Shady Nook Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Lawrenceburg, Indiana.
- Location
- 36 Village Drive, Lawrenceburg, Indiana 47025
- CMS Provider Number
- 155525
- Inspections on file
- 28
- Latest survey
- January 23, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Shady Nook Care Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and Alzheimer's disease sustained facial and arm bruising and broken glasses after being physically assaulted by another severely cognitively impaired resident with a known history of escalating aggressive behaviors. Documentation showed the aggressive resident had prior physical behaviors toward others and delusional beliefs that the setting was her home, with a care plan directing staff to intervene to protect others' safety. On the day of the incident, the aggressive resident was wandering and not redirectable, then began yelling at and grabbing the other resident in a hallway, resulting in the documented injuries, contrary to the facility’s abuse policy prohibiting abuse by other residents.
A resident with severe cognitive impairment and Alzheimer’s disease exhibited escalating verbal and physical aggression toward staff and other residents, including hitting, yelling, grabbing, and shoving, while ambulating around the unit. Although care plans and a dementia protocol called for calm approaches, redirection, and removal from situations, staff interviews showed that behaviors increased over time, staff attempts to keep the resident busy were often ineffective, and supervision relied on trying to watch the resident at all times. Documentation of behaviors was inconsistent, with confusion over whether CNAs could chart and whether behaviors belonged in progress notes or behavior notes, and no behavior sheets were completed, leaving key team members unaware of the full extent of the resident’s aggression and limiting timely adjustment of interventions.
A facility failed to provide timely services for a resident with urinary incontinence, resulting in a deficiency. The resident had a history of urinary retention and was scheduled for a urology appointment and an abdominal ultrasound, which were rescheduled multiple times without proper documentation. The initial appointment was canceled due to weather, and there was a lack of follow-up communication. The facility's policy required adherence to prescriber orders and timely treatment, which was not followed.
The facility failed to maintain sanitary conditions in the kitchen and resident snack refrigerators. Observations included debris and improper storage in the kitchen, with cleaning schedules not followed. Snack refrigerators contained non-food items and outdated foods, violating facility policies on food storage and labeling.
The facility failed to ensure accurate MDS assessments for three residents. A resident was incorrectly documented as having a feeding tube, another was wrongly noted as discharged to a hospital instead of another LTC facility, and a third was inaccurately reported as receiving Hospice care. These errors were confirmed by the MDS Coordinator.
A resident with hypertension, diabetes, and dementia did not have vital signs documented before receiving Lisinopril and Propranolol, as required by physician orders. The EMAR records for September and October 2024 showed missing documentation for blood pressure and heart rate, despite the medications being administered. The resident experienced falls, and interviews confirmed that staff were expected to record vital signs before medication administration, but this was not consistently done.
A facility failed to follow infection control guidelines for a resident with an indwelling urinary catheter, leading to the tubing being observed on the floor multiple times. The resident, who was cognitively intact and had a history of renal issues, was being treated for a UTI. Despite the facility's policy to keep catheter tubing off the floor, staff acknowledged the oversight.
A resident with Parkinson's disease and ventricular fibrillation was administered Metoprolol despite physician's orders to withhold it if the heart rate was below 60 bpm. The facility's staff failed to record vital signs before administering the medication, leading to multiple instances of non-compliance with the prescribed hold parameters.
The facility failed to store medications properly in three medication carts. Loose pills were found in C Street Medication Carts 1 and 2, and B Street Medication Cart 1. The DON acknowledged the issue and was unable to identify the residents to whom the medications belonged. The facility's policy requires medications to be stored securely and properly.
A resident with diabetes did not receive their routine insulin in a timely manner, as prescribed. The facility's records showed multiple instances where insulin was administered after the scheduled time, often after midnight. Interviews confirmed that the facility's policy of administering medications within a one-hour window was not followed.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from resident-to-resident abuse when one cognitively impaired resident with known behavioral issues physically assaulted another cognitively impaired resident. Resident D, who had Alzheimer's disease and was severely cognitively impaired, was documented in a progress note as having been involved in an altercation in which another resident struck her, causing her glasses to break and resulting in bruising to her face and both arms. A weekly skin assessment the following day documented bruising on both antecubital areas of her arms, the left periorbital area, and the left side of her nose, and later observation showed a fading bruise on her left arm. Resident C, also severely cognitively impaired and ambulatory with supervision, had a documented history of physical behaviors toward others and delusional beliefs that the facility was her home and that others needed to leave. Her care plan included an intervention for staff to intervene as necessary to protect the rights and safety of others. On the date of the incident, progress notes indicated Resident C was wandering in the hallway and could not be redirected, and later became aggressive, yelling at and grabbing Resident D and not being easily redirected by staff. Staff interviews described Resident C as a "walking behavior" who had become more aggressive over the prior two and a half months, with recent physical aggression such as randomly hitting other residents or smacking them, while Resident D was described as non-aggressive and not bothersome to others. The facility’s abuse policy stated residents must not be subjected to abuse by anyone, including other residents.
Failure to Monitor and Manage Escalating Dementia-Related Behaviors
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate supervision, documentation, and individualized interventions for a resident with severe cognitive impairment and Alzheimer’s disease with early onset, who exhibited escalating behavioral symptoms. The resident’s MDS showed severe cognitive impairment and diagnoses including Alzheimer’s disease and non-traumatic brain dysfunction, with the ability to ambulate with supervision and a history of physical behaviors toward others. Existing care plans documented verbal behaviors such as yelling and cursing, physical aggression toward staff and others related to delusional beliefs that others were in her home, and delusions and hallucinations, with interventions such as allowing the resident to calm, having other staff approach, offering snacks or beverages for redirection, speaking in a calm manner, and removing the resident from situations as needed. Progress notes documented specific incidents, including the resident striking a staff member and becoming aggressive with another resident, yelling and grabbing the other resident and being difficult to redirect. Staff interviews revealed that the resident’s aggression had increased over the prior months, with reports that she had become more physically aggressive with other residents, including randomly hitting or smacking them as she walked by, screaming in another resident’s face, and shoving a resident’s shoulder. Staff described trying to watch the resident at all times and attempting to keep her busy, but reported that these efforts were not consistently effective. There was confusion and inconsistency regarding behavior documentation, with some staff believing behaviors should be charted in progress notes and others in behavior notes, and the Unit Manager stating CNAs could not chart behaviors. The Social Services Director reported there were no behavior sheets completed for this resident and that she was only aware of behaviors documented by nurses in progress notes, despite additional staff reports of resident-to-resident aggression and an earlier altercation. This pattern of incomplete behavior monitoring and lack of systematic reporting and adjustment of interventions occurred despite a facility dementia protocol requiring progressive or persistent worsening of symptoms and increased need for staff support to be reported to the IDT so that interventions and the overall plan could be adjusted.
Failure to Ensure Timely Urology Services for Resident with Urinary Incontinence
Penalty
Summary
The facility failed to ensure timely services for a resident with urinary incontinence, leading to a deficiency in maintaining continence. The resident, who was cognitively intact, had a history of urinary retention and was scheduled for a urology appointment and an abdominal ultrasound following hospital discharge. However, the appointments were rescheduled multiple times, and there was a lack of documentation in the clinical record regarding the rescheduling process. The initial urology appointment was canceled due to weather, and the rescheduling was not documented until much later, indicating a lapse in communication and follow-up. Interviews with the Director of Nursing (DON) and the urology office revealed that the facility did not ensure the resident attended the scheduled appointments, and there was no evidence of additional contact with the urology office prior to the surveyor's inquiry. The facility's policy required adherence to prescriber orders and timely identification and treatment of urinary issues, which was not followed in this case. This deficiency was related to a complaint investigation and highlighted the facility's failure to provide necessary care for the resident's urinary incontinence.
Sanitation Deficiencies in Kitchen and Snack Refrigerators
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen and resident snack refrigerators, as observed during two separate kitchen tours and inspections of snack refrigerators. During the initial kitchen tour, the dry storage room floor was found littered with various debris, including dry cereal, a package of crackers, and a line of white powder identified as food thickener. The thickener was improperly stored with a scoop left inside the bag. Additionally, silver bowls covering plates in the plate warmer had a sticky residue, and wheeled carts used for meal service were sticky and littered with crumbs. The cleaning schedule was not adhered to, with no cleaning completed since the day shift on a previous date. In a subsequent kitchen tour, similar unsanitary conditions were observed, including dust-covered mechanical apparatuses on a metal shelf unit and sticky spots on a wheeled cart used for meal service. The silver bowls still had residue, and a shelf under the steam table contained loose paper clips among the plastic lids. These observations indicate a failure to follow the facility's cleaning and sanitation policies, which require cleaning after each use and maintaining a comprehensive cleaning schedule. The inspection of resident snack refrigerators revealed improper storage of non-food items and outdated foods. One refrigerator contained an unidentified cold pack, while another had a plastic bag of ice cream cups leaning against a cold therapy ice pack. A third refrigerator contained a grocery bag with outdated coleslaw, onion rings, and a dirty spoon. The facility's policies require labeling and proper storage of food brought by family or visitors, with perishable items discarded after 48 hours. However, these policies were not followed, as evidenced by the presence of outdated and improperly stored items.
Inaccurate MDS Assessments for Three Residents
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for three residents. For Resident 8, the Quarterly MDS assessment inaccurately indicated that the resident was receiving parenteral/intravenous feeding and had a feeding tube, despite the absence of a physician's order for tube feeding and the resident's own statement that he never had a feeding tube. The MDS Coordinator confirmed the inaccuracy of the assessment. For Resident 91, the Discharge MDS assessment incorrectly documented that the resident was discharged to a short-term general hospital, while in reality, the resident was transferred to another long-term care facility. This was corroborated by the Therapy Manager and a nursing note. The MDS Coordinator acknowledged the error in the discharge destination. Similarly, Resident 27's Quarterly MDS assessment inaccurately reported that the resident was receiving Hospice care, which was not supported by the physician's orders. The MDS Coordinator confirmed that the resident did not receive Hospice care, indicating another error in the assessment.
Failure to Document Vital Signs Before Medication Administration
Penalty
Summary
The facility failed to obtain physician-ordered vital signs prior to administering medications for a resident with diagnoses including hypertension, diabetes, and dementia. The resident was prescribed Lisinopril and Propranolol, both of which required staff to hold the medication if the resident's systolic blood pressure was less than 100 or if their heart rate was less than 60 beats per minute. However, the Electronic Medication Administration Records (EMAR) for September and October 2024 showed numerous instances where the required vital signs were not documented before medication administration. In September 2024, the EMAR records for the resident were left blank for blood pressure and heart rate documentation from September 3 through September 30, despite the medications being administered daily. The Vitals records indicated sporadic documentation of vital signs, with significant gaps on several days. A progress note from September 10, 2024, indicated that the medications were held due to a low heart rate, but there was no documentation of vital signs for other prescribed times. The resident experienced falls on September 3 and September 24, 2024, but the clinical record lacked vital signs documentation related to medication administration on multiple other dates. In October 2024, the EMAR records continued to show missing documentation for vital signs from October 1 through October 25, 2024. The Vitals records for October also showed limited documentation, with vital signs recorded only on a few dates. Interviews with RN 4 confirmed that there was a place on the EMAR for recording vital signs if required by medication parameters, and staff were expected to obtain these before administering medication. The facility's policy on administering medications emphasized the need for safe and timely administration, including verifying vital signs when necessary, but this was not consistently followed.
Inadequate Infection Control for Urinary Catheter
Penalty
Summary
The facility failed to adhere to appropriate infection control guidelines concerning the management of indwelling urinary catheters, as observed in the case of a resident who had a urinary tract infection. During multiple observations, it was noted that the resident's indwelling urinary catheter tubing was consistently found lying on the floor under their wheelchair. This occurred on several occasions, including when the resident was in the main dining room and while propelling themselves in their wheelchair. Both the Director of Nursing and a Certified Nurse Aide acknowledged that the catheter tubing should not be in contact with the floor, indicating a lapse in following the facility's infection control protocols. The resident involved was cognitively intact and had a medical history that included hypertension, renal insufficiency, obstructive uropathy, and diabetes. The resident was receiving antibiotic treatment for a urinary tract infection, as indicated in their Electronic Medication Administration Record. The facility's policy on urinary catheter care, revised in December 2007, explicitly stated that catheter tubing and drainage bags should be kept off the floor to prevent infection. Despite this policy, the observations revealed a failure to maintain the catheter tubing in a manner that would prevent contamination and potential infection.
Failure to Follow Medication Hold Parameters
Penalty
Summary
The facility failed to adhere to the physician's orders regarding medication administration for a resident diagnosed with Parkinson's disease and ventricular fibrillation. The resident was prescribed Metoprolol, with specific instructions to withhold the medication if the heart rate was below 60 beats per minute. However, the medication was administered on multiple occasions when the resident's heart rate was below the specified threshold, indicating a failure to follow the prescribed hold parameters. The clinical record review and interviews revealed that the facility's staff did not consistently record vital signs prior to administering the medication, as required by the facility's policy. The EMAR system had a provision for recording vital signs and noting reasons for holding medication, but this protocol was not followed. The facility's policy, which mandates checking vital signs before medication administration, was not adhered to, leading to the administration of Metoprolol outside the prescribed parameters.
Improper Medication Storage in Facility
Penalty
Summary
The facility failed to appropriately store medications in three out of four medication carts reviewed. On C Street Medication Cart 1, a small round yellow pill and a small oblong pale green pill were found loose in the bottom of the second drawer, and a small round white pill was found loose in the third drawer. On C Street Medication Cart 2, a small round white pill and half of another small round white pill were found loose in the bottom of the second drawer. Additionally, on B Street Medication Cart 1, a small round pink pill and a small round white pill were found loose in the bottom of the second drawer. These observations were made in the presence of RN 4 and Unit Manager 7. During an interview, the Director of Nursing (DON) acknowledged that loose pills should not be present in the medication carts and was unable to identify which residents the loose medications belonged to. The facility's current policy on medication storage, provided by the DON, states that medications and biologicals should be stored safely, securely, and properly, following the manufacturer's recommendations or those of the supplier.
Failure to Administer Insulin Timely
Penalty
Summary
The facility failed to administer routine insulin in a timely manner for Resident B, who was cognitively intact and had diagnoses including end stage renal disease, heart failure, hypertension, and diabetes. The resident was prescribed Tresiba, an insulin medication, to be administered at 9:00 P.M. every night. However, the Electronic Medication Administration Record (EMAR) and Electronic Treatment Administration Record (ETAR) for March, April, and May 2024 showed that the insulin was administered twice in 24 hours on multiple occasions, with the second dose often given after midnight, well beyond the prescribed time. Interviews with an LPN and Resident B revealed that the insulin was frequently administered outside the facility's policy, which allowed a one-hour window for medication administration. The LPN confirmed that insulin should be given within an hour of the scheduled time, yet Resident B reported being woken up after midnight to receive their insulin. The facility's policies on insulin administration and medication administration were not adhered to, leading to this 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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