Signature Healthcare Of Muncie
Inspection history, citations, penalties and survey trends for this long-term care facility in Muncie, Indiana.
- Location
- 4301 N Walnut St, Muncie, Indiana 47303
- CMS Provider Number
- 155242
- Inspections on file
- 45
- Latest survey
- February 24, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Signature Healthcare Of Muncie during CMS and state inspections, most recent first.
Surveyors found that food was not consistently served at proper temperatures for safety and palatability. During a test meal tray temperature check, milk measured 46°F and coleslaw measured 64.2°F, and the Dietary Manager acknowledged the milk temperature was too high for service. The Dietary Manager reported that food temperatures were checked before plating, after which food was placed in meal carts and delivered to the halls. These practices did not comply with the facility’s written policy requiring food to be served at safe, appetizing temperatures appropriate to the type of food.
A resident with severe cognitive impairment and multiple medical conditions was hospitalized with altered mental status and found to have unprescribed barbiturates and opiates in her system, requiring Narcan administration. Despite concerns of a medication mix-up and facility policy requiring immediate reporting of potential neglect, the incident was not reported to the state health department because no medication error was confirmed by staff.
A resident with severe cognitive impairment was found to have received unprescribed substances, including opiates and barbiturates, resulting in hospitalization and Narcan administration. The facility's investigation into the incident was incomplete, lacking statements from key staff, emergency medical services, and the resident's roommate, and did not document who completed resident questionnaires or when. The investigation did not meet the facility's policy requirements for investigating alleged violations involving neglect.
A resident with multiple comorbidities was admitted with several pressure injuries, but the facility failed to consistently assess, document, and implement appropriate interventions for these wounds. Wound measurements and characteristics were incompletely recorded, some treatments lacked physician orders, and care plans for pressure injuries were not fully implemented in a timely manner, resulting in a deficiency in pressure injury management.
The facility did not report suspected drug diversion involving narcotic medications for four residents to the appropriate regulatory agencies. Discrepancies in medication administration and documentation were identified, including mismatched narcotic counts and missing signatures. Staff observed an LPN impaired at work and found narcotic counts to be off, but a thorough reconciliation was not performed and the required reporting was not completed.
The facility did not thoroughly investigate suspected drug diversion after discrepancies were found between narcotic sign-out sheets, eMARs, and medication counts for several residents receiving narcotic pain medications. Staff interviews revealed confusion about medication administration, and the Corporate Nurse Consultant did not reconcile records or report the issue to regulatory agencies.
The facility did not ensure accurate documentation and reconciliation of controlled medications for multiple residents with chronic pain and complex medical needs. Discrepancies were found between eMARs, narcotic sign-out sheets, and physical medication counts, with doses administered at unscheduled times, missing signatures, and unaccounted-for tablets. Staff interviews revealed confusion about medication administration responsibilities and failure to follow facility policy for controlled substance handling and documentation.
A resident with multiple chronic conditions and a history of verbal aggression was discharged after a verbal altercation and police involvement, but the facility failed to provide supporting documentation or rationale for the discharge, did not address the resident's needs or preferences, and did not offer the resident the opportunity to return after hospital observation, resulting in a deficiency related to safe and appropriate discharge procedures.
The facility failed to provide adequate dietary staff, resulting in significant delays in dinner meal delivery to residents on three units. Observations and interviews revealed that meal trays were often delivered 30 to 57 minutes late, leading to resident dissatisfaction and cold meals. Despite awareness and some managerial interventions, the issue persisted due to understaffing and ineffective solutions.
The facility failed to inform residents of their right to verbally rescind arbitration agreements within 30 days and did not allow rescission for subsequent stays. This affected 57 residents, with staff uncertain about the rescission process and lacking a policy for arbitration agreements.
A resident was found self-administering multiple eye drops without a completed self-administration assessment or proper physician orders. Staff were aware of the situation, but no formal assessment was conducted to ensure the resident's ability to safely manage her medications, contrary to facility policy.
A resident's funds were misappropriated after a CNA assisted with an online order using the resident's debit card, against facility policy. The resident, who was cognitively intact, reported missing his debit card and unauthorized charges. The facility lacked a clear policy for handling such requests outside normal business hours, contributing to the deficiency.
A resident with a history of UTIs and sepsis experienced a worsening condition due to a UTI, leading to hospitalization. Despite severe symptoms and requests for hospital evaluation, the facility delayed intervention and antibiotics. The care plan lacked specific interventions for sepsis, and the DON prioritized in-house treatment over hospital transfer. The facility's policy on change of condition notification was not effectively followed, contributing to the resident's hospitalization for sepsis.
A facility failed to securely store smoking materials for a resident who was cognitively intact and used oxygen therapy. The resident retained her smoking paraphernalia in her room, contrary to the facility's policy, which required staff to manage and store all smoking materials in a locked tackle box. Interviews revealed that the facility did not track the receipt and return of smoking materials, leading to a deficiency in maintaining a safe environment.
The facility failed to properly label and store medications in two medication rooms and two medication carts. Open vials of vaccines lacked open dates, and loose, unlabeled medications were found in a medication cart. Additionally, treatment cart medications lacked resident identifiers. The facility did not follow its policies or manufacturer guidelines for medication storage and labeling.
The facility failed to implement an effective QAPI program, leading to repeat deficiencies in infection control and medication labeling. Despite having a QAA committee, there were no current PIPs for isolation procedures or medication storage. The survey found issues with labeling and storage in medication rooms and carts, and inadequate infection control measures for two residents.
The facility failed to implement effective infection control measures for two residents, leading to confusion and improper use of PPE. One resident had conflicting isolation orders and unclear PPE requirements, while another lacked necessary signage and PPE for wound care. The Infection Preventionist acknowledged the issues and delayed implementation of Enhanced Barrier Precautions.
A facility failed to maintain its AED in working condition, leading to its inability to function during a cardiac arrest emergency involving a resident. The AED's battery was dead, and staff were unclear about who was responsible for its maintenance. The facility lacked a system for routine monitoring of the AED, and there was no policy in place for its upkeep.
A facility failed to prevent verbal abuse by a CNA towards a resident who required assistance with all ADLs. The CNA used inappropriate language when the resident had feces on her bed sheets and hands. Despite another CNA's intervention, the resident was left alone with the abusive CNA, contrary to the facility's abuse policy. The investigation concluded with no substantiation of abuse, and the Administrator believed the staff acted appropriately.
A facility failed to accurately assess and promptly treat a pressure ulcer for a resident, leading to a deficiency in care. The resident, initially assessed with no wounds, developed a skin tear on the sacrum that was later reclassified as a pressure ulcer. The facility did not implement a care plan with individualized interventions, and treatment orders were delayed by 11 days. Inconsistencies in wound documentation and categorization were noted, and the resident was discharged with the wound still present.
A facility failed to create a care plan for a resident with a history of alcohol use and aggression. The resident, with a complex medical history, was involved in a physical altercation and exhibited aggressive behavior towards staff, requiring police intervention. Despite known behaviors, no care plan or interventions were documented, violating facility policy on comprehensive care plans.
A resident was verbally abused by a CNA, who made derogatory remarks and neglected to provide care, leading to a confrontation. The resident, with multiple medical conditions, reported feeling singled out. The facility's policy on verbal abuse was violated, and the CNA was suspended pending investigation.
A facility failed to report a verbal abuse allegation to the State Agency within the required timeframe. A resident alleged that a CNA intentionally skipped providing ice water, resulting in a loud verbal exchange. The incident was reported three days later, contrary to the facility's policy requiring reporting within two hours.
The facility failed to provide scheduled showers and bed baths for two residents, despite their care plans and preferences. One resident, who required assistance, received only four out of 12 scheduled showers over 29 days, while another resident, dependent on staff for bathing, received only two out of 13 scheduled bed baths over 30 days. Staff often cited time constraints, and the facility did not assess bathing preferences, violating resident rights.
A resident with anemia due to gastrointestinal blood loss did not receive the physician-ordered copper sulfate medication upon admission to the facility. The pharmacy received the order late and did not have the medication in stock, leading to a delay in administration. The facility's DON and nurse practitioner were informed of the issue, but the medication was not obtained promptly, violating the facility's policy to contact the prescriber when medication is unavailable.
The facility failed to ensure effective monitoring and services for a resident who experienced acute abdominal pain and requested hospital transfer. Despite complaints and requests, staff did not perform adequate assessments or notify the physician timely, resulting in delayed treatment and emergent hospitalization for a perforated bowel with sepsis, requiring surgical intervention and a permanent colostomy.
Improper Food Temperatures During Meal Service
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service related to failure to distribute food at correct temperatures for safety and palatability, potentially affecting all 114 residents receiving food from the kitchen. During a test meal tray temperature check conducted at 12:47 p.m. on 2/20/26, with the Dietary Manager present, the milk on a test tray measured 46°F and coleslaw measured 64.2°F. The Dietary Manager acknowledged that the milk temperature was too high for service. In an interview earlier that day at 11:40 a.m., the Dietary Manager explained that food temperatures were checked prior to plating and then the food was placed in meal carts and delivered to the appropriate halls for distribution. The facility’s current policy, dated 5/2014 and titled “Food: Quality and Palatability,” stated that food will be prepared to conserve nutritive value, flavor, and appearance, and will be palatable, attractive, and served at a safe and appetizing temperature, with proper temperature defined as appropriate to the type of food to ensure resident satisfaction and minimize the risk for scalding and burns. The observed temperatures of the milk and coleslaw did not align with this policy requirement. This citation relates to Intakes 2733549 and 2744835 and regulatory reference 3.1-21(a)(2).
Failure to Report Potential Neglect After Unprescribed Controlled Substances Found in Resident
Penalty
Summary
The facility failed to report an unusual occurrence involving potential neglect to the Indiana Department of Health (IDOH) when a dependent resident was found to have unprescribed controlled substances in her system during a hospital stay. The resident, who had diagnoses including unspecified dementia, hypertension, asthma, convulsions, and heart failure, was severely cognitively impaired and required staff assistance for daily activities. Her prescribed medications did not include opioids or barbiturates, and she was allergic to gabapentin. During a hospital admission for altered mental status, the resident was found to have a low respiratory rate, hypoxia, and low blood pressure. A urine drug screen was positive for barbiturates and opiates, and she required Narcan administration for suspected opioid overdose. Despite concerns from emergency medical services and the resident's family about a possible medication mix-up with her roommate's medications, the facility did not report the incident to IDOH. The Director of Nursing indicated that the event was not reported because no medication error was identified by the night shift nurse, and the facility believed it had followed IDOH guidelines for reporting potential neglect. However, facility policy required immediate reporting of all alleged violations involving abuse, neglect, or mistreatment, regardless of whether a medication error was confirmed.
Failure to Thoroughly Investigate Medication Error and Potential Neglect
Penalty
Summary
The facility failed to conduct a thorough investigation into an unusual occurrence involving a potential medication error and possible neglect when a resident with severe cognitive impairment was found to have received unprescribed substances, including opiates and barbiturates, as evidenced by a positive urine drug screen during a hospital stay. The resident, who had a documented allergy to gabapentin and no orders for opiates, was administered her roommate's medications in error on a previous occasion, and subsequently experienced a significant change in condition, including lethargy, low respiratory rate, and hypoxia, leading to hospital admission and administration of Narcan. Despite these events, the facility's investigation into the incident on the day of the resident's hospital transfer was incomplete and lacked critical documentation. The investigation did not include statements from key staff members who were on duty or may have cared for the resident at the time of the incident, nor did it include statements from emergency medical services staff who transported the resident to the hospital. Additionally, the resident's roommate, who was a potential witness and had relevant information regarding the medication administration, was not interviewed or included in the investigation. The facility also failed to collect statements from the resident or her representative, despite the resident's ability to answer yes/no questions, and did not document who completed the resident questionnaires or when they were completed. Interviews with facility staff revealed a lack of clarity regarding who was spoken to during the investigation, and the Director of Nursing and Administrator could not confirm which staff had been interviewed, as no statements were collected. The facility's policy required a reasonable investigation of all alleged violations involving abuse, neglect, or injuries of unknown origin, but the investigation into this incident did not meet those standards, as it lacked essential documentation and failed to include pertinent information from staff, residents, and witnesses directly involved in or knowledgeable about the event.
Failure to Thoroughly Assess and Intervene for Pressure Injuries
Penalty
Summary
The facility failed to thoroughly assess and intervene to promote the healing of pressure injuries for a resident with multiple comorbidities, including a right femoral neck fracture, chronic kidney disease, severe malnutrition, and dementia. Upon admission, the resident was found to have a stage 2 pressure injury on the right elbow, redness to the coccyx, and discoloration to both heels. Orders were in place for wound management, heel protectors, pressure-relieving devices, and other supportive measures. Initial care plans and interventions were documented, but there were gaps in the ongoing assessment and documentation of the resident's pressure injuries. Throughout the resident's stay, documentation of wound assessments and measurements was inconsistent and incomplete. The wound management detail report only included the initial measurement of the right elbow pressure injury and lacked further assessments or documentation for the coccyx and heels. A spreadsheet maintained by the DON contained some wound measurements but was not part of the official clinical record and lacked comprehensive wound characteristics. There was also no documentation of a specific treatment order for the right elbow or coccyx pressure injuries, and the care plan for pressure injuries was not fully implemented until much later, despite the presence of multiple wounds. Interviews with nursing staff and the DON revealed that wound assessments were sometimes missed or not entered into the electronic medical record, and that some treatments were provided as routine nursing measures without physician orders or proper documentation. Weekly skin assessments were recorded as existing skin impairment, but no detailed follow-up or wound progression was documented. The facility's policy required ongoing documentation of all impaired skin integrity areas in the electronic medical record, but this was not consistently followed, leading to a deficiency in the assessment and management of the resident's pressure injuries.
Failure to Report Suspected Drug Diversion to Regulatory Agencies
Penalty
Summary
The facility failed to report a suspected drug diversion involving narcotic medications for four residents to the appropriate regulatory agencies. Multiple discrepancies were identified in the administration and documentation of oxycodone and oxycodone-acetaminophen for residents with chronic pain and other serious conditions. For example, medication administration records and narcotic count sheets did not align, with doses being signed out at incorrect times, missing signatures, and mismatched tablet counts. In one case, a resident's narcotic card showed fewer tablets than should have remained, and in another, a medication card for comparison was not provided. Staff interviews revealed confusion and lack of clarity regarding medication administration and documentation. One LPN was observed to be impaired at work and was sent home, after which narcotic counts were found to be off. Staff reported these discrepancies to their supervisors, but a thorough reconciliation of medication records was not performed. The Corporate Nurse Consultant acknowledged that the narcotic counts were off but did not compare narcotic sheets with the Medication Administration Record during the investigation. Despite the facility's policy requiring immediate reporting of any suspected misappropriation of resident property, including drug diversion, to the State Regulatory Agency within 24 hours, the concerns were not reported as required. The investigation into the missing medications was incomplete, and the appropriate authorities were not notified of the suspected diversion, as mandated by facility policy and federal and state law.
Failure to Investigate Suspected Drug Diversion and Medication Discrepancies
Penalty
Summary
The facility failed to conduct a thorough investigation into suspected drug diversion involving four residents who were prescribed and administered narcotic pain medications. For these residents, discrepancies were found between the electronic medication administration records (eMAR), narcotic sign-out sheets, and the physical count of medication tablets. In several cases, doses were documented as given at times inconsistent with physician orders, and some doses were signed out but not properly accounted for in the medication count. For example, one resident's narcotic card showed fewer tablets remaining than should have been present, and another resident's medication card was not provided for verification. Staff interviews revealed confusion and lack of clarity regarding who administered certain doses, and in one instance, a nurse admitted to removing medication from the card for another staff member to administer, which she acknowledged was inappropriate. The Corporate Nurse Consultant, upon being informed of missing medications, reviewed medication carts and narcotic count books but did not reconcile narcotic sheets with the eMAR or report the discrepancies to regulatory agencies. No medication reconciliation was performed for certain doses, and the investigation did not include a comparison of narcotic sheets with the medication administration records. The facility's failure to properly investigate and reconcile these discrepancies led to the deficiency cited in the report.
Failure to Accurately Document and Reconcile Controlled Medication Administration
Penalty
Summary
The facility failed to ensure accurate documentation and reconciliation of controlled medication administration for four out of six residents reviewed. For one resident with chronic pain and multiple diagnoses, discrepancies were found between the electronic medication administration record (eMAR), the narcotic sign-out sheet, and the physical count of oxycodone tablets. Documentation showed doses being administered at times inconsistent with the schedule, missing signatures, and mismatched tablet counts. Interviews revealed confusion among staff regarding medication administration times and the number of tablets given, with one resident reporting having received two tablets early, though unable to recall specifics during a follow-up interview. Another resident with chronic pain and significant physical disabilities had inconsistencies between the eMAR and the narcotic sheet, including doses marked as not given and missing documentation for certain time slots. For a third resident with COPD and chronic pain, the eMAR and narcotic count sheet showed doses administered at incorrect times and uncertainty among staff about who administered the medication. One LPN admitted to removing medication from the card and having another staff member administer it, which was acknowledged as inappropriate. A fourth resident with a history of opioid use and chronic pain had doses signed out on the narcotic count sheet that were not reconciled with the eMAR, and no medication reconciliation was performed for several doses. Facility policies required physical inventory and reconciliation of controlled medications at each shift change, immediate documentation of administration, and reporting of discrepancies to the DON. However, these procedures were not consistently followed, leading to unaccounted-for medication doses and incomplete records.
Failure to Ensure Safe and Justified Resident Discharge
Penalty
Summary
A resident with multiple chronic conditions, including congestive heart failure, COPD, pressure ulcer, chronic osteomyelitis, polyneuropathy, chronic pain syndrome, and depressive disorder, was admitted to the facility and assessed as cognitively intact with moderate depression. The resident had a history of verbal aggression, but there was no care plan addressing physical aggression. On the day of the incident, the resident became verbally aggressive and threatened staff after being informed of a new roommate assignment, following a previous altercation with a former roommate. Staff attempted to de-escalate the situation, but the resident continued to display verbal aggression and made threatening remarks. The police were called, and the resident was taken to the hospital for evaluation, with staff citing outstanding warrants as a reason for police involvement. The facility initiated an emergency discharge, citing the resident's behavior and the police intervention. However, documentation and interviews revealed inconsistencies regarding the resident's physical aggression, with several staff members and the resident's sister stating that the resident was not physically aggressive, only verbally so. The facility did not provide clear supporting rationale or documentation for the discharge, and the clinical record lacked evidence that the resident's needs and preferences were considered or that the resident was prepared for a safe transfer or discharge. The resident was not offered the opportunity to return to the facility after hospital observation, despite not being arrested, and was instead released to a family member. The facility's actions did not align with its own transfer/discharge policy, which requires that a resident may only be discharged if their needs cannot be met, their health has improved, or the safety or health of others is endangered. The lack of documentation supporting the discharge decision, failure to provide adequate notice, and not allowing the resident to return after hospital observation constituted a deficiency in ensuring that the transfer/discharge met the resident's needs and preferences and that the resident was prepared for a safe transition.
Inadequate Dietary Staffing Leads to Delayed Meal Delivery
Penalty
Summary
The facility failed to provide adequate dietary staff to ensure timely delivery of dinner meal trays to residents on three units, resulting in significant delays. Observations on specific dates revealed that meal trays were delivered much later than scheduled, with delays ranging from 30 to 57 minutes. Residents expressed dissatisfaction, with some waiting in their doorways or calling out for their meals. Interviews with staff and residents confirmed that late meal deliveries were a recurring issue, often resulting in cold meals. The dietary department was consistently understaffed, with only three dietary staff members on duty for dinner service, which was insufficient to serve all residents promptly. Despite the presence of the Dietary Manager and District Dietary Manager on some occasions to assist with meal service, delays persisted. Staff turnover and reliance on a limited number of dietary aides contributed to the problem, and previous reports to management about the issue had not resulted in effective solutions. The facility's internal audits and interviews with staff indicated that the problem had been ongoing for a significant period, with meal delivery times frequently running into residents' evening routines. The Administrator and dietary management were aware of the issue, but efforts to address it, such as meal delivery tracking audits and additional managerial support during meal times, had not resolved the delays. The lack of a timely response to dietary concerns and insufficient staffing levels were key factors leading to the deficiency.
Failure to Inform Residents of Arbitration Agreement Rescission Rights
Penalty
Summary
The facility failed to ensure that residents who entered into a binding arbitration agreement were informed of their right to verbally rescind the agreement within 30 days of signing it. Additionally, the facility did not grant residents the right to rescind the original agreement for a subsequent stay if they were discharged and readmitted to the facility or admitted to another facility owned by the same corporation. This deficiency potentially affected 57 of the 127 residents residing in the facility. During interviews, it was revealed that the facility's arbitration agreement required written notice to rescind, contrary to the verbal rescission right, and staff members, including the Facility Liaison and Admissions Coordinator, were uncertain about the rescission process. The Corporate Legal Counsel confirmed that the arbitration agreement would remain in effect for any subsequent admissions if not rescinded within 30 days, even if the resident was discharged and readmitted. The facility did not have a policy for the arbitration agreement, and staff members were unclear about the process for residents to change their minds and rescind the agreement. The lack of clarity and proper communication regarding the arbitration agreement's terms and the rescission process contributed to the deficiency.
Failure to Conduct Self-Administration Assessment for Resident's Eye Drops
Penalty
Summary
The facility failed to ensure a self-administration assessment was completed for a resident who was self-administering eye drops. During observations, the resident was found with multiple bottles of eye drops on her bedside table, some of which were prescription medications without labels or resident identifiers. The resident indicated she used the eye drops twice daily and that staff were aware of her self-administration. However, the clinical record lacked physician orders for some of the eye drops and did not include an assessment for self-administration of medication. Interviews with staff revealed that they were aware of the resident's self-administration of eye drops, but no formal assessment had been conducted to determine the resident's ability to safely manage her medications. The Director of Nursing confirmed the absence of a self-administration assessment and noted that physician orders did not include instructions for self-administration. The facility's policy requires an interdisciplinary team assessment and a prescriber's order for residents who wish to self-administer medications, but these steps were not documented in the resident's case.
Misappropriation of Resident Funds Due to Lack of After-Hours Policy
Penalty
Summary
The facility failed to prevent the misappropriation of resident funds, specifically for Resident B, who was cognitively intact and required partial assistance with personal care. Resident B reported missing his debit card, grocery card, and driver's license upon returning from dialysis. He suspected CNA 31, who had assisted him with an online order the night before, of taking his belongings. Resident B had to shut off multiple debit cards due to unauthorized charges, which included purchases totaling approximately $500. The facility was notified, and the local police were involved in the investigation. The investigation revealed that CNA 31 had assisted Resident B in ordering a pizza using his debit card, which was against facility policy. CNA 31 was in orientation at the time and was advised by her preceptor, CNA 33, to seek permission from the RN on staff before proceeding. Despite this, CNA 31 took the resident's debit card and returned it after some time. The facility's policy clearly stated that staff should not take money or debit cards from residents, even to assist them with purchases. However, there was no official policy for handling such requests outside of normal business hours. Interviews with various staff members, including the DON, Unit Manager, and Social Services Assistant, confirmed that the facility lacked a clear policy for assisting residents with purchases after hours. The facility's Conduct & Behavior policy prohibited borrowing or accepting money from residents, and the Abuse, Neglect, and Misappropriation of Property policy aimed to prevent such incidents. Despite these policies, the lack of a specific protocol for after-hours assistance contributed to the deficiency, leading to the misappropriation of Resident B's funds.
Failure to Monitor and Intervene in Resident's UTI Leads to Hospitalization
Penalty
Summary
The facility failed to provide adequate monitoring and timely intervention for a resident experiencing a worsening change in condition due to a urinary tract infection (UTI). The resident, who was cognitively intact, reported experiencing severe symptoms such as vomiting and diarrhea in November 2024, and expressed concern over the facility's delay in sending her to the hospital. Despite her requests, the facility was slow to administer antibiotics, and she was eventually hospitalized with a peripherally inserted central catheter (PICC) line due to sepsis secondary to a UTI. The resident's clinical records indicated a history of UTIs and sepsis, with diagnoses including sepsis, overactive bladder, and post COVID-19 condition. The records showed that the resident had frequent urinary and bowel incontinence and required substantial staff assistance for certain activities of daily living. Despite these conditions, the facility's care plan lacked specific interventions for sepsis or being at risk for sepsis. The records also revealed that the resident had bacterial growth on a urine culture for ESBL, but no antibiotics were administered due to the bacteria count being under 100,000 CFU/mL. Interviews with staff and the Director of Nursing (DON) highlighted a lack of urgency in addressing the resident's deteriorating condition. The DON was aware of the resident's history and symptoms but did not prioritize sending her to the hospital, opting instead to treat her in-house. The facility's policy on notifying changes in condition was not effectively followed, as the Medical Director was not contacted for urgent orders, and the resident's condition was not adequately monitored or assessed. This lack of timely intervention and monitoring contributed to the resident's hospitalization for sepsis.
Failure to Securely Store Resident Smoking Materials
Penalty
Summary
The facility failed to ensure that smoking materials were securely stored for a resident, leading to a deficiency in maintaining a safe environment free from accident hazards. Resident 86, who was cognitively intact and used oxygen therapy, was observed to keep her smoking paraphernalia in her room, contrary to the facility's policy. The resident, who had a diagnosis of chronic respiratory failure with hypoxia and current tobacco use, was allowed to retain her cigarettes and lighter in her purse after signing out for a leave of absence, instead of returning them to the staff as required. Interviews with staff, including CNAs and RNs, revealed that the facility's policy mandated that all smoking materials be managed by staff and stored in a locked tackle box in the medication room. However, the resident's smoking materials were not found in the designated storage area, and the facility did not track the receipt and return of smoking materials. The Administrator confirmed that residents were not permitted to keep smoking paraphernalia after smoke breaks or upon returning from a leave of absence, yet the resident's smoking materials were found in her room by the Social Services Assistant, indicating a lapse in adherence to the facility's smoking policy.
Improper Medication Labeling and Storage
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications, treatments, and biological products in two medication rooms and two medication carts. During an observation in the Medication Room East, an open vial of influenza vaccine and an open vial of tuberculin purified protein derivative (PPD) were found without open dates. The Director of Nursing (DON) confirmed that the temperature was recorded daily, but the vials should have been labeled with open dates. Similarly, in the Medication Room [NAME], an open vial of influenza vaccine was found without an open date, and RN 3 acknowledged that open dates should be placed on vials. In the medication cart for the 200 Hall, 11 loose, unlabeled medications were discovered in the drawers, including various capsules and tablets. LPN 4 indicated that these medications should be disposed of immediately. Additionally, the treatment cart for the 800 and 500 hallways contained several tubes of medications without resident identifiers and directions, such as miconazole anti-fungal cream, Medi-honey wound gel, Hydrogel wound dressing, lidocaine anesthetic cream, and mupirocin ointment. RN 22 noted that the cart was used for treatments on these halls and that medications should be labeled with the resident's name. The facility lacked a specific policy on vaccine storage, as indicated by the DON. The manufacturer's instructions for the influenza vaccine and guidelines from the CDC were not followed, as the multi-dose vials were not discarded within the recommended time frame. The facility's policies on medication storage and labeling were not adhered to, resulting in medications being improperly labeled and stored, which could potentially affect their integrity and safety.
Failure to Implement Effective QAPI Program for Infection Control and Medication Labeling
Penalty
Summary
The facility failed to develop and implement a Quality Assurance and Performance Improvement (QAPI) program to address and prevent repeat deficiencies related to infection control and medication labeling. During the last annual recertification and licensure survey, deficiencies were noted in the facility's adherence to infection control guidelines, specifically regarding isolation procedures, and in ensuring medications were labeled with resident identifiers and directions. Despite having a Quality Assessment and Assurance (QAA) committee that met quarterly to review facility concerns, the facility did not have any current Performance Improvement Plans (PIP) in place for these specific issues. The survey conducted on January 23, 2025, revealed repeat concerns in infection control and medication labeling. The facility failed to ensure proper labeling and storage of medications, treatments, and biological products in two medication rooms and two medication carts. Additionally, the facility did not implement an infection control program that provided Enhanced Barrier Precautions (EBP) or isolation services to reduce the risk of contagion spread for two residents reviewed for infection prevention. The facility's policy, revised in September 2023, indicated an ongoing QAPI program, but it did not effectively address the identified problem areas.
Inadequate Implementation of Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, specifically regarding Enhanced Barrier Precautions (EBP) and isolation services, for two residents. Resident 66's room had multiple signs indicating different types of precautions, leading to confusion among staff about the necessary protective measures. Staff members were observed not wearing the required personal protective equipment (PPE) during care, and there was a lack of clarity about when PPE was needed. The resident's clinical records showed conflicting orders for isolation and EBP, and the care plan did not specify when PPE was indicated. The Infection Preventionist acknowledged the confusion and indicated that the resident should not have been on isolation but required EBP. For Resident 86, there was a lack of signage and readily available PPE in or near the resident's room, despite the resident having a pressure ulcer. Staff were observed not wearing gowns during wound care, and the resident's care plan did not include interventions for EBP. The facility's infection control policy required EBP for residents with chronic wounds, but this was not implemented until later. The Infection Preventionist admitted uncertainty about which residents required EBP and had not sought clarification from external sources. The facility's infection control policies and practices were intended to prevent the transmission of infections, but there were significant lapses in their implementation. The Enhanced Barrier Precautions Policy required appropriate signage and PPE for residents with chronic wounds or indwelling devices, but these measures were not consistently applied. The Infection Preventionist's lack of clarity and delayed implementation of EBP contributed to the deficiencies observed in the care of Residents 66 and 86.
Failure to Maintain AED in Working Condition
Penalty
Summary
The facility failed to maintain the automated external defibrillator (AED) in safe operating condition, which was crucial during a medical emergency involving Resident F. The resident was found unresponsive and without a pulse, prompting staff to initiate CPR and call emergency services. However, when the AED was retrieved and attempted to be used, it failed to operate due to a dead battery. This malfunction was discovered during the emergency, and the staff was unable to utilize the AED as intended. Interviews with various staff members, including registered nurses and the unit manager, revealed that there was a lack of clarity regarding who was responsible for ensuring the AED was in working order. The Director of Nursing (DON) and the Administrator were both unaware of the AED's maintenance status until after the incident. The Maintenance Director mentioned that he ordered a battery every six months, but the most recent order was on backorder. The facility lacked a system or practice for routine monitoring and management of the AED, and there was no facility policy related to the AED's maintenance.
Failure to Prevent Verbal Abuse and Implement Abuse Policy
Penalty
Summary
The facility failed to prevent verbal abuse from a staff member towards a resident, identified as Resident F, and did not fully implement its abuse policy to protect the resident from potential further abuse. The incident involved a staff member, CNA 5, who was reported to have used derogatory language towards Resident F, who was dependent on assistance for all activities of daily living due to conditions such as unspecified convulsions and adult failure to thrive. The incident was self-reported by the facility, and immediate actions included a skin assessment of the resident, which showed no signs of injury, and the suspension of the staff member pending an investigation. The investigation revealed that CNA 5 had been impatient and used inappropriate language towards Resident F, who had feces on her bed sheets and hands. Despite being asked by another CNA, CNA 6, not to speak to the resident in such a manner, CNA 5 continued to exhibit inappropriate behavior. The facility's policy required immediate intervention and separation of the resident from the abusive environment, which was not fully adhered to, as CNA 6 left Resident F alone with CNA 5 after the incident. The facility's investigation concluded with no substantiation of abuse, and the Administrator believed that the staff acted appropriately, despite the failure to fully implement the abuse policy.
Failure to Accurately Assess and Treat Pressure Ulcer
Penalty
Summary
The facility failed to accurately and consistently assess a new pressure injury and did not promptly initiate wound treatment for a resident, leading to a deficiency in pressure ulcer care. Resident B, who was cognitively intact and required partial assistance for bed mobility and transferring, was initially assessed with no wounds or pressure ulcers. However, a skin tear was identified on the sacrum, which was later reclassified as a pressure ulcer. The clinical record showed inconsistencies in the documentation of the wound, with different wound types being referred to for the same area. Despite the presence of a skin integrity care plan indicating the resident was at risk for pressure ulcers, the facility did not develop and implement a care plan with individualized interventions to support the healing of the pressure injury. The clinical record lacked treatment orders for the skin impairment until 11 days after the initial identification of the wound. Interviews with staff revealed that there was a delay in obtaining treatment orders and that the wound was not categorized correctly initially. The resident was discharged with the wound still present.
Failure to Develop Care Plan for Resident's Aggressive Behavior
Penalty
Summary
The facility failed to develop a resident-centered care plan and interventions for a resident, identified as Resident K, who exhibited alcohol use and physical aggressive behaviors. Resident K, who was cognitively intact, had a complex medical history including conditions such as chronic kidney disease, congestive heart failure, and opioid use. Despite these conditions, the clinical record lacked a care plan addressing the resident's alcohol consumption and aggressive behavior. An incident occurred where Resident K was involved in a physical altercation with another resident off facility property, after which he returned to the facility exhibiting aggressive behavior towards staff. This behavior included physical aggression such as punching, choking, and grabbing staff members, necessitating police intervention and sedation before being removed to a hospital. Interviews with facility staff revealed that Resident K had a known history of smoking and drinking off facility property, as well as verbal aggression, but no documented care plan or interventions were in place to manage these behaviors. The facility's policy on comprehensive care plans mandates the development of person-centered plans with measurable objectives and time frames to address residents' needs, which was not adhered to in this case. The lack of documentation for new or worsening behaviors was also noted, indicating a failure to update the care plan in response to Resident K's aggressive actions.
Resident Subjected to Verbal Abuse by CNA
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a staff member, specifically a Certified Nursing Assistant (CNA). The incident involved a resident, identified as Resident F, who was subjected to derogatory and disparaging remarks by CNA 6. Witnesses, including other residents, reported that CNA 6 told Resident F that she should leave the facility and live with her ex-husband, and that her grandchildren did not love her. Additionally, CNA 6 was reported to have intentionally neglected to provide ice water to Resident F, which was perceived as singling her out. The situation escalated when Resident F confronted CNA 6, leading to a verbal altercation where CNA 6 accused Resident F of bullying and threatened to have her arrested. Resident F's clinical record indicated she had several medical conditions, including peripheral vascular disease, muscle weakness, and anxiety disorder, and was on medication for anxiety and depression. Despite being cognitively intact, she required supervision for certain activities. The facility's policy on abuse defines verbal abuse as the use of threatening or derogatory language, which was violated in this case. The Administrator was aware of the incident and had suspended CNA 6 pending an investigation, but the clinical record lacked documentation of a care plan or nurses' notes related to the incident.
Failure to Timely Report Verbal Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of verbal abuse to the State Agency in a timely manner. The incident involved a resident who alleged that a CNA intentionally skipped providing ice water, leading to a loud verbal exchange with angry language. The incident occurred on June 27, 2024, at 4:45 p.m., but was not reported to the Indiana State Department of Health until June 30, 2024, at 8:27 a.m. The facility's policy requires that any abuse allegations be reported to the State within two hours from the time the allegation was received. This deficiency was identified during a review of three reportable abuse allegations, and it relates to complaint IN00438076.
Failure to Provide Scheduled Showers and Bed Baths
Penalty
Summary
The facility failed to ensure that dependent residents received showers or bed baths according to their care plans and personal preferences. Resident E, who was cognitively intact and required supervision and touch assistance for showers, was scheduled for showers three times a week but only received four showers over a 29-day period, despite being scheduled for 12. Resident E expressed a preference for showers and reported that staff often told her they did not have time to assist her, leading her to manage on her own. The facility's records did not reflect an assessment of Resident E's bathing preferences, and there was a noted history of refusal for other treatments. Resident M, also cognitively intact and dependent on staff for bathing, was scheduled for complete bed baths three times a week but only received two complete bed baths over a 30-day period, despite being scheduled for 13. Resident M preferred a complete bed bath at night due to her transfer needs and had not refused care. Staff interviews revealed that evening shifts were not completing the assigned showers, and partial bed baths were given instead. The facility's policy on resident rights emphasized the importance of respecting residents' preferences, which was not adhered to in these cases.
Failure to Administer Physician-Ordered Medication
Penalty
Summary
The facility failed to ensure that a physician-ordered medication, copper sulfate, was obtained and administered to a resident, identified as Resident B, who was admitted with a history of anemia due to gastrointestinal blood loss, among other conditions. Upon admission from an acute care hospital, the resident had discharge orders for copper sulfate 2 mg daily for 30 days. However, the medication was not available upon the resident's arrival at the facility. The pharmacy received the order 52 hours after the resident's admission and processed it the following day, but the medication was not in stock. The pharmacy notified the facility's Director of Nursing (DON) about the unavailability of the medication, but the issue was not resolved promptly. The DON was informed of the delay, and the nurse practitioner was unaware of the unavailability until several days later. Despite attempts to obtain the medication from another vendor and eventually ordering it online, the medication was not administered as required. The facility's policy required nursing staff to contact the prescriber for direction when a medication delivery was delayed or unavailable, but this procedure was not followed. This deficiency was identified during a complaint investigation, highlighting a failure in the facility's pharmaceutical services to meet the resident's needs.
Failure to Monitor and Address Resident's Acute Abdominal Pain
Penalty
Summary
The facility failed to ensure effective monitoring and services for Resident B, who experienced acute abdominal pain with nausea and requested to be transferred to the hospital. Despite the resident's complaints and requests, the facility staff did not perform adequate assessments or notify the physician in a timely manner. This resulted in a delay in treatment, leading to the resident's emergent hospitalization for a perforated bowel with sepsis, requiring surgical intervention and a permanent colostomy. Resident B's clinical record indicated she was cognitively intact and had a history of conditions including paroxysmal atrial fibrillation, rheumatoid arthritis, and type 2 diabetes mellitus. She was dependent on others for toileting and frequently incontinent of bowel. The resident had been receiving opioid pain medication, which is known to cause constipation, and had a physician's order to monitor for side effects. Despite this, the facility staff failed to adequately address her complaints of constipation and abdominal pain. On multiple occasions, Resident B complained of pain and constipation, but the staff did not perform thorough assessments or notify the physician. The resident's condition worsened, leading to severe abdominal pain, vomiting, and eventually black coffee ground emesis. It was only after the resident's condition became critical that she was sent to the hospital, where she was diagnosed with a perforated bowel and sepsis. The facility's failure to follow their own policies on change of condition and bowel management contributed to the delay in treatment and the resident's subsequent severe health complications.
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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