Oak Village
Inspection history, citations, penalties and survey trends for this long-term care facility in Oaktown, Indiana.
- Location
- 200 W Fourth St, Oaktown, Indiana 47561
- CMS Provider Number
- 155714
- Inspections on file
- 23
- Latest survey
- December 22, 2025
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Oak Village during CMS and state inspections, most recent first.
Surveyors observed that food items in the kitchen freezer were left open, undated, and unlabeled, and that kitchen areas had visible dust and debris. During meal service, a staff member assisted multiple residents without performing required hand hygiene between contacts, contrary to facility policy.
A nurse preset medications prior to administration, resulting in a resident with multiple medical conditions receiving another resident's medications. The error was identified after the nurse realized the mistake, and the resident required hospital evaluation and IV fluids for hypotension.
The facility failed to serve meals at safe and appetizing temperatures, as observed during a survey. A lunch tray on the 100 hall contained food items below the required temperatures, with chicken strips at 80°F, French fries at 90°F, slaw at 70°F, and applesauce at 55°F. Residents expressed dissatisfaction, noting cold and unappetizing food, and Resident Council minutes highlighted ongoing concerns about food temperatures and repetitive meal options.
The facility failed to store and label food according to professional standards. During a kitchen observation, a freezer contained unsealed and unlabeled frozen vegetables, fish fillets, and meatballs. A refrigerator had an unmarked container of pasta salad. A dietary aide confirmed the requirement for labeling and dating all food items and discarded the unlabeled pasta salad.
A facility failed to maintain accurate controlled drug records for a resident with severe cognitive impairment receiving opioid medications. Discrepancies were found between the medication administration record and the controlled substance count log for Norco 5-325 mg. Interviews revealed a lack of awareness and explanation for these inconsistencies, with staff indicating that both routine and as-needed orders were counted on the same sheet, contributing to the issue.
The facility failed to provide scheduled activities for residents when the Activity Director was absent, affecting several residents. Residents expressed dissatisfaction with the lack of activities, particularly on weekends. Staffing issues contributed to the deficiency, as CNAs were often pulled to work on the floor, leaving no one to conduct activities. Despite residents' medical conditions, they expressed a desire to participate in group activities, which were not being provided consistently.
A facility failed to document post-dialysis vital signs for a resident with end-stage renal disease, despite policy requirements. Additionally, the facility did not document medication administration for several residents, with MARs lacking records of administered medications on specific dates. Interviews revealed that the night shift nurse was not completing documentation as required, indicating a lapse in following established protocols.
The facility failed to create a care plan for a resident with dementia and did not implement person-centered interventions for another resident with dementia and agitation. The care plans were generic and lacked specific, individualized interventions, contrary to the facility's policies.
The facility failed to conduct quarterly care plan meetings for three residents, as required. One resident reported not remembering attending a meeting recently, with records showing only one meeting in the last year. Another resident was unaware of any meetings, with only two documented in the past year. A third resident recalled attending only one meeting, confirmed by records. The SSD acknowledged being behind on scheduling meetings, and the facility's policy requiring a seven-day advance notice was not followed.
A resident with severe cognitive deficit and a history of femur fracture experienced a fall and complained of leg pain. Despite a high pain assessment score, there was a delay in notifying the physician and obtaining necessary medical orders. The resident was eventually sent to the hospital, where an x-ray confirmed a femoral neck fracture.
A resident with a severe cognitive deficit and pressure ulcers experienced significant pain during a dressing change, as the nursing staff failed to pre-medicate or adequately address her pain despite her verbal and non-verbal expressions of discomfort. The resident's care plan and facility policy on pain management were not effectively followed, leading to a deficiency in providing appropriate pain relief.
The facility failed to dispose of expired medications, including an insulin vial and a flu vaccine, as per their policies. An LPN and the RDCS confirmed the insulin was expired, and the DON acknowledged the expired flu vaccine. The facility's policy requires outdated drugs to be returned or destroyed.
The facility failed to ensure the use of facial hair restraints in the kitchen, as observed during inspections. The Dietary Manager was seen with a visible mustache without a hair restraint while preparing food and checking temperatures. The DM believed facial hair coverings were only necessary for full beards, contrary to the facility's policy requiring restraints for long facial hair.
Failure to Maintain Food Safety Standards and Hand Hygiene During Meal Service
Penalty
Summary
The facility failed to store and distribute food in accordance with professional standards for food service safety, as observed during a kitchen inspection. Multiple food items in the reach-in freezer, including peas, broccoli, cookie dough, pancakes, meat patties, and hashbrowns, were found open to air, undated, and unlabeled. Additionally, the kitchen floor under the stove and around the base of the walls had a buildup of dust and debris, ceiling vents and panels above food preparation areas were dusty, and the top of the dishwasher contained dust, debris, and food crumbs. The Dietary Manager confirmed that frozen food should be labeled, dated, and sealed, and that routine cleaning was not documented in a cleaning log, despite a recent deep clean. During meal service, a staff member was observed touching a resident's hair, another resident's shoulder, and then a third resident's cup without performing hand hygiene between contacts. Facility policy requires staff to perform hand hygiene after touching residents and after delivering each tray of food, but this was not followed. The facility's own policies on food storage, cleaning, and hand washing were not adhered to during these observed events.
Medication Administration Error Due to Presetting Medications
Penalty
Summary
A nurse preset medications for multiple residents prior to the medication pass, resulting in a resident receiving another resident's medications. The error was discovered when the nurse returned to the medication cart and realized that the intended medications for the resident were still present, while another resident's medications had been administered in error. The facility's Director of Nursing confirmed that staff should not preset medications and must always verify the correct medications are given to the correct resident. The affected resident had a medical history including paraplegia, anemia, depression, and seizures, and was care planned for gastrointestinal and neurological issues requiring medications as ordered. After receiving the incorrect medications, the resident reported feeling unwell and was found to be hypotensive, requiring transfer to the hospital for intravenous fluids and further observation. The incident was documented in both facility and hospital records.
Failure to Serve Meals at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to provide appetizing and palatable meals, as evidenced by observations and resident complaints. During a survey, it was noted that the lunch trays served on the 100 hall contained food items that were not at appropriate temperatures. Specifically, chicken strips were served at 80 degrees Fahrenheit, French fries at 90 degrees Fahrenheit, slaw at 70 degrees Fahrenheit, and applesauce at 55 degrees Fahrenheit. These temperatures did not meet the facility's policy requirements, which state that hot food should be served at a minimum of 135 degrees Fahrenheit and cold food at 41 degrees Fahrenheit or below. Residents expressed dissatisfaction with the meals, citing issues with cold and unappetizing food. Resident J and Resident M both reported disliking the food, with Resident M specifically mentioning that hot food was often served cold. Resident Council minutes also reflected ongoing concerns about food temperatures and repetitive meal options, such as chicken strips and French fries being served three times in seven days. During an interview, Resident P described the French fries as terrible, cold, and hard. These findings indicate a failure to adhere to the facility's food temperature policy, resulting in unappetizing and potentially unsafe meals for residents.
Deficiency in Food Storage and Labeling
Penalty
Summary
The facility failed to ensure food was stored and distributed in accordance with professional standards for food service safety. During a kitchen observation, a standing reach-in freezer was found to contain a box of frozen vegetables that was not sealed, and a bag of frozen vegetables was open to air. Additionally, a bag of what appeared to be frozen fish fillets and a bag of what appeared to be meatballs were not labeled. In the reach-in refrigerator, there was an unmarked container of what appeared to be pasta salad. During an interview, a dietary aide confirmed that all food items should be labeled and dated, and any unlabeled or undated food must be discarded. The dietary aide then discarded the unlabeled pasta salad. The facility's policy, dated November 2024, requires leftover food to be stored in covered containers or wrapped securely, with each item clearly labeled and dated.
Inaccurate Controlled Drug Records for a Resident
Penalty
Summary
The facility failed to maintain accurate controlled drug records for one of the three residents reviewed for pharmaceutical services. Specifically, the controlled substance count sheets did not match the documented administration of controlled drugs for Resident B over a 30-day review period. Resident B, who had severe cognitive impairment and was receiving opioid medications, had discrepancies in the records for Norco 5-325 mg. On several occasions, the medication administration record (MAR) did not align with the controlled substance count log, indicating either missing documentation of administration or discrepancies in the count log. Interviews with the Director of Nursing (DON) and Licensed Practical Nurses (LPNs) revealed a lack of awareness and explanation for these inconsistencies. The DON was unaware of any issues with controlled substance counts, and LPNs indicated that both routine and as-needed orders were counted on the same sheet, which may have contributed to the discrepancies. The facility's policy on charting and documentation required that all services, including medication administration, be documented in the resident's medical record, but this was not adhered to in the case of Resident B.
Facility Fails to Provide Scheduled Activities for Residents
Penalty
Summary
The facility failed to provide scheduled activities for residents when the Activity Director was absent, affecting 6 out of 7 residents reviewed. Residents expressed dissatisfaction with the lack of activities, particularly on weekends and when the Activity Director was unavailable. The activities calendar posted in the facility indicated scheduled activities, but these were not observed to have taken place. Interviews with residents revealed that they missed the previous staff and were bored due to the lack of engaging activities. The facility's staffing issues contributed to the deficiency, as Certified Nursing Assistants (CNAs) who were supposed to fill in for the Activity Director were often pulled to work on the floor, leaving no one to conduct activities. The Activity Director was frequently absent due to schooling commitments, and the facility had not replaced a long-time Activity Assistant who had quit. This resulted in a significant reduction in the number of activities available to residents, particularly on weekends and evenings. Residents' medical profiles indicated various conditions, including dementia, multiple sclerosis, diabetes, and chronic kidney disease, with most residents being cognitively intact. Despite their conditions, residents expressed a desire to participate in group activities, which were not being provided consistently. The facility's policy on activities was not being adhered to, as evidenced by the lack of documented participation in scheduled activities on the residents' individual activity task forms.
Failure to Document Post-Dialysis Vital Signs and Medication Administration
Penalty
Summary
The facility failed to document post-dialysis vital signs for a resident with end-stage renal disease who required dialysis treatment. The resident's records showed multiple instances from April to September 2024 where post-dialysis vital signs were not documented, despite the facility's policy requiring such documentation. The Regional Director of Clinical Services confirmed the absence of these vital signs in the resident's electronic medical record, indicating a failure to adhere to the facility's policy. Additionally, the facility did not document the administration of medications for several residents as required. For one resident, the medication administration records (MARs) for August and September 2024 lacked documentation of the administration of multiple medications, including omeprazole, metoprolol tartrate, and levothyroxine sodium, on specific dates. There was no documentation of resident refusal for these medications. Similar issues were found for other residents, where MARs lacked documentation of medication administration for various prescribed drugs, again without any record of resident refusal. Interviews with the Regional Director of Clinical Services and a Licensed Practical Nurse revealed that the night shift nurse was not completing documentation as required by the facility's policy. The policy mandates that documentation should be completed immediately after medication administration by the licensed personnel who administer the medication. The failure to document medication administration and post-dialysis vital signs indicates a significant lapse in following established protocols for resident care.
Deficiencies in Dementia Care Planning
Penalty
Summary
The facility failed to create a care plan for a resident with dementia, as required by the Preadmission Screening and Resident Review (PASRR) process. Resident 2, who had a diagnosis of dementia with unspecified severity, was identified as needing a Level II evaluation. However, the facility did not have any documentation of a care plan addressing the resident's dementia or cognitive needs. The Regional Director of Clinical Services confirmed the absence of such a care plan, despite the resident's diagnosis necessitating one. Additionally, the facility did not implement person-centered dementia care plan interventions for another resident, Resident 21, who had dementia with agitation and psychotic disturbance. The care plans in place for this resident were generic and lacked specific, individualized interventions. The interim Director of Nursing acknowledged that the care plans did not contain any information specific to the resident, and the staff assignment sheets also lacked person-centered information or interventions. The facility's policies on care planning and interventions were not followed, as evidenced by the lack of individualized care plans for residents with dementia. The policies required the interdisciplinary team to develop individualized care plans and incorporate the resident's personal and cultural preferences, as well as targeted and meaningful interventions. However, these requirements were not met for the residents reviewed, leading to deficiencies in their care plans.
Failure to Conduct Quarterly Care Plan Meetings
Penalty
Summary
The facility failed to conduct quarterly care plan meetings for three residents, as required. Resident 3 reported not remembering being invited to or attending a care plan meeting recently, and her records showed only one care plan meeting in the last year, despite having no cognitive impairment. The Social Service Director (SSD) confirmed the lack of documentation for quarterly meetings and acknowledged being behind on scheduling them. Similarly, Resident 6 was unaware of any care plan meetings and had only two documented meetings in the past year. Resident 12 also recalled attending only one meeting during her stay, with records confirming just one meeting in the last year. The SSD could not provide additional documentation for these residents, and the facility's policy required a seven-day advance notice for care plan conferences, which was not adhered to.
Delay in Treatment Following Resident Fall
Penalty
Summary
The facility failed to ensure timely treatment for a resident who experienced a fall and subsequent pain. Resident 18, who had a history of severe cognitive deficit, a fracture of the left femur, and pressure ulcers, fell on 7/4/24 and complained of left leg pain. Despite the resident's complaints and a pain assessment score of 8 out of 10, there was a delay in notifying the physician and obtaining necessary medical orders. Initial assessments noted no visible injuries, but the resident continued to experience pain, which was not promptly addressed. The nursing staff left messages for the physician and the Director of Nursing but did not receive a timely response. It was not until 7/5/24 that the physician was notified, and an x-ray was ordered, which was not completed that day. The resident was eventually sent to the hospital on 7/6/24, where an x-ray confirmed a left femoral neck fracture. The delay in treatment and lack of immediate action following the fall contributed to the deficiency identified in the report.
Inadequate Pain Management During Dressing Change
Penalty
Summary
The facility failed to provide adequate pain management for a resident during a pressure ulcer dressing change. On the morning of 9/20/24, Resident 18, who has a severe cognitive deficit and a history of pressure ulcers, was observed experiencing significant pain during a dressing change on her left heel. Despite the resident's verbal and non-verbal expressions of pain, such as wincing, clenching her jaw, and moving her foot away, the nurses continued with the procedure. It was later revealed that the resident had not been pre-medicated with pain relief prior to the dressing change, contrary to what was initially indicated by RN 13. The resident's medical records showed a history of complaints of pain during previous dressing changes, with pain assessments indicating a score of 6 out of 10. The care plan for the resident included interventions to anticipate and respond to pain, but these were not effectively implemented during the dressing change. Interviews with the nursing staff confirmed that the resident was given a pain pill only after the procedure was completed. The facility's policy on pain assessment and management was not adhered to, as the staff failed to recognize and adequately address the resident's pain during the dressing change.
Expired Medications Not Properly Disposed
Penalty
Summary
The facility failed to properly dispose of expired medications, as observed during a survey. On one occasion, a medication cart contained an opened vial of Fiasp insulin labeled for a resident with diabetes mellitus and hyperglycemia. The vial was opened on August 14, 2024, and was still in use on September 19, 2024, despite the facility's policy stating that insulin should be discarded after 28 days. Interviews with an LPN and the Regional Director of Clinical Services confirmed that the insulin was expired and should have been disposed of. Additionally, the medication storage room contained a prefilled flu vaccine syringe with an expiration date of June 30, 2024. An LPN and the Director of Nursing acknowledged that the vaccine was expired and should have been discarded. The facility's policy, provided by the RDCS, indicated that outdated drugs should not be used and must be returned to the pharmacy or destroyed. These findings highlight the facility's failure to adhere to its medication storage and disposal policies.
Failure to Use Facial Hair Restraints in Kitchen
Penalty
Summary
The facility failed to ensure the use of facial hair restraints during kitchen operations, as observed during two separate kitchen inspections. On the initial kitchen tour, the Dietary Manager (DM) was seen moving through various kitchen areas, including food storage and preparation zones, with a visible mustache but without a hair restraint. This observation was repeated during a subsequent kitchen inspection, where the DM was preparing puree food items and checking food temperatures, again without a facial hair covering. During an interview, the DM acknowledged the availability of facial hair coverings but stated that staff were not required to wear them unless they had a full beard. The DM believed that a mustache did not necessitate a facial hair covering. The facility's policy, provided by the Administrator, indicated that mustaches should not extend more than half an inch from the corner of the mouth and that dietary staff must wear hair restraints, with facial coverings required if facial hair is long enough to potentially contaminate food.
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.
