Mason Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Warsaw, Indiana.
- Location
- 900 Provident Drive, Warsaw, Indiana 46580
- CMS Provider Number
- 155003
- Inspections on file
- 30
- Latest survey
- March 9, 2026
- Citations (last 12 mo.)
- 32
Citation history
Health deficiencies cited at Mason Health Care Center during CMS and state inspections, most recent first.
Surveyors found that staff failed to ensure privacy during incontinence care for three residents with dementia, Alzheimer’s disease, overactive bladder, and other neurologic conditions. Two CNAs provided incontinence care to a resident with intracerebral hemorrhage and altered mental status without pulling the privacy curtain between the resident and a roommate. Two other residents with severe cognitive impairment and documented bladder/bowel incontinence received incontinence care while privacy curtains between them and their roommates were not used and, in some instances, window blinds remained open, leaving a window exposed. A CNA acknowledged that curtains and blinds should have been closed, and facility policy stated residents have a right to be treated with respect and dignity.
Staff did not consistently change gloves between soiled incontinence/peri care and application of clean briefs for three residents with dementia, cognitive impairment, and bowel/bladder incontinence. In multiple observed episodes, CNAs removed soiled briefs, performed peri care with disposable wipes, and then, without changing gloves or performing hand hygiene, applied clean incontinence briefs. One affected resident did not yet have an incontinence care plan in place, while others had documented incontinence and required substantial or total assistance with toileting hygiene.
The facility did not notify the physician or NP of significantly elevated blood glucose levels for two residents with diabetes, despite physician orders and facility policy requiring such notification. Blood glucose readings above the specified threshold were not reported, and there was no documentation in the progress notes to indicate that the provider was informed, as confirmed by staff interviews.
Surveyors found that appropriate care was not consistently provided to residents who were continent or incontinent of bowel and bladder, including improper catheter care and insufficient prevention of UTIs. These failures resulted in a deficiency related to resident care.
A resident with a gastrostomy tube did not have physician orders or documentation for required water flushes before and after medication administration, nor for insertion site care, despite facility policies and care plan directives. Nursing staff confirmed these orders and care should have been in place, resulting in a deficiency for inadequate feeding tube care.
A resident with complex medical conditions did not receive scheduled pain medication timely due to communication issues with an RN. The resident's pain medication, Norco, was often administered late, exceeding the facility's policy of a one-hour window. Despite the resident and her daughter addressing the issue, the RN failed to ensure timely administration, leading to increased pain levels for the resident.
The facility failed to maintain sanitary conditions in its kitchen and nutrition pantries, affecting all residents consuming food. Observations revealed improperly stored and expired food items, and staff handling food without gloves. Microwaves in pantries contained dried food debris, violating the facility's food safety policies.
A facility failed to update a resident's activity care plan to reflect their current preferences and needs. The resident, with multiple health conditions, expressed a desire for activities like listening to music and participating in religious activities, but the care plan included irrelevant interventions. Despite an updated activity assessment, the care plan was not revised, leading to a deficiency.
A facility failed to provide appropriate communication devices for a Spanish-speaking resident with cognitive deficits and multiple medical conditions. Despite a care plan indicating the need for translation services, staff were not adequately equipped to communicate with the resident, and a Spanish communication board was not available as required. Observations showed the resident frequently yelling in Spanish, with staff using ineffective ad-hoc methods for communication.
A facility failed to change a resident's respiratory equipment as per physician orders. Observations showed that the oxygen tubing and humidification bottle, dated 8/18/2024, were not changed weekly as required, and the humidification bottle was empty. The resident, with a history of COPD, was receiving oxygen at 2 liters per minute. The facility's policy and physician orders required weekly changes, which were not followed, as confirmed by an LPN.
The facility failed to ensure proper medication storage and handling, with unlocked medication carts, inappropriate items stored with medications, expired medications, and improper labeling. Additionally, a medication room refrigerator had significant ice build-up and was consistently below the appropriate temperature range. Staff interviews confirmed these practices did not align with facility policies.
A facility failed to ensure staff used appropriate PPE when emptying a Foley catheter drainage bag for a resident with a neurogenic bladder and ESBL infection. A QMA was observed performing this task without a face shield or gown, contrary to the facility's Enhanced Barrier Precautions policy, which requires such PPE during high-contact care activities.
Failure to Ensure Privacy During Incontinence Care
Penalty
Summary
The deficiency involves failure to provide privacy during incontinence care for three residents during early morning care. For Resident B, surveyors observed two CNAs providing incontinence care without pulling the privacy curtain between the resident and his roommate. Resident B’s diagnoses included nontraumatic intracerebral hemorrhage, dementia, and altered mental status. At the time of the survey, an admission MDS was in progress and Resident B did not yet have a care plan addressing incontinence care. For Resident C, two CNAs assisted with placement of an incontinence brief while the resident was in bed. One CNA pulled the resident’s lower garment to her ankles and placed the brief underneath her without pulling the privacy curtain between her and her roommate or closing the window blinds. Resident C had Alzheimer’s disease, dementia, and overactive bladder, with an MDS indicating severe cognitive impairment and a need for substantial assistance with toileting hygiene; her care plan documented intermittent incontinence and the need for assistance with incontinence care. For Resident D, two CNAs provided incontinence care with the privacy curtain by the window only partially pulled, leaving an exposed window with open blinds, and the curtain between the resident and her roommate not pulled. Resident D had spastic hemiplegia, cerebral infarction, and overactive bladder, with an MDS indicating severe cognitive impairment and total dependence for toileting hygiene; her care plan documented bladder and bowel incontinence and staff assistance with incontinence care. During interview, one CNA acknowledged that privacy curtains and window blinds should have been closed during incontinence care. The facility’s Resident Rights policy stated that residents have the right to be treated with respect and dignity.
Failure to Change Gloves Between Soiled and Clean Incontinence Care
Penalty
Summary
Staff failed to change gloves between providing soiled incontinence/perineal care and applying clean incontinence briefs for multiple residents. During an early morning observation, two CNAs assisted a resident with dementia and altered mental status who was incontinent of urine in bed. After removing the soiled brief and performing peri care with disposable wipes, one CNA did not change gloves before helping apply a clean brief. This resident’s admission MDS was still in progress and there was no care plan addressing incontinence care at the time of review. In separate observations, another resident with Alzheimer’s disease, dementia, overactive bladder, severe cognitive impairment, and a care plan for intermittent bowel and bladder incontinence received peri care while sitting on the edge of the bed; the assisting CNA did not change gloves before placing a clean brief. A third resident with spastic hemiplegia, cerebral infarction, overactive bladder, severe cognitive impairment, and total incontinence of bowel and bladder was provided incontinent peri care by a CNA who then neither washed hands nor changed gloves before applying a clean brief. The CNA later stated that gloves should have been changed after providing incontinence care and before placing clean briefs. The facility’s incontinence policy stated that incontinent residents would receive appropriate treatment and services, including treatment to prevent infections.
Failure to Notify Physician of Elevated Blood Glucose Levels
Penalty
Summary
The facility failed to notify the physician or Nurse Practitioner of significantly elevated blood glucose levels for two residents with diabetes, as required by physician orders. For one resident with type 2 diabetes, blood glucose readings exceeded the ordered notification threshold of 400 mg/dl on multiple occasions, specifically with values of 443 mg/dl, 546 mg/dl, and 436 mg/dl, without documentation that the physician or Nurse Practitioner was notified. Interviews with nursing staff and the Director of Nursing confirmed that the protocol was to notify the provider and document the notification in the progress notes, which was not done in these instances. Another resident with multiple diagnoses, including type 2 diabetes and acute kidney failure, had several blood glucose readings ranging from 319 mg/dl to 397 mg/dl over two days. Despite facility policy and staff statements indicating that elevated blood glucose levels should prompt notification of the physician and documentation in the progress notes, there was no evidence in the resident's record that the physician was notified of these abnormal results. The facility's policy required following physician orders and parameters, but this was not adhered to in these cases.
Deficient Bowel/Bladder and Catheter Care Leading to UTI Risk
Penalty
Summary
The report identifies a deficiency related to the provision of care for residents who are continent or incontinent of bowel and bladder, as well as the management of catheter care and the prevention of urinary tract infections (UTIs). Surveyors found that appropriate care was not consistently provided to residents in these areas. Specific failures included inadequate attention to the needs of residents with incontinence, improper catheter care practices, and insufficient measures to prevent UTIs. These lapses were observed during the survey and contributed to the deficiency cited.
Failure to Ensure Proper Feeding Tube Care and Documentation
Penalty
Summary
The facility failed to provide appropriate feeding tube care for one resident who was cognitively intact and had a history of cerebral infarction, dysphagia, severe protein-calorie malnutrition, and adult failure to thrive. The resident had a gastrostomy tube for artificial nutrition and hydration, with a care plan indicating the need for site care and water flushes as ordered. However, a review of physician orders revealed there were no orders for water flushes before and after medication administration, nor for gastrostomy site care. Documentation was also lacking regarding water flushes and insertion site dressing changes. During interviews, nursing staff confirmed that residents should have orders for both medication flushes and insertion site care. Facility policies required staff to follow protocols for flushing feeding tubes before and after feedings and medications, and to perform daily or as-needed gastrostomy site care per physician order and professional standards. Despite these policies, the required orders and documentation were not present for the resident in question, resulting in a deficiency related to feeding tube care.
Failure to Administer Pain Medication Timely
Penalty
Summary
The facility failed to provide scheduled pain medication in a timely manner for a resident, identified as Resident B, who was reviewed for pharmaceutical services. Resident B, who was cognitively intact and had complex medical conditions including leukemia, anemia, and anxiety disorder, had a physician's order for Norco to be administered every four hours for pain management. However, the Medication Administration Audit Report revealed multiple instances where the medication was administered significantly later than the scheduled times, often exceeding the facility's policy of administering medication within an hour before or after the scheduled time. Resident B expressed that her pain level increased if she waited more than 40 minutes past the scheduled administration time, and she had to wake up during the night to ensure she received her medication. The issue was compounded by a communication problem involving RN 2, who was responsible for informing other nursing staff to administer the medication during his shifts but failed to do so. Despite Resident B and her daughter addressing the issue with RN 2, he did not take responsibility for ensuring timely medication administration, leading to the deficiency.
Sanitation and Food Handling Deficiencies in Kitchen and Pantries
Penalty
Summary
The facility failed to maintain sanitary conditions in its kitchen and nutrition pantries, as observed during a survey. In the kitchen, black specs were found on a shelf in the walk-in cooler, and several food items, including tater tots and diced pepperoni, were improperly stored without dates or seals. Additionally, expired spices were found on a kitchen shelf. During meal observations, staff members were seen handling food improperly; CNAs passed lunch trays with fingers over the rims of plates and handled a dinner roll with bare hands, contrary to the facility's policy requiring gloves for ready-to-eat foods. Further observations revealed unsanitary conditions in the nutrition pantries, where microwaves contained dried food debris. The facility's policies on food safety, including proper labeling, dating, and handling of food, were not adhered to, as evidenced by the undated and improperly sealed food items and the lack of glove use when handling ready-to-eat foods. These deficiencies had the potential to affect all residents consuming food from the kitchen and pantries.
Failure to Update Resident's Activity Care Plan
Penalty
Summary
The facility failed to ensure that the care plan for a resident was revised and updated in accordance with the resident's current needs and preferences. The resident, who has multiple diagnoses including hemiplegia, dysphagia, and chronic kidney disease, expressed specific preferences for activities such as listening to music, being around pets, and participating in religious activities. However, the care plan, which was last updated in July 2023, did not reflect these preferences accurately. Instead, it included interventions that were not aligned with the resident's stated interests, such as providing magazines and crosswords, which the resident indicated were not very important. The deficiency was identified during a record review and interview process. The facility's policy requires care plans to be reviewed and revised as necessary when a resident experiences a status change. Despite an activity assessment update in June 2024, which noted the resident's participation in sensory club and acceptance of pet visits, the care plan was not updated to reflect these changes. The Activities Director was responsible for updating the care plan but failed to do so, leading to a discrepancy between the resident's current needs and the documented care plan.
Failure to Provide Communication Devices for Spanish-Speaking Resident
Penalty
Summary
The facility failed to provide appropriate communication devices for a Spanish-speaking resident, identified as Resident 29, who was reviewed for communication needs. Resident 29 had a medical history that included hemiplegia, hemiparesis, anxiety disorder, dysphagia, and major depressive disorder. The resident's care plan indicated that her primary language was Spanish and that she required a translator at times. Despite these documented needs, the facility did not ensure the availability of a communication board or other effective communication tools for Resident 29. Observations revealed that Resident 29 was frequently yelling out in Spanish, and staff members, including a housekeeper and a Qualified Medication Aide (QMA), were not adequately equipped to communicate with her. The staff relied on ad-hoc methods such as using Google Translate or asking Spanish-speaking staff members to assist, which were not consistently effective. Interviews with staff members, including the Executive Director and Registered Nurses (RNs), revealed a lack of awareness and availability of the Spanish communication board, which was supposed to be accessible at the nursing station. The Executive Director mentioned that an in-service training on the Spanish communication board had been conducted, but housekeeping staff were not in attendance, and the communication board was not found at the designated location. The facility's policy on communicating with persons with Limited English Proficiency (LEP) outlined the need for meaningful communication and the use of language assistance services, but these measures were not effectively implemented for Resident 29.
Failure to Change Respiratory Equipment as Ordered
Penalty
Summary
The facility failed to ensure that respiratory equipment was changed according to physician orders for a resident using oxygen. Observations on multiple dates revealed that the oxygen tubing and humidification bottle for a resident were not changed weekly as required. Specifically, the oxygen tubing and humidification bottle were dated 8/18/2024 and remained unchanged and empty during observations on 8/26/2024, 8/28/2024, and 8/29/2024. The resident's physician orders, dated 5/28/2024, specified that the oxygen tubing and supplies should be changed weekly, every night shift on Sunday. The resident in question had a history of paraplegia, malnutrition, depression, and asthma, and was receiving oxygen at 2 liters per minute via nasal cannula for chronic obstructive pulmonary disease (COPD). The care plan indicated that the resident should receive oxygen as ordered and that the oxygen tubing should be changed weekly. However, the Treatment Administration Record (TAR) showed that the oxygen tubing and water bottle had not been changed since 8/18/2024. An interview with an LPN confirmed that the tubing had not been changed and the humidification bottle should not have been empty. The facility's policy required changing the oxygen tubing and mask/cannula weekly and the humidifier bottle when empty or weekly, which was not adhered to in this case.
Medication Storage and Handling Deficiencies
Penalty
Summary
The facility failed to ensure proper medication storage and handling across four medication storage areas. Observations revealed that a medication cart on the 400 hall was left unlocked when not in use, as a QMA walked away from it, and an LPN passed by it twice without securing it. Additionally, the 300 hall medication cart contained inappropriate items, such as a bottle of shampoo and an expired container of skin cream. The 100 hall medication cart had an opened and undated bottle of Miralax, indicating a lack of proper labeling and dating of medications. Furthermore, the medication room on the 100 hall had a refrigerator with a significant ice build-up in the freezer section, and the temperature log indicated that the refrigerator's temperature was consistently below the appropriate range on several dates. The facility's policies on medication storage and drug disposition were not adhered to, as evidenced by the presence of expired and improperly stored medications. Interviews with staff confirmed these deficiencies, acknowledging that the observed practices did not align with the facility's policies.
Failure to Use Appropriate PPE During Catheter Care
Penalty
Summary
The facility failed to ensure that staff used appropriate personal protective equipment (PPE) when emptying a Foley catheter drainage bag for a resident. During an observation, a Qualified Medication Aide (QMA) was seen emptying the urine drainage bag of a resident without wearing a face shield or gown, which are required under the facility's Enhanced Barrier Precautions policy. The resident in question had a Foley catheter due to a neurogenic bladder and was on enhanced barrier precautions due to an extended-spectrum beta-lactamase (ESBL) infection in the urine. The resident's medical history included paraplegia, malnutrition, depression, and neuromuscular dysfunction of the bladder. The facility's policy, provided by the Director of Nursing, indicated that enhanced barrier precautions require the use of gowns and gloves during high-contact care activities, such as device care involving urinary catheters. The QMA was unaware of the need for a gown and face shield, indicating a lapse in adherence to the infection control policy.
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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