Majestic Care Of New Haven
Inspection history, citations, penalties and survey trends for this long-term care facility in New Haven, Indiana.
- Location
- 1201 Daly Drive, New Haven, Indiana 46774
- CMS Provider Number
- 155207
- Inspections on file
- 41
- Latest survey
- January 9, 2026
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Majestic Care Of New Haven during CMS and state inspections, most recent first.
Dining staff did not consistently follow meal tickets, resulting in several residents not receiving menu items such as broccoli salad and garlic bread, with no substitutions provided. Grievances and interviews confirmed that staff failed to reference meal tickets as required by facility policy.
Dietary staff did not consistently temperature-test pureed meals for four residents on pureed diets. Observations and interviews revealed that food was sometimes served below the required temperature, and food temperature logs showed multiple days with missing records for pureed meals, contrary to the facility's safe food handling policy.
A multiple dose liquid medication bottle was found on a medication cart without an open date, despite being marked 'NOT OPEN' and having been used, with a punctured seal and residue present. The medication had been discontinued and was not on the active MAR. An LPN was observed handling the bottle, and the DON confirmed there was no current improvement plan for medication storage, despite a history of similar citations and ongoing audits reported in QAPI meetings.
A resident with a history of heart disease and other conditions was transferred to the ER for chest pain, but the facility did not notify the resident's emergency contact. Documentation did not show that the resident declined such notification, and the care plan indicated family involvement. Staff interviews provided conflicting explanations, and facility policy on notification was not followed.
A resident was subjected to inappropriate verbal comments by the Rehabilitation Director during a discussion about room conditions, including a reference to prison and a remark about being 'outnumbered' in the presence of staff and the resident, all of whom were black except the RD. The resident, who was cognitively intact, became visibly upset by the comments, which were corroborated by other staff present. The facility's policy on verbal abuse was not followed in this incident.
A resident with chronic pain conditions received oxycodone-acetaminophen for pain levels below the physician-ordered threshold, and there was no documentation that nonpharmacological pain interventions were provided as outlined in the care plan. The DON confirmed the medication was administered outside of the prescribed parameters without justification.
A resident with end stage renal disease requiring dialysis did not consistently have pre-dialysis vital signs and communication forms completed by facility staff before appointments. The dialysis center RN reported that the communication sheets were often blank and no separate facility assessment was provided, despite facility policy requiring this documentation. The DON could not verify that the necessary paperwork was sent with the resident.
A bottle of Guaifenesin liquid was found in a medication cart with 'NOT OPEN' written on the label, but the inner seal was punctured and some medication had been used. The bottle lacked an open date, and a resident did not have an active order for this medication. The DON confirmed the absence of a current order, and facility policies did not clearly address required labeling practices.
A facility failed to properly label and store medications on a medication cart, affecting three residents with respiratory conditions. Observations revealed inhalers without open or expiration dates, contrary to facility policy. The DON confirmed the inhalers should have been removed, highlighting a lapse in adherence to medication administration protocols.
A facility failed to properly assess and care plan for a resident with recurrent head lice. Despite a history of lice after leave of absences, the resident's care plan did not address the condition, and there were no documented protocols or assessments during isolation. Treatment was ordered, but no additional orders or staff education on lice protocols were documented. The facility's policies on lice and isolation precautions were not followed, contributing to the deficiency.
A facility failed to ensure residents were not given psychotropic medications without specific targeted behaviors identified and non-pharmacological interventions in place. A resident with dementia and depression was administered Haloperidol without documented behaviors or follow-up, while another resident with COPD and depression was prescribed Xanax without clear indication or behavior monitoring. The facility did not adhere to its policies requiring behavior monitoring and non-pharmacological interventions before psychotropic medication use.
Failure to Follow Resident Meal Tickets and Menu Postings
Penalty
Summary
The facility failed to ensure that dining staff followed resident meal tickets for four residents, resulting in residents not receiving items listed on their menus. During dining observations, two residents were not served broccoli salad as indicated on their meal tickets, and one resident reported not receiving garlic bread, with no substitutions provided. Review of posted menus confirmed that these items were scheduled to be served, and the postings were not updated to reflect any changes or substitutions. Additionally, grievances from two residents documented ongoing issues with meal trays, specifically that dining staff were not referencing meal tickets and were omitting food items. Interviews with facility leadership confirmed that staff are expected to review meal tickets to ensure residents receive appropriate items and avoid serving restricted foods. The facility's policy requires menus to be followed and to accommodate resident preferences, but observations and records indicated this was not consistently practiced.
Failure to Consistently Temperature-Test Pureed Meals
Penalty
Summary
The facility failed to ensure that pureed meals were consistently temperature-tested for four residents who required pureed diets. During an observation, dietary staff was seen checking the temperature of pureed broccoli, which registered at 130°F. A staff member acknowledged that the food was below the required temperature and indicated that she would reheat it. Interviews confirmed that on multiple occasions, food was not at the appropriate temperature before being served. A review of food temperature logs for December revealed that there were numerous days when no temperature records were documented for breakfast, lunch, or dinner pureed meals, despite four residents being on pureed diets during those times. The facility's policy on safe food handling, which aims to reduce the risk of foodborne illness, was not followed as evidenced by the lack of temperature documentation and inconsistent temperature checks for pureed meals.
Recurring Medication Storage Deficiency Due to Inadequate Labeling and Oversight
Penalty
Summary
The facility failed to maintain an effective process to prevent recurring medication storage issues, as evidenced by the observation of a multiple dose liquid medication bottle on a medication cart that was not properly labeled with an open date. The bottle, marked 'NOT OPEN' in black marker, was found to have been opened and used, with a punctured inner seal and visible red liquid residue. Review of the resident's record revealed that the medication had been discontinued and did not have an active order. This incident was cited under F0761 for improper labeling and storage of drugs and biologicals. Additionally, the facility had a history of similar citations for the same deficiency on multiple previous survey dates. During an interview, the DON confirmed that there was no current improvement plan specifically addressing medication storage, although routine audits were being conducted and results reported in QAPI meetings.
Failure to Notify Emergency Contact of Resident Transfer
Penalty
Summary
The facility failed to notify the emergency contact of a resident who was transferred to the emergency room for chest pain that was not relieved by Nitroglycerin and at the resident's request. Record review showed no documentation that the resident's emergency contact, his brother, was notified of the transfer. There was also no documentation indicating that the resident did not want his emergency contact notified. The resident's care plan indicated family involvement in the last 14 days and did not specify any wishes to exclude the brother from notification in emergencies. Interviews with facility staff revealed conflicting information. The DON stated that the resident did not wish for his brother to be notified and that this was reflected in the care plan, but review of the care plan did not support this claim. The Regional Nurse Consultant indicated that the brother was not notified because the resident was his own responsible party. Facility policy allows for disclosure of information to individuals involved in the resident's care or for notification purposes, but there was no evidence that this policy was followed in this instance.
Verbal Abuse Involving Inappropriate and Racially Charged Comments by Staff
Penalty
Summary
A deficiency occurred when a resident was subjected to inappropriate and potentially racially charged verbal comments by the Rehabilitation Director (RD) in the presence of other staff members. The incident took place during a discussion about the condition of the resident's room, specifically the walls being only half painted. The RD responded to the resident's complaint by making a comment referencing prison, which the resident found offensive, especially as he stated he had never been to prison and that prison was no place for an educated black man. The RD then remarked that she was 'outnumbered' and left the room, a statement interpreted by those present as referring to the racial makeup of the group. The resident was visibly upset during subsequent interviews, raising his voice and appearing emotional when recounting the incident. Multiple staff members, including an LPN and a QMA who were present, corroborated the resident's account of the RD's comments. The facility's investigation included statements from those involved, confirming the sequence of events and the nature of the remarks made. The resident was found to be cognitively intact, with a BIMS score of 15, and was able to clearly articulate his experience. The facility's policy defines verbal abuse as the use of disparaging or derogatory language toward residents, which was not adhered to in this instance.
Failure to Follow Pain Management Orders and Document Nonpharmacological Interventions
Penalty
Summary
A resident with multiple pain-related diagnoses, including arthritis, lupus, and sciatica, had physician orders for oxycodone-acetaminophen to be administered every 8 hours as needed for severe pain greater than 7 on the pain scale. However, the medication was administered on several occasions when the resident reported pain levels below the threshold specified in the order, with documented pain scores of 4 and 6. There was no documented justification for administering the medication outside the prescribed parameters. Additionally, the resident's care plan included interventions for nonpharmacological pain management, such as position changes, relaxation, a quiet environment, back rubs, and diversional activities. Despite this, there was no documentation in the progress notes that these nonpharmacological interventions were provided on the dates when the medication was administered for pain levels below 7. The DON confirmed that the medication should not have been given for pain less than 7 and could not provide a reason for the deviation from the physician's order.
Failure to Ensure Proper Dialysis Communication and Collaboration
Penalty
Summary
The facility failed to ensure proper collaboration with an off-site dialysis center for a resident diagnosed with end stage renal disease and dependent on renal dialysis. Review of the resident's dialysis communication records revealed that the pre-dialysis section, which should include vital signs, was incomplete or missing on multiple dates. The resident reported that the facility did not always complete the required communication form that he took to dialysis appointments, which contained his medications and the dialysis communication sheet. Interviews with facility staff and the dialysis center RN confirmed that the facility often sent the dialysis communication sheet blank and did not provide a separate facility assessment with the resident. The DON stated that the facility conducted its own assessments and sent them in a packet with the resident, but could not provide evidence that these assessments were actually sent, as no folder was maintained and the information was not tracked. The facility's policy required continued assessment and appropriate paperwork to be sent with the resident to the off-site dialysis center, which was not consistently followed.
Failure to Properly Label and Store Medications in Medication Cart
Penalty
Summary
The facility failed to ensure that only current medications with appropriate labeling were present in medication carts, as observed during a review of one out of three carts. A bottle of Guaifenesin liquid labeled for a specific resident was found with the words 'NOT OPEN' written on it, but the inner seal was punctured and some medication had been used, indicating it had been opened. There was no open date on the bottle, and the resident did not have an active order for this medication at the time of the review. The Director of Nursing confirmed that the resident should have had an order but did not currently have one. The facility's medication storage policy did not specify labeling practices, while the labeling policy required multidose vials to be labeled with the date opened or accessed.
Medication Labeling and Storage Deficiency
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications on one of the two medication carts reviewed. During an observation, it was found that an inhaler for a resident with chronic obstructive pulmonary disease had no open date labeled, and another resident's inhaler had an open date but no expiration date. Additionally, a third resident's inhaler had neither an open date nor an expiration date. These labeling deficiencies were identified during a review of the medication cart in the 200 Hall, and the Qualified Medical Assistant indicated that staff usually checked the cart to ensure proper labeling and discarded any medications that were not labeled or expired. The Director of Nursing confirmed that the inhalers should have been removed from the cart. The residents involved had various respiratory conditions, including chronic obstructive pulmonary disease and asthma, and had specific physician orders for their inhalers. The facility's policy on medication administration required the disposal of medications that were not securely closed, outdated, contaminated, or deteriorated, and emphasized the timely removal of such medications from stock. However, the facility did not adhere to this policy, resulting in the observed deficiencies.
Failure to Assess and Care Plan for Resident with Head Lice
Penalty
Summary
The facility failed to ensure proper assessment and care planning for a resident with a known contagious condition, specifically head lice. Resident E, who had a history of recurrent head lice after returning from leave of absences, was not adequately assessed or care planned for this condition. The Director of Nursing indicated that Resident E was to be checked for lice upon return to the facility, and treatment orders were to be obtained and communicated to staff. However, Resident E's care plan did not address lice infestation, and there were no documented protocols or assessments conducted during her isolation period. Resident E's medical record indicated she had been seen by a nurse practitioner for head lice, and treatment was ordered. Despite this, there were no additional treatment orders or documentation of staff education on lice protocols. Progress notes revealed that Resident E had been isolated in her room for approximately four weeks due to lice, but there was no formal documentation of when the isolation began or ended. Additionally, there was no evidence that other residents sharing her bathroom were checked for lice. The facility's policies on head lice and isolation precautions were not followed, as there was no documentation of assessments, treatment regimens, or decontamination procedures. The Director of Nursing was unable to find any orders for isolation or documentation of staff education on lice protocols. This lack of adherence to policies and procedures contributed to the deficiency in providing appropriate treatment and care for Resident E.
Failure to Implement Non-Pharmacological Interventions Before Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that residents were not given psychotropic medications without specific targeted behaviors identified and non-pharmacological interventions in place. Resident D, who had diagnoses including dementia, chronic pain, generalized anxiety disorder, sleep disorder, and major depressive disorder, was hospitalized for a change in condition. Upon her return to the facility, she was administered Haloperidol Lactate for anxiety/agitation without documentation of behaviors requiring its use, notification to the provider, or follow-up documentation after administration. The care plans for Resident D included non-pharmacological interventions, but there was no evidence that these were implemented prior to the administration of the psychotropic medication. Resident J, diagnosed with chronic obstructive pulmonary disease and major depressive disorder, was also given psychotropic medication without proper documentation of behaviors or non-pharmacological interventions. Despite having no documented symptoms of anxiety, Resident J was prescribed Xanax, an anti-anxiety medication, without a clear indication for its use. The facility's records did not include a care plan or behavior monitoring for the use of Xanax, nor did they document potential adverse effects due to its use alongside other sedating medications. The facility's policies on Mood and Behavior Management and Psychotropic Management require that residents receiving psychotropic medications have a supporting diagnosis, appropriate indication for use, and a behavior monitoring program in place. However, these requirements were not met for Residents D and J, as there was a lack of documentation and implementation of non-pharmacological interventions and behavior monitoring. This deficiency was identified during a survey, which included interviews and record reviews, revealing the facility's failure to adhere to its own policies and regulatory requirements.
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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