Signature Healthcare Of Terre Haute
Inspection history, citations, penalties and survey trends for this long-term care facility in Terre Haute, Indiana.
- Location
- 3500 Maple Ave, Terre Haute, Indiana 47804
- CMS Provider Number
- 155426
- Inspections on file
- 59
- Latest survey
- March 6, 2026
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Signature Healthcare Of Terre Haute during CMS and state inspections, most recent first.
The facility failed to ensure critical and STAT lab results were communicated and documented according to policy for two residents. One resident with COPD, diabetes, and hypertension had critical hemoglobin results reported to the facility after a prior hospitalization for low hemoglobin, but there was no documentation that the physician was notified of these abnormal labs. Another resident with advanced dementia had STAT labs ordered twice for a change in condition and increased pain; when the lab could not send a technician and the resident refused hospital labs, there was no documentation that the practitioner or responsible party were notified, nor that subsequent STAT labs not obtained were reported. Staff interviews and facility policy confirmed that such changes in condition and lab issues were expected to be communicated and documented in the EMR.
A resident with COPD, unspecified dementia, and a care plan identifying risk for malnutrition repeatedly requested larger meal portions but continued to receive regular portions despite a physician’s order for a regular diet with double portions. Observation of a lunch tray and review of the meal ticket showed no indication or provision of double portions, and dietary staff were unclear about portion notations such as “2 HLF” and “4 HLF.” The RD acknowledged that meal tickets did not clearly reflect portion sizes or special resident choice meals, resulting in the resident’s preference and ordered double portions not being followed.
Surveyors found that the facility failed to notify a cognitively impaired resident’s healthcare representatives of multiple significant events, including diagnostic test results, STAT lab orders that could not be completed, medication changes, new orders, abnormal labs, and a fall, with no documentation of required notifications despite facility policy and staff statements that such notifications should occur. In a separate case, a resident with COPD, HTN, CAD, prior MI, and history of venous thrombosis/embolism did not receive ordered doses of azithromycin and Xarelto when the medications were unavailable, and the record lacked evidence that the physician was notified of the missed doses or unavailability, contrary to the facility’s medication policy.
A resident with multiple complex medical conditions was admitted after a hospital stay, but the facility did not complete a nursing admission assessment, physical and skin assessments, or a baseline care plan within the required 48-hour timeframe. The DON confirmed the absence of timely documentation, which was not consistent with facility policy.
A newly admitted resident with multiple complex medical conditions did not receive a nursing admission assessment, timely wound assessments, or admission orders for respiratory medications and catheter care. Documentation of vital signs and nursing progress notes was delayed, and necessary care orders were not entered until several days after admission, resulting in a lack of quality care upon admission.
A dietary staff member was seen preparing peanut butter and jelly sandwiches without gloves, directly handling bread with bare hands before being stopped by the Dietary Manager. The sandwiches were intended for about ten residents, and facility policy requires glove use and hand hygiene during food preparation.
Staff failed to administer scheduled morphine doses as ordered for a resident with multiple chronic conditions, withholding medication based on their own observations and family input without completing required nursing assessments or notifying the physician. Documentation did not reflect appropriate assessment or physician contact when scheduled doses were omitted.
A resident with Alzheimer's disease and a history of aggressive and wandering behaviors was not provided with individualized interventions or consistent monitoring, despite known risks. The resident entered another resident's room unsupervised, resulting in physical harm to both individuals, including significant injuries and subsequent death. Care plans were not updated to reflect the resident's behaviors, and staff monitoring was insufficient to prevent the incident.
A resident with a history of aggressive behavior was seen leaving another resident's room immediately before the latter was found on the floor with serious injuries, including a clavicle fracture and subdural hematoma. Despite staff observations, statements from the injured resident, and concerns raised by family and hospital staff, the facility did not report the incident as suspected abuse within the required timeframe, instead treating it as a fall with injury. The facility's policy required immediate reporting of all alleged abuse, but this was not followed.
A facility failed to issue a 30-day discharge notice for a resident with cognitive impairment and substantial care needs, who was scheduled to be discharged to a motel. The resident and family were not informed of the discharge plans or appeal rights, and the facility's records lacked documentation of proper discharge planning. Staff interviews revealed a lack of communication and coordination regarding the resident's discharge, and the facility did not follow its policy requiring a 30-day notice.
A facility failed to ensure a safe discharge for a resident with significant clinical needs, including catheter care, oxygen use, and wound care. The resident, who was cognitively impaired and required substantial assistance, was scheduled for discharge without a clear plan for post-discharge care. The Social Services Director did not address payor issues or provide necessary education to the resident and family. The facility's discharge planning process was not followed, leading to confusion and potential risk to the resident's health and safety.
A resident with mental health issues experienced verbal abuse from an agency LPN during a behavioral episode. The LPN engaged in a derogatory verbal exchange with the resident, which was witnessed by CNAs. The facility took immediate action to ensure the resident's safety and removed the LPN from the facility.
A facility failed to accurately report a verbal abuse incident involving an LPN and a resident with mental health issues. The resident and LPN exchanged inappropriate remarks, and staff confirmed the LPN's use of foul language. Although the incident was initially reported, the final report inaccurately stated the allegation was unsubstantiated, contradicting the investigation findings.
The facility failed to provide Notice of Transfer/Discharge forms for four residents hospitalized, including those with Alzheimer's, traumatic amputation, encephalopathy, and respiratory failure. The absence of documentation was confirmed by the Administrator and consultants, indicating a systemic issue in the facility's transfer process.
The facility failed to complete and provide bed hold forms to residents or their representatives during hospital transfers. This deficiency affected three residents, including one with Alzheimer's disease and another with a traumatic amputation. The facility's policy required notification of the bed hold policy at admission and during transfers, but this was not followed, as confirmed by interviews with facility staff.
Two residents in the facility did not receive prescribed medications on multiple occasions, and the facility failed to notify the physician of these administration issues. Resident 76, with multiple health conditions, missed several medications, including Ativan and Atorvastatin, without documentation of physician notification. Similarly, Resident 74 did not receive risperidone due to unavailability, and the physician was not informed until days later. The DON confirmed that staff should notify the physician when medications are unavailable, but this protocol was not followed.
The facility failed to notify the Ombudsman of resident transfers to hospitals for three residents during a specified month. A resident with Alzheimer's was transferred to a psychiatric hospital, another with a traumatic amputation expired at a hospital, and a third with encephalopathy and heart failure was transferred multiple times. The facility's policy requires Ombudsman notification for all transfers, but documentation was lacking due to staffing changes.
A facility failed to ensure QMAs adhered to their scope of practice by documenting treatments on a resident's open wounds, which is outside their authorized duties. The resident had multiple medical conditions, including Alzheimer's and stage 3 pressure ulcers. Despite knowing their limitations, QMAs recorded performing treatments on open wounds, as confirmed by interviews and TAR reviews. The facility's consultant acknowledged the breach of state guidelines, which restrict QMAs from treating advanced skin conditions.
A resident with a history of osteomyelitis, muscle weakness, and severe malnutrition developed new pressure wounds due to the facility's failure to consistently apply offloading heel boots as per physician orders. Despite recommendations from wound care services, the resident was observed multiple times without the boots, and the medical record lacked documentation of an updated care plan or resident refusal to wear the boots.
The facility failed to provide adequate hydration for two residents, leading to a deficiency. One resident was observed with dry skin and mouth, with water often out of reach, despite needing total assistance due to severe malnutrition and dementia. Another resident, also with malnutrition and dementia, was found with an empty water cup and expressed thirst. Staff interviews indicated water was provided twice daily, but observations showed this was not consistently followed.
A facility failed to maintain sanitary conditions for a resident's oxygen equipment. The resident's nasal cannula was found in a trash can, and the oxygen tubing was undated and not stored properly. The resident had chronic heart conditions requiring oxygen therapy, but facility records lacked documentation of proper tubing changes. Staff interviews confirmed the need for bagging and dating the equipment, which was not consistently followed.
A facility failed to complete AIMS assessments for a resident on anti-psychotic medication, Zyprexa, who had Alzheimer's, anxiety disorder, and acute kidney failure. Despite the requirement for assessments every six months, none were documented between October 2023 and January 2025. The DON acknowledged the backlog in assessments, and the SCC confirmed the absence of a specific policy, though the facility's policy emphasized compliance with regulations.
The facility failed to date opened medications in four out of five medication carts, including insulin and eye drops for residents with diabetes and glaucoma. This was observed during inspections with the QMA and DNS, despite the facility's policy requiring such medications to be discarded after a specific period once opened.
A facility failed to complete required post-fall assessments for a resident who fell from a wheelchair. Despite a physician's order for 72-hour follow-up assessments, documentation was missing. The resident, with a history of falls and cognitive impairments, had interventions in place, but the fall risk assessment was not updated. Staff acknowledged documentation deficiencies.
A resident with multiple medical conditions, including functional quadriplegia, missed a physician appointment due to the facility's failure to arrange necessary transportation. Despite being rescheduled, the appointment was missed again as the facility did not coordinate transportation, leading to the resident's transfer to a hospital. Interviews revealed a lack of communication and documentation regarding transportation arrangements.
Two cognitively impaired residents were involved in multiple incidents of inappropriate touching, with one resident repeatedly touching another in common areas and private rooms. Despite staff interventions to separate them and conduct 15-minute checks, the behavior continued. The DON was informed but did not ensure adequate measures were taken, and staff were instructed not to document the incidents. The facility's policy on abuse was not followed, leading to a deficiency for failing to protect residents from abuse.
The facility failed to report and document allegations of abuse involving two residents. Staff observed inappropriate behavior by a resident with dementia towards another resident, but the DON did not report the incidents immediately due to technical issues and instructed staff not to document them. The facility's policy required immediate reporting, which was not followed, leading to a deficiency.
The facility failed to investigate and document allegations of abuse involving two residents. Despite multiple observations of inappropriate touching by one resident towards another, the DON did not ensure a thorough investigation or collect written statements from staff. Monitoring documentation was inconsistent, and staff were reportedly instructed not to document the incidents in medical records. The facility's response lacked a comprehensive care plan and effective interventions, leading to a deficiency in resident safety.
A facility failed to provide personalized care for a resident with schizophrenia, leading to multiple altercations with other residents. Despite several incidents, the facility's documentation lacked evidence of interventions to prevent further events. Staff attempted to redirect the resident, but these actions were not part of a comprehensive care plan.
Failure to Communicate Critical and STAT Lab Results to Practitioner and Responsible Party
Penalty
Summary
The deficiency involves the facility’s failure to ensure critical abnormal laboratory results were promptly reported to the practitioner and to obtain STAT laboratory tests as ordered. For one resident (Resident D), who had diagnoses including COPD, diabetes, and hypertension and was cognitively impaired requiring maximum assistance, the record showed a history of a recent hospital stay related to a critical low hemoglobin level. After returning to the facility with hemoglobin at non-critical levels, blood was drawn again for diagnostic labs on 7/3/25, and critical lab values were reported to the facility at 2:30 p.m. The medical record, however, lacked documentation that the physician was notified of these critical abnormal lab results, despite facility policy requiring documentation of notification or notification attempts to the medical provider in the electronic medical record when there is a change in condition. The deficiency also includes the facility’s failure to obtain STAT labs and to notify the practitioner and responsible party when labs could not be obtained for another resident (Resident Q). This resident had Alzheimer’s disease with late onset, dementia, severe cognitive impairment, and required assistance with daily care needs. STAT labs were ordered on 11/29/25 due to a change in condition and increased pain complaints, but the lab was unable to send a technician to draw blood, and the record lacked documentation that the physician was notified that the labs could not be obtained or that the resident refused to go to the hospital for labs, as well as lacking documentation of notification of the responsible party. STAT labs were again ordered on 1/22/26, and the record again lacked documentation that the physician was notified when the labs were not obtained. Interviews with nursing staff and the DON confirmed expectations that changes in condition, including labs, should be communicated to the provider and responsible party, and the facility’s written policy required such notifications and documentation in the electronic medical record.
Failure to Provide Ordered Double Meal Portions per Resident Preference
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s meal preference for larger portions despite a physician’s order and the resident’s repeated requests. During an initial interview, Resident J reported that he had asked for more food with his meals for quite some time but continued to receive regular, small portions and felt hungry between meals. Observation of his lunch tray showed that he did not receive double portions when compared to a regular tray, and his meal ticket did not document any order for double portions. Record review showed that Resident J had COPD, unspecified dementia with moderate cognitive deficit, required set-up assistance with eating, and was care planned as being at risk for malnutrition, with interventions including meals as ordered by the physician. A physician’s order dated 1/26/26 directed that he receive a regular diet with double portions per his request. Interviews and documentation revealed confusion and lack of clarity in the dietary system for indicating portion sizes and special meal preferences. The Dietary Manager initially stated that the resident’s ticket showed “4 HLF,” which she said meant double portions, while regular tickets showed “2 HLF,” but the observed lunch tray did not reflect double portions, and the resident choice meal tickets did not show any deviation in portion size. Two dietary staff members reported they did not know what “2 HLF” and “4 HLF” meant and indicated that double portions should be explicitly written on the ticket. The Registered Dietician confirmed there was an issue with meal tickets not clearly indicating portion sizes or special resident choice meals, and that the resident’s ticket did not indicate double portions. The facility’s Resident Rights policy stated that residents’ individuality and input through self-determination would be respected, but Resident J’s expressed preference and physician-ordered double portions were not implemented as ordered.
Failure to Notify Responsible Parties and Physicians of Condition Changes and Unavailable Medications
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s responsible parties and physician of significant changes in condition, diagnostic results, medication changes, and incidents, as well as failure to document such notifications. One resident with Alzheimer’s disease, dementia, severe cognitive impairment, and impaired cognition requiring cues and reminders had multiple events in the medical record where no documentation of responsible party notification was present. These events included review of diagnostic testing results, STAT lab orders related to a change in condition and increased pain when the lab could not send a technician and the resident refused hospital labs, medication changes, new orders, a fall in the resident’s room, diagnostic lab reports, orders for additional lab testing and medication discontinuation, and abnormal lab results. The record repeatedly lacked documentation that the resident’s durable POA for healthcare was notified, despite the daughter’s report that neither she nor her sister had been informed of changes in condition, medication changes, or the fall. Staff interviews confirmed that the expectation was to notify the responsible party and physician of changes in condition, labs, and medication changes, particularly for cognitively impaired residents. RNs and the DON stated they would notify the responsible party of any changes in condition, including labs and medication changes, and that cognitively impaired residents would not be considered their own person for notification purposes. The facility’s policy titled “Notification of Change if Condition” required documentation of notification or notification attempts in the electronic medical record and required that the resident and/or representative and medical provider be notified of a change in condition. Despite this policy and staff statements, the medical record for this cognitively impaired resident lacked the required documentation of notifications for multiple significant clinical events. A second deficiency involved failure to notify a physician when ordered medications were unavailable and therefore not administered to another resident. This resident, who had COPD, a history of venous thrombosis/embolism, HTN, CAD, and a history of MI, had orders for azithromycin for COPD and Xarelto for a history of thrombosis/embolism. The MAR showed that the initial 500 mg dose of azithromycin was unavailable and not administered, and there was no documentation that the resident ever received that dose or that the physician was notified of the unavailability. The MAR also showed that Xarelto was unavailable and not administered on two separate days, with no documentation of physician notification. The Clinical Consultant stated that azithromycin was available in the EDK, that the physician should have been notified when medications were not available, and that the nurse should have administered the antibiotic as soon as it arrived, but she could not provide documentation that the antibiotic was given or that the physician was notified. The facility’s “Non-Controlled Medication Orders” policy required nursing to contact the prescriber when delivery of a medication would be delayed or the medication was not available, which was not reflected in the resident’s record.
Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for one resident following an acute care hospital stay. The resident had multiple diagnoses, including COPD, diabetes mellitus II, atrial fibrillation, end-stage renal disease requiring dialysis, altered mental status, and a history of stroke, and required assistance with personal care. Upon review, the clinical record lacked documentation of a nursing admission assessment, physical assessment, skin assessment, baseline care plan, and catheter assessment until the afternoon of the fourth day after admission. The DON confirmed that there was no documentation regarding the resident's admission in the clinical record, and the baseline care plan was not completed in a timely manner, contrary to the facility's policy requiring completion within 48 hours.
Failure to Complete Admission Assessment and Orders for Newly Admitted Resident
Penalty
Summary
Staff failed to complete a nursing admission assessment, wound assessments, and admission orders for two respiratory medications and a urinary catheter for a newly admitted resident. The clinical record for this resident, who had multiple complex diagnoses including COPD, diabetes, atrial fibrillation, end-stage renal disease requiring dialysis, altered mental status, and a history of stroke, lacked documentation of a nursing admission assessment, including vital signs, skin assessment, and catheter assessment. There was no nursing progress note entered until two days after admission, and vital signs were not documented until two days post-admission. Additionally, orders for necessary respiratory medications and catheter care were not entered until several days after admission. A skin and wound assessment was not completed until two days after admission, at which time multiple pressure injuries and arterial ulcers were identified. The resident was subsequently sent to an acute care hospital due to respiratory distress and other symptoms. The Director of Nursing confirmed the absence of documentation regarding the resident's admission in the clinical record. Facility policy requires that information needed for immediate care, including routine care orders, be provided prior to or at the time of admission, but this was not followed in this case.
Failure to Use Gloves During Food Preparation
Penalty
Summary
A dietary staff member was observed preparing peanut butter and jelly sandwiches without wearing gloves, handling sandwich bread with bare hands while spreading peanut butter. This occurred during an initial kitchen tour, with the staff member acknowledging that gloves should have been worn and that food should not be touched with bare hands. The Dietary Manager intervened, instructing the staff member to perform hand hygiene before donning gloves. The sandwiches being prepared at the time were intended for approximately ten residents for lunch and snacks throughout the day. Facility policy requires proper hand washing and glove use during food preparation, in accordance with the FDA Food Code.
Failure to Administer Scheduled Comfort Medication per Physician Order
Penalty
Summary
Facility staff failed to administer scheduled doses of comfort medication, specifically morphine, as ordered by the physician for a resident with diagnoses including dementia, COPD, atrial fibrillation, heart disease, and anxiety disorder. The physician had changed the morphine order from as-needed to scheduled every four hours to address increased pain and agitation. Despite this, Qualified Medication Aides (QMAs) did not administer several scheduled doses, documenting reasons such as the resident having no pain, being asleep, or being unable to be aroused. In some instances, the medication was withheld because the resident appeared comfortable or was unable to take the medication due to clenching teeth, and family members were present and agreed with the decision to hold the dose. The clinical record did not contain documentation of nursing assessments justifying the omission of scheduled doses, nor was there evidence that the physician was notified when doses were held. Interviews with QMAs confirmed that they made independent decisions to withhold scheduled morphine based on their observations and family input, without completing required assessments or contacting the physician. The facility's policy required that physician orders be followed and that staff notify the physician if scheduled medications were not administered, which was not done in these instances.
Failure to Implement Individualized Dementia Care Interventions Resulting in Resident Harm
Penalty
Summary
The facility failed to implement resident-specific interventions for a resident diagnosed with early onset Alzheimer's disease and anxiety disorder, who exhibited known behaviors such as intrusive wandering, verbal and physical aggression, and exit-seeking. Despite documented incidents of aggression and altercations at a previous facility, as well as multiple episodes of wandering and combative behavior upon admission, the care plans for this resident did not include individualized interventions addressing these behaviors. The care plans lacked updates to reflect the resident's history of altercations, exit-seeking, and aggressive behaviors, and did not document the implementation of increased monitoring or 15-minute checks as ordered. Observations and interviews revealed that the resident frequently wandered into other residents' rooms, including the room of another resident who later sustained significant injuries. Staff were aware of the resident's aggressive tendencies and history of entering other residents' rooms, but monitoring was inconsistent, and staff were not always positioned to observe the resident's movements. On the night of the incident, staff were occupied with care for another resident and were not able to maintain continuous observation, allowing the resident to enter another resident's room unsupervised. As a result, the resident was found leaving the room of another resident who was discovered on the floor with skin tears, scratches, and later diagnosed with a clavicle fracture and subdural hematoma. The injured resident subsequently died. Documentation and staff interviews confirmed that the facility did not have a behavior management policy available during the survey, and there was a lack of clear, individualized interventions or consistent monitoring to address the known risks associated with the resident's dementia-related behaviors.
Failure to Timely Report Suspected Resident-to-Resident Abuse
Penalty
Summary
The facility failed to timely report an allegation of suspected resident-to-resident abuse involving a resident who sustained significant injuries, including a non-displaced acute distal right clavicle fracture, diffuse osteopenia, and a subdural hematoma with mild midline shift, after being found on the floor in her room. The incident was initially documented as an unwitnessed fall, but multiple staff interviews and confidential concerns indicated that another resident, known for aggressive behaviors and prior resident-to-resident altercations, was seen exiting the injured resident's room immediately after the event, with fresh scratches on her arm. The injured resident, while at the hospital, repeatedly stated that a nurse had twisted her arm behind her back, causing her to fall, and also pointed to the other resident as being involved when questioned by staff. Despite these statements and observations, the facility did not immediately report the incident as suspected abuse. The facility's internal teams, including the Interdisciplinary team, Quality Assurance, and QAPI, reviewed the event and decided not to report it as resident-to-resident abuse, concluding it was a fall with injury. The incident was only reported to the state as a fall with injury after the hospital report confirmed the extent of the injuries. The facility did not attempt to contact the EMTs, hospital staff, or the family member after the resident was discharged to the hospital, and relied on a conversation with the family member, who appeared to agree it was an accident, as justification for not reporting suspected abuse. The resident who was suspected of causing the injury had a documented history of aggression, wandering, and prior altercations, both at the current facility and at a previous facility. Staff were instructed to keep the resident on 15-minute checks and to monitor her closely, but at the time of the incident, staff were occupied with other duties and did not have eyes on her. The facility's policy required all alleged violations involving abuse to be reported immediately, but no later than 2 hours after the allegation was made. However, the facility did not report the incident as abuse within this timeframe, despite multiple indicators and concerns raised by staff, family, and external parties.
Failure to Issue 30-Day Discharge Notice
Penalty
Summary
The facility failed to issue a 30-day notice of discharge prior to the planned date of a facility-initiated discharge for a resident. The resident, who was cognitively impaired and required substantial assistance with daily activities, was scheduled to be discharged to a motel without proper notification or planning. The resident's family was not issued a 30-day notice of discharge, and the resident himself was not aware of the discharge plans or his rights to appeal the decision. Interviews with staff revealed a lack of communication and coordination regarding the resident's discharge. The Social Services Director (SSD) was not aware of the resident's payor issues until it was time for discharge, and there was no documentation of discussions with the resident or family about discharge planning or alternative options. The resident's family expressed concerns about the safety of discharging the resident to a motel, given his inability to care for himself, but these concerns were not adequately addressed by the facility. The facility's records lacked documentation of a 30-day notice of discharge, and there was no evidence that the resident or his family were informed of their right to appeal the Medicare Advantage plan's decision to cut the resident's skilled stay. The facility's policy required a 30-day notice of discharge, but this was not followed, leading to confusion and potential risk for the resident.
Inadequate Discharge Planning for Resident with Complex Needs
Penalty
Summary
The facility failed to adequately plan and ensure a safe and orderly discharge for a resident with significant clinical needs, including catheter care, oxygen use, and wound care. The resident, who was cognitively impaired and required substantial assistance with activities of daily living, was scheduled for discharge without a clear plan for his care post-discharge. Interviews with staff revealed a lack of communication and coordination regarding the resident's discharge, with the Qualified Medication Aide and Certified Nurse Aides unaware of the discharge details or the resident's ability to care for himself. The Social Services Director (SSD) was not involved in addressing the resident's payor issues until the discharge was imminent, and there was no documentation of discussions with the resident or family about alternative payor options or safe discharge plans. The SSD also failed to provide necessary education to the resident and family about the resident's clinical needs and how to manage them post-discharge. The resident's family expressed concerns about the safety of discharging the resident to a motel, given his inability to care for himself, but these concerns were not adequately addressed by the facility. The facility's discharge planning process was not followed, as there was no evidence of interdisciplinary team involvement or regular re-evaluation of the resident's discharge plan. The resident's record lacked documentation of medical equipment arrangements or education provided for discharge, and the SSD did not ensure that the resident's clinical needs were addressed as part of the discharge process. The facility's failure to plan for a safe discharge resulted in confusion and potential risk to the resident's health and safety.
Verbal Abuse Incident Involving Agency LPN and Resident
Penalty
Summary
The facility failed to protect a resident's right to be free from verbal abuse when a Licensed Practical Nurse (LPN) engaged in inappropriate verbal exchanges with a resident. The incident involved a resident with a history of mental health issues, including schizoaffective disorder, bipolar disorder, dementia, and anxiety disorder. The resident, identified as having moderate cognitive impairment, was known to exhibit behaviors such as screaming, cursing, and making repetitive statements. On the night of the incident, the resident was experiencing behavioral issues and approached the nurse's station, where the exchange occurred. The incident began when the resident, who was having a difficult night, approached the nurse's station and requested medication and a cigarette. The LPN, who was an agency nurse, responded inappropriately by engaging in a verbal altercation with the resident. The resident called the LPN a derogatory name, and the LPN retaliated by using the same derogatory term and further antagonized the resident with racially charged language. This exchange was witnessed by two Certified Nursing Aides (CNAs) who reported being shocked by the LPN's behavior. The facility's response included immediate actions to ensure the resident's safety, such as separating the resident from the LPN and notifying the appropriate staff members, including the Administrator and Director of Nursing (DON). The LPN was suspended and removed from the facility. Witness statements and interviews confirmed the inappropriate conduct of the LPN, and the incident was documented in the facility's records. The facility's policy on abuse, neglect, and misappropriation of property was referenced, highlighting the organization's intention to prevent occurrences of abuse, including verbal abuse.
Failure to Accurately Report Verbal Abuse Incident
Penalty
Summary
The facility failed to accurately report an incident of verbal abuse involving a nurse and a resident to the Indiana Department of Health (IDOH). The incident occurred when a Licensed Practical Nurse (LPN) and a resident, who has a history of mental health issues including schizoaffective disorder and bipolar disorder, exchanged inappropriate remarks. The resident called the nurse a derogatory term, and the nurse responded with similar language, escalating the situation. Witness statements from staff confirmed the use of foul language by the nurse towards the resident. Although the incident was initially reported to IDOH, the final report inaccurately stated that the allegation was unsubstantiated. The investigation summary and staff interviews indicated that the verbal abuse allegation was substantiated, contradicting the final report submitted to IDOH. The Assistant Administrator and Clinical Support Nurse acknowledged the error in the final report, which was submitted without completing the investigation. The facility's policy on abuse, neglect, and misappropriation of property mandates immediate reporting and investigation of such incidents, but this protocol was not followed accurately in this case. This deficiency relates to complaints IN00454858 and IN00454449.
Failure to Provide Transfer/Discharge Notices
Penalty
Summary
The facility failed to ensure that the Notice of Transfer/Discharge forms were completed and provided to residents and/or their representatives for four residents who were hospitalized. Resident 18, diagnosed with Alzheimer's disease, was discharged to an inpatient psychiatric hospital without the necessary documentation of the Notice of Transfer/Discharge forms. The Administrator confirmed that no such forms were found, indicating a lapse in the facility's protocol. Resident 165, who had a complete traumatic amputation of the left lower leg, was transferred to an acute care hospital and subsequently expired there. The record lacked documentation of the Notice of Transfer/Discharge forms, and the State Signature Care Consultant confirmed the absence of these forms, highlighting a failure in the facility's process for hospital transfers. Resident 138, with diagnoses including encephalopathy and malignant neoplasm, was transferred to the hospital multiple times without the completion of the required forms. Similarly, Resident 54, who had acute and chronic respiratory failure, was transferred to the hospital without the necessary documentation. The Signature Clinical Consultant acknowledged a system failure and the need for a new process to ensure compliance with transfer documentation requirements.
Failure to Complete Bed Hold Forms for Hospitalized Residents
Penalty
Summary
The facility failed to ensure that bed hold forms were completed and provided to residents or their representatives in cases of hospitalization or therapeutic leave. This deficiency was identified for three out of four residents reviewed. Resident 18, who had Alzheimer's disease, was hospitalized for a urinary tract infection and increased altered mental status, but there was no documentation of a bed hold form being completed or provided. The facility administrator confirmed the absence of the form during an interview. Resident 165, who had a complete traumatic amputation of the left lower leg, was discharged to an acute care hospital and later expired there. The hospital transfer document lacked documentation of a bed hold form, and the State Signature Care Consultant confirmed the absence of the form during an interview. Similarly, Resident 138, who had multiple hospital transfers due to conditions such as encephalopathy and heart failure, also lacked documentation of bed hold forms for her transfers. The facility administrator acknowledged the missing documentation during an interview. Additionally, Resident 54, who had been hospitalized recently, also lacked documentation of a bed hold form for their transfer. The Signature Clinical Consultant identified a system failure in completing these forms and acknowledged the need for a new process and staff re-education. The facility's policy required that residents and their representatives be notified of the bed hold policy at admission and during any hospital transfer, but this was not adhered to in the cases reviewed.
Failure to Notify Physician of Medication Administration Issues
Penalty
Summary
The facility failed to notify the physician of not administering medications as ordered for two residents, leading to a deficiency in medication management. Resident 76, who had multiple diagnoses including type 2 diabetes mellitus, schizophrenia, and hypertension, did not receive several prescribed medications on multiple occasions. The Electronic Medication Administration Record (EMAR) showed that medications such as Ativan, Atorvastatin, Buspirone, and others were not administered on specified dates, and there was no documentation of physician notification or resident refusal of medication. The Signature Clinical Consultant indicated that if a medication was unavailable, the nurse should contact the physician and check the emergency drug kit for alternatives. Resident 74, diagnosed with brief psychotic disorder and major depressive disorder, also experienced medication administration issues. The January 2025 Medication Administration Record (MAR) indicated that risperidone was not administered on several occasions due to unavailability, and there was no documentation of physician notification. A late entry in the physician progress note revealed that the physician was only informed of the medication unavailability during a visit on January 20, 2025, despite the medication being unavailable for several days prior. The Director of Nursing (DON) confirmed that the facility's expectation was for staff to complete a Situation, Background, Assessment, and Recommendation (SBAR) form and notify the physician when medications were not available. The lack of timely physician notification and documentation of medication administration failures for both residents highlights a significant deficiency in the facility's medication management practices.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to notify the Ombudsman of resident transfers to hospitals for three residents during a specified month. Resident 18, diagnosed with Alzheimer's disease, was hospitalized and later transferred to an inpatient psychiatric hospital, but there was no documentation of Ombudsman notification. The Administrator confirmed the lack of documentation for any resident transfers during that month. Resident 165, who had a complete traumatic amputation of the left lower leg, was transferred to a hospital where they later expired. Again, there was no documentation of Ombudsman notification. Similarly, Resident 138, with diagnoses including encephalopathy and acute on chronic systolic heart failure, was transferred to a hospital multiple times without Ombudsman notification. The Signature Care Consultant confirmed the absence of documentation due to staffing changes. The facility's policy requires Ombudsman notification for all facility-initiated transfers or discharges.
Failure to Adhere to QMA Scope of Practice for Wound Care
Penalty
Summary
The facility failed to ensure that Qualified Medication Aides (QMAs) adhered to proper standards of practice for a resident with multiple medical conditions, including Alzheimer's disease, anxiety disorder, acute kidney failure, and several stage 3 pressure ulcers. The resident's care plan required specific wound care interventions, such as cleansing wounds and applying various dressings. However, the Treatment Administration Records (TARs) indicated that QMAs documented completing treatments on open wounds, which is outside their scope of practice. The documentation showed that QMAs and Certified Medication Aides (CMAs) recorded performing treatments on dates when they were not authorized to do so, as they are only permitted to treat intact skin. Interviews with QMAs confirmed that they were aware of their limitations and that they should not have performed treatments on open wounds. Despite this, the TARs reflected that treatments were signed off as completed by QMAs on multiple occasions. The facility's Signature Clinical Consultant acknowledged that QMAs must practice within their scope and follow state guidelines, which prohibit them from administering treatments on advanced skin conditions, including stage II, III, and IV pressure ulcers. The deficiency was identified through a review of the resident's records and interviews with staff, highlighting a failure to adhere to professional standards of quality care.
Failure to Prevent New Pressure Wounds in Resident
Penalty
Summary
The facility failed to prevent new pressure wounds for a resident, identified as Resident 131, who was observed multiple times without offloading heel boots while lying in bed on a low air loss mattress. Despite physician orders and recommendations from wound care services to ensure the resident's heels were offloaded and to apply heel boots, the resident was repeatedly observed without the boots, which were found in the wheelchair next to the bed. The resident's medical record lacked documentation of an updated care plan reflecting the deep tissue injuries to the bilateral feet and heels, and there was no documentation of the resident's refusal to wear heel boots or to be repositioned and turned when in bed. Resident 131 had a complex medical history, including osteomyelitis, muscle weakness, a sacral pressure ulcer, dementia, severe protein-calorie malnutrition, and functional quadriplegia. The resident was cognitively impaired and required total assistance for care needs. Despite the presence of a sacral wound upon admission and new areas on both heels, the facility did not consistently follow the physician's orders or the wound care recommendations, leading to the development of new pressure wounds. The Director of Nursing Services indicated that if a resident refused to follow the plan of care, it would typically be documented in the care plan, but such documentation was absent in this case.
Inadequate Hydration for Two Residents
Penalty
Summary
The facility failed to provide adequate hydration for two residents, leading to a deficiency in maintaining their health. Resident 131 was observed multiple times lying in bed with dry skin and mouth, indicating dehydration. On several occasions, the resident's water cup was either empty or out of reach, and there was no evidence of staff ensuring the resident had sufficient fluids. The resident's medical history included severe protein-calorie malnutrition, dementia, and functional quadriplegia, requiring total assistance for care needs. Despite physician orders to monitor fluid intake and provide supplements, the resident's hydration needs were not adequately met. Resident 109 was also found to be inadequately hydrated. Observations revealed that the resident, who was sitting in a recliner, had an empty water cup on the overbed table and could not recall when it was last filled. The resident expressed thirst, and there was no indication that staff had provided sufficient fluids. The resident's medical conditions included protein-calorie malnutrition and dementia, necessitating a mechanically altered diet and extensive assistance with care. Despite care plans and physician orders to encourage fluid intake and monitor meals, the resident's hydration needs were not sufficiently addressed. Interviews with facility staff, including a Qualified Medication Aide and a Certified Nurse Aide, indicated that water was typically provided twice per day and upon request. However, the observations and resident reports suggest that this practice was not consistently followed, leading to the deficiency. The facility's hydration policy stated that residents should be provided with sufficient fluids to maintain proper hydration, but this was not effectively implemented for the residents in question.
Failure to Maintain Sanitary Oxygen Equipment
Penalty
Summary
The facility failed to ensure proper respiratory care for a resident, specifically in the management and storage of oxygen tubing and nasal cannula. During multiple observations, the resident's oxygen tubing was found undated, and the nasal cannula was not stored in a sanitary manner. On one occasion, the nasal cannula was observed lying inside a trash can with visible trash items, and the tubing was not dated or stored in a bag when not in use. These observations were made over several days, indicating a lack of adherence to the facility's policy on oxygen administration. The resident involved had a medical history of chronic systolic heart failure and atherosclerotic heart disease, conditions that necessitate careful management of oxygen therapy. Despite a physician's order for oxygen administration and a care plan indicating the need for oxygen as ordered, the facility's records lacked documentation of proper tubing changes after the nasal cannula was found in the trash. Interviews with facility staff confirmed that the oxygen supplies should be bagged when not in use and that the tubing should be dated when changed, which was not consistently done in this case.
Failure to Complete AIMS Assessments for Resident on Anti-Psychotic Medication
Penalty
Summary
The facility failed to ensure that AIMS (Abnormal Involuntary Movement Scale) assessments were completed for a resident who was on anti-psychotic medication. The resident, who had diagnoses including Alzheimer's disease, anxiety disorder, and acute kidney failure, was receiving Zyprexa via gastric tube. Despite the requirement for AIMS assessments every six months for residents on anti-psychotic medication, there was no documentation of such assessments being completed for the resident between October 2023 and January 2025. Interviews with the Director of Nursing (DON) revealed that the facility was behind on completing AIMS assessments for some residents, and a new process had been initiated to address this issue. The Signature Clinical Consultant (SCC) confirmed the absence of a specific policy regarding AIMS assessments but acknowledged the need for them every six months. The facility's Psychotropic Medications Policy, revised in May 2024, emphasized compliance with state and federal regulations, including regular reviews for continued need and side effects of psychotropic medications.
Medication Labeling and Storage Deficiency
Penalty
Summary
The facility failed to ensure that medications were properly dated and stored in accordance with professional guidelines, as observed in four out of five medication administration carts. During the survey, it was noted that multiple insulin vials and pens, as well as eye drops, were opened but not dated. This included medications for several residents with diabetes, such as Admelog, Basaglar, Lantus, Humalog, Trulicity, Ozempic, and Tresiba, as well as Latanoprost eye drops for a resident with glaucoma. The lack of dating on these medications is contrary to the facility's policy, which requires insulin and certain other medications to be discarded after a specific number of days once opened. The observations were made during a series of inspections with the Qualified Medication Aide (QMA) and the Director of Nursing (DNS). The DNS confirmed that insulin pens should be labeled with the date they were opened, and the facility administrator indicated adherence to manufacturer guidelines for medication use. However, the failure to date these medications suggests a lapse in following these guidelines, as confirmed by the facility's policy document provided by the Signature Clinical Consultant, which outlines the expiration periods for various medications once opened.
Failure to Complete Post-Fall Assessments for Resident
Penalty
Summary
The facility failed to ensure that post-fall assessments and vital signs were completed for 72 hours following a fall incident involving Resident P. On the date of the fall, Resident P was found on the floor next to his wheelchair, incontinent of urine, but with no injuries noted after a skin assessment. Although vital signs were taken immediately after the fall, there was no documentation of further vital signs or assessments being completed in the following days as required by a physician's order. The order specified that a 72-hour follow-up assessment, including skin assessment, vital signs, and pain assessment, should be documented every shift, but the records lacked this documentation. Resident P had a history of falls and was at moderate risk for falling, with diagnoses including paroxysmal atrial fibrillation, altered mental status, and diffuse traumatic brain injury. Despite the care plan interventions to mitigate fall risks, such as offering toileting before and after meals, the facility did not update the fall risk assessment since the resident's admission. Interviews with facility staff revealed an acknowledgment of the lack of documentation and room for improvement in nursing staff's documentation practices. The facility's policy required fall risk assessments and care plan reviews following each fall, but these were not adequately followed in this case.
Failure to Arrange Transportation for Resident's Medical Appointment
Penalty
Summary
The facility failed to assist Resident C in arranging transportation to a physician office appointment. Resident C, who was admitted with conditions including diabetes, osteomyelitis of bilateral heels, hypertension, and functional quadriplegia, required maximum assistance for daily care needs. The resident was scheduled for a physician appointment but was unable to sit up and travel, leading to a rescheduling of the appointment. However, the facility did not arrange transportation for the rescheduled appointment, resulting in the resident missing the appointment. Consequently, the resident's family requested a transfer to the hospital due to the missed appointments and the need for care. Interviews with facility staff revealed a lack of coordination and communication regarding transportation arrangements. The Regional Nurse Consultant indicated that the facility used multiple companies for transfers, but there was no evidence that transportation was arranged for the rescheduled appointment. The receptionist, who was responsible for scheduling appointments, did not recall arranging transportation for the resident. Additionally, the local ambulance service confirmed that Resident C was not scheduled for a pick-up on the rescheduled date. The facility's documentation lacked evidence of the appointment and transportation arrangements, and the Assistant Administrator acknowledged that such arrangements should be reflected in the nurses' notes.
Failure to Protect Residents from Sexual Abuse
Penalty
Summary
The facility failed to protect residents from sexual abuse, specifically involving two cognitively impaired residents, Resident B and Resident C. On multiple occasions, Resident B was observed inappropriately touching Resident C in common areas and private rooms. Despite staff interventions to separate the residents and place Resident B on 15-minute checks, the inappropriate behavior continued throughout the day. The Director of Nursing (DON) was informed of the incidents but did not ensure adequate measures were taken to prevent further occurrences. Staff members reported the incidents to the DON, who instructed them to separate the residents and conduct 15-minute checks on Resident B. However, the staff did not document the incidents in the residents' medical records as instructed by the DON. The facility's failure to implement effective interventions and document the incidents contributed to the ongoing inappropriate interactions between the residents. Additionally, the facility did not have care plan interventions in place for Resident B's inappropriate behavior or Resident C's safety. The facility's policy on abuse, neglect, and misappropriation of property was not followed, as the incidents were not reported immediately to the appropriate authorities. The lack of documentation and inadequate response to the incidents resulted in a deficiency, as the facility did not protect the residents' right to be free from abuse. The immediate jeopardy was identified due to the facility's failure to prevent further abuse and ensure the safety of the residents involved.
Failure to Report and Document Resident Abuse Allegations
Penalty
Summary
The facility failed to report allegations of resident abuse immediately to the Administrator and the Indiana Department of Health (IDOH) for two residents. The Director of Nursing (DON) attempted to report the incidents through the IDOH facility reported incident (FRI) system but encountered technical difficulties and was unaware of alternative reporting methods. The incidents involved Resident B allegedly touching Resident C inappropriately, which was observed by multiple staff members, including CNAs and a QMA. Despite these observations, the incidents were not documented in the residents' medical records as instructed by the DON. Resident B, diagnosed with unspecified dementia and anxiety, was observed by staff members engaging in inappropriate behavior with Resident C, who had vascular dementia and anxiety. Staff members reported seeing Resident B with his hand down Resident C's pants and later found them lying together in a bed. The DON was informed of these incidents and instructed staff to separate the residents and conduct 15-minute checks on Resident B. However, the DON also instructed staff not to document the incidents in the medical records, and no additional staff was called to monitor Resident B. The facility's policy required immediate reporting of abuse allegations to the Administrator and state agencies within two hours. Despite this, the DON did not report the incidents immediately due to technical issues with the reporting system and a lack of knowledge about alternative reporting methods. The facility's failure to report the incidents promptly and the lack of documentation in the residents' medical records contributed to the deficiency identified by the surveyors.
Failure to Investigate and Document Abuse Allegations
Penalty
Summary
The facility failed to adequately investigate and respond to allegations of abuse involving two residents, Resident B and Resident C. The incident began when Resident B was observed by staff members, including CNAs and QMAs, to be inappropriately touching Resident C on multiple occasions. Despite these observations, the Director of Nursing (DON) did not ensure that a thorough investigation was conducted. The DON was informed of the incidents but did not collect written statements from the staff involved, and there was a lack of documentation regarding the incidents in the residents' medical records. The DON implemented 15-minute checks for Resident B and instructed staff to keep the residents separated. However, the monitoring documentation was inconsistent and lacked details about Resident B's activities or interactions with other residents. Additionally, the facility's policy on abuse and neglect was not followed, as the investigation was not documented thoroughly, and the staff were reportedly instructed not to document the incidents in the medical records. The facility's response did not include a comprehensive care plan for Resident B's inappropriate behavior or interventions to ensure Resident C's safety. Interviews with anonymous staff members revealed that the incidents were not properly addressed, and the DON's actions were insufficient to protect Resident C from further inappropriate contact. The facility's failure to conduct a proper investigation and implement effective interventions led to a deficiency in ensuring the safety and well-being of the residents involved. The lack of documentation and failure to follow the facility's abuse policy contributed to the deficiency identified by the surveyors.
Failure to Provide Personalized Care for Resident with Schizophrenia
Penalty
Summary
The facility failed to provide personalized care and interventions for a resident diagnosed with schizophrenia and other cognitive impairments, leading to multiple resident-to-resident altercations. Resident F, who resided in a secured behavioral unit, was involved in several incidents where she made physical contact with other residents or threw objects at them. Despite these occurrences, the facility's documentation lacked evidence of interventions implemented to prevent further incidents. Resident F's clinical record and behavioral care plan did not include specific strategies to address her behaviors or prevent future altercations. The care plan mentioned general interventions such as separating residents and notifying family and physicians, but it did not detail personalized approaches to manage Resident F's specific triggers and behaviors. The facility's investigations into the incidents also lacked documentation of preventive measures. Interviews with facility staff, including a Qualified Medication Aide and the Director of Nursing, revealed that staff attempted to redirect Resident F and separate her from other residents. However, these actions were not documented as part of a comprehensive care plan. The facility's administration acknowledged that Resident F was inappropriate for the facility due to her interactions with other residents, yet there was no evidence of a tailored plan to address her needs and prevent further altercations.
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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