Pilgrim Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Plymouth, Indiana.
- Location
- 222 Parkview St, Plymouth, Indiana 46563
- CMS Provider Number
- 155073
- Inspections on file
- 24
- Latest survey
- February 13, 2026
- Citations (last 12 mo.)
- 20
Citation history
Health deficiencies cited at Pilgrim Manor during CMS and state inspections, most recent first.
A facility failed to follow bowel movement protocols for a resident with Alzheimer's and constipation, leading to an ileus. Despite a care plan and bowel protocol, the facility did not document or assess bowel movements for several days, nor did they administer prescribed medications. Staff interviews revealed non-compliance with the protocol, contributing to the resident's condition.
The facility's kitchen was found to have unsanitary conditions, including improperly stored and dated food items, a malfunctioning sanitation system, and a mini freezer with heavy ice buildup. The Dietary Manager acknowledged these issues, which were not in compliance with the facility's policies on food storage and sanitation.
The facility failed to honor residents' rights to choose where to eat, as three residents reported being unable to receive meals in their rooms unless deemed too ill. Despite being cognitively intact and requiring minimal assistance, residents were encouraged to eat in the dining room, contradicting the facility's policy of allowing self-determination in daily routines.
The facility failed to provide quarterly personal fund statements to two residents, despite their policy requiring it. Both residents, who are cognitively intact, reported not receiving the statements, with one receiving only verbal updates and the other receiving just one statement since admission. The BOM confirmed the lack of a specific schedule for issuing statements and could not provide documentation of compliance with the policy.
A facility failed to conduct a timely self-administration of medication assessment for a resident. The resident was allowed to self-administer medications, with a care plan and physician's order supporting this practice. However, the last assessment was completed several months prior, and no recent assessments were available, contrary to the facility's policy requiring quarterly evaluations.
The facility failed to create comprehensive care plans for three residents with specific medical conditions. A resident with hemiplegia, seizure disorder, GERD, and glaucoma did not have a care plan for these conditions. Another resident with a splint on her wrist and finger lacked a care plan for splint use, and a resident with a pacemaker did not have a care plan for its use and care. The Director of Nursing confirmed the absence of these care plans, which is against the facility's policy requiring comprehensive, person-centered care plans.
A resident with Alzheimer's and physical debility suffered burns from spilled soup due to inadequate supervision and assistance during meals. Despite conflicting staff accounts and a physician's determination of nonthermal wounds, the facility failed to develop a care plan for burn prevention. The resident's cognitive and physical impairments increased the risk of such incidents, highlighting a lapse in implementing safety evaluations and precautions.
The facility failed to properly store and date respiratory equipment for three residents, leading to deficiencies in care. A resident's nebulizer was not stored correctly, and nasal cannula changes were not performed as ordered. Another resident's oxygen tubing was not changed, and the concentrator filter was dusty. A third resident's oxygen tubing lacked a humidification bottle, contrary to orders and policy. Staff interviews confirmed these issues.
A resident with cognitive impairment did not receive prescribed medications for constipation over several days, and the facility failed to document narcotic counts every shift. An LPN confirmed the lack of signatures in the narcotic logbook, and facility policies on medication management were not followed.
The facility failed to ensure proper storage and labeling of medications. Observations revealed loose pills in medication carts, expired glucose test strips, and an opened container of Miralax without an opened date. Staff acknowledged these issues, which were contrary to the facility's policy requiring medication carts to be clean and orderly.
The facility failed to implement enhanced barrier precautions during wound care for a resident with a pressure ulcer, as staff did not wear gowns or face masks despite a physician's order. Additionally, catheter tubing and drainage bags for another resident were improperly stored, with the drainage bag resting on the floor and the tube filled with urine, contrary to facility policy.
A resident with dementia was improperly restrained to a wheelchair using a bed sheet by two staff members, Employees 4 and 5, to prevent him from standing up. The incident was reported but not thoroughly investigated by the facility. The resident was severely cognitively impaired and dependent on a wheelchair for mobility.
A facility failed to report and investigate an alleged abuse incident where a resident was secured to a wheelchair with a sheet by two staff members. The incident was not reported to the State Agency, and the staff involved were not suspended pending investigation, contrary to the facility's abuse prevention policy. The resident, who has dementia and is wheelchair-dependent, was allegedly restrained to prevent falls, but the facility did not conduct a thorough investigation.
A resident was secured to a wheelchair with a bed sheet by two staff members, which was not reported to the State Agency. The incident involved tying the sheet behind the wheelchair, and although reported internally, no immediate action was taken against the staff involved. The resident, who was severely cognitively impaired and dependent on staff, was at risk due to this inappropriate intervention.
A resident was allegedly secured to a wheelchair with a sheet by two staff members, but the facility failed to conduct a thorough investigation. Despite the incident being reported, the involved employees were not suspended as per policy. Discrepancies in staff accounts and lack of proper investigation highlight a deficiency in handling abuse allegations.
A resident with cognitive impairments sustained second-degree burns after spilling hot tea in a facility that failed to monitor beverage temperatures. Staff interviews revealed that the facility did not check hot liquid temperatures before serving, and a hot liquid safety evaluation for the resident was not conducted until after the incident.
Failure to Follow Bowel Movement Protocols Leads to Resident's Ileus
Penalty
Summary
The facility failed to adhere to bowel movement protocols for Resident K, who was diagnosed with Alzheimer's disease and constipation. The resident's care plan, initiated in July 2024, included interventions to prevent constipation, such as administering medications as ordered and monitoring bowel movements. However, the August 2024 physician's orders did not include any as-needed medications for bowel movements, and the facility did not document any bowel movements for Resident K from August 17 to August 18, and again from August 20 to August 25, 2024. Despite the facility's bowel protocol requiring action after two days without a bowel movement, no assessments or notifications to the physician were made during these periods. On August 26, 2024, the resident's family expressed concern about abdominal swelling, leading to an abdominal x-ray that revealed an ileus. New medication orders were given, but the facility failed to administer these medications from August 26 to August 29, 2024. The resident continued to have infrequent bowel movements, with documentation showing only small bowel movements on August 26 and August 28, 2024. The facility's failure to follow the bowel protocol and administer prescribed medications contributed to the resident's condition. Interviews with facility staff revealed that the bowel movement regimen was not followed, as the protocol required specific actions after two, three, four, and five days without a bowel movement. The facility's policy outlined the need for documentation and assessment of bowel movements each shift, with evening shift nurses responsible for responding according to the protocol. Despite these guidelines, the facility did not take appropriate action, resulting in the resident's ileus and ongoing bowel issues.
Sanitation and Food Storage Deficiencies in Kitchen
Penalty
Summary
The facility failed to ensure food was stored and prepared in a sanitary manner, as observed during a survey of the kitchen. Several food items, including cream base soup, biscuit gravy mix, coconut, pasta, and spices, were found opened without proper sealing or documentation of open dates. Additionally, chopped garlic was improperly stored on a shelf instead of being refrigerated. The mini freezer was observed to have heavy ice buildup, and the sanitation bucket at the prep counter and dishwashing machine was found to have zero concentration of sanitation chemicals, indicating a malfunction in the automated sanitation disbursement system. The Dietary Manager acknowledged these issues, noting that the opened bags of food should have been sealed and dated, and the garlic should have been refrigerated. The sanitation solution was not flowing through the tubing, and it was unclear how long this had been the case. The mini freezer was not on a defrosting schedule, although it was typically unplugged monthly to defrost. The facility's policies on dietary stock procedures, freezer cleaning, and cleaning cloths and buckets were not adhered to, contributing to the unsanitary conditions observed in the kitchen.
Failure to Honor Residents' Dining Preferences
Penalty
Summary
The facility failed to honor the residents' rights to choose where to eat, as evidenced by interviews and record reviews for three residents. Resident C, who was cognitively intact and required only set-up assistance for eating, reported that she was not allowed to eat in her room unless she was too sick to go to the dining room. Staff interviews confirmed that residents on the North Hall were encouraged to eat in the dining room and would not receive meals in their rooms unless deemed too ill. This practice was in contradiction to the facility's policy, which allowed residents to choose their daily routines, including where to eat. Resident N, also cognitively intact, indicated that she had to keep food in her room because staff would not bring meals to her room if she chose not to go to the dining room. Similarly, Resident D, who was independent in eating, reported having to go to the dining room even when she did not feel well, as staff would not provide meals in her room. The Dietary Manager was unaware of any residents receiving room trays, further highlighting the facility's failure to adhere to its policy of allowing residents to exercise their rights to self-determination and participation in their daily routines.
Failure to Provide Quarterly Personal Fund Statements
Penalty
Summary
The facility failed to provide quarterly statements for personal funds to two residents, Resident 5 and Resident E, as required by their policy. Resident 5, who is cognitively intact and has diagnoses including dementia with psychotic disturbance and bipolar disorder, reported not receiving quarterly statements for her personal funds account. Instead, she was verbally informed of her account balance by the Business Office Manager (BOM) when she inquired. Similarly, Resident E, who is also cognitively intact and has diagnoses including heart failure and atrial fibrillation, indicated he had only received one quarterly statement since his admission to the facility. The BOM confirmed that residents received personal fund statements upon request or when they withdrew money, but there was no specific schedule for providing these statements. The BOM was unable to provide documentation that the residents or their representatives had received the required quarterly statements. The facility's policy, titled 'Accounting and Records,' mandates that individual financial records be available through quarterly statements and upon request. This lack of adherence to the policy resulted in the deficiency noted by the surveyors.
Failure to Conduct Timely Medication Self-Administration Assessment
Penalty
Summary
The facility failed to complete a timely self-administration of medication assessment for Resident N, who was reviewed for self-administration of medications. During an interview, Resident N stated that a nurse left her medications in her room, which she took herself. QMA 16 confirmed that it was acceptable to leave medications in Resident N's room because she was alert and oriented. The resident's care plan, initiated on 7/28/2024, indicated that she requested to administer her own medications, with interventions allowing medications to be left with her except for narcotics. A physician's order from 8/18/2024 permitted medications to be left at the bedside every shift. However, the last Self Administration of Medications Assessment was completed in May 2024, and no more recent assessments were available for August or November, despite the facility's policy requiring quarterly assessments.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for three residents with specific medical conditions. Resident 39, who had diagnoses including hemiplegia, seizure disorder, GERD, and glaucoma, did not have a care plan addressing these conditions despite receiving medications such as clopidogrel, levetiracetam, carbamazepine, pantoprazole, and dorzolamide-timolol. The Director of Nursing confirmed the absence of a care plan for these conditions during an interview. Resident 22, who had a splint on her right wrist and fifth finger, also lacked a care plan for the use of splints, despite recommendations from an Occupational Therapy Evaluation. Similarly, Resident 29, who had a pacemaker, did not have a care plan for its use and care. The Director of Nursing acknowledged the absence of care plans for both the splint and pacemaker during interviews. The facility's policy requires the Interdisciplinary Team to develop comprehensive, person-centered care plans, which was not adhered to in these cases.
Failure to Prevent Burn Incident in Resident with Cognitive Impairment
Penalty
Summary
The facility failed to prevent a burn incident involving a resident, identified as Resident M, who was reviewed for accident hazards. During a routine skin assessment, a nurse discovered blisters on Resident M's bilateral inner legs, which were believed to have resulted from hot soup being spilled on her lap. The incident was reported, and an investigation was initiated. However, there were no witnesses to confirm the exact cause of the burns. Resident M required staff assistance to eat, and her care plan was reviewed and updated following the incident. Witness statements from staff members, including CNAs and LPNs, provided conflicting accounts of the incident. CNA 16 reported that during supper, Resident M had soup in front of her, which was later found missing and allegedly spilled on her lap. CNA 19, who was present, also observed the soup spill and noted redness on Resident M's thigh. LPN 17 and RN 18 confirmed the presence of blisters during their assessments. Despite these observations, the physician determined the wounds to be nonthermal, and the facility's Regional Director of Nursing Services concluded that no further action was needed. Resident M's medical records indicated diagnoses of Alzheimer's disease, contracture of the right hand, and physical debility, with severe cognitive deficiency and a need for maximal assistance with eating. A Hot Liquid Safety Evaluation was conducted, highlighting Resident M's cognitive impairment and physical limitations that increased her risk of burns. Despite these findings, a care plan for burn prevention was not developed. The facility's policy on hot liquid safety emphasized evaluating residents for potential injury risks and implementing precautions, but these measures were not effectively applied in Resident M's case.
Deficiencies in Respiratory Equipment Management
Penalty
Summary
The facility failed to ensure proper storage and dating of respiratory equipment for three residents, leading to deficiencies in respiratory care. For Resident 53, the handheld aerosol nebulizer was repeatedly observed lying on the bedside table without a cover or proper storage, and the nasal cannula was not changed as per physician orders. The resident's care plan indicated a need for oxygen therapy and regular equipment changes, but these were not consistently followed. Interviews with the resident and staff confirmed the lack of proper storage and dating of equipment. Resident 16's oxygen tubing was not changed according to physician orders, and the oxygen concentrator filter was covered with dust on multiple occasions. The care plan required regular monitoring and equipment changes, which were not adhered to. Similarly, Resident F's oxygen tubing was connected directly to the machine without a humidification water bottle, contrary to physician orders and facility policy. Interviews with staff confirmed the absence of required equipment, and the facility's policy on oxygen administration was not followed, contributing to the deficiencies observed.
Medication Administration and Narcotic Count Deficiencies
Penalty
Summary
The facility failed to ensure that physician-ordered medications were administered and available for a resident, identified as Resident K, who had significant cognitive impairment and was frequently incontinent of bowel. Despite orders for bisacodyl, docusate sodium, and milk of magnesia to manage constipation, Resident K did not receive these medications as prescribed from August 26, 2024, to August 29, 2024. There was no documentation in the nursing progress notes or the facility's bowel tracking system to indicate that Resident K had regular bowel movements during this period. Additionally, the facility did not maintain accurate narcotic count documentation. An observation of the medication cart revealed that the narcotic logbook lacked 24 signatures, indicating that narcotic counts were not completed every shift as required. An LPN confirmed that the narcotic log sheets should have been signed every shift. The facility's policies on ordering and receiving medications and controlled medication storage were not adhered to, contributing to these deficiencies.
Medication Storage and Labeling Deficiency
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications and biologicals, as observed during a survey. On the 400 hall medication cart, six loose pills were found in three of the four main drawers. An LPN confirmed that loose pills should not be present in the medication cart. Similarly, on the 100 hall medication cart, a box of expired glucose test strips, three loose pills in two drawers, and an opened container of Miralax without an opened date were found. An RN acknowledged that loose pills should not be in the medication cart and that the laxative should have a date indicating when it was opened. The Director of Nursing provided the facility's policy on medication cart disinfecting, which stated that the medication cart should be maintained in a clean and orderly manner at all times. However, the observations indicated non-compliance with this policy, as evidenced by the presence of loose pills, expired items, and improperly labeled medications.
Infection Control Deficiencies in Wound Care and Catheter Management
Penalty
Summary
The facility failed to implement enhanced barrier precautions during wound care for a resident with multiple diagnoses, including rhabdomyolysis, atrial fibrillation, and a pressure ulcer. Despite a physician's order and a visible instruction sign for enhanced barrier precautions, staff members did not wear gowns or face masks while performing wound care. Interviews with employees confirmed that enhanced barrier precautions required the use of gowns and gloves during such procedures, indicating a lapse in adherence to infection control protocols. Additionally, the facility did not properly store catheter tubing and drainage bags for another resident with a Foley catheter. Observations revealed that the urinary catheter drainage bag was resting on the floor, and the drainage tube was filled with urine, preventing proper drainage. The facility's policy required that catheter tubing and drainage bags be kept off the floor, which was not followed in this instance. An LPN acknowledged that the drainage bag was not standard for the facility and confirmed that the tubing should not be on the floor.
Resident Improperly Restrained with Bed Sheet
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident C, was free from physical restraints, as required by regulations. On the evening of August 13, 2024, Employees 4 and 5 used a bed sheet to secure Resident C to his wheelchair by tying it around the back of the chair. This action was taken while Resident C was being supervised on the West Wing, and it was later discovered by Employee 14 when the resident was returned to his room on the East Wing. Employee 16 reported the incident to the Administrator, but no immediate action was taken against Employees 4 and 5 pending an investigation. Resident C, who has diagnoses including dementia and is severely cognitively impaired, was dependent on a wheelchair and staff assistance for locomotion needs. The resident displayed behaviors such as reaching for things and attempting to stand up from the wheelchair, which led Employees 4 and 5 to use the sheet as a restraint. Despite Employee 4's claim that the sheet was intended to provide dignity and not to restrain movement, the Director of Nursing confirmed that such an intervention was inappropriate and should have been reported. The facility did not conduct a thorough investigation into the incident, as acknowledged by the Administrator.
Failure to Report and Investigate Alleged Abuse Involving Physical Restraint
Penalty
Summary
The facility failed to implement its abuse prevention policy when an allegation of abuse involving the use of a physical restraint on a resident was not reported to the State Agency. The incident involved Resident C, who was secured to his wheelchair with a sheet by two staff members, Employees 4 and 5. Employee 16 reported the incident to the Administrator, but neither Employee 4 nor Employee 5 were suspended pending an investigation, as required by the facility's policy. Interviews revealed that Employee 5, who was supervising Resident C, did not report the incident to the Director of Nursing or the Administrator due to fear of job repercussions. Employee 4 and Employee 5 placed a bed sheet over Resident C's lap and tied it behind the wheelchair, allegedly to prevent the resident from falling or getting up. However, Employee 4 claimed the sheet was intended to provide dignity and not to restrain the resident. The Director of Nursing was unaware of the incident until the survey, although Employee 13 indicated that the Director of Nursing had discussed suspending Employee 4. The Administrator reviewed video footage and did not observe any restraint, but acknowledged that the facility failed to investigate the allegation further. Resident C, who has diagnoses including dementia and is dependent on a wheelchair, was described as severely cognitively impaired and displaying behaviors that disrupted the living environment. The facility's policy mandates immediate suspension of employees involved in abuse allegations and reporting to the Administrator, which was not followed in this case.
Failure to Report Alleged Abuse of Resident
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident, identified as Resident C, to the State Agency. The incident occurred when two staff members, Employees 4 and 5, secured Resident C to his wheelchair using a bed sheet. Employee 16 reported that on the evening of the incident, Employee 4 tied the sheet around the back of the wheelchair while Resident C was on the West Wing for supervision. This was discovered by Employee 14 when the resident was returned to his room on the East Wing. Although Employee 15 reported the incident to the Administrator, Employees 4 and 5 were not sent home pending an investigation. Employee 5 admitted to participating in the act, stating that Resident C was very active and attempting to stand up from the wheelchair. She and Employee 4 used a bed sheet to secure the resident to prevent him from falling. Employee 5 did not report the incident to the Director of Nursing (DON) or the Administrator due to fear of job repercussions. Employee 4, during a telephone interview, claimed the sheet was used to provide dignity and was not intended as a restraint, although it was tied behind the wheelchair. The Director of Nursing was unaware of the incident until the survey, despite Employee 13 indicating that the DON had discussed suspending Employee 4. The Administrator confirmed the incident was reported to her, but the facility did not conduct a thorough investigation or report the allegation to the State. Resident C's clinical record indicated severe cognitive impairment and dependency on staff for daily activities, highlighting the vulnerability of the resident involved in the incident.
Failure to Investigate Alleged Abuse of Resident
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of abuse involving Resident C, who was reportedly secured to his wheelchair with a sheet by two staff members, Employees 4 and 5. Employee 16 reported that on the evening of 8/13/24, the resident was tied to his wheelchair with a sheet by these employees. Despite the incident being reported to the Administrator, neither Employee 4 nor Employee 5 were suspended pending an investigation, as per the facility's policy. Interviews with the involved staff revealed discrepancies in their accounts. Employee 5 admitted to assisting Employee 4 in placing a sheet over Resident C's lap and tying it behind the wheelchair to prevent the resident from falling or standing up. However, Employee 4 claimed the sheet was used to provide dignity and was not intended as a restraint. The Director of Nursing was initially unaware of the incident until the survey, although it was later indicated that she had discussed suspending Employee 4. The Administrator reviewed video footage but did not observe the sheet being tied, and acknowledged that the facility did not investigate the allegation further. Resident C's clinical record indicated severe cognitive impairment and dependency on staff for daily activities, including mobility in a wheelchair. The facility's policy on abuse prevention required immediate suspension of employees pending investigation of abuse allegations, which was not followed in this case. The failure to properly investigate and address the incident involving Resident C represents a deficiency in the facility's handling of abuse allegations.
Failure to Monitor Hot Liquid Temperatures Leads to Resident Burns
Penalty
Summary
The facility failed to monitor the temperatures of coffee and hot water before serving them to residents, which led to a resident, identified as Resident B, spilling hot liquid onto her lap and sustaining second-degree burns on her legs. Observations revealed that Resident B had significant burns on both thighs, with blisters and raw tissue. Interviews with staff indicated that the kitchen and dining staff had not been checking the temperatures of hot liquids from the dispensers until after the incident occurred. Resident B, who had a history of dementia, delusional disorder, anxiety, and mild cognitive impairment, was having breakfast in the dining room when she spilled her mug of hot tea. The resident was known to use her personal large mug and required minimal assistance with meals. Staff interviews revealed that Resident B was capable of holding her own cup, but the mug was likely too hot, leading to the spill. The facility had not conducted a hot liquid safety evaluation for Resident B prior to the incident, despite her cognitive impairments and poor decision-making abilities. The Dietary Manager and other staff confirmed that the facility had not been monitoring the temperatures of hot liquids from the dispensers or carafes before the incident. The facility's policy required regular hot liquid safety evaluations and documentation of risk factors for burns, but these measures were not implemented for Resident B until after she sustained burns. The facility also lacked temperature logs for hot liquids prior to the incident, indicating a failure to adhere to their own safety protocols.
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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