Otterbein Franklin Seniorlife Comm Res & Com Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Franklin, Indiana.
- Location
- 1070 W Jefferson St, Franklin, Indiana 46131
- CMS Provider Number
- 155771
- Inspections on file
- 36
- Latest survey
- December 4, 2025
- Citations (last 12 mo.)
- 36 (4 serious)
Citation history
Health deficiencies cited at Otterbein Franklin Seniorlife Comm Res & Com Care during CMS and state inspections, most recent first.
An allegation of abuse involving a resident was not immediately reported to the Administrator or the state survey agency as required by facility policy. The incident was documented by an activity assistant who left a note under the DON's door describing a CNA making a kicking motion toward a resident during an activity. Staff interviews confirmed the delay in reporting the allegation.
During a random kitchen inspection, surveyors found a buildup of old food, dirty containers, silverware, and dust under serving and prep areas. Dietary staff confirmed that daily cleaning was required, but the facility could not provide a cleaning policy for kitchen floors.
A resident with dementia and delirium, identified as a wander and elopement risk, exited the facility unsupervised after a wanderguard-equipped door failed to lock and alarm, and subsequently exited through sliding doors without alarms. The resident was found outside near the employee parking lot, despite interventions in place to prevent such incidents.
A severely cognitively impaired resident, identified as at risk for elopement and wearing a wanderguard, was able to exit the facility without staff knowledge after a staff member opened the elevator for her. The resident accessed the first floor, exited through the main entrance, and walked outside for several minutes before being assisted back inside. The incident revealed a failure in supervision and the effectiveness of elopement prevention measures.
Two residents were not protected from the misappropriation of their controlled medications. In one case, oxycodone tablets were missing without proper documentation, and in another, a resident received an unknown pill instead of her prescribed oxycodone. Staff discovered discrepancies in medication administration and reporting, and the DON did not promptly report the incidents as required by facility policy.
Two residents experienced misappropriation of their prescribed narcotic pain medications, with missing or substituted pills discovered by staff. In both cases, the incidents were reported to the DON but not promptly relayed to the Administrator as required by facility policy, resulting in delayed reporting to authorities.
The facility did not accurately reconcile or document controlled medications for two residents, resulting in incomplete records and unaccounted doses. In one case, a medication monitoring record for oxycodone was found with missing documentation and unexplained discrepancies. In another, a resident alleged not receiving her prescribed oxycodone, and a nurse found an unidentified pill in the medication packet. These incidents showed failures in following the facility's policy for controlled substance documentation and reconciliation.
A cognitively impaired resident with a history of exit-seeking behavior eloped from a secured memory care unit due to inadequate supervision. The resident, diagnosed with Alzheimer's and dementia, expressed a desire to go to work and was left unsupervised while a CNA assisted others. The resident exited through a courtyard door that did not latch properly and fell in the parking lot. The facility's elopement policy was not followed, leading to the incident.
The facility failed to maintain sanitary food service practices as staff were observed in the kitchen without proper hair coverings during meal preparation and plating. Despite the facility's policy requiring hair restraints, several staff members, including the Assistant Dietary Manager and Dietary Aides, had loose hair that was not covered, violating sanitation requirements.
A resident with COPD and respiratory failure was not provided continuous oxygen therapy as prescribed. Observations showed the resident without oxygen, leading to low oxygen saturation and slurred speech. The facility's policy and care plan to administer oxygen as ordered were not followed.
The facility failed to document drug dispositions for two residents upon their discharge and death, respectively. Despite having a policy requiring medication disposal in accordance with regulations, the facility did not complete the necessary records for non-narcotic medications. This deficiency was acknowledged by the Administrator and Unit Manager during interviews.
Staff failed to follow enhanced barrier precautions for a resident with a stage 3 pressure ulcer. During wound care, an RN, LPN, and CNA wore gloves but did not don gowns as required. The RN also neglected hand hygiene after changing gloves. The resident's records and facility policy mandated the use of gloves and gowns, which the administrator confirmed should have been followed.
Failure to Immediately Report Alleged Abuse to Administrator and State Agency
Penalty
Summary
The facility failed to ensure that an allegation of abuse was immediately reported to the Administrator and the state survey agency, as required by facility policy. An activity assistant made an allegation of abuse by leaving a handwritten note under the Director of Nursing's (DON) door, describing an incident where a CNA made a kicking motion toward a resident during a birthday gathering. At the time the note was left, neither the DON nor the Administrator was present in the facility. The note detailed that the resident had been redirected to her room twice and, while her back was turned, the CNA made the inappropriate motion. The resident subsequently rejoined the activity. Interviews with staff confirmed that the abuse allegation was not reported immediately to the Administrator or the state department of health, as required by the facility's policy on abuse, mistreatment, neglect, exploitation, and misappropriation of resident property. The delay in reporting was acknowledged by both the CNA and the Administrator during interviews. The documentation provided included the original handwritten note and the relevant facility policy, which clearly states the requirement for immediate reporting of abuse allegations.
Failure to Maintain Cleanliness in Kitchen Areas
Penalty
Summary
The facility failed to ensure thorough cleaning of the kitchen, as observed during a random inspection. Dietary staff indicated that kitchen floors were supposed to be swept and mopped daily, with particular attention to areas under the serving line, heat tables, and prep tables. However, during the observation, there was a noticeable buildup of old dried food particles, grapes, dirty food containers, silverware, and thick dust and debris under these areas. Additionally, the facility was unable to provide a policy regarding the cleaning of kitchen floors when requested.
Failure to Prevent Elopement of Cognitively Impaired Resident
Penalty
Summary
A cognitively impaired resident with diagnoses of dementia and delirium exited the facility without staff knowledge. The resident, who had a history of wandering and was assessed as being at risk for elopement, was wearing a wanderguard device intended to lock doors and sound an alarm when a resident at risk approaches an exit. On the day of the incident, the resident left the rehab unit, which was not a secured unit but had a door equipped with a wanderguard alarm and keypad. However, the door did not lock or alarm as intended when the resident approached, allowing her to exit. The resident then proceeded to another set of sliding glass doors, which did not have a wanderguard alarm, and exited the building. She was found by staff on a sidewalk near the employee parking lot, approximately 150 feet from the building. Interviews and record reviews confirmed that the resident had previously displayed exit-seeking behaviors and was disoriented to place, with poor safety awareness. The care plan identified her as being at risk for wandering and elopement, and she had previously attempted to follow family members out of the facility. Despite these known risks and interventions in place, the failure of the wanderguard system and lack of alarms on the sliding doors allowed the resident to leave the facility unsupervised.
Resident Elopement Due to Inadequate Supervision and Access Control
Penalty
Summary
A severely cognitively impaired resident with diagnoses including Alzheimer's disease, anxiety disorder, and osteoporosis was able to exit the facility without staff knowledge. The resident was identified as being at risk for elopement and had interventions in place, such as wearing a wanderguard and being provided with diversions and structured activities. Despite these measures, the resident was able to access an elevator after a dietary aide scanned their badge to open the elevator doors, which allowed the resident to reach the first floor and exit through the main entrance. Observations and interviews revealed that the elevator was equipped with a wanderguard alarm system, which should have sounded when the resident approached the threshold. The system required staff to scan a badge or enter a code to silence the alarm. On the day of the incident, the resident was able to use the elevator and leave the building, walking outside and around the premises for several minutes before being assisted back inside by another resident and staff. Security footage confirmed the resident's path from the elevator to the exterior and eventual re-entry into the facility. Documentation showed that the resident's care plan included elopement risk interventions, and a recent assessment had categorized the resident as low risk for elopement. However, the resident was able to leave the secured area without staff awareness, indicating a failure in supervision and the effectiveness of the elopement prevention measures in place at the time of the incident.
Failure to Protect Residents from Misappropriation of Controlled Medications
Penalty
Summary
The facility failed to protect residents from the misappropriation of controlled medications for two residents. In the first instance, a medication monitoring record for a resident with diagnoses including cerebral palsy and cervical disc disorder showed that two oxycodone 15 mg tablets were unaccounted for, with no documentation of waste, spoilage, or disposition. The discrepancy was discovered when the medication monitoring record was found in an incorrect location, and upon review, the remaining medication was missing. The resident was cognitively intact, and the medication was prescribed for pain management. In the second case, another cognitively intact resident with chronic respiratory and anxiety conditions reported that an RN had not been administering her prescribed oxycodone 15 mg, but instead was giving her an unknown white pill. Staff statements confirmed that a white pill was found taped into the resident's oxycodone packet, and that a suspicious pink liquid, purported to be destroyed oxycodone, was also observed. The resident noticed differences in her reaction to the medication and became concerned, leading to further investigation by staff. The facility's policy states that residents have the right to be free from misappropriation of property. Staff interviews and documentation revealed that the DON was made aware of both incidents but failed to report the allegations of misappropriation to the Administrator in a timely manner. The lack of proper medication reconciliation and failure to follow reporting protocols contributed to the deficiency.
Failure to Timely Report Misappropriation of Narcotic Medications
Penalty
Summary
The facility failed to report allegations of misappropriation of residents' narcotic pain medications to the Administrator in a timely manner for two residents. In the first instance, a Unit Manager discovered that two oxycodone tablets were missing from a resident's medication packet, despite the medication monitoring record indicating they should have been present. This finding was reported to the Director of Nursing (DON) on the same day, but there is no indication that it was reported to the Administrator as required. In the second instance, a nurse found an unknown white pill taped into a resident's oxycodone packet, replacing a missing oxycodone tablet. The nurse immediately reported this to the DON, but the DON did not inform the Administrator until several days later. Facility policy requires all allegations of misappropriation of resident property to be reported to the state health department immediately, but this protocol was not followed in these cases.
Failure to Accurately Reconcile and Document Controlled Medications
Penalty
Summary
The facility failed to ensure accurate reconciliation and documentation of controlled medications for two residents, resulting in incomplete records and unaccounted controlled substances. For one resident with diagnoses including cerebral palsy, spondylosis, contractures, and cervical disc disorder with myelopathy, a medication monitoring record for oxycodone 15 mg was found misplaced in a binder. The record, covering several days, showed multiple documentation errors such as missing dates, times, signatures, and amounts administered or remaining. Additionally, the final count did not account for two remaining oxycodone tablets, and the process for staff reconciliation did not consistently involve both staff members observing the controlled medication during shift changes. Another incident involved a resident with anxiety, COPD, and chronic respiratory failure, who alleged that a nurse had not been administering her prescribed oxycodone 15 mg but was instead giving her allergy pills. A nurse discovered a white pill, not matching the prescribed oxycodone, taped into the resident's oxycodone packet. The nurse also noted that the oxycodone packet was not present during the morning controlled substance reconciliation, raising further concerns about the accuracy and integrity of the medication administration and documentation process. The facility's policy required maintaining a signed medication count record for controlled substances, but the observed practices and documentation did not meet this standard. The deficiencies included incomplete and inaccurate medication monitoring records, lack of proper reconciliation procedures, and failure to account for all controlled drugs, as evidenced by the findings for both residents.
Failure to Prevent Elopement of Cognitively Impaired Resident
Penalty
Summary
The facility failed to provide adequate supervision to prevent a cognitively impaired resident from eloping from a secured memory care unit. On the morning of the incident, a resident with a history of exit-seeking behavior, diagnosed with Alzheimer's disease and dementia, expressed a desire to go to work. Despite being informed by a CNA that he did not need to work, the resident was left unsupervised while the CNA assisted another resident and a phlebotomist. During this time, the resident exited the unit through a courtyard door that did not latch properly and made his way to the parking lot, where he fell. The facility's investigation revealed that the courtyard door was unlocked, and the wooden door leading to the parking lot was found open. The resident's care plan identified him as an elopement risk and included interventions such as offering distractions and residing on a secured unit. However, these measures were not effectively implemented, leading to the resident's unsupervised exit and subsequent fall. The facility's policy on elopement, which mandates steps to protect residents from elopement risks, was not adhered to in this instance.
Failure to Maintain Sanitary Food Service Practices
Penalty
Summary
The facility failed to ensure that food was served in a sanitary and safe manner, as observed during multiple kitchen inspections. During these observations, several staff members, including the Assistant Dietary Manager, Chef, Dietary Aides, and a Kitchen Contractor, were seen in the kitchen food preparation area without their hair properly covered. This was noted during the preparation and plating of meals, where staff had loose hair that was not restrained, contrary to the facility's policy and sanitation requirements. Interviews with the Dietary Manager and the Corporate Traveling Chef confirmed that all staff were expected to keep their hair covered while in the kitchen. The facility's Employee Sanitary Practices policy, dated 2013, mandates that kitchen employees wear hair restraints to prevent hair from contacting exposed food. This policy aligns with the Retail Food Establishment Sanitation Requirements, which also require food employees to wear hair restraints. Despite these guidelines, the facility did not adhere to these standards, resulting in the observed deficiencies.
Failure to Provide Continuous Oxygen Therapy
Penalty
Summary
The facility failed to ensure continuous oxygen therapy for a resident diagnosed with Chronic Obstructive Pulmonary Disease and acute and chronic respiratory failure with hypoxia. During multiple observations, the resident was found without the prescribed oxygen therapy. On one occasion, the resident was observed in bed with the oxygen tubing out of reach, resulting in slurred speech and difficulty keeping her eyes open. A pulse oximeter reading showed an oxygen saturation level of 75 percent, significantly below the physician's order to maintain levels greater than 90 percent. After the nasal cannula was placed on the resident, her condition improved, becoming more alert with clear speech. Further observations revealed the resident propelling herself in a wheelchair in the hallway without oxygen, despite having a physician's order for continuous oxygen therapy. The facility's Oxygen Therapy Policy, which mandates administering oxygen in accordance with physician's orders, was not adhered to, as evidenced by the resident's lack of access to necessary oxygen therapy. The resident's care plan also included interventions to administer oxygen as ordered, which were not followed, leading to the deficiency.
Failure to Document Drug Dispositions for Discharged and Deceased Residents
Penalty
Summary
The facility failed to document the drug dispositions for two residents, Resident 139 and Resident 44, upon their discharge and death, respectively. Resident 139, who had multiple diagnoses including multiple sclerosis, dementia, and epilepsy, was discharged home without a documented drug disposition for their non-narcotic medications. Similarly, Resident 44, who had conditions such as hypertension, type 2 diabetes, and chronic kidney disease, passed away without a documented drug disposition for their non-narcotic medications. The facility's records lacked the necessary documentation to confirm the proper disposal of these medications. During interviews, the Administrator and Unit Manager acknowledged the absence of non-narcotic drug disposition records for these residents. The facility's policy, dated 2017, required the disposal of medications in accordance with local, state, and federal regulations, but this was not adhered to in these cases. The failure to complete the drug disposition records was identified as a deficiency in the facility's pharmaceutical services, as it did not meet the regulatory requirements for documenting the disposal of medications.
Failure to Adhere to Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that staff adhered to the required infection prevention and control protocols for a resident under enhanced barrier precautions. During an observation, a registered nurse (RN), a licensed practical nurse (LPN), and a certified nursing assistant (CNA) entered the room of a resident with a stage 3 pressure ulcer to provide wound care. Although they donned gloves, they did not wear gowns as mandated by the enhanced barrier precautions for wound care. Additionally, the RN did not perform hand hygiene after changing gloves during the procedure. The resident's clinical record indicated a diagnosis of a stage 3 pressure ulcer on the right buttock, and physician orders required the use of gloves and gowns during treatment. The resident reported that nurses never wore gowns during wound care. The facility's policy on isolation precautions, revised in August 2022, specified that gloves and gowns should be worn during high-contact resident care, including wound care. The administrator confirmed that staff should have worn gloves and gowns as per the enhanced barrier precautions.
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.
