Parkview Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Evansville, Indiana.
- Location
- 2819 North St Joseph Ave, Evansville, Indiana 47720
- CMS Provider Number
- 155348
- Inspections on file
- 30
- Latest survey
- December 11, 2025
- Citations (last 12 mo.)
- 25
Citation history
Health deficiencies cited at Parkview Care Center during CMS and state inspections, most recent first.
Surveyors found that multiple resident rooms and shared bathrooms had persistent urine odors, damaged flooring, debris, and cobwebs, despite daily cleaning routines. Residents expressed dissatisfaction with bathroom cleanliness and requested a deep cleaning schedule, while facility policy required maintaining a sanitary and comfortable environment.
Two residents admitted with wounds did not have immediate physician orders for wound care upon admission. One resident with multiple wounds, including a stage 2 pressure ulcer and a traumatic wound, experienced a delay in receiving specific treatment orders. Another resident with a recent above-knee amputation also lacked timely wound care orders, leading to concerns about missed dressing changes. Nursing staff confirmed that orders were not promptly obtained as required by facility policy.
The facility failed to properly store medications in four out of six medication carts, with loose pills found in the drawers of several carts, including Cherry Lane and Dogwood Lane. A bottle of water was also found in one cart. RN 5 confirmed that loose pills should not be present and should be placed in a drug buster. The facility's policy requires all medications to be securely locked and inaccessible to residents and visitors.
The facility failed to develop comprehensive care plans for several residents, leading to deficiencies in addressing their medical needs. A resident with a UTI lacked a care plan for infection and antibiotic use, while another on diuretics for edema had no plan for medication use or side effects. A resident with a treatment-resistant UTI and mobility issues also lacked appropriate care plans. Additionally, a resident on hospice care and diuretics, and another dependent on enteral feeding, were not adequately monitored or had care plans in place.
The facility failed to provide scheduled bathing and hygiene assistance to residents requiring help with ADLs. Several residents, including those with specific medical conditions like spinal muscular atrophy and COPD, did not receive showers or bed baths as per their care plans. Documentation showed numerous missed bathing opportunities, and staff cited time constraints and resident difficulty as reasons for non-compliance.
The facility failed to provide restorative nursing services to two residents with limited range of motion. One resident with spinal muscular atrophy and scoliosis did not receive planned passive ROM exercises, with documentation showing multiple days marked as 'not applicable' or 'resident refused.' Another resident with muscle weakness and dementia also missed active ROM exercises, with several days marked as 'not available' or left blank. The facility's policy required documentation of objectives and interventions, which was not consistently followed.
A facility failed to maintain an oxygen concentrator for a resident with COPD, as the filter was observed with dust on two occasions. The resident's records lacked documentation for cleaning the filter, contrary to the facility's policy requiring weekly maintenance. The DON confirmed the task should have been documented.
The facility failed to ensure complete documentation for two residents regarding falls. A resident with diabetes and COPD was found on the floor, and the neurological assessment was incomplete. Another resident with dementia and schizoaffective disorder experienced multiple falls, with missing vital signs and neuro checks. The DON confirmed that all documentation should be complete, as per the facility's Fall Management policy.
A facility failed to implement a communication process with hospice personnel, resulting in a lack of documented communication for a resident receiving hospice care. The resident's clinical record lacked a hospice care plan and documentation of communication between hospice and facility staff. Staff interviews revealed that not all were aware of the hospice provider's switch to an online portal, and access to hospice records was limited to certain staff members.
A facility failed to notify a physician and a resident's representative about changes in the resident's medical status, including new wounds and a UTI. The resident had multiple diagnoses and was dependent on staff for care. Documentation was lacking for notifying the physician and family about skin impairments and a UTI diagnosis, contrary to facility policies.
The facility failed to post accurate actual hours worked for nursing staff responsible for resident care for five out of six days during the survey period. Observations showed that the posted staffing sheets did not specify actual hours worked by LPNs, QMAs, and CNAs. The Director of Nursing confirmed the inability to determine actual hours from the sheets, contrary to the facility's policy.
Failure to Maintain Sanitary and Comfortable Resident Environment
Penalty
Summary
Surveyors identified that the facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents across all three units reviewed. Observations revealed strong urine odors in multiple resident bathrooms at different times of the day, as well as damaged and unclean flooring, including crumbling caulking, debris, cobwebs, and holes in linoleum. These issues were present in several shared bathrooms and resident rooms, indicating a widespread problem with cleanliness and maintenance. Interviews and record reviews further supported these findings. A housekeeper reported that resident rooms were cleaned daily, including dusting, sweeping, mopping, cleaning high-touch surfaces, removing trash, and cleaning toilets. However, resident council meeting minutes indicated ongoing dissatisfaction with the cleanliness of bathrooms, with requests for a deep cleaning schedule and specific complaints about the condition of bathroom floors. The facility's housekeeping policy required maintaining a sanitary, orderly, and comfortable interior, but the observed conditions did not meet these standards.
Failure to Obtain Immediate Wound Care Orders for Newly Admitted Residents
Penalty
Summary
The facility failed to ensure that newly admitted residents with wounds had immediate physician orders for wound care, as evidenced by the cases of two residents. For one resident with a history of a displaced intertrochanter fracture, chronic pain, fibromyalgia, and recent surgeries, the admission records indicated the presence of a stage 2 pressure ulcer, a third-degree burn, and a non-healing surgical wound. Although care plans and wound observation tools documented these wounds and their characteristics, there was a delay in obtaining specific physician orders for wound care upon admission. The only documented order for the right inner ankle wound was initiated several days after admission, and it was later clarified that the wound was traumatic rather than pressure-related. Another resident, admitted following a right above-knee amputation due to vascular issues, also lacked immediate wound care orders upon arrival. The resident's care plan referenced the need for treatment and weekly skin checks, and progress notes indicated the use of betadine and Kerlix on the surgical stump. However, the facility did not have physician orders for wound care at the time of admission, and the orders were only received and implemented after a delay. The resident expressed concern about the lack of timely dressing changes, which was attributed to the absence of hospital-provided wound care orders and a delay in obtaining them from the physician. Interviews with nursing staff and the DON confirmed that it was the responsibility of the admitting nurse to obtain wound care orders if not provided by the transferring facility. The facility's policies required immediate assessment and treatment in accordance with professional standards, but in these cases, there was a failure to secure timely physician orders for wound care upon admission, resulting in a deficiency related to the immediate care needs of residents with wounds.
Improper Storage of Medications in Facility
Penalty
Summary
The facility failed to ensure proper storage of medications in four out of six medication carts, as observed during a survey. Loose pills were found in the drawers of the Cherry Lane Medication Cart, Dogwood Lane Cart 1, and two carts on [NAME] Lane. Specific observations included various loose pills of different shapes and colors, such as small oblong white pills, broken pieces of peach pills, and small round pink pills, among others. Additionally, a bottle of water was found in the lower drawer of the Cherry Lane Medication Cart, which was acknowledged as inappropriate by RN 3 during an interview. RN 5 confirmed that there should be no loose pills in the carts and mentioned that any loose pills should be placed in a drug buster. The facility's policy on the storage and expiration dating of medications, revised on 8/7/23, was provided by the Administrator. This policy mandates that all medications must be securely locked in a cabinet or cart that is inaccessible to residents and visitors. The presence of loose pills and inappropriate items in the medication carts indicates a failure to adhere to this policy.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for several residents, leading to deficiencies in addressing their medical needs. Resident C, diagnosed with a urinary tract infection, was prescribed Keflex, an antibiotic, but lacked a care plan for the infection or antibiotic use. Similarly, Resident N, who was cognitively intact and required assistance for toileting, was on diuretics for edema but did not have a care plan addressing the use of these medications or monitoring for potential side effects. The Director of Nursing acknowledged the absence of these care plans. Resident L, with diagnoses including atrial fibrillation and diabetes, was being treated for a treatment-resistant urinary tract infection but lacked a care plan for the infection and antibiotic use. Additionally, there was no care plan addressing Resident L's mobility and assistance needs. Resident Z, who had a history of stroke and coronary artery disease, was taking antiplatelet and antianxiety medications but did not have corresponding care plans. The Director of Nursing indicated that a care plan for aspirin was not expected, but one for Ativan was. Resident J, receiving hospice care and diagnosed with heart failure and atrial fibrillation, was on a diuretic but lacked a care plan for its use. Resident V, dependent on enteral feeding, reported delays in feeding administration and had not been weighed since admission due to refusal, yet there was no alternative process for weight monitoring. The facility's policies on care plan development and changes in resident condition were not adequately followed, contributing to these deficiencies.
Failure to Provide Scheduled Bathing and Hygiene Assistance
Penalty
Summary
The facility failed to ensure that residents requiring assistance with Activities of Daily Living (ADLs) were bathed or assisted to bathe as needed. Resident V, who was completely dependent on staff for bathing, expressed a desire for more frequent complete bed baths than the once-a-week schedule provided. Documentation revealed numerous dates where Resident V did not receive a complete bath or shower, with no records of refusals. Similarly, Resident P, who required supervision for transfers and preferred showers twice a week, only received three showers in the last 30 days, all on Fridays, contrary to her scheduled days. Resident S, who needed substantial assistance with hygiene, reported not receiving bed baths on scheduled days. Documentation showed several missed bed baths over several months. Resident T, who required substantial assistance and preferred hair washing with bed baths, was observed with oily hair and reported infrequent hair washing. Records indicated multiple missed showers or bed baths with hair washing over several months. LPN 7 noted that Resident T was difficult to get up, which contributed to missed showers. Resident C, who preferred showers twice a week due to eczema, often received two bed baths instead of a shower and was observed with facial stubble despite a care plan for daily shaving. Documentation showed missed showers and bed baths on scheduled days. The DON indicated that shower sheets were not part of the clinical record, and all showers should be documented in the Point of Care (POC) Tasks. The facility's ADLs policy stated that residents unable to carry out ADLs should receive necessary services to maintain hygiene, which was not consistently followed.
Failure to Provide Restorative Nursing Services
Penalty
Summary
The facility failed to provide restorative nursing services to residents with limited range of motion, as evidenced by the cases of two residents. Resident V, who has contractures of all extremities and diagnoses including spinal muscular atrophy and scoliosis, reported not receiving restorative nursing services during a week in September. The care plan for Resident V included passive range of motion exercises, but documentation showed multiple days marked as 'not applicable' or 'resident refused,' with no further documentation to explain the lack of services. The clinical record lacked sufficient documentation to account for the days when restorative nursing was not provided. Similarly, Resident 35, diagnosed with muscle weakness and dementia, was also on a restorative program that included active range of motion exercises. However, the documentation for Resident 35 showed several days marked as 'not available' or left blank, indicating a failure to provide the planned restorative services. The facility's policy required measurable objectives and interventions to be documented in the care plan and medical record, but this was not consistently done. The administrator confirmed that residents care planned for restorative nursing should receive services daily unless specified otherwise in the care plan.
Failure to Maintain Oxygen Concentrator for Resident with COPD
Penalty
Summary
The facility failed to ensure proper maintenance of an oxygen concentrator for a resident with chronic obstructive pulmonary disease (COPD), identified as Resident P. On two separate occasions, the oxygen concentrator's filter was observed to have moderate dust accumulation, indicating it had not been cleaned as required. The resident's clinical record did not include an order for cleaning the filter in the Treatment Administration Record, despite the facility's policy that required nurses to clean the filters weekly and as needed. The Director of Nursing confirmed that the task was expected to be documented, but it was not present in the resident's records.
Incomplete Documentation of Falls for Two Residents
Penalty
Summary
The facility failed to ensure accurate and complete documentation for two residents regarding falls. Resident P, who has diagnoses including diabetes mellitus and COPD, was found on the floor in her room, believed to have rolled out of bed. The clinical record for Resident P lacked a completed neurological assessment following the fall, with several time slots on the neurological checklist left blank without documentation. The Director of Nursing (DON) confirmed that a risk assessment and complete neurological checklist should have been completed after each fall event. Similarly, Resident 12, who has diagnoses including dementia disorder and schizoaffective disorder, experienced multiple falls. The neurological checklists for these falls were incomplete, with missing vital signs and neuro checks at various intervals. The DON acknowledged that all boxes on the Neurological Check List should be completed. The facility's Fall Management policy requires documentation of vital signs with any fall event, which was not adhered to in these cases.
Failure to Implement Hospice Communication Protocol
Penalty
Summary
The facility failed to establish and implement a communication process with hospice personnel, which resulted in a lack of documented communication between the long-term care facility staff and the hospice provider for a resident receiving hospice care. The clinical record of Resident J, who had diagnoses including heart failure and atrial fibrillation, did not contain a care plan related to hospice services or any documentation of communication between hospice staff and facility staff. Additionally, there was no hospice medical record within the resident's clinical record. Interviews with facility staff revealed that the hospice provider had transitioned to using an online portal for documentation, but not all staff were aware of this change. The Director of Nursing (DON) indicated that unit managers and the infection prevention nurse had access to the hospice portal using her login credentials. However, if the DON was not present, staff would have to contact her or the hospice directly to access the records. The facility's hospice policy required a written communication protocol to ensure the needs of hospice patients were addressed, but this protocol was not effectively implemented or communicated to all relevant staff.
Failure to Notify Physician and Family of Resident's Medical Changes
Penalty
Summary
The facility failed to notify the physician and resident representative of changes in a resident's medical status, specifically for a resident with skin conditions and a urinary tract infection (UTI). The physician was not informed of a new wound, and the resident's representative was not notified of the new wound, new diagnosis, and new medication order. A family member discovered a dressing on the resident's foot and additional sores on various parts of the body, prompting a request for a skin assessment. Despite the family suspecting a UTI, lab work had not been returned, and antibiotics had not been started. The clinical record review revealed that the resident had multiple diagnoses, including hemiplegia, aphasia, atopic dermatitis, and a UTI. The most recent Minimum Data Set (MDS) assessment indicated the resident was not assessed for cognitive impairment and was dependent on staff for various needs. The facility's records lacked documentation of a care plan for the UTI and did not show that the physician or resident representative had been notified of the skin impairments. Progress notes from the nurse practitioner did not include assessments or treatments for the identified skin impairments. The Director of Nursing (DON) confirmed that documentation of notifications to the physician and family was missing from the clinical record. The facility's policies required communication of changes in a resident's status to the appropriate practitioner and family, along with proper documentation. However, these procedures were not followed, as evidenced by the lack of notification regarding the resident's skin conditions and UTI diagnosis.
Inaccurate Posting of Nurse Staffing Hours
Penalty
Summary
The facility failed to post accurate actual hours worked for licensed and unlicensed nursing staff directly responsible for resident care per shift daily for five out of six days during the annual survey period. Observations on specific dates revealed that the posted nurse staffing data sheets did not specify the actual hours worked by staff members, including LPNs, QMAs, and CNAs. For instance, on one occasion, the sheet indicated that two LPNs worked 20 hours between 7:00 A.M. and 7:00 P.M. without specifying the actual hours worked. Similar discrepancies were noted for QMAs and CNAs on other days. The Administrator provided copies of the posted nurse staffing sheets for several dates, all of which failed to reflect the actual hours worked. The Director of Nursing confirmed the inability to determine the actual hours worked from the posted sheets. The facility's policy, revised in July 2023, requires posting the total number and actual hours worked by nursing staff at the beginning of each shift, which was not adhered to during the survey period.
Latest citations in Indiana
Surveyors observed that dietary staff repeatedly worked in kitchen and meal service areas with uncovered facial hair, despite facility policy and state sanitation requirements mandating effective hair restraints. Two dietary aides with short beards or mustaches were seen walking through food preparation areas, taking food temperatures, handling food, and plating meals at steamtables in dining rooms without any facial hair coverings, while the current policy required all hair, including facial hair, to be restrained to prevent contamination.
The facility failed to consistently provide and document required bed-hold policy notices when several residents were transferred to the hospital. In multiple cases, residents with dementia, psychotic disorders, COPD, chronic respiratory failure, altered mental status, and cerebral infarction were sent out for acute changes in condition, and while transfer notes reflected physician and family notifications, they lacked documentation that the bed-hold policy was discussed with the resident or responsible party. Notices of Transfer or Discharge often indicated a copy of the bed-hold policy was sent with the resident, but the records did not show signed and dated acknowledgment by the resident or appropriate representative, including in situations where a resident had moderate cognitive impairment, short-term memory issues, or a documented need for a proxy and a financial POA authorizing an agent for health care decisions.
Surveyors found that the facility failed to provide trauma‑informed and culturally competent care by not incorporating two residents’ extensive trauma histories and specific behavioral triggers into their care plans. One resident with documented homelessness, polysubstance abuse, severe accidents with multiple fractures, viral encephalitis with coma, physical and sexual abuse, loss of family contact, and a past suicide attempt had multiple behavior‑focused care plans that referenced identifying triggers but listed none and did not mention their physical, sexual, medical, or psychosocial trauma. Another resident with TBI from being struck by a truck, an 11‑month coma, long‑term state hospital residence, alleged shooting of a parent, and diagnoses including intermittent explosive disorder and borderline personality disorder had a PASRR identifying a specific trigger and notes of inappropriate sexual behavior, yet their care plans omitted these traumatic events, the identified trigger, and the sexual behavior. Staff interviews confirmed that residents were screened for trauma, but the trauma histories and triggers were not reflected in the individualized plans of care.
A resident with schizophrenia, post‑stroke hemiparesis, and mild cognitive impairment expressed feeling down and wanting to kill himself, but staff did not document asking about a specific plan, did not notify the physician or psychiatric NP as expected, and did not develop or update a care plan addressing depression or suicidal ideation. The SSD documented offering support and initiating 15‑minute checks once, but there was no further follow‑up or documentation of interventions after subsequent suicidal statements made in a care plan meeting with the resident’s father. The DON and Administrator reported that facility policy requires immediate notification of key staff, assessment for a plan and means of self‑harm, and thorough documentation, which were not carried out or reflected in the medical record for this resident.
A resident with schizophrenia, post-stroke hemiparesis, and mild cognitive impairment verbalized suicidal ideation, but the care plan did not address depression or suicidal thoughts, and required assessments and services were not accurately or timely documented. An SSD note recorded the resident saying he wanted to kill himself and referenced 15‑minute checks and a care plan update, yet the active care plan lacked depression/suicidal ideation interventions. Multiple late-entry Social Services notes were later added, describing follow-up visits and the resident denying suicidal ideation, but the SSD later reported she did not typically ask about a suicide plan and did not personally provide individual follow-up visits as described. These practices conflicted with the facility’s policy requiring factual, first-hand, and timely documentation of assessments and services.
A resident was observed with an Albuterol inhaler on an overbed table and later reported keeping the inhaler in a nightstand drawer, with no staff present during these observations. Record review showed the resident had no cognitive impairment on the admission MDS but lacked any documented self-medication administration assessment. The DON acknowledged that the required assessment had not been completed, despite facility policy requiring staff and the practitioner to evaluate each resident’s mental and physical abilities before allowing self-administration of medications.
Surveyors found that the facility submitted inaccurate direct care staffing data to CMS through the PBJ system over multiple days in a quarter. CASPER reports showed apparent gaps in 24-hour licensed nurse coverage, low weekend staffing, and a 1-star staffing rating, while internal staffing sheets documented that licensed nurses were present and the facility was fully staffed on those days. The Administrator reported that the discrepancies were due to PBJ data entry errors, despite a facility policy requiring all PBJ entries to be accurate, auditable, and verifiable against payroll, invoices, or contracts.
Surveyors found that the facility did not provide or document required written transfer/discharge notices and bed-hold policy information for four residents who were sent to the hospital, including individuals with conditions such as dementia, CHF, chronic respiratory failure, and CKD. In each case, progress notes showed that the resident was transferred for acute issues, but the clinical records lacked evidence that written notices were given to the residents or their representatives, and in one case lacked documentation that required information was sent to the receiving provider. Facility leadership, including the ADON, DON, and Administrator, acknowledged that the records did not contain the required documentation, despite a written policy requiring such notices and information exchange.
A resident with Alzheimer’s disease and depression, previously on an antidepressant, exhibited intermittent refusals of medications and care, occasional yelling at staff, and reports of unusual perceptions, such as believing men were in or near her room. Nursing notes over several months documented these refusals and complaints but did not show that the behaviors were evaluated or recorded as dangerous, non-redirectable, or causing significant distress, nor did they document specific non-pharmacological interventions attempted or their outcomes. Despite this, a psychiatric NP later added new diagnoses of schizoaffective disorder, borderline personality disorder, and delusional disorder and ordered an antipsychotic (Seroquel) without a comprehensive evaluation in the record to support these diagnoses. The facility’s psychotropic medication policy, which requires identification and documentation of target behaviors, use of nonpharmacological interventions, and ongoing behavior monitoring, was not followed for this resident.
The facility failed to keep PASARR Level I screenings accurate and current for three residents when new mental health diagnoses and psychoactive medications were initiated. One resident’s PASARR omitted a PTSD diagnosis and an added antidepressant, despite documentation of PTSD on the MDS and care plan and a physician order for Pristiq. Another resident’s PASARR listed only depression and dementia, even after additional diagnoses such as borderline personality disorder, delusional disorder, and schizoaffective disorder were added and an antipsychotic (quetiapine) was ordered, with the MDS later reflecting psychotic disorder, schizophrenia, and depression with antipsychotic and antidepressant use. A third resident’s PASARR did not include a depression diagnosis or newly ordered escitalopram and lorazepam, although the admission MDS documented depression with antianxiety and antidepressant use. These omissions occurred despite facility policy requiring a new Level I review after significant mental status changes, including new mental health diagnoses or new psychotropic medications.
Uncovered Facial Hair During Food Preparation and Meal Service
Penalty
Summary
The deficiency involves the facility’s failure to ensure that food was served in a sanitary and safe manner in accordance with professional standards and facility policy during multiple kitchen and meal service observations. During an initial kitchen observation, two dietary aides were seen walking through the kitchen food preparation area with uncovered facial hair. One aide had facial hair above and below the lip and along the jaw line, approximately one-fourth inch in length, and the other had a mustache of similar length; neither used any facial hair covering. These observations occurred while staff were present in the kitchen area where food was stored and prepared. During subsequent observations on the same day, the same two dietary aides were again observed with uncovered facial hair while directly involved in meal preparation and service. One aide walked through the kitchen while the noon meal was being prepared and placed into a transport cart for service in the south dining room, and later was observed plating the noon meal at the steamtable in that dining room, still without a facial hair covering. The other aide walked through the kitchen while the noon meal was being prepared and placed into the steamtable for the north dining room, took food temperatures, assisted with plating meals at the steamtable, and retrieved food items and supplies from the kitchen, all while having an uncovered mustache approximately one-fourth inch in length. The Dietary Manager stated that staff hair was to be covered when in the kitchen and during meal service, and the facility’s written policy and the cited Indiana Food Establishment Sanitation Requirements both required effective hair restraints, including for facial hair, to prevent contamination of food, equipment, and utensils.
Failure to Provide and Document Bed-Hold Policy at Time of Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure that required bed-hold policy information was provided and documented for four residents transferred to the hospital. For a resident with dementia, psychotic disorder, and autistic disorder who had a BIMS score of 0 indicating severe cognitive impairment, progress notes documented physician notification and guardian notification when the resident was sent to the hospital, but there was no documentation that the bed-hold policy was provided to the responsible party. A Notice of Transfer or Discharge later indicated a copy of the bed-hold policy was sent with the resident. Another resident with COPD and chronic respiratory failure, cognitively intact with a BIMS score of 13, experienced a decline in condition and was transferred to the hospital by ambulance; progress notes documented family notification but did not document any discussion of the bed-hold policy, although a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident. A third resident with altered mental status and cerebral infarction, with a BIMS score of 10 indicating moderate cognitive impairment and documented short-term memory impairment, experienced changes in condition and was transferred to the hospital. Progress notes stated the resident was their own responsible party and that no other notification was completed, and transfer documentation did not include the bed-hold policy, although an untimed Notice of Transfer or Discharge indicated a copy of the bed-hold policy was signed by the resident. A financial power of attorney document in the record showed the resident had designated an agent to act in consent or refusal of health care. For a fourth resident with dementia and osteomyelitis, transfer documentation and a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident, and the transfer form noted the resident required a proxy for decision making. The facility’s policy required that at the time of transfer to a hospital, written notice specifying the duration of the bed-hold policy and information on return to the next available bed be provided, and that a signed and dated copy of the bed-hold notice given to the resident or representative be kept in the resident file, which was not consistently documented for these residents.
Failure to Integrate Trauma Histories and Behavioral Triggers Into Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to identify and incorporate residents’ trauma histories and specific behavioral triggers into their care plans, despite documented histories of significant trauma and behavioral health issues. For one resident, extensive social service and progress notes documented homelessness, polysubstance abuse, major depressive and anxiety disorders, chronic pain, a history of severe car accidents with multiple fractures, viral encephalitis resulting in a three‑month coma, loss of child custody, multiple divorces, physical abuse by a spouse, the death of a fiancé who was struck by a car while in a wheelchair, lack of family contact, and a past suicide attempt by Valium overdose. Additional documentation noted a history of rape by a brother at age eight and prior placement under direct supervision and 15‑minute checks related to suicidal ideation. Despite these documented traumatic events and behavioral health concerns, the resident’s care plans did not identify a history of physical trauma, sexual trauma, homelessness, substance abuse, medical trauma, or attempted suicide. For this same resident, the MDS showed no cognitive deficit and identified behaviors such as verbal aggression and rejection of care, along with diagnoses including seizure disorder, depression, chronic pain syndrome, homelessness, and anxiety disorder. Multiple care plans addressed behaviors such as drug‑seeking, pretending to have seizures for attention or medication, making false allegations, verbal aggression when unable to smoke, and a desire for intimate relationships with consenting male residents. These care plans referenced goals such as effective coping skills, seeking staff support, and compliance with the smoking policy, and they called for identification and reduction of behavioral triggers. However, none of these care plans actually listed any specific triggers. The care plan addressing the resident’s right to consensual intimate relationships focused on assessment and education regarding consent but did not integrate the resident’s extensive trauma history. Staff interviews indicated the resident had displayed sexual behaviors since admission, including an incident where the resident expressed anger at another resident for not buying a soda after engaging in sexual acts. A second resident with a documented history of traumatic brain injury (TBI), dementia, seizure disorder, borderline personality disorder, anxiety, intermittent explosive disorder, tobacco use, and other behavioral/emotional disorders was also affected by the same deficiency. Social history and progress notes documented that this resident sustained a TBI after being hit by a semi‑truck while riding a bicycle at age 18, resulting in an 11‑month coma, followed by 13 years in a state hospital and subsequent residence in a group home. Additional documentation indicated the resident allegedly shot their father at age 26 after being sworn at and had a PASRR identifying TBI, intermittent explosive disorder, and borderline personality disorder, with a specific trigger of hearing the name of the current U.S. President. Progress notes also described inappropriate sexual behavior toward staff, including touching themselves intimately during personal care and refusing to stop when redirected. Despite this, the resident’s care plans, which addressed explosive disorder and history of altercations, risk for decreased psychosocial well‑being, and refusal to bathe or shower, did not list any specific behavioral triggers, did not reference the traumatic events such as being hit by a truck or shooting their father, and did not document the inappropriate sexual behavior. The Administrator and Social Service Director acknowledged that residents were to be screened for trauma and that trauma responses and PTSD should be added to care plans, but the specific trauma histories and triggers for these two residents were not incorporated into their plans of care.
Failure to Assess and Care Plan for Resident Suicidal Ideation
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess, investigate, and care plan for a resident’s suicidal ideation in accordance with its own policy and staff expectations. The resident had diagnoses including schizophrenia, cerebral edema, and hemiparesis/hemiplegia following a cerebral infarction, and a current MDS showed mild cognitive impairment (BIMS score 12). A progress note documented that the resident told the Social Services Director (SSD) he was feeling down and wanted to kill himself; the SSD offered assistance, activities, and initiated 15‑minute checks, and the note stated the care plan was updated. However, the note did not indicate that the SSD asked whether the resident had a plan to kill himself, and there were no additional notes regarding suicidal ideation or follow‑up. Review of the current care plan showed no problem, goal, or interventions addressing depression or suicidal ideation, and progress notes over the following month contained no documentation of physician notification related to the suicidal statement. Further record and interview evidence showed that the care plan conference summary did not document interventions for suicidal ideation, and the SSD acknowledged she did not normally ask residents expressing suicidal ideation if they had a plan. The SSD reported that the resident had admission paperwork mentioning suicidal ideation related to depression after a stroke and that the resident again vocalized suicidal ideation during a care plan meeting with his father, after which emotional support was offered and the father took the resident out on a leave of absence; no further visits or follow‑up were done. The DON stated that, upon notification of suicidal verbalization, staff should assess the resident, ask if there is a plan, remove potential means of self‑harm, immediately notify the psychiatric NP, and document the occurrence, and that a detailed progress note and updated care plan were expected but not present for this resident. The Administrator similarly stated that staff should ask about a plan, document interventions, notify the physician and family, and update the care plan, and indicated the resident should have had a care plan addressing depression with suicidal ideation. The facility’s written policy required immediate notification of the DON, SSD, and physician, an interview including asking about a plan and assessing mood and means for self‑harm, and thorough documentation of mood, behavior, and all actions taken, which were not reflected in the resident’s record.
Incomplete and Inaccurate Documentation of Suicidal Ideation and Follow-Up
Penalty
Summary
The facility failed to ensure accurate, complete, and timely documentation of assessments and services for a resident who verbalized suicidal ideation. Resident 6, who had schizophrenia, cerebral edema, and right-sided hemiparesis/hemiplegia following a cerebral infarction, had a BIMS score of 12 indicating mild cognitive impairment. The resident’s admission paperwork mentioned suicidal ideation related to depression after a stroke, and a Social Services note on 3/11/2026 documented that the resident was feeling down and said he wanted to kill himself. The Social Services Director (SSD) documented that she talked with the resident, coordinated with Activities, advised the resident to contact SSD or nursing if he wanted to talk, and that the resident was scheduled for 15-minute checks and the care plan was updated. However, the current care plan initiated on 2/26/2026 did not address depression or suicidal ideation. Multiple Social Services progress notes were later entered as late entries in April, with effective dates in March, stating that the resident had no plan and no longer had suicidal ideation, that he felt much better after 1:1 time, and that he continued his daily routine and therapy. These late entries described follow-up visits and reassessments of suicidal ideation on several consecutive days, but in interviews the SSD stated she did not normally ask residents about having a plan when they verbalized suicidal ideation and did not recall any other occurrences beyond the initial event. She further indicated she did not personally provide individual follow-up visits with this resident regarding suicidal ideation, despite the late-entry notes describing such visits. The DON acknowledged that late entries had been added to address concern about suicidal verbalization, and the Administrator stated that upon suicidal statements staff should ask about a plan, notify the physician and family, and update the care plan, and that this resident should have had a care plan addressing depression with suicidal ideation. The facility’s documentation policy required factual, first-hand, timely documentation, which was not followed in this case.
Failure to Complete Required Self-Administration Assessment for Inhaler Kept at Bedside
Penalty
Summary
Surveyors identified that a resident was allowed to keep and access an Albuterol inhaler without the facility completing the required self-administration medication assessment. During an initial tour, the resident was observed sitting in a wheelchair with a handheld Albuterol inhaler on the overbed table and no staff present in the room or hallway. On a subsequent observation, the resident again was in a wheelchair and reported that the Albuterol inhaler was stored in the top drawer of the nightstand, where it was found. Review of the clinical record showed an admission MDS indicating no cognitive impairment, but there was no documentation of a self-medication administration assessment. In an interview, the DON confirmed that the resident did not have the required self-medication assessment, despite the facility’s policy stating that staff and the practitioner must assess each resident’s mental and physical abilities to determine whether self-administering medications is clinically appropriate. This failure to complete and document a self-administration medication assessment for a resident who had an Albuterol inhaler kept at bedside constituted noncompliance with the facility’s own policy and with 410 IAC 16.2-3.1-11(a).
Inaccurate PBJ Staffing Data Submission to CMS
Penalty
Summary
The deficiency involves the facility’s failure to electronically submit complete and accurate direct care staffing information to CMS through the Payroll-Based Journal (PBJ) system for 22 days in a fiscal quarter. A CASPER report review on 4/6/26 showed that, according to PBJ data, the facility did not have licensed nursing coverage 24 hours per day on multiple specific dates across three months, had low weekend staffing, and held a 1-star staffing rating. However, review of the facility’s internal staffing sheets for that quarter indicated the facility was fully staffed and had licensed nurse coverage on all of the dates in question. During an interview, the Administrator stated that the PBJ information must have contained data entry errors, as she had verified licensed staff coverage on the timesheets. The facility’s PBJ policy in effect stated that all staffing data entered into the PBJ system would be auditable and verifiable through payroll, invoices, or contracts, but the submitted PBJ data did not accurately reflect the facility’s actual licensed nurse staffing as documented on internal records. No specific residents or clinical conditions were mentioned in the report, and the deficiency centers solely on inaccurate staffing data submission rather than direct resident care events.
Failure to Provide and Document Required Transfer/Discharge and Bed-Hold Notices
Penalty
Summary
The deficiency involves the facility’s failure to provide and document required written notices of transfer/discharge and bed-hold policies, as well as required information to receiving providers, for four residents who were transferred or discharged to the hospital. For a resident with generalized anxiety disorder, major depressive disorder, and dementia, progress notes showed that the resident was sent to the hospital via 911 for chest pain, lower back pain, and shortness of breath and later returned to the facility, but the clinical record lacked documentation that a written Notice of Transfer/Discharge and the bed-hold policy were provided to the resident or representative, and lacked documentation that required information was conveyed to the receiving facility. The ADON and the Administrator both confirmed there was no documentation that these written notices were provided. For a resident with congestive heart failure and muscle weakness who was sent to the emergency room for painful urination and bloody urine, the clinical record lacked documentation that a Notice of Transfer/Discharge or bed-hold policy was given to the resident or representative, which the DON confirmed. Another resident with chronic respiratory failure and diabetes was discharged to the hospital for respiratory failure, and a resident with chronic kidney disease and dementia was discharged to the hospital, but in both cases there was no documentation that a written notice of transfer/discharge or bed-hold policy was provided to the residents or their representatives. Review of the facility’s Transfer and Discharge policy, dated 1/15/26, showed that the policy required the facility to provide written transfer/discharge notices and bed-hold information to residents and representatives and to provide specified information to receiving providers, but the records for these four residents did not contain the required documentation.
Failure to Document Target Behaviors and Non-Pharmacological Interventions Before Initiating Antipsychotic
Penalty
Summary
The deficiency involves the facility’s failure to document how a resident’s behaviors presented danger or distress to self or others, and failure to document non-pharmacological interventions attempted prior to initiating an antipsychotic medication. Resident 6 had documented diagnoses of Alzheimer’s disease, depression, and severe cognitive impairment, and was receiving sertraline for depression. A PASSAR identified only depression and dementia, and the admission MDS listed Alzheimer’s disease and depression as active diagnoses. Over several months, nursing progress notes documented that the resident intermittently reported unusual perceptions, such as believing there were men causing trouble, a man in her room, or a man wanting to marry her and yelling through the walls, but there was no documentation that these episodes caused danger to the resident or others or that they resulted in unmanageable distress. From late April through mid-July, nursing notes primarily described the resident’s frequent refusals of evening and morning medications, blood sugar checks, blood pressure checks, insulin administration, hygiene care, and showers. Staff documented that the resident sometimes yelled at staff, said “Get out!”, was visibly upset by a room move, was leery of staff and asked to see name badges, and became upset about a pillow under her head until it was removed, after which she calmed down. The notes also recorded instances where the resident believed housekeeping had not cleaned her room or that she had not received medications when she had. However, there were no progress notes or assessments indicating that these behaviors were evaluated as dangerous, non-redirectable, or causing significant distress or functional impairment, and no detailed behavior monitoring logs were present as required by facility policy. On a psychiatric NP visit for initial psychotropic medication management, new mental health diagnoses of schizoaffective disorder, borderline personality disorder, and delusional disorder were added, and Seroquel 25 mg, an antipsychotic, was ordered. The clinical record did not contain a comprehensive evaluation to support these new diagnoses, and there was no documentation of target behaviors meeting the facility’s policy criteria for psychotropic use, such as behaviors representing danger to self or others, causing distress and impairment in functional abilities, or clearly attributable to psychosis or mania. The resident’s representative reported that the resident had no prior history of mental health disorders or psychiatric hospitalization and was unaware of the new diagnoses. The facility’s own psychotropic medication policy required identification and documentation of specific target behaviors, use and documentation of nonpharmacological interventions, and ongoing monitoring of behaviors and interventions, which were not reflected in the record for this resident.
Failure to Update PASARR Screens for New Mental Health Diagnoses and Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that Preadmission Screening and Resident Review (PASARR) Level I screenings were accurate and updated when new mental health diagnoses and psychoactive medications were initiated for multiple residents. For one resident with dementia, anxiety, depression, and post-traumatic stress disorder (PTSD), the PASARR completed on admission listed anxiety, depression, and dementia with sertraline and quetiapine, but did not include the PTSD diagnosis or the antidepressant Pristiq, despite the admission MDS and care plan documenting PTSD and a subsequent physician’s order for Pristiq. For another resident with Alzheimer’s disease, borderline personality disorder, delusional disorder, schizoaffective disorder, and depression, the PASARR only reflected depression and dementia with sertraline, even though additional mental health diagnoses were added later and an antipsychotic (quetiapine) was ordered for borderline personality disorder, and the quarterly MDS documented psychotic disorder, schizophrenia, and depression with antipsychotic and antidepressant use. A third resident had diagnoses including Alzheimer’s disease, depression, anxiety disorder, irritability and anger, and nonrheumatic aortic valve stenosis. The PASARR for this resident listed dementia and anxiety with Risperdal but omitted the diagnosis of depression and the medications escitalopram and lorazepam, although physician’s orders were in place for escitalopram for depression and lorazepam for anxiety, and the admission MDS documented depression with antianxiety and antidepressant use. Interviews with the Assistant Director of Nursing confirmed that new Level I PASARR screens should have been completed when new mental health diagnoses and psychoactive medications were added, and that the PASARR for one resident, completed prior to arrival, should have included all mental health diagnoses and medications. The facility’s own policy required notification of the state mental health authority within 14 days after a significant change in mental condition and specified that a new Level I screen is required for new mental health diagnoses or newly prescribed psychotropic medications, which was not followed in these cases.
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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.
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