Signature Healthcare At Parkwood
Inspection history, citations, penalties and survey trends for this long-term care facility in Lebanon, Indiana.
- Location
- 1001 N Grant St, Lebanon, Indiana 46052
- CMS Provider Number
- 155378
- Inspections on file
- 31
- Latest survey
- March 6, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Signature Healthcare At Parkwood during CMS and state inspections, most recent first.
Two residents with CHF, edema, and lymphedema did not receive ordered weekly weight monitoring as required by physician orders and care plans. For one resident, staff repeatedly documented temperatures instead of weekly weights in the MAR after an order was incorrectly entered in the EHR with a temperature task, and no weights appeared in the vitals section despite ongoing edema and diuretic use. For the other resident, whose plan of care and physician note called for weekly weights and who later had IV furosemide and fluid restriction for worsening edema and shortness of breath, there were no corresponding weight orders or documented weekly or daily weights in the EHR, even though a progress note stated the resident was placed on daily weights. Interviews with nursing, clinical support, and leadership staff confirmed that weight orders were either entered incorrectly or not entered at all, and that monitoring relied on incomplete EHR documentation rather than the actual physician orders.
The facility failed to conduct required quarterly care plan meetings for four residents, as mandated by their policies and federal and state laws. Residents with various medical conditions, including major depressive disorder, dementia, and COPD, did not have care plan meetings within the required timeframe. The Social Service Director confirmed the absence of these meetings, and there was no documentation to support that they occurred.
A resident in a memory care unit was not provided with cognitively stimulating activities as per her care plan. Despite her interest in group activities and crafts, she was observed multiple times alone in her room without engagement. Staff interviews revealed missing resources like a TV remote and no available magazines or coloring books, contrary to her preferences. The facility's policy on activity scheduling was not followed, leading to the deficiency.
The facility failed to maintain sanitary wound care for a resident, with dressings not changed promptly and soiled sheets not replaced. Additionally, the facility did not notify the physician of another resident's blood glucose readings outside the ordered parameters, leading to a lack of documentation and communication. These actions were inconsistent with the facility's policies on physician orders, resident rights, and skin integrity.
The facility failed to obtain consent and offer Influenza and Pneumococcal vaccinations to three residents. Two residents were not documented as being offered these vaccinations, and one resident received an Influenza vaccine without a signed consent. The Administrator acknowledged a lapse in the process, despite existing policies requiring consent and education on vaccinations.
The facility failed to offer COVID-19 vaccinations to three residents as required by policy. One resident had received vaccinations in 2021 and 2022, another in 2021, and a third declined upon admission in 2024, with no further offers documented. The Administrator acknowledged a failure in the follow-through process for obtaining consents and administering vaccinations.
The facility failed to provide effective dementia care, resulting in residents wandering into the room of a resident with aggressive and inappropriate behaviors. Despite care plans addressing wandering and cognitive impairments, incidents continued due to inadequate monitoring and documentation. The facility's actions were insufficient to prevent these interactions, highlighting a deficiency in person-centered care.
The facility failed to re-admit a cognitively impaired resident after hospitalization, did not provide adequate documentation for his discharge, and did not assist in finding alternative placement, leaving the resident at risk of homelessness.
The facility failed to follow up with psychiatric services for a resident with a history of cognitive and behavioral issues, leading to the resident's elopement. Despite repeated exit-seeking behavior and aggressive actions, the facility did not secure psychiatric care or adequately document the incident. The lack of documentation and follow-up contributed to the deficiency cited in the report.
The facility failed to ensure a cognitively impaired resident was safe from an injury of unknown origin, allowed a resident to have vaping materials in their room, and did not prevent recurring falls for a high-risk resident. These deficiencies resulted in a resident sustaining a left arm fracture, another resident having unauthorized vaping materials, and a high-risk resident experiencing multiple falls.
Failure to Implement and Document Ordered Weekly Weights for Residents with CHF and Edema
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders for weekly weights for two residents with CHF, edema, and lymphedema. For one resident, multiple observations over several days showed the resident asleep in a recliner with legs elevated, wearing pants that had been cut from the hem to the calf and appeared wet, with bilateral lower leg edema noted each time. The resident’s care plans, addressing CHF, edema, diuretic use, and nutritional risk, directed staff to obtain and document weights as ordered. A physician’s order dated 12/19/25 specified weekly weights on Tuesday mornings. However, review of the MAR showed that staff documented weekly temperatures instead of weights, and the vitals section of the EHR contained no documentation of the ordered weekly weights. Interviews revealed that the QMA/Scheduler responsible for obtaining weights acknowledged that temperatures were documented instead of weights and that she was responsible for ensuring weights were completed and re-weights obtained for significant changes. An LPN confirmed that the physician’s order was for weekly weights but that temperatures were entered and documented, indicating the order had been entered incorrectly into the EHR. The Clinical Support Nurse explained that the order had been placed in the EHR with a task incorrectly set to “temperature” rather than “weight,” and that the IDT reviewed only the compiled weight report, not the underlying orders, when monitoring residents. The Executive Director stated that a nurse should have caught the entry error when completing the task, and the NP indicated that weights were difficult to monitor because they were not always documented in the same EHR location and that she relied on nurses to notify her of changes. For the second resident, observations documented the presence of a midline IV in the right upper arm and bilateral lower extremity edema, with the resident reporting weight gain from swelling and uncertainty about how often he was weighed. An empty IV bag labeled Furosemide 80 mg IV was observed, and later the midline had been removed while edema persisted. The resident’s diagnoses included CHF, edema, and lymphedema, and a care plan directed that his weight be obtained and documented per order. A physician visit note dated 1/28/26 included a plan to monitor weekly weights, but no weekly weight documentation or corresponding physician order was found in the EHR. A change in condition note on 2/20/26 documented increased edema and shortness of breath and new orders for IV Furosemide and fluid restriction, but did not include weight monitoring. A progress note on 2/25/26 stated that the DON contacted the MD, confirmed IV Lasix 80 mg, and indicated the resident was placed on daily weights, yet no daily weight documentation or physician order for daily weights was found in the EHR. In a later text message, the MD clarified the resident was supposed to be on weekly weights, and the DON acknowledged she had not placed an order for weekly weights in the EHR, contrary to the facility’s policy requiring physician orders to be followed and reviewed.
Failure to Conduct Required Care Plan Meetings
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were invited to participate in care plan meetings, as required by their policies and federal and state laws. This deficiency was identified for four residents who were reviewed for care plan conferences. The facility's policy mandates that care plan meetings should be held quarterly, yet these meetings were not conducted for the residents in question during the specified periods. For instance, Resident 36, diagnosed with major depressive disorder, type 2 diabetes, and muscle weakness, had not had a care plan meeting since November 2023. Similarly, Resident 64, with diagnoses including dementia and anxiety disorder, had not had a care plan meeting since October 2023. Resident 75, who has anxiety, schizoaffective disorder, and a history of myocardial infarction, attended a care plan meeting in April 2024, but the subsequent meeting scheduled for July 2024 did not occur. Resident 58, diagnosed with chronic obstructive pulmonary disease, heart failure, and pain, had not had a care plan meeting since July 2024. The Social Service Director confirmed during interviews that the care plan meetings were not held as required, and there was no documentation to support that these meetings took place. The facility's policies emphasize the importance of developing and implementing comprehensive person-centered care plans and ensuring residents' rights to participate in care planning decisions.
Failure to Provide Activities for Resident in Memory Care Unit
Penalty
Summary
The facility failed to provide cognitively stimulating activities for a resident residing in the locked memory care unit, as per the plan of care. The resident, diagnosed with Alzheimer's disease, dementia, and major depressive disorder, was observed multiple times over several days either awake or asleep in her room without engaging in any activities. Despite activities occurring in the lounge, the resident was not invited or escorted to participate, as required by her care plan. The care plan indicated that the resident enjoyed group activities, crafts, painting, and spending time in common areas, yet she was left in her room with the TV off and no other activities available. Interviews with staff revealed that the resident was not a morning person and preferred watching TV, reading magazines, and coloring in her room. However, the TV remote was missing, and there were no magazines or coloring books available in her room. The facility's policy on activity programs stated that group and individual activities should be scheduled according to residents' preferences and schedules, but this was not adhered to for the resident in question. The lack of engagement and failure to follow the care plan led to the deficiency identified by the surveyors.
Deficiencies in Wound Care and Blood Glucose Monitoring
Penalty
Summary
The facility failed to maintain a sanitary dressing for a non-pressure wound and did not change soiled bed sheets for Resident 139. Observations revealed that the resident's wound dressing was not changed promptly despite being soaked through with drainage, and the bed sheets were not replaced after being soiled. The resident was not educated on the risks of infection from not keeping the wound dressing clean and dry. The physician's order required daily dressing changes and as needed for soilage, but these were not adhered to consistently. Additionally, the facility did not notify the physician of blood glucose readings outside the ordered parameters for Resident 50. The resident's blood glucose levels were below the threshold set by the physician multiple times, yet there was no documentation of physician notification. The facility's messaging system and call orders were not aligned with the physician's order, leading to a failure in communication and documentation. The facility's policies on physician orders, resident rights, and skin integrity were not followed, resulting in deficiencies in the care provided to the residents. The lack of adherence to these policies contributed to the issues observed with wound care and blood glucose monitoring, impacting the quality of care for the residents involved.
Failure to Obtain Consent and Offer Vaccinations
Penalty
Summary
The facility failed to ensure proper consent and offering of Influenza and Pneumococcal vaccinations for three residents. Specifically, there was no documentation indicating that two residents were offered these vaccinations in 2024 or 2025. Additionally, one resident received an Influenza vaccination without a documented signed consent, and there was no record of a Pneumococcal vaccination being offered. Interviews with the Administrator revealed that obtaining vaccine consents was part of the admission process, but there was a lapse in ensuring that each resident signed or declined the vaccination consent forms. The facility's policies, which were last revised in late 2024 and early 2025, stated that all residents should be offered vaccines unless medically contraindicated, and that residents or their legal representatives should be informed about the benefits and potential side effects of the vaccinations. However, these policies were not effectively implemented, leading to the deficiencies noted.
Failure to Offer COVID-19 Vaccinations to Residents
Penalty
Summary
The facility failed to ensure COVID-19 vaccinations were offered to three residents, as required by their policy. Resident 53 had received the COVID-19 vaccination in 2021 and 2022, but there was no documentation indicating they were offered the vaccine after 2022. Similarly, Resident 139 had received the vaccine in 2021, with no subsequent offer documented. Resident 23 declined the vaccine upon admission in 2024, but there was no documentation of any further offer after admission. Interviews with the Administrator revealed that the process of obtaining vaccine consents and ensuring vaccination administration was part of the admission process, but there was a failure in follow-through. The facility's policy required that all residents be offered vaccines unless contraindicated or already vaccinated, and that residents or their legal representatives be informed about the benefits and potential side effects of vaccinations. However, the facility did not adhere to this policy, resulting in the deficiency.
Inadequate Dementia Care Leads to Wandering and Inappropriate Interactions
Penalty
Summary
The facility failed to provide effective person-centered dementia care, resulting in residents on the locked dementia unit wandering into the room of a resident with known aggressive, impulsive, and sexually inappropriate behaviors. This deficiency was observed in four residents who were reviewed on the dementia care unit. The incidents involved residents wandering into the room of a resident who did not have a diagnosis of dementia but had a history of inappropriate sexual behaviors and aggression. The facility's actions to prevent such occurrences were inadequate, as evidenced by multiple incidents where residents entered the room of the aggressive resident, leading to situations where residents were found disrobed and inappropriately interacting. Resident D, who was involved in these incidents, had a history of inappropriate sexual behaviors, delusional disorders, and substance abuse. His care plan included interventions to manage his impaired cognition and behavior episodes, but these measures were insufficient to prevent other residents from entering his room. Despite being moved to the end of the hallway to reduce interactions, Resident D continued to experience incidents where other residents entered his room, leading to aggressive responses. The facility's documentation did not adequately record these interactions, indicating a lack of proper monitoring and intervention. Residents B and C, who wandered into Resident D's room, had their own care plans addressing their wandering behaviors and cognitive impairments. However, the facility's failure to effectively monitor and redirect these residents resulted in repeated incidents of inappropriate interactions. The lack of documentation in the residents' records further highlights the facility's inadequate response to these incidents, as staff were instructed to write statements but did not document the events in the residents' records. This deficiency in care and documentation contributed to the ongoing issues within the dementia care unit.
Failure to Re-Admit Resident After Hospitalization
Penalty
Summary
The facility failed to accept a cognitively impaired resident back after hospitalization and did not adequately document the reason for his discharge. The resident, who had a traumatic brain injury and seizure disorder, was transferred to the hospital after eloping from the facility. Despite the hospital and the guardian requesting the resident's return, the facility refused to accept him back, citing an inability to meet his needs. The facility did not provide a 30-day written notice of involuntary discharge to the guardian and did not assist in finding alternative placement, leaving the resident at risk of homelessness. The resident's record lacked documentation from a physician or the facility for a permissible reason for his permanent discharge. The facility's documentation indicated the resident was transferred for behavior problems but did not provide specific details. The hospital's records showed that the resident was brought in for a psychiatric evaluation and had no aggressive behavior en route or in the emergency room. The facility's Executive Director claimed the resident was a danger to himself and others, but there was no detailed documentation to support this claim. Interviews with facility staff revealed inconsistencies in their accounts of the events. The Executive Director stated that the hospital never made a referral for the resident's return, while the hospital's social worker documented multiple attempts to contact the facility. The facility's policy required written notice and documentation for transfers and discharges, which were not adequately followed in this case. The facility's failure to document the resident's needs and the reasons for discharge, along with the lack of proper communication and assistance in finding alternative placement, led to the deficiency.
Failure to Secure Psychiatric Services for Resident B
Penalty
Summary
The facility failed to follow up with psychiatric services for Resident B, who had a history of cognitive communication deficit, encephalopathy, epilepsy, traumatic brain injury, and other conditions. Despite the resident's repeated exit-seeking behavior and aggressive actions, the facility did not secure psychiatric care or adequately document the elopement incident. On 2/15/24, Resident B exhibited agitated behavior, threatening staff and attempting to leave the facility. Although a referral was made to an inpatient psychiatric hospital, the admission was declined, and no further psychiatric services were sought. On 2/16/24, Resident B continued to show signs of anxiety, and a new medication order was placed to manage his condition. Despite these measures, the resident's care plan, which included monitoring for exit-seeking behavior, did not result in effective intervention. On 3/2/24, Resident B again expressed a desire to leave the facility, and staff noted his ongoing exit-seeking behavior. However, there was no documentation of additional attempts to secure psychiatric services or hospital admission for the resident. The facility's Executive Director (ED) and Director of Nursing (DON) confirmed that no other psychiatric hospitals or services were contacted to evaluate Resident B. The DON indicated that due to the resident's age, no psychiatric service companies were willing to come to the facility. The lack of documentation regarding efforts to obtain psychiatric care and the failure to follow up with additional services contributed to the resident's elopement and the deficiency cited in the report.
Failure to Prevent Accidents and Ensure Resident Safety
Penalty
Summary
The facility failed to ensure a cognitively impaired and dependent resident was safe from an injury of unknown origin. Resident F, who had severe cognitive impairment and was totally dependent on staff for transfers and other activities of daily living, sustained a left arm fracture. The facility did not complete an investigation to identify the root cause of the injury, and there was no documentation to show how the injury occurred. The resident's care plan did not reflect the most recent assessment indicating total dependence on staff, and the facility did not provide sufficient documentation to corroborate the suspicion of a fall as the cause of the injury. The facility also failed to ensure that a resident did not have vaping materials in their room. Resident 72, who had a cognitive communication deficit and other diagnoses, was observed with two vapes in their room. The facility's policy prohibited any type of smoking or vaping materials in resident rooms. Despite this, Resident 72 admitted to occasionally using the vape in their room, and the facility staff were unaware of this violation. Additionally, the facility failed to prevent recurring falls for a resident identified as high risk for falls. Resident H, who had multiple diagnoses including hemiplegia, repeated falls, and altered mental status, experienced several falls, including one from a shower bed and another from her bed. The facility's interventions were not effective in preventing these falls, and there were lapses in staff adherence to safety protocols, such as leaving the resident unattended on an unlocked shower bed with the side rails down. The resident expressed fear of falling again, indicating ongoing concerns about her safety.
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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