Majestic Care Of Southport
Inspection history, citations, penalties and survey trends for this long-term care facility in Indianapolis, Indiana.
- Location
- 8549 S Madison Ave, Indianapolis, Indiana 46227
- CMS Provider Number
- 155247
- Inspections on file
- 35
- Latest survey
- September 26, 2025
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Majestic Care Of Southport during CMS and state inspections, most recent first.
A facility failed to document a resident's transfer to the emergency department in the medical record. The resident, with conditions including bladder cancer and chronic atrial fibrillation, was found lethargic by her daughter, who called 911. The Director of Nursing confirmed that the nurse should have documented the transfer, as required by the facility's policy.
A resident with anxiety and depression was verbally and physically abused by another resident with schizophrenia and dementia. The aggressor followed the victim to her room, threatened her, and spat on her, despite staff intervention. Witnesses confirmed the incident, highlighting a failure to uphold the facility's abuse prevention policy.
A facility failed to report an abuse incident where a resident verbally abused and attempted to spit on another resident. The incident was documented, and the Director of Nursing was notified, but the report to the state health department was delayed. Interviews revealed that an LPN witnessed the incident but did not report it until the next day, and another LPN was unsure if she had reported it. The facility's policy requires immediate reporting of abuse allegations, which was not followed.
A facility failed to maintain resident dignity during meal assistance when a staff member stood over a resident with Alzheimer's disease, instead of sitting at eye level as required by policy. The resident required extensive assistance with eating.
A resident's call light was repeatedly found out of reach, despite facility policy and care plan requirements to keep it accessible due to the resident's fall risk. Observations and interviews confirmed the deficiency, highlighting a failure to accommodate the resident's needs.
A facility failed to provide a written Notice of Transfer and Discharge to a resident and their representative for a hospital transfer. The clinical record lacked documentation of the notice, and Unit Manager 2 confirmed the transfer without evidence of notice issuance. The facility's policy requires such notices, but it was not followed in this instance.
A facility failed to provide a written bed hold notification to a resident with COPD, heart failure, and type 2 diabetes, and their representative during a hospital transfer. The clinical record lacked documentation of the notification, and the Unit Manager confirmed the oversight. The facility's policy requires notifications at the time of transfer or within 24 hours for emergencies, with a signed copy in the resident's file.
A facility failed to create a comprehensive care plan for a resident who refused care, including showers, resulting in a strong foul odor in the resident's room. Despite the resident's diagnoses of morbid obesity, respiratory failure, heart failure, and decreased mobility, the care plan did not address the refusal of care. The DON confirmed the lack of a care plan for the resident's refusal, which is required by the facility's policy.
A facility failed to record and monitor a resident's weight changes as ordered by a physician. Despite a history of abnormal weight loss and a care plan indicating nutritional risk, the resident's weekly weights were not documented, and significant weight changes were not reported to the physician. Interviews revealed that the weights were not entered into the clinical record, and no interventions were implemented.
The facility failed to document drug disposition records for two discharged residents, leading to a deficiency in pharmaceutical services. One resident passed away without documentation of medication return or destruction, while another was discharged without a medication release form. The Director of Nursing confirmed the lack of documentation, which violated the facility's policy.
The facility failed to ensure posted menus matched the meals served, causing resident confusion. Observations showed discrepancies between posted menus and actual meals, with staff confirming the menus were outdated. A resident reported never knowing meal details until receiving their tray, as posted menus were consistently incorrect.
The facility failed to report allegations of abuse for two residents to the State Survey Agency. One resident, who is severely cognitively impaired, reported being hit by a staff member, and another resident, who is cognitively intact, reported rough care. Both allegations were investigated but not substantiated, and the required reporting was not completed.
The facility failed to provide appropriate care for a resident diagnosed with PTSD, who was found consuming and distributing alcohol. Despite a diagnosis of PTSD, the resident's care plan did not address this condition, contrary to the facility's policy on individualized interventions.
Failure to Document Resident Transfer to Emergency Department
Penalty
Summary
The facility failed to document a resident's transfer to the emergency department in the medical record, as required by their policy. Resident B, who had diagnoses including bladder cancer, asthma, and chronic atrial fibrillation, was observed by her daughter to be lethargic, prompting a call to 911 for emergency assistance. The hospital palliative care note confirmed that Resident B was admitted to the hospital with altered mental status. During an interview, the Director of Nursing acknowledged that the nurse responsible for Resident B at the time of transfer should have documented the event in the resident's medical record. The facility's policy, titled Transfer Discharge, mandates that relevant information regarding transfers be documented, which was not adhered to in this instance.
Failure to Protect Resident from Verbal and Physical Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from verbal and physical abuse when Resident C verbally and physically assaulted Resident B. On the evening of January 22 or 23, Resident B was waiting to go outside to smoke when Resident C approached and verbally abused her, calling her derogatory names. Resident B, feeling scared, attempted to retreat to her room, but Resident C followed her, continuing the verbal assault and threatening physical harm. Despite the intervention of LPN 2, who directed Resident C to the nursing station, Resident C returned shortly after and spat on Resident B, further escalating the situation. Resident B, who has diagnoses including anxiety, depression, and psychotic disorder, was left feeling unsafe and tearful, expressing fear of Resident C. The incident was corroborated by other residents, Resident D and Resident E, who witnessed the altercation and confirmed Resident C's aggressive behavior. Resident C, with a history of schizophrenia, alcohol abuse, and dementia, was noted to be moderately cognitively impaired. The facility's policy on abuse, which states residents have the right to be free from abuse, was not upheld in this instance, as evidenced by the failure to prevent Resident C's repeated aggressive actions towards Resident B.
Failure to Report Resident Abuse Incident
Penalty
Summary
The facility failed to report an allegation of abuse to the state health department involving two residents. Resident B reported that on the evening of January 22 or 23, Resident C verbally abused and attempted to spit on Resident B. The clinical record for Resident C, who has diagnoses including schizophrenia and substance abuse, noted that Resident C became agitated and argumentative with Resident B, and attempted to spit on her. The incident was documented in a progress note, and the Director of Nursing was notified. Interviews revealed that the facility staff did not report the incident in a timely manner. The Administrator was informed of the verbal altercation by an LPN, who witnessed the incident but did not report it until the following day. Another LPN was unsure if she had reported the incident to the Administrator and Director of Nursing. The facility's policy requires all allegations of abuse to be reported immediately to the Administrator or designee, which was not adhered to in this case.
Failure to Maintain Dignity During Meal Assistance
Penalty
Summary
The facility failed to ensure that residents were treated with dignity during meal times, as observed with one resident during the noon meal. The Unit Manager assisted the resident with their meal while standing over them, rather than sitting at eye level, which is against the facility's policy. The Director of Nursing confirmed that staff should be seated at eye level when assisting residents with meals. The resident involved had a diagnosis of Alzheimer's disease and required extensive assistance with eating, as indicated in their clinical record and a recent Minimum Data Set assessment.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to provide reasonable accommodation of needs for a resident, identified as Resident 8, by not ensuring the call light was within reach. During observations on two separate occasions, the call light was found mounted to the wall between Resident 8's bed and the roommate's bed, with the cord lying on the floor behind the headboard, making it inaccessible to the resident. Interviews with Resident 8, RN 3, and Unit Manager 2 confirmed that the call light was not within reach, which contradicted the facility's policy and the resident's care plan that emphasized keeping the call light accessible due to the resident's risk for falls. Resident 8's clinical record indicated a history of falling and anemia, and the resident was assessed as moderately cognitively intact. The care plan, revised months prior, included an intervention to keep the call light within reach, highlighting the importance of this measure for the resident's safety. The Director of Nursing Services confirmed the facility's policy required call lights to be accessible to residents while in bed, aligning with the resident's right to a safe environment as per the Resident Rights policy.
Failure to Provide Transfer Notice
Penalty
Summary
The facility failed to provide a written Notice of Transfer and Discharge to a resident and the resident's representative for a facility-initiated hospital transfer. This deficiency was identified during a review of Resident 10's clinical record, which showed that the resident was transferred to the hospital emergency department on May 23, 2024. The clinical record did not contain documentation that the required notice was given to either the resident or their representative. During an interview, Unit Manager 2 confirmed that the transfer occurred on the specified date, but the facility could not provide evidence that the notice was issued. The facility's Transfer & Discharge policy, dated December 12, 2023, mandates that such notices be provided in a language and manner understandable to the resident and their representative, including information about the facility's bed hold policy. However, this procedure was not followed in the case of Resident 10.
Failure to Provide Bed Hold Notification
Penalty
Summary
The facility failed to provide written bed hold notifications to a resident and their representative during a hospital transfer. Resident 10, who has diagnoses including COPD, heart failure, and type 2 diabetes, was transferred to the hospital emergency department. The clinical record indicated that the resident returned from the emergency department, but there was no documentation of a written bed hold notification being provided to the resident or their representative. During an interview, the Unit Manager confirmed the lack of verification for the bed hold notification. The facility's bed hold policy requires that such notifications be given at the time of transfer or within 24 hours for emergency transfers, with a signed and dated copy kept in the resident's file.
Failure to Develop Comprehensive Care Plan for Resident Refusing Care
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident who refused care, specifically showers and other activities of daily living. This deficiency was identified through observations and interviews conducted over several days. On multiple occasions, a strong foul odor was noted in the resident's room, indicating a lack of personal hygiene care. The resident, diagnosed with morbid obesity, acute on chronic respiratory failure, heart failure, and decreased mobility, required assistance with activities of daily living. However, the care plan dated July 19, 2024, did not address the resident's refusal of care. During an interview, the Director of Nursing (DON) confirmed that the resident refused care, including showers, and acknowledged that there was no care plan available to address this refusal. The facility's policy on comprehensive care plans, dated January 2, 2024, requires that the care plan describe any services not provided due to the resident's refusal of treatment. The absence of a care plan addressing the resident's refusal of care constitutes a failure to meet the facility's policy requirements.
Failure to Monitor and Record Resident's Weight Changes
Penalty
Summary
The facility failed to ensure that weekly weights were recorded in the clinical record and did not monitor a resident's weight for significant changes. Resident 23, who had a history of abnormal weight loss and required assistance with meals, was not properly monitored despite physician orders for weekly weights. The clinical record lacked documentation of the actual weekly recorded weight amounts, and there was no evidence that the physician was notified of significant weight changes. The resident's care plan indicated a potential nutritional risk, but the necessary interventions were not implemented. Interviews with facility staff revealed that the weekly weights were supposed to be recorded in the electronic clinical record, but the actual weight amounts were missing. The Assistant Director of Nursing Services suggested a possible issue with the weight scale machine, but no updated weight monitoring or interventions were documented. The Director of Nursing Services confirmed that the weekly weights should have been accurately entered into the clinical record, and no additional assessments or interventions were made in response to the resident's weight changes. The facility's Nutrition Management and Physician Orders policies were not followed, leading to this deficiency.
Failure to Document Drug Disposition Records for Discharged Residents
Penalty
Summary
The facility failed to document the drug disposition records for two discharged residents, leading to a deficiency in pharmaceutical services. Resident 77, who had diagnoses including COPD and type 2 diabetes, passed away at the facility. The clinical record for Resident 77 lacked documentation of medications being sent back to the pharmacy or destroyed, as required by the facility's policy. This oversight was identified during a review of the resident's clinical record, which included various medications such as acetaminophen, insulin, and sertraline. Similarly, Resident 78, who had diagnoses including COPD and unspecified heart failure, was discharged from the facility with all medications and belongings. However, the clinical record for Resident 78 did not include a medication release form listing all medications sent home with the resident or their representative. The Director of Nursing confirmed the lack of documentation for drug dispositions for both residents. The facility's policy, which mandates logging all items returned to the pharmacy on a medication return form, was not adhered to in these cases.
Inaccurate Menu Postings Lead to Resident Confusion
Penalty
Summary
The facility failed to ensure that the posted menus accurately reflected the meals being served to residents. On October 7, 2024, observations revealed discrepancies between the posted menus and the actual meals served. In the main dining room, the posted menu indicated it was week 4, with a lunch of turkey, carrots, mashed potatoes, and a roll, while another menu at the entrance to the B wing indicated it was week 3, with a lunch of cheesy ham and macaroni, spinach, corn bread, and pineapple tidbits. However, the meal served to residents consisted of brochette chicken, parmesan noodles, green beans, and a dinner roll. Interviews with the Staff Scheduler and the Dietary Manager confirmed that the posted menus should have been updated to reflect day two of week one, and the menus should have been changed on October 5, 2024. During a Resident Council meeting on October 9, 2024, a resident expressed that they were unaware of what meals they would receive until the meal tray was delivered, as the posted menus were consistently incorrect. The facility's policy, dated October 2022, stated that menus should be served as written unless a substitution is provided in response to preference, and that menus should be posted in the Dining Services department, dining rooms, and resident/patient care areas. This policy was not adhered to, leading to confusion and dissatisfaction among residents regarding their meals.
Failure to Report Allegations of Abuse
Penalty
Summary
The facility failed to ensure allegations of abuse were reported to the State Survey Agency for two residents. Resident B, who is severely cognitively impaired with diagnoses including anxiety and depression, reported that a staff member hit him in the back of the head. Despite the facility's investigation, which could not substantiate the allegation, the incident was not reported to the State Survey Agency as required. The incident was documented in the resident's clinical record and a concern form was filled out, but the necessary reporting was not completed. Similarly, Resident C, who is cognitively intact with diagnoses including alcohol abuse, altered mental status, and major depression, alleged that a staff member was rough while providing care. The allegation was reported internally, and the Administrator spoke with Resident C, but the facility did not substantiate the claim and failed to report it to the State Survey Agency. The facility's policy on abuse prevention clearly states that such allegations should be reported to the State certification agency, but this protocol was not followed in these instances.
Failure to Provide Care for Resident with PTSD
Penalty
Summary
The facility failed to provide appropriate care and services for a resident diagnosed with PTSD. Resident D, who had a history of schizophrenia, major depression, psychoactive substance abuse, and alcohol dependence, was found to have brought vodka into the facility and consumed it, leading to increased hallucinations. Despite being diagnosed with PTSD by a psychiatric progress note, Resident D's clinical record lacked a person-centered care plan for this condition. The facility's policy on mood and behavior management, which emphasizes individualized interventions, was not followed in this case. Multiple residents reported to the Administrator that Resident D was supplying alcohol to other residents. The Administrator confirmed finding a bottle of vodka in Resident D's room and subsequently discontinued Resident D's independent leave of absence. However, the facility did not address Resident D's PTSD in their care plan, as confirmed by the Administrator and the review of the clinical records. This oversight indicates a failure to provide necessary mental health services and interventions tailored to Resident D's specific needs.
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.
The facility failed to ensure timely electronic transmission of MDS assessment data to CMS for a resident. Record review showed an annual MDS that was more than 120 days overdue for submission. The MDS coordinator reported that two care area assessments on the annual MDS had remained incomplete until just before surveyor review, at which time the MDS was finished and submitted. The Administrator acknowledged there was no facility policy in place governing MDS transmissions.
Surveyors found that MDS assessments were inaccurately coded for two residents. One resident with a prior Level II PASARR for serious mental illness was incorrectly coded on the Annual MDS as not having a serious mental illness or related condition. Another resident with generalized anxiety disorder, major depressive disorder, and dementia, who was receiving Lorazepam for anxiety, was not coded with an active anxiety disorder diagnosis on the Quarterly MDS, despite active orders documented on the MAR. The MDS coordinator acknowledged both coding errors, and leadership reported there was no facility-specific MDS policy, relying instead on the RAI manual.
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 Timely Transmit MDS Assessment Data to CMS
Penalty
Summary
The facility failed to ensure timely electronic transmission of MDS (Minimum Data Set) assessment data to the CMS system for one resident. Review of the clinical record for Resident 36 on 4/9/26 showed an annual MDS assessment dated 2/23/26 that was more than 120 days overdue for submission to CMS. During an interview on 4/10/26 at 11:22 a.m., the MDS coordinator stated she still had two care area assessments left to complete on the annual MDS assessment and that she had just finished them and submitted the MDS to CMS, indicating the assessment had not been completed and transmitted within the required timeframe. In a separate interview on 4/10/26 at 12:05 p.m., the Administrator reported that the facility did not have a policy regarding MDS transmissions, further demonstrating the lack of an established process to ensure that MDS data were encoded and transmitted to the State and CMS within the required time limits.
Inaccurate MDS Coding for Mental Health and PASARR Status
Penalty
Summary
The deficiency involves the facility’s failure to ensure that MDS assessments accurately reflected residents’ clinical status for two residents. For one resident with diagnoses including bipolar disorder and anxiety, the Annual MDS dated 3/11/26 indicated the resident was not considered by the state Level II PASARR process to have a serious mental illness or intellectual disability/related condition, despite a Level II PASARR having been completed on 3/31/23. This discrepancy was identified through record review and confirmed in an interview with the MDS coordinator, who acknowledged that the MDS assessment did not accurately reflect the existing Level II PASARR information. For another resident with generalized anxiety disorder, major depressive disorder, and dementia, the Quarterly MDS dated 3/30/26 did not code anxiety as an active diagnosis. However, review of the MAR showed active orders as of 2/27/26 for Lorazepam, prescribed for generalized anxiety disorder, and the RAI manual specifies that active diagnoses should be identified using sources such as medication sheets and physician orders during the 7-day look-back period. In an interview, the MDS coordinator confirmed that the resident did have an active anxiety disorder diagnosis and that the MDS should have been coded “yes” for anxiety disorder but was incorrectly coded “no.” The Administrator and MDS coordinator also stated the facility did not have an MDS policy and relied on the RAI manual for completing assessments.
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