Morristown Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Morristown, Indiana.
- Location
- 868 S Washington St, Morristown, Indiana 46161
- CMS Provider Number
- 155691
- Inspections on file
- 31
- Latest survey
- June 16, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Morristown Manor during CMS and state inspections, most recent first.
A resident with multiple medication orders was allowed to self-administer medications without the required assessment and documentation by the IDT. Although the resident was cognitively intact and able to take medications independently, the facility did not follow its policy to assess and document the resident's ability to safely self-administer medications.
A resident's call light was repeatedly found out of reach while she was in her wheelchair, with observations showing it placed on the bed or between the wall and bed. The SSD confirmed the call light should have been accessible, and the DON stated there was no specific policy for call light use.
A resident with dementia and mood disturbance exhibited escalating physically abusive and exit-seeking behaviors, including attempts to leave the facility and increased agitation. Although staff and the IDT implemented new interventions such as increased monitoring, medication adjustments, and relocation to a secured unit, these changes were not promptly updated in the resident's care plan, resulting in a lack of individualized documentation for behavior management.
A resident with COPD, hypoxemia, and sleep apnea did not have required monitoring and documentation performed during use of a non-invasive ventilator, as ordered by the physician. The necessary information was not recorded in the MARs or TARs because the order was placed on a respiratory flowsheet that nursing staff could not access, resulting in a lack of documented respiratory assessments and resident tolerance.
A QMA was observed preparing and administering medications to three residents, including those with vascular dementia and hypertension, without performing required hand hygiene before donning gloves or administering medications. The aide touched multiple surfaces and objects during preparation and administration, contrary to facility policy and infection control standards.
The facility failed to follow proper medication administration procedures by preparing medications for multiple residents at a time. Observations revealed that a QMA and an LPN had prepped medications for several residents and left them in the medication carts, contrary to the facility's policy against presetting medications.
The facility failed to ensure that controlled medications for two residents were properly labeled with required information, including the resident's full name, prescribed dose, and route of administration. The medications were obtained from the facility's medication management machine and not from the pharmacy, leading to the absence of proper labeling.
The facility failed to complete the BIMS section of the MDS for three residents with dementia, despite their ability to understand and communicate. This was confirmed by the Social Services Director and the MDS Coordinator, who acknowledged that the assessments should have been completed.
The facility failed to timely initiate transmission-based precautions for a resident with COVID-19. Despite a physician order for isolation dated two days after admission, there was no documentation that the resident was placed in TBP until then, contrary to the facility's COVID-19 policy.
A resident with heart failure, diabetes, and weakness did not receive the annual influenza vaccine as ordered, despite consent being given and facility policy requiring vaccination. The electronic medication administration record showed the vaccine was not signed off as administered, and the Infection Preventionist confirmed the oversight.
The facility failed to protect a resident from physical abuse by another resident, resulting in injuries. Resident D, with dementia and mood disorder, shoved Resident P to the floor, causing a skin tear and hematoma. The incident was captured on camera, and Resident D was placed on one-on-one supervision and sent to a psychiatric facility.
The facility failed to timely report an incident where a resident with dementia inappropriately touched another resident. The incident was reported to the state agency a day later, violating the facility's abuse policy.
The facility failed to thoroughly investigate a reportable incident where a resident with dementia was observed holding another resident's genitalia. The investigation did not include statements from all staff present during the incident, leading to a deficiency.
The facility failed to provide appropriate catheter care and timely monitoring of urine characteristics for two residents, leading to potential health risks. One resident with an indwelling urinary catheter experienced foul-smelling, dark urine and a contaminated urine sample, while another resident reported symptoms of a urinary tract infection and experienced delays in being taken to the bathroom, leading to urinary accidents.
The facility failed to provide adequate supervision for three residents with dementia, leading to multiple incidents of inappropriate behavior and physical altercations. Despite various interventions, one resident continued to wander into other residents' rooms, causing distress and demonstrating the facility's inability to manage her behaviors effectively.
Failure to Assess and Document Resident's Ability for Self-Administration of Medications
Penalty
Summary
The facility failed to have the interdisciplinary team (IDT) determine and document whether self-administration of medications was clinically appropriate for a resident. The resident, who had diagnoses including hypertension and was assessed as cognitively intact, had multiple physician orders for medications such as magnesium oxide, diltiazem, a calcium supplement, carboxymethylcellulose sodium eye drops, and metoprolol. During a medication administration observation, a Qualified Medication Aide (QMA) prepared the resident's medications and placed them on the bedside table, allowing the resident to take them without direct supervision. The QMA confirmed that the resident was able to take her medications independently. However, the Director of Nursing (DON) stated that the resident had not been assessed by the IDT to determine if she could safely self-administer her medications. The facility's policy requires that each resident who desires to self-administer medication must be assessed by the IDT for cognitive, physical, and visual ability, and that this assessment be documented. In this case, the required assessment and documentation were not completed prior to allowing the resident to self-administer medications.
Call Light Not Accessible to Resident
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, as observed on multiple occasions. On two separate days, the resident was seen sitting in her wheelchair with the call light either lying across her bed or positioned between the wall and the bed, making it inaccessible. During an interview, the Social Services Director confirmed that the call light should have been within the resident's reach. The Director of Nursing also indicated that the facility did not have a policy specific to the use of call lights.
Failure to Timely Update Care Plan for Resident with Dementia and Behavioral Issues
Penalty
Summary
The facility failed to timely update the care plan for a resident with dementia and mood disturbance, who exhibited physically abusive and exit-seeking behaviors. Despite multiple documented incidents, including verbal aggression, wandering, attempts to leave the building, and increased agitation, the care plan was not revised to include new interventions such as fifteen-minute checks, medication changes, or relocation to a secured dementia unit. Progress and social service notes indicated that staff and the interdisciplinary team (IDT) responded to these behaviors with various interventions and meetings, but these changes were not reflected in the resident's official care plan. The resident's clinical record showed ongoing behavioral issues and a pattern of staff attempting different non-pharmacological and pharmacological interventions, including increased monitoring and environmental changes. However, the care plan remained largely unchanged and did not document the new strategies implemented in response to the resident's evolving needs. Interviews with facility leadership confirmed that care plans were generalized and not sufficiently individualized to reflect the resident's specific behavioral interventions.
Failure to Monitor and Document Non-Invasive Ventilator Use
Penalty
Summary
The facility failed to monitor and document the use of a non-invasive ventilator (NIV) for a resident with chronic obstructive pulmonary disease (COPD), hypoxemia, and sleep apnea. The resident's care plan included interventions such as applying the NIV machine as ordered, listing settings, monitoring oxygen saturation levels, and contacting the physician as needed. A physician's order specified that the NIV should be applied at bedtime with particular settings, and required staff to monitor and document respiratory rate, minute volume, exhaled tidal volume, and the resident's tolerance. Upon review, there was no documentation in the Medication Administration Records (MARs) or Treatment Administration Records (TARs) of the required monitoring when the NIV was used. The Director of Nursing (DON) explained that the order was entered on a respiratory flowsheet that was not visible to nursing staff, resulting in the absence of documentation. The facility's policy required trained personnel to perform equipment setup, monitoring, and documentation as per physician orders, including detailed respiratory assessments and resident tolerance, which was not completed in this case.
Failure to Perform Hand Hygiene During Medication Administration
Penalty
Summary
The facility failed to maintain proper infection control practices during medication administration for three residents. Qualified Medication Aide (QMA) 2 was observed preparing and administering medications without performing hand hygiene at critical points, such as before donning and after doffing gloves, and prior to administering medications. During medication preparation, QMA 2 touched various surfaces and objects, including scissors, storage bags, medication drawers, and a computer mouse, without performing hand hygiene before proceeding to handle medications or interact with residents. For one resident with vascular dementia, QMA 2 prepared and crushed medications, mixed them with pudding, and administered them without hand hygiene before glove use or medication administration. For another resident with hypertension, QMA 2 prepared medications, donned gloves, administered eye drops, and touched the resident's face without hand hygiene before leaving the medication cart or donning gloves. In a third case involving a resident with vascular dementia, QMA 2 prepared oral medications and a medication patch, touched multiple surfaces, and applied the patch without hand hygiene prior to administration. Interviews with QMA 2 and the Infection Preventionist confirmed that hand hygiene should have been performed at these points, and the facility's policy also required hand hygiene before medication pass and before leaving the medication cart.
Improper Medication Administration Procedures
Penalty
Summary
The facility failed to ensure proper medication administration procedures were followed by preparing medications for more than one resident at a time. During an observation of the Pine and Juniper units' medication carts, it was found that medications were prepped for multiple residents simultaneously. On the Pine unit, a Qualified Medication Assistant (QMA) was found to have prepared medications for two residents, Resident Q and Resident R, and left them in the medication cart. The QMA acknowledged that medications should not be prepped ahead of time for any residents. Resident Q's medication cup contained Tramadol, gabapentin, acetaminophen, atorvastatin, Lasix, melatonin, pramipexole, and Xarelto, while Resident R's cup contained Aptiom, Lasix, oyster shell calcium, and lamotrigine. Similarly, on the Juniper unit, an LPN was found to have prepared medications for five residents and left them in the medication cart. The LPN identified the medications in each cup, which included various medications such as buspirone, diltiazem, Trazadone, Xanax, depakote, senna, atorvastatin, carvedilol, melatonin, coreg, Cymbalta, Norco, and tramadol. The facility's policy, as provided by the Director of Nursing (DON), explicitly stated that there should be no presetting of medications. This deficiency was related to a complaint investigation (IN00431737).
Failure to Properly Label Controlled Medications
Penalty
Summary
The facility failed to ensure that controlled medications stored in the locked medication storage drawer in the medication refrigerator were properly labeled. During an observation of the main nursing station medication room, it was found that a multi-dose bottle of lorazepam for Resident C and another for Resident P were not labeled with the required information, including the resident's full name, prescribed dose, and route of administration. The medications were obtained from the facility's medication management machine and not from the pharmacy, leading to the absence of proper labeling. The Director of Nursing (DON) confirmed that the medications were not labeled according to the facility's Medication Labeling policy, which mandates that all prescriptions filled by the pharmacy or outside pharmacies must include specific information such as the name of the drug, route of administration, strength, volume, control number, expiration date, and other relevant details. The failure to adhere to these labeling requirements was observed during a survey, highlighting deficiencies in the facility's medication management practices for two residents.
Failure to Complete Cognitive Assessments
Penalty
Summary
The facility failed to accurately complete the cognitive assessment portion of the MDS (Minimum Data Set) Assessment for three residents diagnosed with dementia. Specifically, the BIMS (Brief Interview for Mental Status) section of the MDS was not completed for Residents 28, 54, and 78, despite their ability to understand and make themselves understood. This was confirmed through clinical record reviews and interviews with the Social Services Director and the MDS Coordinator, who both acknowledged that the BIMS assessments should have been completed for these residents. Resident 28 had a Quarterly MDS Assessment completed on 1/29/24, Resident 54 had a Quarterly MDS Assessment completed on the same date, and Resident 78 had a Significant Change of Status MDS Assessment completed on 2/29/24. All three assessments indicated that the residents were usually able to make themselves understood and understand others, yet the BIMS assessments were omitted. The Social Services Director and the MDS Coordinator both confirmed that the residents were capable of answering the BIMS questions and that the assessments should have been conducted as per the facility's policy using the RAI (Resident Assessment Instrument).
Failure to Timely Initiate Transmission-Based Precautions for COVID-19 Resident
Penalty
Summary
The facility failed to ensure timely initiation of transmission-based precautions (TBP) for a resident with COVID-19. Resident 255, who had diagnoses including COVID-19, cough, and hypertension, was admitted to the facility from the hospital on 3/16/24. Despite a physician order dated 3/18/24 indicating the need for droplet/contact isolation and in-room services with isolation precautions, there was no documentation in the progress notes or physician orders that the resident was placed in TBP until 3/18/24. The facility's COVID-19 Policy and Procedure, dated 8/6/23, required healthcare personnel to wear additional PPE when providing direct care within 6 feet of a resident in a Red Zone, but this was not followed for Resident 255 until two days after admission.
Failure to Administer Annual Influenza Vaccine
Penalty
Summary
The facility failed to ensure the annual influenza immunization was administered per physician orders for one resident. The clinical record for the resident, who had diagnoses including heart failure, diabetes mellitus, and weakness, showed that consent for the influenza vaccine was given. However, the electronic medication administration record indicated that the dose of the flu vaccine was not signed off as administered on the specified date. An interview with the Infection Preventionist confirmed that the vaccine had not been administered, and a new order was obtained to administer it within the appropriate window for the annual influenza vaccine. The facility's policy on influenza immunization, revised in 2020, stated that all residents would be offered the influenza vaccination starting October 1 and continuing through the influenza season, following CDC recommendations. Despite this policy, the resident did not receive the vaccine as ordered. The CDC document provided by the facility indicated that September and October are generally good times for vaccination, ideally by the end of October. This discrepancy between policy and practice led to the identified deficiency.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse by another resident. Resident D, who had diagnoses including dementia and mood disorder, was involved in a physical altercation with Resident P. The incident occurred in a common area where Resident D forcefully shoved Resident P to the floor after throwing a metal drinking cup at her. This resulted in Resident P sustaining a skin tear to her right hand and a hematoma to the back of her head. The incident was captured on camera, and staff arrived approximately 30 seconds later to assess and care for Resident P. Resident D was placed on one-on-one supervision immediately following the incident and was later sent to a psychiatric facility for evaluation and treatment. Interviews with Resident D and the Social Services Director confirmed that Resident D's discharge from the facility was related to the abusive behavior. Resident D had a history of aggressive behaviors, including hiding knives and scissors, which posed a risk to other residents. The facility's policy on Abuse, Neglect, and Misappropriation Prohibition and Prevention was reviewed, which stated that the facility would not condone resident abuse by anyone, including other residents. Despite this policy, the facility failed to prevent the abusive incident between Resident D and Resident P, leading to physical harm and distress for Resident P.
Failure to Timely Report Abuse Incident
Penalty
Summary
The facility failed to timely report a reportable incident involving two residents with dementia and psychotic disturbances. Resident 94, who was severely impaired, touched Resident E inappropriately on the outside of his pants in his lap area. This incident occurred on the morning of 2/26/24 but was not reported to the Indiana Department of Health until 2/27/24. The Executive Director initially did not consider the incident reportable but later realized the necessity of reporting it. The clinical records and social services notes indicate that both residents were severely impaired and had difficulty recalling the incident. Resident E did not express distress over the incident, and Resident 94 did not remember the event. Despite this, the facility's abuse policy mandates immediate reporting of such incidents to state agencies. The delay in reporting the incident was a clear violation of this policy, as the incident was not reported within the required timeframe of 24 hours.
Incomplete Investigation of Reportable Incident
Penalty
Summary
The facility failed to thoroughly investigate a reportable incident involving two residents with dementia and psychotic disturbances. Resident 94, who was severely impaired, was observed by a CNA holding Resident E's genitalia through his clothing in the hallway. The CNA intervened and called for assistance from an RN, who helped separate the residents and assessed Resident E for injuries, finding none. However, the investigation did not include statements from all staff present during the incident, specifically the RN who assisted but was not asked for a written statement. The facility's abuse policy requires a thorough investigation, including interviews with all staff who had contact with the residents before, during, and immediately after the incident. Despite this, the investigation was deemed complete by the Clinical Specialist without obtaining all necessary staff statements. This incomplete investigation process led to the deficiency noted in the report.
Failure to Provide Appropriate Catheter Care and Urine Monitoring
Penalty
Summary
The facility failed to ensure that a resident with an indwelling urinary catheter received appropriate treatment and services to prevent urinary tract infections and to monitor the urine characteristics of a resident being evaluated for a urinary tract infection. Resident H, who had diagnoses including urinary tract infection, acute pyelonephritis, and neuromuscular dysfunction of the bladder, had an indwelling urinary catheter. Despite a physician's order for daily catheter care, there was no documentation verifying that catheter care was performed every shift from January 15 to February 5, 2024. Additionally, the facility lacked a specific policy for indwelling urinary catheter care, relying instead on a general bed bath/perineal care procedure that did not adequately address catheter care specifics. This led to Resident H experiencing foul-smelling, dark urine and a contaminated urine sample, which delayed appropriate treatment and monitoring for a urinary tract infection. The resident's care plan also indicated the need for catheter care every shift, which was not documented as being followed consistently. The Clinical Specialist confirmed the absence of documentation for catheter care during the specified period, highlighting a significant lapse in care and monitoring for Resident H. Resident L, who had a diagnosis of cerebral infarct and dysuria, was also affected by the facility's failure to provide timely and appropriate care. Despite being cognitively intact and reporting symptoms of a urinary tract infection, Resident L experienced delays in being taken to the bathroom, leading to urinary accidents. A urine sample collected for analysis was reported as possibly contaminated, and there was no documentation of the urine's color, characteristics, or odor. The Director of Nursing confirmed that a repeat urine sample was ordered and collected using an in-and-out catheter, but the nursing progress notes lacked detailed assessments of the urine. This deficiency in documentation and timely care contributed to Resident L's ongoing discomfort and potential urinary tract infection. The facility's failure to provide appropriate catheter care and timely monitoring of urine characteristics for both residents highlights significant lapses in care and documentation, leading to potential health risks for the affected residents.
Inadequate Supervision and Behavioral Management for Dementia Patients
Penalty
Summary
The facility failed to provide adequate supervision for three residents diagnosed with dementia, leading to multiple incidents of inappropriate behavior and physical altercations. Resident E, who was severely cognitively impaired, was involved in an incident where Resident 94, also severely cognitively impaired, touched him inappropriately in the hallway. Despite being on 15-minute checks, Resident 94 was able to approach and grab Resident E's genitalia through his clothing. Staff intervened to separate the residents, but the incident highlighted a lack of effective supervision and monitoring for Resident 94's behaviors. Resident 94 exhibited multiple behavioral issues, including wandering into other residents' rooms, taking their belongings, and displaying hypersexual behaviors. Despite various interventions such as medication adjustments, 15-minute checks, and the use of stop signs on doors, Resident 94 continued to enter other residents' rooms and cause distress. On one occasion, Resident 94 wandered into Resident 15's room and was struck in the back by Resident 15 before staff could intervene. This incident further demonstrated the facility's inability to manage Resident 94's behaviors effectively. The facility's behavioral health management program aimed to identify, monitor, and manage disruptive behaviors using the least invasive approach. However, the repeated incidents involving Resident 94 indicated that the interventions in place were insufficient to prevent her from causing distress to other residents. The facility's failure to provide adequate supervision and effective behavioral management for Resident 94 resulted in multiple incidents of resident-to-resident altercations and inappropriate behavior, highlighting a significant deficiency in the care provided to cognitively impaired residents.
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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