Morgantown Woods Of Journey
Inspection history, citations, penalties and survey trends for this long-term care facility in Morgantown, Indiana.
- Location
- 140 W Washington St, Morgantown, Indiana 46160
- CMS Provider Number
- 15E683
- Inspections on file
- 25
- Latest survey
- March 11, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Morgantown Woods Of Journey during CMS and state inspections, most recent first.
A resident with a history of aggression physically assaulted another resident experiencing psychosis by punching him multiple times in the face, resulting in visible injury. Staff intervened to separate the residents, but the incident revealed a failure to prevent abuse as required by facility policy.
A sanitation bucket in the kitchen was found to have a sanitizing solution concentration below the required level, as determined by the Assistant Dietary Manager using a test strip. The staff member was unsure of the correct concentration and later confirmed it was lower than the facility's policy requirement, potentially affecting all residents served from the kitchen.
Surveyors identified that MDS assessments for four residents were inaccurately coded, including errors in documenting admission source, daily use of limb restraints, anticoagulant medication use, and prognosis related to hospice care. Staff interviews and record reviews confirmed these discrepancies, and it was noted that the facility lacked a specific policy for MDS coding, relying instead on the RAI manual.
Staff assisted a resident with dementia and psychosis during meals by standing rather than sitting, and failed to engage with the resident, instead conversing with other staff. The resident, who was fully dependent on staff for eating, was not treated in accordance with dignity and respect policies.
A resident with a history of stroke, hemiplegia, and schizophrenia was admitted without their POST form being properly documented or communicated to staff. The POST form, indicating a request for CPR and full medical attention, was not found in the EHR or at the nurse's station as required by facility policy, and was only located later in a scanned pile not accessible to staff.
A resident with dementia and other conditions was repeatedly observed secured in a Broda chair with leg straps to prevent self-transfer. Although there was a physician order for the restraint and instructions for periodic release, the clinical record lacked required documentation of daily use, specific release schedules, and quarterly re-evaluations. The DON confirmed that ongoing assessments were not completed as required by facility policy.
The facility failed to protect residents from improper use of restraints. A resident was observed in a Broda chair with leg straps not ordered by a physician, and there was no documentation of regular release and repositioning. Another resident was restrained without prior informed consent, and documentation of release and repositioning was lacking. A third resident was observed straining against restraints, with no documentation of being released every two hours. Interviews revealed staff uncertainty about restraint protocols.
A resident with Alzheimer's disease was prescribed antipsychotic medications without an adequate diagnosis or attempt at gradual dose reduction (GDR). The facility's policy requires GDR to determine if symptoms can be managed with a lower dose, but the resident's medication regimen was not evaluated for GDR, and antipsychotics were prescribed for longer than 14 days without proper evaluation.
The facility did not ensure that daily posted nurse staffing information accurately reflected the actual hours worked by staff over five consecutive days. Observations showed that the staffing sheets lacked actual hours worked, and the Clinical Support Nurse confirmed the need for updates. The facility also lacked a policy on staffing sheet requirements.
A resident with a history of elopement exited the facility unsupervised on three consecutive days due to inadequate supervision and a malfunctioning door alarm. Despite being placed on 15-minute checks, the resident managed to leave through the same emergency exit door, which was not connected to the internal alarm system. The facility's failure to provide continuous supervision and secure the door led to repeated elopements, posing a significant risk to the resident's safety.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A deficiency occurred when a male resident physically assaulted another male resident by punching him in the face multiple times. On the day of the incident, the aggressor had been agitated and displayed verbal and physical aggression toward staff, while the victim was experiencing an episode of psychosis and was not easily redirected. Staff witnessed the assault in the facility's front lobby area, where the aggressor struck the victim with a closed fist, resulting in a small, bluish-purple, swollen area and a cut under the victim's right eye. The two residents were immediately separated by staff, and the victim received ice for his injury. The clinical records indicated that the victim had diagnoses including Alzheimer's disease, schizophrenia, and anxiety, and was cognitively intact according to a recent assessment. The aggressor had diagnoses of dementia, anxiety, and depression, and was noted to be severely cognitively impaired. The facility's policy, which was in place at the time, required the prevention of abuse, but the incident demonstrated a failure to protect a resident from physical abuse by another resident.
Sanitizing Solution in Kitchen Below Required Concentration
Penalty
Summary
During an initial kitchen tour, the Assistant Dietary Manager tested the sanitizing solution in the sanitation bucket at the three-compartment sink and found the concentration to be 170, as indicated by the test strip. The Assistant Dietary Manager was unsure of the correct color on the test strip bottle that should be matched. Later, she acknowledged that the sanitizing solution was low and that the required concentration should have been between 272-700, according to facility policy. The facility's policy, revised recently, states that cleaning and sanitizing buckets must be prepared at the start of each shift and replaced as needed to maintain proper concentration. This deficiency was identified for 1 of 1 sanitation bucket reviewed and had the potential to affect all 35 residents served from the kitchen.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for four residents, resulting in incorrect coding of key clinical information. For one resident with Alzheimer's disease, the admission source was inaccurately coded as a nursing home, despite documentation and staff interviews confirming the resident was admitted from a private home after living with a family member. Another resident with dementia and COPD had daily use of limb restraints in a Broda chair, as ordered by a physician, but the MDS assessment did not reflect this use during the required look-back period. A third resident with COPD, dementia, and schizophrenia was incorrectly coded as receiving anticoagulant medication on the MDS, even though the medication had been discontinued prior to the assessment period. Additionally, a resident with Alzheimer's and Parkinson's disease was coded as not having a life expectancy of less than six months, despite being admitted to hospice care, which was documented in the medical record. Interviews with staff confirmed these inaccuracies and revealed a lack of facility policy on MDS coding, with reliance on the RAI manual for guidance.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
Staff failed to maintain a resident's dignity during meal assistance, as observed on two separate occasions. On the first occasion, a CNA stood to the left of a resident with dementia and psychosis while assisting with the meal, placing her hand on the resident's forehead to hold her head up and feeding her without engaging in conversation. The CNA instead conversed with other staff members during the meal. On the second occasion, the Activity Director also stood in front of the same resident while assisting with eating. The resident's care plan indicated a total dependence on staff for meal assistance due to dementia. Staff interviews confirmed that proper protocol requires sitting and engaging with residents during meal assistance, rather than standing and conversing with other staff. The facility's Resident Rights policy emphasized the right to a dignified existence and being treated with respect and consideration, which was not upheld during these observed meal times.
Failure to Communicate Resident Advance Directive to Care Staff
Penalty
Summary
The facility failed to communicate a resident's advance directive choice to the staff responsible for their care. A review of the clinical record for a resident with diagnoses including cerebral infarction, left side hemiplegia, and schizophrenia revealed that documentation of the Indiana Physician Orders for Scope of Treatment (POST) form was missing from both the electronic health record (EHR) and the binder at the nurse's station. The Director of Nursing (DNS) confirmed that the POST form, which indicated the resident requested CPR and full medical attention, was not available in the expected locations and was only later found in a scanned pile not accessible at the nurse's station. Facility policy requires that advance directives be copied, placed on the chart, and communicated to staff upon admission, but this was not done for the resident in question.
Failure to Document and Re-Evaluate Use of Physical Restraints
Penalty
Summary
A resident with diagnoses including dementia, COPD, anxiety, and psychosis was observed multiple times seated in a Broda chair with leg straps securing both legs, preventing her from getting out of the chair. These observations occurred in various locations, including the hallway and her room, both while awake and asleep. Staff were seen releasing and repositioning the leg straps at intervals. The resident's clinical record included a physician order for the use of the Broda chair with straps for safety and positioning, with instructions for release and repositioning every two hours and quarterly review for continued use. However, documentation in the resident's record was incomplete. The Minimum Data Set (MDS) assessment did not document daily use of limb restraints, and the care plan referenced the use of the Broda chair with straps but lacked specific details. The informed consent form for restraint use did not specify the recommended duration or release schedule. Additionally, the quarterly adaptive device review noted the device's initiation and rationale but lacked evidence of previous quarterly reviews. The Director of Nursing Services confirmed that no further evaluations had been completed, despite facility policy requiring ongoing re-evaluation of restraint need.
Failure to Protect Residents from Improper Use of Restraints
Penalty
Summary
The facility failed to protect the rights of residents to be free from physical restraints, as observed in three residents. Resident 16 was repeatedly observed in a Broda chair with leg straps, which were not ordered by the physician, and there was no documentation of the resident being released and repositioned every two hours as required. The care plan and informed consent indicated the need for regular release and repositioning, but this was not documented in the clinical record. Resident 3 was also observed in a Broda chair with lap straps, without prior informed consent for the use of restraints. The consent form was signed after the resident was already restrained, and there was no documentation of the resident being released and repositioned every two hours. The Director of Nursing confirmed the lack of prior consent and documentation for the release and repositioning of the resident. Resident 27 was observed straining against restraints in a Broda chair, with no documentation of being released every two hours. The care plan required regular release and repositioning, but this was not documented. Interviews with CNAs revealed uncertainty about the frequency of releasing the resident from restraints. The facility's policy did not require documentation of repositioning or informed consent prior to restraint use.
Failure to Implement Gradual Dose Reduction for Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary medications, specifically regarding the use of antipsychotic medications. A resident was observed sitting in a broda chair with lower limb restraints and was prescribed olanzapine and prochlorperazine maleate, both antipsychotic medications. The resident's clinical record indicated diagnoses of Alzheimer's disease, a personal history of traumatic brain injury, insomnia, and anxiety. However, the record lacked an adequate diagnosis for the continued use of antipsychotics, and there was no attempt at a gradual dose reduction (GDR) for these medications, nor was it documented as contraindicated. The facility's policy on GDR, which was revised earlier in the year, outlines the need for stepwise tapering of psychotropic drugs to determine if symptoms can be managed with a lower dose or if the medication can be discontinued. Despite this policy, the resident's medication regimen was not evaluated for GDR, and the antipsychotic medication was prescribed for longer than 14 days without proper evaluation. The Clinical Support Nurse acknowledged that antipsychotic medication should not be used for dementia without behaviors and suggested that the resident's hospice care might have been a reason for not attempting a GDR.
Inaccurate Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the daily posted nurse staffing information accurately reflected the actual hours worked by staff over a period of five consecutive days. Observations made on June 26, 27, 28, July 1, and July 2, 2024, revealed that the posted nurse staffing sheets did not include the actual hours worked by the nursing staff. During an interview on July 2, 2024, the Clinical Support Nurse acknowledged that the facility should have been updating the staffing sheets to reflect the actual hours worked by licensed staff the following day. It was also noted that the facility lacked a policy specifying the requirements for the nurse staffing sheets.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision to prevent a resident with a history of elopement from exiting the facility on three consecutive days. Resident B, who had a history of elopement and was diagnosed with non-traumatic brain dysfunction, schizophrenia, psychotic disorder, and bilateral hand amputation, was able to leave the facility unsupervised on three separate occasions. On the first occasion, Resident B was found 1.1 miles away in an empty commercial lot by the police. Despite being placed on 15-minute checks after the first elopement, Resident B managed to exit the facility again on the following two days through the same emergency exit door in the dining room, which was not connected to the internal alarm system and had a malfunctioning battery-operated alarm. The emergency exit door in the dining room was observed to be shut but not secured, with a small, battery-operated door alarm that was not functioning properly. Staff interviews revealed that Resident B was not on 1-on-1 supervision during the night shift following the initial elopement and that the staff were not adequately informed or trained to handle the situation. The Vice President of Clinical Operations (VPCO) and other staff members were not promptly notified of the subsequent elopements, and the necessary documentation was not completed. Additionally, the facility's policy on elopements and wandering residents was not effectively implemented, as alarms are not a replacement for necessary supervision. Resident B's clinical record indicated a history of elopement and a court order appointing a guardian due to incapacity to make healthcare decisions. Despite this, the facility did not take appropriate measures to ensure Resident B's safety. The care plan for Resident B, which included monitoring the placement and function of a bracelet alarm, was not adequately followed. The facility's failure to provide continuous supervision and secure the emergency exit door led to Resident B's repeated elopements, posing a significant risk to the resident's safety.
Removal Plan
- Inserviced the staff on supervision
- Ensured the unsecured door was under supervision until it could be replaced
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
