Seymour Crossing
Inspection history, citations, penalties and survey trends for this long-term care facility in Seymour, Indiana.
- Location
- 707 S Jackson Park Dr, Seymour, Indiana 47274
- CMS Provider Number
- 155377
- Inspections on file
- 29
- Latest survey
- January 12, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Seymour Crossing during CMS and state inspections, most recent first.
A cognitively intact resident with cardiac and hematologic conditions reported that over four hundred dollars in cash kept in her dresser went missing after she and an LPN friend had previously counted and documented a higher amount in an envelope. Financial records showed a large petty cash check from the resident’s account written directly to an LPN, contrary to the stated practice of issuing such checks for family to cash, and the administrator and DON were unaware the check had been made out to staff. In addition, several cognitively intact residents with COPD, heart failure, cerebral palsy, stroke, depression, anxiety, diabetes, and hypertension had orders for PRN or scheduled hydrocodone-acetaminophen or oxycodone-acetaminophen, and review of MARs and controlled substance records revealed multiple instances where an LPN signed out extra narcotic doses between scheduled times that were not documented as given on the MAR and were not reported as received by the residents. When confronted, an LPN admitted in a signed statement to taking residents’ narcotic medications for personal use beginning shortly after hire, constituting misappropriation of both resident funds and medications.
Multiple residents, including those with cognitive impairment and significant medical needs, were exposed to excessive heat in common areas due to a broken air conditioning unit. The facility did not monitor or document air temperatures as required by policy, and residents avoided activities and dining in affected areas. The deficiency was identified during a complaint investigation.
The facility did not have an RN on duty for eight consecutive hours on two days, as required. The DON was unsure why coverage was lacking, and the Administrator confirmed there was no specific policy for RN coverage, relying instead on State and Federal regulations.
The facility failed to follow physician orders for three residents, including not administering midodrine for low blood pressure for a resident with atrial fibrillation, administering Lisinopril-Hydrochlorothiazide despite low blood pressure for another resident, and not following nephrostomy tube care orders for a third resident. These actions were contrary to the specified medical orders and facility policies.
The facility failed to document meal consumption for two severely cognitively impaired residents, both with significant medical conditions. Despite the facility's policy requiring staff to document nutritional intake after each meal, records for these residents were incomplete on multiple occasions, leading to a deficiency in maintaining accurate documentation.
A facility failed to implement pharmacy recommendations for a resident's medication regimen. Despite a physician's agreement to switch the resident's iron therapy from ferrous sulfate to Ferrex, the change was not reflected in the EMAR, and the resident continued receiving the incorrect medication. The facility's policy required timely review and implementation of pharmacy recommendations, which was not followed in this case.
A medication error occurred when an LPN initially prepared the wrong insulin dosage for a resident without verifying the current order. Upon checking the EMAR, the LPN corrected the dosage from 2 units to 6 units, as required by the resident's blood sugar level. The facility's policy mandates a 3-way check to ensure correct medication administration.
A resident receiving Coumadin therapy experienced a significant medication error due to delayed communication of PT/INR lab results. The resident continued to receive a 7.5 mg dose of Coumadin daily without necessary adjustments, as the high PT/INR results were not communicated to the physician until several days later. The facility's process required timely communication of lab results to adjust medication dosages appropriately.
A facility failed to ensure a resident was clinically appropriate for self-administration of medication before leaving it unattended at the bedside. The resident was found with a medicine cup and bottles on her table, indicating she sometimes administered them herself. Staff interviews revealed a lack of awareness and adherence to the facility's medication policy, with no care plan or order for self-administration in place prior to the incident.
Misappropriation of Resident Funds and Narcotic Medications by Nursing Staff
Penalty
Summary
The deficiency involves the facility’s failure to prevent misappropriation of a cognitively intact resident’s money and misappropriation of multiple cognitively intact residents’ narcotic pain medications. One resident, diagnosed with heart failure, hypertension, and anemia, kept a large amount of cash in an envelope in her dresser drawer. She reported that over four hundred dollars was missing from this envelope, which she kept in her room where she had no roommate and no family visitors, and she rarely left the room except for showers or using the restroom. A close friend who was an LPN at the facility had helped her count the money the day after Christmas, documenting $510 on the outside of the envelope, but when they recounted the money in early January, only $77 remained, leaving $433 unaccounted for. The administrator later confirmed the envelope amounts and stated he had not known the resident had that much money in her possession. Further review of the resident’s financial records showed that the business office had written a petty cash check for $767 from the resident’s account payable to the same LPN, with the resident’s name in the memo line, leaving only $0.81 in the resident’s facility account. The business office manager stated that the facility’s practice was to allow residents to receive up to $50 in cash per day, and for amounts over $50, checks were written so that a resident’s family could cash them; however, in this case, the check was written directly to the LPN, who reported that she cashed the check and returned the cash to the resident. The LPN stated that after the resident made some Christmas purchases and mailed a gift to an out-of-state loved one, there was still $510 left in the envelope. The administrator and DON reported they were unaware that a check for this resident had been written in the LPN’s name, and the resident had no family involvement. The deficiency also includes misappropriation of narcotic pain medications for several cognitively intact residents with diagnoses such as COPD, cerebral palsy, heart failure, depression, anxiety, stroke, diabetes, and hypertension. For one resident receiving hydrocodone-acetaminophen as needed every eight hours, the MAR showed a single narcotic dose administered by an LPN on a specific date, while the controlled substance record showed another nurse signing out multiple doses that same day at different times. Another resident with heart failure, hypertension, diabetes, depression, and COPD had an order for hydrocodone-acetaminophen every 12 hours; the controlled substance record showed multiple doses signed out by an LPN on several days and times, including doses between scheduled intervals, while the MAR reflected only some of these administrations and lacked documentation for others. Similar discrepancies were found for two additional residents ordered oxycodone-acetaminophen as needed every six hours, where the controlled substance records showed multiple doses signed out by the same LPN at various times, but the MARs documented far fewer administrations. The administrator and DON reported that the LPN who began working in early August had initially done well in orientation, but it was later reported that she appeared to have signed out too many narcotic pills over a weekend. Upon investigation, the DON identified multiple instances where this LPN had signed out narcotic doses between scheduled times for residents. Interviews with the involved residents confirmed they received their scheduled pain medications but did not receive any additional doses beyond what was ordered. When confronted with documentation showing narcotics signed out outside of scheduled doses, the LPN admitted in a written, signed statement that she had been taking narcotic medications from residents for her own use starting about two weeks after hire. A nurse described that narcotics were kept under double lock in medication carts, with each administration documented in a narcotic count book, and a random count of one cart on the day of survey was correct. The facility’s abuse policy defined misappropriation of resident funds or property as wrongful use of a resident’s property or money without consent, which was not adhered to in these instances.
Failure to Maintain Safe and Comfortable Environment Due to Excessive Heat
Penalty
Summary
The facility failed to maintain a safe, comfortable, and homelike environment for five of seven residents reviewed, as evidenced by excessive heat in common areas due to a broken air conditioning unit. Resident B, who was cognitively intact and had diagnoses including hypertension, diabetes, and asthma, reported that the air conditioning in the hallway and dining room was broken, causing him to avoid these areas due to excessive heat. He stopped attending activities and sometimes avoided eating in the dining room. The Maintenance Director confirmed that the air conditioning unit serving the B hallway, kitchen, and dining room had been nonfunctional for about two months and required replacement. During this period, the facility did not have a thermometer to monitor air temperatures and relied on thermostats, which showed temperatures in the common areas ranging from 81 to 83 degrees Fahrenheit. Observations revealed that the main dining room, where multiple residents were eating, was affected by heat from the kitchen, as the door was propped open. Residents D, E, F, and G, all of whom were severely cognitively impaired, required extensive staff assistance for mobility, and had significant medical conditions, were present in the restorative dining area during these conditions. The facility's Emergency Operations Plan required monitoring and documentation of ambient air temperatures and specified actions if temperatures exceeded 81 degrees Fahrenheit, but these procedures were not followed. The deficiency was identified during a complaint investigation and related to the facility's failure to ensure a safe and comfortable environment as required.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide the required Registered Nurse (RN) coverage for eight consecutive hours a day on two specific days, as identified during a review of the nursing schedule from July to September 2024. On Saturday, September 28, 2024, and Sunday, September 29, 2024, there was no RN on duty for the required duration. During an interview, the Director of Nursing (DON) acknowledged that the schedule typically included an RN for eight hours each day but was unsure why coverage was lacking on those two days. The facility's Administrator confirmed that there was no specific policy for RN coverage, and they adhered to State and Federal regulations without any nursing waivers in place.
Failure to Follow Physician Orders for Medication and Treatment
Penalty
Summary
The facility failed to adhere to physician's medication hold parameters and treatment orders for three residents. Resident 18, who was cognitively intact and had diagnoses including atrial fibrillation and renal insufficiency, did not receive midodrine as ordered when their blood pressure was below 110 on multiple occasions. Despite having an order to administer midodrine for low blood pressure, the medication was not given when the resident's blood pressure readings were below the specified threshold. Interviews confirmed that the medication should have been administered according to the physician's order. Resident 70, also cognitively intact, had an order to hold Lisinopril-Hydrochlorothiazide if their systolic blood pressure was less than 130. However, the medication was administered on several occasions when the resident's blood pressure was below this parameter. Additionally, Resident 38's nephrostomy tube care was not performed according to the physician's order, which specified cleansing with soap and water. Instead, normal saline was used, contrary to the order. The facility's policies were not followed, and there was no specific policy on adhering to physician orders, which was considered standard practice.
Failure to Document Meal Consumption for Cognitively Impaired Residents
Penalty
Summary
The facility failed to document meal consumption for two residents who were severely cognitively impaired. Resident 16, with diagnoses including hypertension, diabetes, non-Alzheimer's dementia, anxiety, and depression, had missing meal consumption records on multiple occasions throughout January and February 2025. These omissions included several meals such as dinner, lunch, and breakfast on specific dates, indicating a lack of consistent documentation of the resident's nutritional intake. Similarly, Resident 36, who was also severely cognitively impaired and diagnosed with anemia, heart failure, hypertension, non-Alzheimer's dementia, and depression, experienced weight loss without being on a prescribed weight loss regimen. The resident's meal consumption records were incomplete on several dates, mirroring the pattern observed with Resident 16. During an interview, a CNA confirmed that staff were responsible for documenting meal consumption after each meal, as per the facility's policy. However, the records for these residents were not consistently maintained, leading to a deficiency in documenting nutritional intake.
Failure to Implement Pharmacy Recommendations for Resident's Medication
Penalty
Summary
The facility failed to follow pharmacy recommendations for a resident reviewed for medication irregularities. The resident, who was moderately cognitively impaired, had diagnoses including hypertension, diabetes, cirrhosis, malnutrition, and anemia. A Pharmacy Consultation Report recommended optimizing the resident's iron therapy by switching from ferrous sulfate 325 mg every other day to Ferrex 150 mg daily. Although the physician agreed with this recommendation, the change was not implemented in the resident's medication administration record. The February 2025 Electronic Medication Administration Record showed that the resident continued to receive ferrous sulfate every other day, and there was no new order for Ferrex 150 mg daily. During an interview, the IP Nurse indicated that the signed recommendations were given to the nurse responsible for the resident's care to transcribe the physician's order, but the medication changes were not made. The facility's policy required pharmacy recommendations to be reviewed and followed up by the physician within 30 days, but this process was not completed for the resident in question.
Medication Error in Insulin Administration
Penalty
Summary
The facility failed to prevent a medication error during the administration of insulin to Resident 69. During an observation, an LPN prepared to administer 2 units of insulin without verifying the resident's current insulin order on the computer. Upon being prompted to verify the order, the LPN checked the Electronic Medication Administration Record (EMAR) and discovered that the resident's blood sugar level of 207 required 6 units of insulin according to the sliding scale order. The LPN then corrected the dosage and administered the correct amount of insulin to the resident. The clinical record for Resident 69 included a physician's order for insulin administration based on a sliding scale, which specified different insulin dosages according to blood sugar levels. The facility's policy on medication administration required a 3-way check to ensure the correct medication, dose, route, rate, time, and resident. The LPN initially failed to follow this policy by not verifying the insulin order before preparing the medication, leading to a potential medication error.
Failure to Prevent Significant Medication Error in Coumadin Therapy
Penalty
Summary
The facility failed to prevent a significant medication error for a resident who was receiving Coumadin therapy. The resident, who was cognitively intact and had diagnoses including hypertension, diabetes, anxiety, depression, and cerebrovascular accident, was supposed to have their PT/INR levels monitored to adjust the Coumadin dosage accordingly. However, the PT/INR lab results, which were drawn on a Friday, were not received by the facility until the following Monday. During this period, the resident continued to receive the prescribed 7.5 mg dose of Coumadin daily without the necessary adjustment based on the lab results. The facility's process required that the PT/INR results be communicated to the physician before administering the next dose of Coumadin. Despite this, the results indicating a high PT/INR were not communicated to the physician until several days later. The Director of Nursing acknowledged that the staff should have contacted the Nurse Practitioner on the day the lab was drawn to verify the medication dosage. This oversight led to the resident receiving potentially inappropriate doses of Coumadin for several days.
Failure to Ensure Clinical Appropriateness for Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a resident was clinically appropriate for self-administration of medication before leaving medication unattended at the bedside. During an observation, a resident was found in her wheelchair with a medicine cup filled with various colored pills on her bedside table and two separate medicine bottles with liquid drop medications on the bed. The resident indicated that the nurse left the medications on the table for her to take while she was in the restroom, and she sometimes administered them herself. No staff were present in the room or within sight of the resident at the time. Interviews with facility staff revealed a lack of awareness and adherence to the facility's medication administration policy. A Qualified Medication Aide mentioned the presence of a confused resident who wandered the hallway regularly, while an LPN stated she was unaware of any residents self-administering medications and emphasized that staff should remain in the room until medication is taken. The Director of Nursing confirmed that the resident lacked a care plan and an order for self-administration prior to the incident. The resident's clinical record, reviewed after the observation, showed no assessment or order for self-administration until after the deficiency was noted.
Latest citations in Indiana
Surveyors observed that dietary staff repeatedly worked in kitchen and meal service areas with uncovered facial hair, despite facility policy and state sanitation requirements mandating effective hair restraints. Two dietary aides with short beards or mustaches were seen walking through food preparation areas, taking food temperatures, handling food, and plating meals at steamtables in dining rooms without any facial hair coverings, while the current policy required all hair, including facial hair, to be restrained to prevent contamination.
The facility failed to consistently provide and document required bed-hold policy notices when several residents were transferred to the hospital. In multiple cases, residents with dementia, psychotic disorders, COPD, chronic respiratory failure, altered mental status, and cerebral infarction were sent out for acute changes in condition, and while transfer notes reflected physician and family notifications, they lacked documentation that the bed-hold policy was discussed with the resident or responsible party. Notices of Transfer or Discharge often indicated a copy of the bed-hold policy was sent with the resident, but the records did not show signed and dated acknowledgment by the resident or appropriate representative, including in situations where a resident had moderate cognitive impairment, short-term memory issues, or a documented need for a proxy and a financial POA authorizing an agent for health care decisions.
Surveyors found that the facility failed to provide trauma‑informed and culturally competent care by not incorporating two residents’ extensive trauma histories and specific behavioral triggers into their care plans. One resident with documented homelessness, polysubstance abuse, severe accidents with multiple fractures, viral encephalitis with coma, physical and sexual abuse, loss of family contact, and a past suicide attempt had multiple behavior‑focused care plans that referenced identifying triggers but listed none and did not mention their physical, sexual, medical, or psychosocial trauma. Another resident with TBI from being struck by a truck, an 11‑month coma, long‑term state hospital residence, alleged shooting of a parent, and diagnoses including intermittent explosive disorder and borderline personality disorder had a PASRR identifying a specific trigger and notes of inappropriate sexual behavior, yet their care plans omitted these traumatic events, the identified trigger, and the sexual behavior. Staff interviews confirmed that residents were screened for trauma, but the trauma histories and triggers were not reflected in the individualized plans of care.
A resident with schizophrenia, post‑stroke hemiparesis, and mild cognitive impairment expressed feeling down and wanting to kill himself, but staff did not document asking about a specific plan, did not notify the physician or psychiatric NP as expected, and did not develop or update a care plan addressing depression or suicidal ideation. The SSD documented offering support and initiating 15‑minute checks once, but there was no further follow‑up or documentation of interventions after subsequent suicidal statements made in a care plan meeting with the resident’s father. The DON and Administrator reported that facility policy requires immediate notification of key staff, assessment for a plan and means of self‑harm, and thorough documentation, which were not carried out or reflected in the medical record for this resident.
A resident with schizophrenia, post-stroke hemiparesis, and mild cognitive impairment verbalized suicidal ideation, but the care plan did not address depression or suicidal thoughts, and required assessments and services were not accurately or timely documented. An SSD note recorded the resident saying he wanted to kill himself and referenced 15‑minute checks and a care plan update, yet the active care plan lacked depression/suicidal ideation interventions. Multiple late-entry Social Services notes were later added, describing follow-up visits and the resident denying suicidal ideation, but the SSD later reported she did not typically ask about a suicide plan and did not personally provide individual follow-up visits as described. These practices conflicted with the facility’s policy requiring factual, first-hand, and timely documentation of assessments and services.
A resident was observed with an Albuterol inhaler on an overbed table and later reported keeping the inhaler in a nightstand drawer, with no staff present during these observations. Record review showed the resident had no cognitive impairment on the admission MDS but lacked any documented self-medication administration assessment. The DON acknowledged that the required assessment had not been completed, despite facility policy requiring staff and the practitioner to evaluate each resident’s mental and physical abilities before allowing self-administration of medications.
Surveyors found that the facility submitted inaccurate direct care staffing data to CMS through the PBJ system over multiple days in a quarter. CASPER reports showed apparent gaps in 24-hour licensed nurse coverage, low weekend staffing, and a 1-star staffing rating, while internal staffing sheets documented that licensed nurses were present and the facility was fully staffed on those days. The Administrator reported that the discrepancies were due to PBJ data entry errors, despite a facility policy requiring all PBJ entries to be accurate, auditable, and verifiable against payroll, invoices, or contracts.
Surveyors found that the facility did not provide or document required written transfer/discharge notices and bed-hold policy information for four residents who were sent to the hospital, including individuals with conditions such as dementia, CHF, chronic respiratory failure, and CKD. In each case, progress notes showed that the resident was transferred for acute issues, but the clinical records lacked evidence that written notices were given to the residents or their representatives, and in one case lacked documentation that required information was sent to the receiving provider. Facility leadership, including the ADON, DON, and Administrator, acknowledged that the records did not contain the required documentation, despite a written policy requiring such notices and information exchange.
A resident with Alzheimer’s disease and depression, previously on an antidepressant, exhibited intermittent refusals of medications and care, occasional yelling at staff, and reports of unusual perceptions, such as believing men were in or near her room. Nursing notes over several months documented these refusals and complaints but did not show that the behaviors were evaluated or recorded as dangerous, non-redirectable, or causing significant distress, nor did they document specific non-pharmacological interventions attempted or their outcomes. Despite this, a psychiatric NP later added new diagnoses of schizoaffective disorder, borderline personality disorder, and delusional disorder and ordered an antipsychotic (Seroquel) without a comprehensive evaluation in the record to support these diagnoses. The facility’s psychotropic medication policy, which requires identification and documentation of target behaviors, use of nonpharmacological interventions, and ongoing behavior monitoring, was not followed for this resident.
The facility failed to keep PASARR Level I screenings accurate and current for three residents when new mental health diagnoses and psychoactive medications were initiated. One resident’s PASARR omitted a PTSD diagnosis and an added antidepressant, despite documentation of PTSD on the MDS and care plan and a physician order for Pristiq. Another resident’s PASARR listed only depression and dementia, even after additional diagnoses such as borderline personality disorder, delusional disorder, and schizoaffective disorder were added and an antipsychotic (quetiapine) was ordered, with the MDS later reflecting psychotic disorder, schizophrenia, and depression with antipsychotic and antidepressant use. A third resident’s PASARR did not include a depression diagnosis or newly ordered escitalopram and lorazepam, although the admission MDS documented depression with antianxiety and antidepressant use. These omissions occurred despite facility policy requiring a new Level I review after significant mental status changes, including new mental health diagnoses or new psychotropic medications.
Uncovered Facial Hair During Food Preparation and Meal Service
Penalty
Summary
The deficiency involves the facility’s failure to ensure that food was served in a sanitary and safe manner in accordance with professional standards and facility policy during multiple kitchen and meal service observations. During an initial kitchen observation, two dietary aides were seen walking through the kitchen food preparation area with uncovered facial hair. One aide had facial hair above and below the lip and along the jaw line, approximately one-fourth inch in length, and the other had a mustache of similar length; neither used any facial hair covering. These observations occurred while staff were present in the kitchen area where food was stored and prepared. During subsequent observations on the same day, the same two dietary aides were again observed with uncovered facial hair while directly involved in meal preparation and service. One aide walked through the kitchen while the noon meal was being prepared and placed into a transport cart for service in the south dining room, and later was observed plating the noon meal at the steamtable in that dining room, still without a facial hair covering. The other aide walked through the kitchen while the noon meal was being prepared and placed into the steamtable for the north dining room, took food temperatures, assisted with plating meals at the steamtable, and retrieved food items and supplies from the kitchen, all while having an uncovered mustache approximately one-fourth inch in length. The Dietary Manager stated that staff hair was to be covered when in the kitchen and during meal service, and the facility’s written policy and the cited Indiana Food Establishment Sanitation Requirements both required effective hair restraints, including for facial hair, to prevent contamination of food, equipment, and utensils.
Failure to Provide and Document Bed-Hold Policy at Time of Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure that required bed-hold policy information was provided and documented for four residents transferred to the hospital. For a resident with dementia, psychotic disorder, and autistic disorder who had a BIMS score of 0 indicating severe cognitive impairment, progress notes documented physician notification and guardian notification when the resident was sent to the hospital, but there was no documentation that the bed-hold policy was provided to the responsible party. A Notice of Transfer or Discharge later indicated a copy of the bed-hold policy was sent with the resident. Another resident with COPD and chronic respiratory failure, cognitively intact with a BIMS score of 13, experienced a decline in condition and was transferred to the hospital by ambulance; progress notes documented family notification but did not document any discussion of the bed-hold policy, although a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident. A third resident with altered mental status and cerebral infarction, with a BIMS score of 10 indicating moderate cognitive impairment and documented short-term memory impairment, experienced changes in condition and was transferred to the hospital. Progress notes stated the resident was their own responsible party and that no other notification was completed, and transfer documentation did not include the bed-hold policy, although an untimed Notice of Transfer or Discharge indicated a copy of the bed-hold policy was signed by the resident. A financial power of attorney document in the record showed the resident had designated an agent to act in consent or refusal of health care. For a fourth resident with dementia and osteomyelitis, transfer documentation and a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident, and the transfer form noted the resident required a proxy for decision making. The facility’s policy required that at the time of transfer to a hospital, written notice specifying the duration of the bed-hold policy and information on return to the next available bed be provided, and that a signed and dated copy of the bed-hold notice given to the resident or representative be kept in the resident file, which was not consistently documented for these residents.
Failure to Integrate Trauma Histories and Behavioral Triggers Into Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to identify and incorporate residents’ trauma histories and specific behavioral triggers into their care plans, despite documented histories of significant trauma and behavioral health issues. For one resident, extensive social service and progress notes documented homelessness, polysubstance abuse, major depressive and anxiety disorders, chronic pain, a history of severe car accidents with multiple fractures, viral encephalitis resulting in a three‑month coma, loss of child custody, multiple divorces, physical abuse by a spouse, the death of a fiancé who was struck by a car while in a wheelchair, lack of family contact, and a past suicide attempt by Valium overdose. Additional documentation noted a history of rape by a brother at age eight and prior placement under direct supervision and 15‑minute checks related to suicidal ideation. Despite these documented traumatic events and behavioral health concerns, the resident’s care plans did not identify a history of physical trauma, sexual trauma, homelessness, substance abuse, medical trauma, or attempted suicide. For this same resident, the MDS showed no cognitive deficit and identified behaviors such as verbal aggression and rejection of care, along with diagnoses including seizure disorder, depression, chronic pain syndrome, homelessness, and anxiety disorder. Multiple care plans addressed behaviors such as drug‑seeking, pretending to have seizures for attention or medication, making false allegations, verbal aggression when unable to smoke, and a desire for intimate relationships with consenting male residents. These care plans referenced goals such as effective coping skills, seeking staff support, and compliance with the smoking policy, and they called for identification and reduction of behavioral triggers. However, none of these care plans actually listed any specific triggers. The care plan addressing the resident’s right to consensual intimate relationships focused on assessment and education regarding consent but did not integrate the resident’s extensive trauma history. Staff interviews indicated the resident had displayed sexual behaviors since admission, including an incident where the resident expressed anger at another resident for not buying a soda after engaging in sexual acts. A second resident with a documented history of traumatic brain injury (TBI), dementia, seizure disorder, borderline personality disorder, anxiety, intermittent explosive disorder, tobacco use, and other behavioral/emotional disorders was also affected by the same deficiency. Social history and progress notes documented that this resident sustained a TBI after being hit by a semi‑truck while riding a bicycle at age 18, resulting in an 11‑month coma, followed by 13 years in a state hospital and subsequent residence in a group home. Additional documentation indicated the resident allegedly shot their father at age 26 after being sworn at and had a PASRR identifying TBI, intermittent explosive disorder, and borderline personality disorder, with a specific trigger of hearing the name of the current U.S. President. Progress notes also described inappropriate sexual behavior toward staff, including touching themselves intimately during personal care and refusing to stop when redirected. Despite this, the resident’s care plans, which addressed explosive disorder and history of altercations, risk for decreased psychosocial well‑being, and refusal to bathe or shower, did not list any specific behavioral triggers, did not reference the traumatic events such as being hit by a truck or shooting their father, and did not document the inappropriate sexual behavior. The Administrator and Social Service Director acknowledged that residents were to be screened for trauma and that trauma responses and PTSD should be added to care plans, but the specific trauma histories and triggers for these two residents were not incorporated into their plans of care.
Failure to Assess and Care Plan for Resident Suicidal Ideation
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess, investigate, and care plan for a resident’s suicidal ideation in accordance with its own policy and staff expectations. The resident had diagnoses including schizophrenia, cerebral edema, and hemiparesis/hemiplegia following a cerebral infarction, and a current MDS showed mild cognitive impairment (BIMS score 12). A progress note documented that the resident told the Social Services Director (SSD) he was feeling down and wanted to kill himself; the SSD offered assistance, activities, and initiated 15‑minute checks, and the note stated the care plan was updated. However, the note did not indicate that the SSD asked whether the resident had a plan to kill himself, and there were no additional notes regarding suicidal ideation or follow‑up. Review of the current care plan showed no problem, goal, or interventions addressing depression or suicidal ideation, and progress notes over the following month contained no documentation of physician notification related to the suicidal statement. Further record and interview evidence showed that the care plan conference summary did not document interventions for suicidal ideation, and the SSD acknowledged she did not normally ask residents expressing suicidal ideation if they had a plan. The SSD reported that the resident had admission paperwork mentioning suicidal ideation related to depression after a stroke and that the resident again vocalized suicidal ideation during a care plan meeting with his father, after which emotional support was offered and the father took the resident out on a leave of absence; no further visits or follow‑up were done. The DON stated that, upon notification of suicidal verbalization, staff should assess the resident, ask if there is a plan, remove potential means of self‑harm, immediately notify the psychiatric NP, and document the occurrence, and that a detailed progress note and updated care plan were expected but not present for this resident. The Administrator similarly stated that staff should ask about a plan, document interventions, notify the physician and family, and update the care plan, and indicated the resident should have had a care plan addressing depression with suicidal ideation. The facility’s written policy required immediate notification of the DON, SSD, and physician, an interview including asking about a plan and assessing mood and means for self‑harm, and thorough documentation of mood, behavior, and all actions taken, which were not reflected in the resident’s record.
Incomplete and Inaccurate Documentation of Suicidal Ideation and Follow-Up
Penalty
Summary
The facility failed to ensure accurate, complete, and timely documentation of assessments and services for a resident who verbalized suicidal ideation. Resident 6, who had schizophrenia, cerebral edema, and right-sided hemiparesis/hemiplegia following a cerebral infarction, had a BIMS score of 12 indicating mild cognitive impairment. The resident’s admission paperwork mentioned suicidal ideation related to depression after a stroke, and a Social Services note on 3/11/2026 documented that the resident was feeling down and said he wanted to kill himself. The Social Services Director (SSD) documented that she talked with the resident, coordinated with Activities, advised the resident to contact SSD or nursing if he wanted to talk, and that the resident was scheduled for 15-minute checks and the care plan was updated. However, the current care plan initiated on 2/26/2026 did not address depression or suicidal ideation. Multiple Social Services progress notes were later entered as late entries in April, with effective dates in March, stating that the resident had no plan and no longer had suicidal ideation, that he felt much better after 1:1 time, and that he continued his daily routine and therapy. These late entries described follow-up visits and reassessments of suicidal ideation on several consecutive days, but in interviews the SSD stated she did not normally ask residents about having a plan when they verbalized suicidal ideation and did not recall any other occurrences beyond the initial event. She further indicated she did not personally provide individual follow-up visits with this resident regarding suicidal ideation, despite the late-entry notes describing such visits. The DON acknowledged that late entries had been added to address concern about suicidal verbalization, and the Administrator stated that upon suicidal statements staff should ask about a plan, notify the physician and family, and update the care plan, and that this resident should have had a care plan addressing depression with suicidal ideation. The facility’s documentation policy required factual, first-hand, timely documentation, which was not followed in this case.
Failure to Complete Required Self-Administration Assessment for Inhaler Kept at Bedside
Penalty
Summary
Surveyors identified that a resident was allowed to keep and access an Albuterol inhaler without the facility completing the required self-administration medication assessment. During an initial tour, the resident was observed sitting in a wheelchair with a handheld Albuterol inhaler on the overbed table and no staff present in the room or hallway. On a subsequent observation, the resident again was in a wheelchair and reported that the Albuterol inhaler was stored in the top drawer of the nightstand, where it was found. Review of the clinical record showed an admission MDS indicating no cognitive impairment, but there was no documentation of a self-medication administration assessment. In an interview, the DON confirmed that the resident did not have the required self-medication assessment, despite the facility’s policy stating that staff and the practitioner must assess each resident’s mental and physical abilities to determine whether self-administering medications is clinically appropriate. This failure to complete and document a self-administration medication assessment for a resident who had an Albuterol inhaler kept at bedside constituted noncompliance with the facility’s own policy and with 410 IAC 16.2-3.1-11(a).
Inaccurate PBJ Staffing Data Submission to CMS
Penalty
Summary
The deficiency involves the facility’s failure to electronically submit complete and accurate direct care staffing information to CMS through the Payroll-Based Journal (PBJ) system for 22 days in a fiscal quarter. A CASPER report review on 4/6/26 showed that, according to PBJ data, the facility did not have licensed nursing coverage 24 hours per day on multiple specific dates across three months, had low weekend staffing, and held a 1-star staffing rating. However, review of the facility’s internal staffing sheets for that quarter indicated the facility was fully staffed and had licensed nurse coverage on all of the dates in question. During an interview, the Administrator stated that the PBJ information must have contained data entry errors, as she had verified licensed staff coverage on the timesheets. The facility’s PBJ policy in effect stated that all staffing data entered into the PBJ system would be auditable and verifiable through payroll, invoices, or contracts, but the submitted PBJ data did not accurately reflect the facility’s actual licensed nurse staffing as documented on internal records. No specific residents or clinical conditions were mentioned in the report, and the deficiency centers solely on inaccurate staffing data submission rather than direct resident care events.
Failure to Provide and Document Required Transfer/Discharge and Bed-Hold Notices
Penalty
Summary
The deficiency involves the facility’s failure to provide and document required written notices of transfer/discharge and bed-hold policies, as well as required information to receiving providers, for four residents who were transferred or discharged to the hospital. For a resident with generalized anxiety disorder, major depressive disorder, and dementia, progress notes showed that the resident was sent to the hospital via 911 for chest pain, lower back pain, and shortness of breath and later returned to the facility, but the clinical record lacked documentation that a written Notice of Transfer/Discharge and the bed-hold policy were provided to the resident or representative, and lacked documentation that required information was conveyed to the receiving facility. The ADON and the Administrator both confirmed there was no documentation that these written notices were provided. For a resident with congestive heart failure and muscle weakness who was sent to the emergency room for painful urination and bloody urine, the clinical record lacked documentation that a Notice of Transfer/Discharge or bed-hold policy was given to the resident or representative, which the DON confirmed. Another resident with chronic respiratory failure and diabetes was discharged to the hospital for respiratory failure, and a resident with chronic kidney disease and dementia was discharged to the hospital, but in both cases there was no documentation that a written notice of transfer/discharge or bed-hold policy was provided to the residents or their representatives. Review of the facility’s Transfer and Discharge policy, dated 1/15/26, showed that the policy required the facility to provide written transfer/discharge notices and bed-hold information to residents and representatives and to provide specified information to receiving providers, but the records for these four residents did not contain the required documentation.
Failure to Document Target Behaviors and Non-Pharmacological Interventions Before Initiating Antipsychotic
Penalty
Summary
The deficiency involves the facility’s failure to document how a resident’s behaviors presented danger or distress to self or others, and failure to document non-pharmacological interventions attempted prior to initiating an antipsychotic medication. Resident 6 had documented diagnoses of Alzheimer’s disease, depression, and severe cognitive impairment, and was receiving sertraline for depression. A PASSAR identified only depression and dementia, and the admission MDS listed Alzheimer’s disease and depression as active diagnoses. Over several months, nursing progress notes documented that the resident intermittently reported unusual perceptions, such as believing there were men causing trouble, a man in her room, or a man wanting to marry her and yelling through the walls, but there was no documentation that these episodes caused danger to the resident or others or that they resulted in unmanageable distress. From late April through mid-July, nursing notes primarily described the resident’s frequent refusals of evening and morning medications, blood sugar checks, blood pressure checks, insulin administration, hygiene care, and showers. Staff documented that the resident sometimes yelled at staff, said “Get out!”, was visibly upset by a room move, was leery of staff and asked to see name badges, and became upset about a pillow under her head until it was removed, after which she calmed down. The notes also recorded instances where the resident believed housekeeping had not cleaned her room or that she had not received medications when she had. However, there were no progress notes or assessments indicating that these behaviors were evaluated as dangerous, non-redirectable, or causing significant distress or functional impairment, and no detailed behavior monitoring logs were present as required by facility policy. On a psychiatric NP visit for initial psychotropic medication management, new mental health diagnoses of schizoaffective disorder, borderline personality disorder, and delusional disorder were added, and Seroquel 25 mg, an antipsychotic, was ordered. The clinical record did not contain a comprehensive evaluation to support these new diagnoses, and there was no documentation of target behaviors meeting the facility’s policy criteria for psychotropic use, such as behaviors representing danger to self or others, causing distress and impairment in functional abilities, or clearly attributable to psychosis or mania. The resident’s representative reported that the resident had no prior history of mental health disorders or psychiatric hospitalization and was unaware of the new diagnoses. The facility’s own psychotropic medication policy required identification and documentation of specific target behaviors, use and documentation of nonpharmacological interventions, and ongoing monitoring of behaviors and interventions, which were not reflected in the record for this resident.
Failure to Update PASARR Screens for New Mental Health Diagnoses and Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that Preadmission Screening and Resident Review (PASARR) Level I screenings were accurate and updated when new mental health diagnoses and psychoactive medications were initiated for multiple residents. For one resident with dementia, anxiety, depression, and post-traumatic stress disorder (PTSD), the PASARR completed on admission listed anxiety, depression, and dementia with sertraline and quetiapine, but did not include the PTSD diagnosis or the antidepressant Pristiq, despite the admission MDS and care plan documenting PTSD and a subsequent physician’s order for Pristiq. For another resident with Alzheimer’s disease, borderline personality disorder, delusional disorder, schizoaffective disorder, and depression, the PASARR only reflected depression and dementia with sertraline, even though additional mental health diagnoses were added later and an antipsychotic (quetiapine) was ordered for borderline personality disorder, and the quarterly MDS documented psychotic disorder, schizophrenia, and depression with antipsychotic and antidepressant use. A third resident had diagnoses including Alzheimer’s disease, depression, anxiety disorder, irritability and anger, and nonrheumatic aortic valve stenosis. The PASARR for this resident listed dementia and anxiety with Risperdal but omitted the diagnosis of depression and the medications escitalopram and lorazepam, although physician’s orders were in place for escitalopram for depression and lorazepam for anxiety, and the admission MDS documented depression with antianxiety and antidepressant use. Interviews with the Assistant Director of Nursing confirmed that new Level I PASARR screens should have been completed when new mental health diagnoses and psychoactive medications were added, and that the PASARR for one resident, completed prior to arrival, should have included all mental health diagnoses and medications. The facility’s own policy required notification of the state mental health authority within 14 days after a significant change in mental condition and specified that a new Level I screen is required for new mental health diagnoses or newly prescribed psychotropic medications, which was not followed in these cases.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
