and repositioning, use of a prevalon boot, and skin inspections, but there was no documentation of these interventions being consistently implemented. Resident 96 developed an unstageable pressure ulcer on her right heel, which was later classified as a stage 3 pressure ulcer. The wound nurse practitioner recommended pressure reduction and turning protocols, including floating the resident's heels, but there was no documentation that these recommendations were followed. Additionally, the facility did not document any new interventions when the sore was first identified, and there was a delay in obtaining the recommended prevalon boot for the resident. Interviews with facility staff revealed that the resident had not been provided with the necessary prevalon boots until weeks after the wound clinic's recommendation. The facility's wound management policy stated that residents should not develop new skin conditions and that interventions should be implemented timely, but this was not adhered to in the case of Resident 96. The lack of timely and appropriate interventions contributed to the development and progression of the pressure ulcer.
Failure to Provide Nephrostomy Dressing Changes
Penalty
Summary
The facility failed to provide appropriate nephrostomy dressing changes for a resident, identified as Resident G, who was reviewed for catheter care. Resident G, who was cognitively intact and had an indwelling catheter, reported that her nephrostomy dressings had not been changed for some time, and a new dressing was only recently applied. She also mentioned that the staff seemed unfamiliar with the correct application of the dressings. A review of her medical records revealed diagnoses including nephrostomy, obstructive and reflexive uropathy, overactive bladder, and carcinoma of the bladder. Despite a physician's order to monitor the nephrostomy tube sites every shift, there were no specific orders for routine dressing changes to the nephrostomy sites or the stopcock dressings. Observations confirmed that Resident G's nephrostomy tube sites had undated padded dressings, which were dirty and had excessive zinc oxide ointment with darkened edges. A CNA had changed the dressings after they had fallen off, but there was no physician's order specifying the frequency of dressing changes. An RN confirmed that nephrostomy tube dressings should be changed daily and that there should have been a physician's order for the dressing changes. The facility's policy indicated that care and maintenance of nephrostomy tubes should be in accordance with physician orders, which were lacking in this case.
Failure to Schedule Timely Specialty Appointments for Residents
Penalty
Summary
The facility failed to ensure timely follow-up specialty appointments and referrals for two residents, leading to a deficiency in providing medically-related social services. Resident G, who had a history of cervical cancer, was in need of a gynecological oncology appointment after a hospital ultrasound revealed a 3-centimeter mass in her uterus. Despite a physician's order to schedule the appointment as soon as possible, the facility delayed securing the appointment for over eleven weeks. The resident expressed distress over the delay, and the facility's attempts to schedule the appointment were hindered by miscommunication and the resident's preference for a specific office. Similarly, Resident 64, who had multiple diagnoses including chronic kidney disease and anemia, did not have specialty referrals scheduled in a timely manner. Physician's orders were issued for referrals to hematology, vascular surgery, and nephrology, but there was no documentation in the medical record indicating that these appointments were scheduled. The facility staff indicated that some referrals were still being processed, and there was confusion regarding the resident's refusal to attend appointments. The facility's policy on change in condition and physician notification was not effectively followed, contributing to the deficiency.
Lack of Documentation for Gradual Dose Reduction Contraindications
Penalty
Summary
The facility failed to ensure that the physician documented a clinical contraindication when a gradual dose reduction (GDR) was declined for two residents reviewed for unnecessary medications. Resident 18, who had diagnoses including renal insufficiency, diabetes, depression, anxiety, dementia, and PTSD, was receiving Haloperidol and Trazadone. Despite pharmacy recommendations to reduce the dosages, the facility did not provide a clinical rationale for why the GDR was contraindicated. The documentation merely noted that the GDR was addressed with a nurse practitioner and marked as contraindicated due to hospice care, without further explanation. Similarly, for Resident 101, who had diagnoses of anxiety and depression, the facility did not document a clinical rationale for continuing the use of Alprazolam PRN beyond the recommended short-term use. Pharmacy recommendations suggested evaluating the continued need for the medication and adding a stop date for short-term use. However, the facility's response was to continue the medication without providing a documented clinical rationale for this decision. During an interview, the Director of Nursing acknowledged the lack of documentation to support a medical contraindication for the GDR recommendations. The facility's policy on unnecessary drugs emphasized the need for ongoing review of each resident's drug regimen, considering factors such as dose, duration, and clinical need. However, the facility did not adhere to this policy, as evidenced by the lack of documentation supporting the decisions to decline GDRs for the residents involved.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper medication storage and labeling practices, as observed during a survey. On the 100 hall medication cart, several issues were identified, including a bottle of Latanoprost eye drops without a resident identifier, an opened and unlabeled bottle of Timolol eye drops, an opened bottle of Lactulose with no opened date, and four loose pills in two drawers. During an interview, a Qualified Medication Aide (QMA) acknowledged that medications should have an opened date, eye drops should be labeled, and loose pills should not be present in the cart. On the 200 hall middle medication cart, further deficiencies were noted, such as the improper storage of topical creams with oral medications. Items found included four tubes of diclofenac sodium 1% stored with oral medications, a tube of triad wound paste, three tubes of Mupirocin ointment, a tube of nystatin ointment, and a tube of polygrip denture adhesive without a resident identifier. Additionally, an opened bottle of eye drops had a label over the drug name with no resident identifiers. An LPN confirmed that treatments and topical cream medications should not be stored in the medication cart. The facility's policy on medication storage was provided, but a policy regarding labeling medications was not available before the survey concluded.
Failure to Complete Timely Laboratory Testing for a Resident
Penalty
Summary
The facility failed to complete laboratory testing as ordered by the physician for a resident with multiple health conditions, including diabetes mellitus type 2, chronic kidney disease, and a stage 3 pressure ulcer. The resident's care plan required regular monitoring and laboratory tests, such as a Hemoglobin A1c every three months and specific tests ordered by a wound center. However, the facility did not document the completion of the A1c test due on November 18, 2024, and there were delays in conducting the C-reactive protein and erythrocyte sedimentation rate tests ordered by the wound center. Interviews with facility staff, including the Assistant Director of Nursing (ADON) and the Director of Nursing (DON), revealed that the laboratory orders were not executed in a timely manner, despite being entered into the electronic system. The lab was scheduled to visit the facility three times a week, yet the tests were not completed as required. The facility's policy on change in condition and physician notification was provided, indicating the need for prompt action and communication regarding changes in resident conditions, but this was not adhered to in the case of the resident's laboratory testing needs.
Failure to Provide Adequate Bathing and Oral Care
Penalty
Summary
The facility failed to provide adequate bathing opportunities and oral care for two residents who were dependent on staff for assistance with Activities of Daily Living (ADL). Resident B, who has a diagnosis of neurogenic bladder, end-stage renal disease, spinal injury, and quadriplegia, was observed with greasy hair and a white film on his teeth. He reported not receiving showers on his scheduled days and having difficulty shaving due to his condition. The care plan indicated he required substantial assistance with bathing and oral hygiene, but records showed inconsistencies in the provision of these services. Resident G, diagnosed with cervical spina bifida and neuromuscular dysfunction of the bladder, also reported not receiving showers on her preferred days, which were important for her social activities. Despite her care plan specifying assistance with ADLs and a shower schedule, records indicated she did not receive showers on the specified days. The Resident Council had previously raised concerns about the shower schedule, but the issue persisted. The facility's policy on ADLs stated that necessary services would be provided to maintain personal hygiene, which was not adhered to in these cases.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement necessary interventions to prevent falls for a resident identified as being at high risk for falls. The resident, who had diagnoses including Alzheimer's Disease, dementia, anxiety, and depression, was observed seated in a wheelchair without the prescribed non-slip pad (dycem) that was intended to prevent sliding. Despite a care plan initiated due to the resident's history of falls and impaired cognition, the intervention to place a dycem on the wheelchair cushion was not followed. This oversight was noted during an observation when the resident was found without the dycem on her wheelchair, which was a critical intervention to prevent falls. The resident had previously experienced falls, including an incident where she slid off her wheelchair in the activity room, prompting the interdisciplinary team to update her care plan with the dycem intervention. However, the failure to implement this intervention was evident when the resident was found on the floor after sliding off her wheelchair again. The resident's family expressed concern over the repeated falls, questioning why the incidents continued to occur. The facility's policy on incidents, accidents, and supervision emphasized the need for adequate supervision and assistive devices to prevent accidents, which was not adhered to in this case.
Deficiencies in Urinary Catheter Management and Documentation
Penalty
Summary
The facility failed to ensure proper management of urinary catheters for three residents, leading to deficiencies in catheter care and documentation of urine output. Resident B was observed multiple times with a full Foley catheter collection meter and a partially filled collection bag, indicating that staff had not emptied the catheter as required. Despite the care plan's directive to document catheter output every shift, the Treatment Administration Records (TARs) for October and November showed no documentation of urine output. Resident B, who has a neurogenic bladder, End Stage Renal Disease, spinal injury, and quadriplegia, reported that staff rarely emptied the catheter. Resident G expressed concerns about the infrequent emptying of her Foley catheter, which was observed with significant urine accumulation. The TAR for Resident G showed multiple instances of undocumented catheter output, despite the care plan's requirement for documentation every shift. Similarly, Resident E's TARs for October and November lacked any documentation of urinary catheter output. The facility's policy on indwelling catheters, which mandates appropriate care in line with professional standards, was not adhered to, resulting in these deficiencies.
Failure to Follow Bowel Protocol for Resident
Penalty
Summary
The facility failed to follow the bowel protocol for a resident, identified as Resident B, who was under review for bowel movements. Resident B had a history of right femur fracture, cardiomyopathy, and chronic kidney disease. After being hospitalized for fractures and receiving narcotic pain medication, which can cause constipation, Resident B was discharged with orders for Docusate Sodium 100 mg daily for constipation. However, upon admission to the facility, the medication was not administered as per the physician's orders. The resident had not had a bowel movement for seven days while hospitalized and continued to experience constipation upon admission to the facility. Interviews revealed that the facility did not input some of Resident B's physician's orders into the Electronic Medical Record (EMR) on the day of admission, leading to a delay in medication administration. The Assistant Director of Nursing acknowledged that the facility's bowel movement protocol should have been initiated when Resident B did not have a bowel movement for three days, but it was not. Additionally, a 3-day Voiding and Elimination Pattern assessment, which was part of the facility's policy, was not completed. This oversight resulted in Resident B experiencing significant discomfort due to constipation.
Failure to Prevent Pressure Wound Development
Penalty
Summary
The facility failed to provide timely care and treatment to prevent the development of a pressure wound for Resident B, who was admitted with a right femur fracture, cardiomyopathy, and chronic kidney disease. Upon admission, Resident B was assessed as severely cognitively impaired, requiring extensive assistance for bed mobility, transfers, and toilet use, and was at risk for skin breakdown. Despite these risks, the facility did not complete a skin assessment upon admission, and there was no documentation of any pressure wounds at that time. However, a subsequent assessment by a Nurse Practitioner on 7/22/24 revealed a Stage 1 pressure wound on Resident B's right buttock, which was not identified by the hospital at discharge. The facility's failure to implement timely interventions, such as the use of a pressure-reducing mattress, contributed to the development of the pressure wound. The Administrator acknowledged that some of Resident B's physician's orders were not entered into the Electronic Medical Record on the day of admission, causing a delay in care. Additionally, the Assistant Director of Nursing confirmed that a skin assessment should have been completed upon admission but was not, and there were no admission orders regarding a pressure wound. This oversight led to a delay in the initiation of appropriate preventive measures, such as the pressure-reducing mattress, which was ordered but not implemented in a timely manner.
Failure in Pain Management and Assessment for a Resident
Penalty
Summary
The facility failed to provide appropriate pain management and conduct a pain assessment upon admission for Resident B, who had a history of severe cognitive impairment and required extensive assistance for daily activities. Resident B was admitted to the facility following a fall that resulted in multiple fractures, including a right femur fracture that required surgical repair. Despite hospital discharge orders for pain management with Hydrocodone-Acetaminophen and Morphine Sulfate, Resident B did not receive any pain medication until over 16 hours after his last dose at the hospital. During this time, Resident B experienced severe pain, rated at a 10 on a scale of 1 to 10, and his responsible party reported that the facility staff did not administer pain medication because it had not yet been delivered from the pharmacy. The delay in pain management was attributed to the facility's failure to enter Resident B's physician's orders into the Electronic Medical Record (EMR) on the day of admission, which also affected other treatments such as wound care. The facility had a system (Pyxis) that could have provided the necessary medications, but it was not utilized. Additionally, a pain assessment was not completed upon Resident B's admission, contrary to the facility's policy that required evaluation for pain and its causes upon admission. Interviews with the Administrator and Assistant Director of Nursing confirmed these oversights, and the facility's policies on pain management and pharmacy services were not adhered to, leading to Resident B's prolonged period of unmanaged pain.
Failure to Accommodate Resident's Bathing Preferences
Penalty
Summary
The facility failed to honor the bathing preferences of a resident, identified as Resident C, who was cognitively intact and had specific preferences for showering on Mondays, Thursdays, and Saturdays during the day shift. Despite these preferences being documented in her care plan, the facility altered her shower schedule to Tuesdays and Thursdays, and informed her that she was not eligible for a Saturday shower if she had one on Thursday. This change in schedule resulted in Resident C missing 11 out of 26 scheduled showers over a period from July 1 to August 13, 2024, with no documentation of refusals. The lack of adherence to her preferred shower schedule affected her ability to participate in social activities, such as attending Sunday worship services, due to feeling unkempt. Resident C's clinical record indicated she required substantial to maximal assistance for showering due to her medical conditions, which included spina bifida, chronic respiratory failure, paraplegia, and obstructive and reflux uropathy. The facility's failure to provide showers as per her preference was also highlighted in Resident Council Minutes from July and August 2024, where residents expressed concerns about not receiving scheduled showers. The facility's policy on resident showers and rights emphasized the importance of maintaining proper hygiene and respecting residents' preferences, which was not adhered to in this case.
Failure to Develop Comprehensive Care Plan for Urostomy Care
Penalty
Summary
The facility failed to develop a comprehensive and person-centered care plan for a resident requiring urostomy care. During an observation and interview, it was noted that the resident's urostomy bag was not being emptied regularly, as indicated by the resident. The resident's medical record review revealed diagnoses including spina bifida, chronic respiratory failure, paraplegia, and obstructive and reflux uropathy. The resident was cognitively intact and required substantial to maximal assistance for most activities of daily living, including the management of a urostomy. However, the care plan lacked specific interventions related to urostomy care, management, or monitoring, despite a physician's order to empty the urostomy bag every shift. The facility's policy on comprehensive care plans and ostomy care required the inclusion of measurable objectives and timeframes to meet the resident's needs, including the frequency of pouch changes and monitoring of the surrounding skin for any issues. Despite these policies, the care plan for the resident did not reflect these requirements, leading to a deficiency in providing adequate and person-centered care for the resident's urostomy needs. The facility's failure to adhere to its policies and ensure a comprehensive care plan was in place was identified during a complaint investigation.
Failure to Provide Scheduled Showers for Residents
Penalty
Summary
The facility failed to provide scheduled showers and bathing opportunities for six residents, leading to a deficiency in resident rights. Resident B, who has a history of stroke and requires substantial assistance, missed 14 out of 21 scheduled showers. Despite documented refusals on some dates, the majority of missed showers were not accounted for, indicating a failure in adhering to the resident's care plan. Resident C, who is cognitively intact and has conditions such as spina bifida and paraplegia, expressed dissatisfaction with the change in her shower schedule, which affected her social activities. She missed 11 out of 26 scheduled showers, with no refusals documented, highlighting a lack of compliance with her care plan and personal preferences. Similarly, Resident D, who also has spina bifida and paraplegia, missed 7 out of 12 scheduled showers, with no refusals documented, further demonstrating the facility's failure to meet scheduled care requirements. Other residents, including Residents J, K, and M, also experienced missed showers, with no refusals documented, indicating a systemic issue within the facility. The Resident Council minutes from July and August noted complaints about the lack of showers, and the facility's policy on resident showers was not being followed. The Assistant Director of Nursing and the Administrator acknowledged the issue, but the deficiency remained unaddressed at the time of the report.
Failure in Urostomy Care and Monitoring
Penalty
Summary
The facility failed to ensure proper urostomy care and monitoring for a resident, identified as Resident C, who required such services. During an observation, it was noted that Resident C's urostomy bag was not being emptied regularly, as indicated by the resident herself. The urostomy bag was connected to a catheter bag that was observed to be holding 600 CCs of urine, and the resident reported that her catheter bag was often not emptied during the day shift. The facility's administrator acknowledged that the urostomy orders were not entered into the Electronic Medical Records (EMR) system following the hiring of a new medical director, which contributed to the oversight in care. Resident C's medical records revealed a lack of documentation regarding the emptying of the urostomy bag from the time the new orders were supposed to be in place. The resident's diagnoses included spina bifida, chronic respiratory failure, paraplegia, and obstructive and reflux uropathy, and she required substantial assistance for daily activities. Despite a physician's order to empty the urostomy bag every shift, there was no evidence of compliance with this order. The facility's policy on ostomy care, which was supposed to ensure care consistent with professional standards, was not adhered to, leading to the deficiency noted in the report.
Failure to Follow Up on UTI Symptoms in Residents
Penalty
Summary
The facility failed to complete follow-up assessments for changes in condition related to urinary tract infections (UTIs) for three residents. Resident B, who had diagnoses including acute cystitis with hematuria and chronic kidney disease, was discharged to the hospital due to hematuria and a UTI. Despite being readmitted, the record lacked follow-up of symptoms between 6/21/2024 and 6/26/2024, when the resident was symptomatic with hematuria and sent to the emergency room. The care plan for Resident B included interventions such as administering medication, observing for adverse side effects, and documenting abnormal findings, but these were not adequately followed. Resident D, with diagnoses including type 2 diabetes mellitus and overactive bladder, showed increased confusion and refused medication. Despite receiving antibiotics, the record lacked follow-up assessments between 6/18/2024 and 6/22/2024. The care plan for Resident D also included similar interventions to Resident B, such as administering medication and observing for symptoms of infection, but these were not properly documented or executed. Resident E, who had multiple rib fractures and a UTI, experienced confusion and unwitnessed falls. Although a urine specimen was obtained on 7/18/2024, the antibiotic was not ordered until 7/23/2024, and there was a lack of clear documentation of the resident's symptoms between these dates. The care plan for Resident E included interventions like administering medication and observing for symptoms of infection, but these were not adequately documented. The facility's policy on change in condition did not address follow-up assessments, contributing to the deficiency.
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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