Sellersburg Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Sellersburg, Indiana.
- Location
- 7823 Old State Road 60, Sellersburg, Indiana 47172
- CMS Provider Number
- 155659
- Inspections on file
- 41
- Latest survey
- June 24, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Sellersburg Healthcare Center during CMS and state inspections, most recent first.
A resident with hypotension was administered Midodrine HCl multiple times when their systolic blood pressure was above the physician-ordered hold parameter. Despite clear orders to withhold the medication if SBP exceeded 120, staff administered the medication on several occasions with SBP readings between 125 and 141, as confirmed by medication records and staff interviews.
The facility failed to administer insulin as ordered for three residents, resulting in consistent delays. A resident with diabetes experienced late administration of Lantus and Humalog, affecting blood sugar levels. Another resident faced similar issues with insulin glargine and Humalog, with late administration documented throughout September and October. A third resident, with diabetes and a below-the-knee amputation, also received insulin late, raising concerns about high blood sugar levels. Staff interviews revealed challenges in managing medication administration due to workload.
The facility failed to meet residents' meal preferences due to repeated substitutions and unavailability of scheduled menu items, leading to dissatisfaction and dietary issues. Residents reported receiving the same meals multiple times a week, and a resident on a renal diet was served unsuitable foods. Observations showed that planned menus were not followed, with substitutions made without informing residents. The facility's policies on food quality and menu planning were not adhered to, contributing to the deficiency.
The facility failed to serve meals at appropriate temperatures and ensure palatability, affecting many residents. Residents reported cold, unappealing food, and repetitive meals. Temperature checks revealed food items not meeting required temperatures, with some needing reheating or removal. A test tray showed unsatisfactory temperatures and taste. A resident on a renal diet received unsuitable foods. The facility's policy on food quality was not followed.
The facility failed to maintain sanitary conditions in the kitchen, with observations of food particles, grime, and unsanitary equipment during inspections. The cleaning schedule did not address key areas, and the facility's policy on cleanliness was not followed.
The facility failed to ensure proper infection control measures during high contact care, with CNAs observed not following hand hygiene protocols after handling soiled linens and trash. Residents with severe medical conditions, including those with tracheotomies and multidrug-resistant infections, were at risk due to these lapses. Despite previous staff education on infection control, the facility's policies were not consistently enforced, particularly in high-risk units.
The facility failed to provide adequate mobility assistance and mouth care for two residents. One resident with a below-the-knee amputation was not consistently assisted to get out of bed despite a physician's order for daily mobility. Another resident, fully dependent on staff for care, was observed with poor personal hygiene and inadequate oral care, contrary to the prescribed care plan. These deficiencies highlight a lack of adherence to care protocols for residents' daily living activities.
Two residents in the facility experienced deficiencies in perineal and catheter care, leading to urinary tract infections. A resident with an indwelling catheter received improper cleaning, and the catheter bag was mishandled, causing urine backflow. Another resident, incontinent due to impaired mobility, had a resistant bacterial infection requiring antibiotics. Facility policies on hygiene were not adequately followed, contributing to these issues.
The facility failed to increase free water flushes for a resident with a gastrostomy as ordered, and did not adhere to blood pressure medication parameters for another resident with orthostatic hypotension. The nurse practitioner did not enter the increased water flush order into the system, and the medication was administered despite the resident's SBP exceeding the prescribed limit.
A facility failed to provide indwelling catheter care for a resident upon readmission. The resident, with a history of cerebral infarction and urinary retention, had a care plan requiring catheter care every shift. However, after readmission, there was no documentation of catheter care for two days, despite the RN confirming it should be implemented upon admission.
A facility failed to implement a lab order for a resident with hypercalcemia, as a nurse practitioner did not enter the order for a BMP into the system. Despite notes indicating the need for the test, the clinical record lacked documentation of it being obtained. The DON confirmed the nurse practitioner's responsibility for entering the order, which was not fulfilled.
Failure to Hold Blood Pressure Medication per Physician Order
Penalty
Summary
A deficiency occurred when a resident with a diagnosis of hypotension received Midodrine HCl, a blood pressure medication, despite physician orders specifying that the medication should be held if the resident's systolic blood pressure (SBP) was greater than 120. The medication administration record showed multiple instances where the medication was given when the resident's SBP exceeded the ordered hold parameter, with recorded SBP values ranging from 125 to 141 at the time of administration. During interviews, a Qualified Medication Aide confirmed that medications should be held if the resident's blood pressure is outside the physician's ordered parameters. The Director of Nursing provided a copy of the facility's medication administration policy, which states that medications are to be administered only as prescribed by the provider. The failure to follow the physician's order for holding the medication was identified during a review of the resident's clinical record and medication administration documentation.
Insulin Administration Delays in LTC Facility
Penalty
Summary
The facility failed to ensure insulin was administered as ordered by the physician for three residents, leading to significant discrepancies in medication administration. Resident 207, diagnosed with type 2 diabetes mellitus, experienced multiple instances where insulin was administered late. The Medication Administration Record (MAR) showed that both Lantus and Humalog were consistently given outside the prescribed times, sometimes hours after the scheduled administration. This inconsistency in administering insulin could potentially affect the resident's blood sugar levels, as evidenced by the wide range of blood sugar readings recorded. Resident 83, also with type 2 diabetes mellitus, faced similar issues with the administration of insulin glargine and Humalog. The MAR indicated that insulin was frequently administered late, sometimes several hours past the scheduled time. This pattern of late administration was consistent throughout September and into October, with blood sugar readings reflecting a range from 123 mg/dL to 351 mg/dL. The resident's care plan emphasized the importance of timely medication administration, yet the facility failed to adhere to these orders. Resident 204, with a history of diabetes and a below-the-knee amputation, also experienced delays in receiving insulin. The MAR showed that both Lantus and Humalog were administered late on multiple occasions. Interviews with the resident revealed concerns about high blood sugar levels and uncertainty about whether insulin was received on time. Staff interviews highlighted challenges in managing medication administration due to workload, which contributed to the delays. The facility's current medication administration policy requires medications to be given within a specific time frame, which was not consistently followed, leading to the deficiencies noted.
Failure to Meet Residents' Meal Preferences and Dietary Needs
Penalty
Summary
The facility failed to meet the preferences of residents' meal choices due to the unavailability of scheduled menu items, leading to repeated substitutions and dissatisfaction among residents. During confidential interviews, residents expressed concerns about receiving the same food items multiple times a week, such as hamburgers being served four days in a row, and issues with food quality, including undercooked broccoli and cold meals. Additionally, a resident on a renal diet was served meals containing tomatoes and potatoes, which were not suitable for their dietary restrictions. Observations revealed that the facility did not follow the planned menus, resulting in substitutions without informing or consulting the residents. For instance, on one occasion, teriyaki chicken, stewed tomatoes, and mashed potatoes were served instead of the scheduled bruschetta chicken, seasoned beans, and garlic roasted red potatoes. The Dietary Manager was unaware of the substitutions and the reasons behind running out of the scheduled items. Furthermore, a temperature check of a Caesar salad showed it was not at a safe temperature, leading to its disposal and substitution with broccoli. The facility's policies on food quality and menu planning were not adhered to, as evidenced by the repeated substitutions and failure to serve meals as written. The policies required that food be prepared to conserve nutritive value and served at safe temperatures, with menus planned in advance to meet residents' nutritional needs. However, the facility did not maintain a menu substitution log or inform residents of changes, contributing to the deficiency in meeting residents' meal preferences and dietary needs.
Deficiency in Meal Temperature and Palatability
Penalty
Summary
The facility failed to ensure that meals were served at appropriate temperatures and were palatable for residents. During confidential interviews, residents expressed concerns about the food being cold, unappealing, and lacking in taste. One resident, who was diabetic, mentioned not receiving enough to eat, while another resident noted that the food often sat in the halls, causing it to cool down before reaching them. These issues were observed during two temperature checks and a meal test tray, affecting a significant number of residents. During a lunch food temperature observation, several food items did not meet the required serving temperatures. For instance, puree chicken and green beans were initially served at lower temperatures and had to be reheated. Potato soup was not served due to inadequate temperature. On another occasion, salads were found to be at inappropriate temperatures and were removed from trays. The replacement food, steamed broccoli, also failed to maintain the required temperature by the time it was served. A test tray revealed that the food items were not at appetizing temperatures, and the taste was unsatisfactory, with ravioli being dry and clumped together, and broccoli undercooked. Residents voiced additional concerns about the repetitive nature of the meals, incorrect meal deliveries, and inadequate portion sizes. One resident, who was on a renal diet, reported being served foods that were not suitable for their dietary restrictions, such as tomatoes and potatoes. The facility's policy on food quality and palatability was not adhered to, as evidenced by the failure to prepare and serve food that was palatable, attractive, and at a safe and appetizing temperature.
Facility Fails to Maintain Sanitary Kitchen Conditions
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, as observed during three separate inspections. During the initial tour, surveyors noted a greenish/gray substance around a drain in the dry storage room, a heavy accumulation of food particles and dirt under the steamer, and multiple white streaks on the steamer and oven doors. The trash can lid near the steamer was heavily soiled, and the ice maker had a coating of white/gray substance. Additionally, the stove top and tray carts were found with food particles and liquid spills, and the entire kitchen floor had a buildup of grime. Subsequent observations revealed that these issues persisted, with additional concerns such as sticky canisters and a greasy preparation sink. The facility's cleaning schedule, which was reviewed, did not address cleaning the dry storage room, food carts, preparation sink, stove, or the floor under equipment. The facility's policy on maintaining a clean environment was not adhered to, as evidenced by the ongoing unsanitary conditions in the kitchen.
Inadequate Infection Control Practices Observed
Penalty
Summary
The facility failed to ensure appropriate infection control measures were followed during high contact care, as observed in multiple instances involving Certified Nurse Aides (CNAs). During an initial tour, it was noted that several residents were under enhanced barrier precautions and droplet precautions due to multidrug-resistant organisms and respiratory infections. However, CNAs were observed handling soiled linens and trash without proper hand hygiene. For instance, CNA 39 and CNA 40 were seen carrying soiled linen bags and either not sanitizing their hands or doing so inadequately while still holding the contaminated items. Similar lapses were observed with other CNAs, who failed to wash or sanitize their hands after disposing of waste, potentially contributing to the spread of infections. The report highlights specific cases of residents with severe medical conditions, such as acute respiratory failure, tracheotomies, and multidrug-resistant infections, who were dependent on staff for all activities of daily living. Despite the critical need for stringent infection control in these cases, the facility's staff did not consistently adhere to hand hygiene protocols. For example, Resident 91, who required enhanced barrier precautions due to open wounds and indwelling medical devices, was in a unit where staff were observed not following proper hand hygiene after handling contaminated materials. This lack of compliance with infection control measures was noted despite previous education provided to staff on the importance of hand hygiene, especially in units with high infection rates. Additionally, the facility's infection prevention policies were not adequately implemented, as evidenced by the observations of CNA 4 during perineal care. The CNA did not follow the facility's policy of drying the resident after cleaning, which is a critical step in preventing skin infections and maintaining hygiene. The Infection Preventionist and other staff acknowledged the importance of hand hygiene and proper use of personal protective equipment (PPE) but did not consistently enforce these practices. The report indicates a systemic issue with infection control practices, particularly in high-risk areas such as the ventilation unit, where residents are more susceptible to infections.
Deficiencies in Mobility and Mouth Care for Residents
Penalty
Summary
The facility failed to provide adequate care related to mobility and mouth care for two residents. Resident 46, who had a below-the-knee amputation on the left leg, was observed in bed expressing a desire to get up, but was unsure why he was not assisted. His records indicated he required complete dependence on staff for transfers and needed a wheelchair for mobility. Despite a physician's order to encourage daily mobility, the resident was not consistently assisted to get out of bed. Interviews revealed that staff were aware of the resident's needs and preferences, but there was a lack of consistent action to ensure he was mobilized as required. Resident 250 was observed with greasy, tangled hair and a dry mouth with dried mucous, indicating a lack of personal care. The resident's records showed she was totally dependent on staff for activities of daily living and had a physician's order for mouth care every shift. However, observations and interviews indicated that oral care was not being provided as frequently as needed, with staff acknowledging that oral care should be done every two hours. This lack of adherence to care protocols resulted in the resident's poor personal hygiene and unmet care needs.
Inadequate Perineal and Catheter Care Leads to UTIs
Penalty
Summary
The facility failed to ensure proper prevention of urinary tract infections and adequate perineal care for two residents. Resident 4, who has an indwelling urinary catheter due to a neurogenic bladder, was observed receiving inadequate catheter care. During an incontinence care observation, CNAs used the same area of wipes multiple times to clean the resident's scrotum and penis, and did not clean the penis properly. Additionally, the catheter bag was lifted above the resident's bladder, causing urine to flow back toward the resident. The resident's urinalysis indicated a bacterial infection, and subsequent treatment with antibiotics was required. Resident 36, who is incontinent of urine due to impaired mobility, also experienced issues related to urinary tract infections. The resident's urinalysis showed the presence of Klebsiella pneumoniae ESBL, a resistant strain of bacteria, and required treatment with intravenous antibiotics. The resident's care plan included interventions for incontinence management and monitoring for signs of UTI, but the documentation lacked details on cognitive status and specific care actions taken during the resident's admission. The facility's policies on perineal and catheter care emphasize the importance of proper hygiene to reduce the risk of bacteremia and biofilm formation, which can lead to infections. However, the observations and records indicate that these policies were not adequately followed, contributing to the deficiencies noted in the care of Residents 4 and 36.
Failure to Implement Orders and Follow Medication Parameters
Penalty
Summary
The facility failed to implement an increase in free water flushes for a resident with a gastrostomy status, as ordered by a nurse practitioner. The resident's clinical record showed an elevated BUN level, indicating potential kidney function issues. Despite a nurse practitioner's note to increase the free water flushes from 30 ml to 40 ml every hour, the clinical record lacked documentation of this order being entered into the system. The Director of Nursing indicated that the nurse practitioner was responsible for entering the order, but it was not done. Additionally, the facility did not adhere to the parameters for administering blood pressure medication to another resident diagnosed with orthostatic hypotension. The resident was prescribed Midodrine HCl to be administered three times daily, with instructions to hold the medication if the systolic blood pressure (SBP) exceeded 120. However, the medication was administered multiple times when the resident's SBP was above the specified threshold. This was confirmed by a review of the medication administration records and an interview with a registered nurse, who acknowledged that medication parameters should always be followed.
Failure to Implement Indwelling Catheter Care Upon Readmission
Penalty
Summary
The facility failed to provide appropriate indwelling catheter care for a resident, identified as Resident B, upon their readmission. Resident B had a medical history that included cerebral infarction, bacterial meningitis, gastrostomy status, and urinary retention, necessitating the use of an indwelling catheter. The care plan, dated July 5, 2024, specified that catheter care should be provided every shift. However, after Resident B was readmitted to the facility following a hospital stay where the catheter was replaced, there was no documentation of catheter care on August 25 and August 26, 2024. An interview with RN 5 confirmed that catheter care should be implemented upon admission, but this was not done for Resident B, as evidenced by the lack of documentation.
Failure to Implement Laboratory Order for Resident
Penalty
Summary
The facility failed to implement a laboratory order for a resident, identified as Resident B, who was one of three residents reviewed for laboratory services. Resident B had diagnoses including cerebral infarction, respiratory failure, and hypercalcemia. A nurse practitioner noted on two occasions, first on 7/16/24 and again on 7/19/24, that a basic metabolic panel (BMP) was needed due to an elevated calcium level of 10.9, which was above the normal range of 8.5 to 10.2. However, the clinical record lacked documentation of the BMP being obtained as requested. During an interview, the Director of Nursing indicated that the nurse practitioner was responsible for entering the lab order into the system, but this was not done. The facility's policy on laboratory services was provided, which emphasized meeting the physical needs of residents, but the order was not executed, leading to the deficiency.
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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