Southwood Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Terre Haute, Indiana.
- Location
- 2222 Margaret Ave, Terre Haute, Indiana 47802
- CMS Provider Number
- 155484
- Inspections on file
- 50
- Latest survey
- February 26, 2026
- Citations (last 12 mo.)
- 23 (2 serious)
Citation history
Health deficiencies cited at Southwood Healthcare Center during CMS and state inspections, most recent first.
A resident with dementia, oropharyngeal dysphagia, and protein-calorie malnutrition, who required supervision with eating and had an order for a dysphagia-advanced diet, was served whole Brussels sprouts instead of chopped vegetables as specified on the diet ticket. During a lunch meal, a CNA observed the resident rapidly shoving food into her mouth without chewing and pocketing food, then noted bluish lips and performed the Heimlich maneuver, expelling a whole Brussels sprout before an LPN took over care. The facility’s risk management nurse confirmed that the vegetables had not been prepared in the chopped form required by the resident’s ordered modified diet.
A resident with a history of TIA and seizure disorder experienced an acute neurological change after being found on the bathroom floor unresponsive with right-sided facial droop and inability to raise the right arm. Staff called 911 and the resident was transferred by ambulance to a local ED and later to an ICU where life-sustaining interventions, including a ventilator, were initiated. Although the resident’s sister was listed as the emergency contact, the clinical record showed no documentation that she was notified of the fall, significant change in condition, or hospital transfer, and the transfer form indicated she was not aware of the transfer. The family member reported multiple unsuccessful attempts to reach the resident that day and only learned of the events during a late evening call, despite facility policy requiring prompt notification of the resident representative for significant changes in condition and transfers to the hospital.
A resident with multiple chronic conditions and a history of falls was not monitored or provided care during an entire night shift. Staff did not enter the resident's room or visualize her, relying on the assumption that she would request help if needed. The resident was found deceased on the floor between her bed and wheelchair the next morning, with records and staff interviews confirming that required checks and care were not performed.
A facility failed to provide adequate night shift staffing, with only one nurse, one QMA, and one CNA covering multiple units and nearly 100 residents. A resident with multiple chronic conditions was not checked on throughout the night and was found deceased in the morning, with staff admitting they did not perform required two-hourly checks. Documentation showed missed care, and both staff and residents reported ongoing issues with insufficient staffing and delayed care.
The facility did not ensure thorough investigations or maintain complete records for abuse allegations involving three residents with cognitive impairments. In two separate incidents, required documentation such as resident and staff interviews, as well as proper entries in the residents' medical records, was missing or incomplete, contrary to facility policy.
A resident with paraplegia and diabetes had inaccurate wound documentation upon admission, with wound measurements not matching those from an outside wound center and staff uncertainty about proper measurement protocols. Another resident with diabetes had multiple instances of insulin administration documented at times inconsistent with physician orders, with staff citing delayed documentation and time management issues. Facility policies required accurate and timely documentation, but these were not followed in both cases.
Insulin and other diabetes medications were not consistently administered or documented according to physician orders for four residents with diabetes. Doses were frequently given outside the prescribed time frames, sometimes hours late or not documented at all. Residents reported inconsistent administration times, and staff cited high workload as a reason for delays. Medical records showed repeated late or missing entries for both scheduled and sliding scale insulin, despite facility policy requiring timely administration and documentation.
A resident with a stage four pressure ulcer required enhanced barrier precautions during wound care. During a dressing change, an LPN followed proper protocol, but a CNA assisting did not perform hand hygiene upon entering the room, donned gloves without a gown, and removed a dressing without changing gloves or performing hand hygiene afterward. Facility policy required the use of gowns and gloves and hand hygiene for such procedures, but these were not followed by the CNA.
The facility failed to provide adequate nurse staffing, resulting in missed insulin doses for residents with diabetes. A resident on the 400 unit and another on the 2A unit reported not receiving their insulin as prescribed. The review of staffing schedules and MARs revealed multiple instances of insufficient nurse coverage, leading to missed doses of Lispro, Glargine, Fiasp, Exenatide, and Basaglar insulin. The facility's practice of having one nurse oversee multiple QMAs across different units contributed to the deficiencies.
The facility failed to administer insulin medications as ordered for three residents, leading to significant medication errors. Residents with diabetes did not receive several doses of their prescribed insulin, and there was a lack of documentation in the Medication Administration Record (MAR). Interviews revealed that staff were overwhelmed, leading to missed doses and improper documentation. The Regional Director of Clinical Operations acknowledged the issue and mentioned ongoing re-education of the nursing staff.
The facility failed to ensure proper hand hygiene and dishwashing temperatures. Staff used commercial paper towel rolls, leading to contamination, and dish machine temperatures were below required levels due to lime buildup and faulty gauges. The facility had a supply issue with paper towels, and the dish machine company was contacted for repairs.
A facility failed to document and communicate a resident's code status, leading to difficulty in accessing this critical information. The resident, with severe cognitive deficits and heart disease, did not have their DNR status readily available in the EMR or physician's orders. Staff interviews revealed that the code status should have been easily accessible, but it was not documented as expected, contrary to the facility's policy on advanced directives.
A facility failed to notify the Ombudsman of a resident's hospital discharge, as required. The resident, with conditions including hemiplegia, COPD, and CHF, was transferred to the hospital due to a change in condition. The Social Services Director, new to her position, did not send the required notification for the discharge, which was confirmed by the Regional Director of Clinical Operations and the Ombudsman.
The facility failed to complete MDS assessments in a timely manner for two residents discharged without anticipated return. The assessments were delayed and only identified by the corporate office, highlighting a lack of timely audits at the facility level.
A facility failed to implement timely treatment for a resident with a stage 4 pressure ulcer. The resident was admitted with the ulcer, but the prescribed wound vacuum treatment was delayed by two days, and there was a lack of documentation for five days. The care plan did not reflect the necessary treatment, and staff interviews revealed that the admitting nurse did not obtain immediate wound care orders. The facility's policy for obtaining physician orders and documenting treatment was not followed, resulting in the deficiency.
The facility failed to maintain sufficient weekend staffing during a fiscal quarter, as revealed by staffing data and staff interviews. A CNA and an LPN reported challenges in completing assignments due to low staffing levels, with CNAs handling up to two halls and even fewer staff on weekends. The facility's staffing schedules lacked necessary details, and the Nurse Staff Scheduler acknowledged ongoing staffing issues, particularly with CNAs. The facility did not have a staffing policy in place.
The facility failed to ensure staff competency in medication administration, leading to deficiencies for two residents. An LPN improperly used and cleaned a glucometer and left medication carts unlocked, while a QMA administered medications in coffee, including crushing a do-not-crush medication. The incidents highlighted lapses in adherence to facility policies on staff education and competency testing.
A facility failed to ensure the correct diagnosis for prescribing an antipsychotic to a resident and did not attempt a Gradual Dose Reduction (GDR) for another resident. The first resident was prescribed Invega for schizophrenia without a documented diagnosis, while the second resident's records lacked evidence of behaviors justifying continued psychotropic use or GDR attempts. Staff interviews revealed inadequate documentation and failed GDR attempts due to family intervention.
A facility failed to properly label an insulin pen for a resident with type 2 diabetes. An undated and opened Novolog insulin pen was found in a medication cart, and the LPN was unaware of how long it had been opened. Another LPN confirmed that insulin pens should have an open date and are good for 28 days once opened. The facility's policy required an open date sticker for medications with a specified usable duration after opening.
The facility failed to follow infection control protocols during medication administration and in the laundry room. An LPN did not use bleach wipes to clean a glucometer or place a barrier under it, and disposed of a lancet improperly. In the laundry room, clean items were stored in the soiled area, violating the facility's policy.
A facility failed to supervise and implement effective interventions for a dementia resident with intrusive wandering behaviors, leading to an altercation with another resident. Despite being on one-on-one observation, the resident entered another's room and was hit, resulting in a reddened area on her temple. The care plans lacked specific, person-centered interventions, and documentation of intervention efficacy was insufficient, contributing to the incident.
A facility failed to maintain a system for narcotic reconciliation, resulting in drug diversion incidents involving a resident's Norco and tramadol medications. Despite suspending staff and conducting investigations, the facility could not determine the whereabouts of the missing medication cards. Discrepancies in narcotic counts and inadequate documentation practices were identified, highlighting a breach in regulatory compliance.
A resident with multiple medical conditions was transported to a urology appointment in an undignified manner, wrapped in a sheet covered in feces, wearing only an adult diaper, with a leaking colostomy bag and a falling catheter. Staff were aware of the resident's care needs but failed to ensure he was properly cleaned and clothed before the appointment.
The facility failed to ensure accurate documentation of IV medication administration for a resident with multiple diagnoses, including metabolic encephalopathy and acute kidney failure. The MAR lacked documentation for several doses of cefazolin sodium, heparin sodium lock flush, and sodium chloride flush. Interviews revealed that staff did not understand the blanks in the MAR, and the facility's medication administration policy was not followed.
Failure to Provide Diet Texture Consistent With Dysphagia Order
Penalty
Summary
The deficiency involves the facility’s failure to provide food in a form consistent with a physician-ordered modified diet for a resident with dysphagia and severe cognitive impairment. The resident had diagnoses including dementia, oropharyngeal phase dysphagia, and protein-calorie malnutrition, and required supervision and/or touching assistance for eating. A physician’s order specified a regular diet with dysphagia advanced texture and regular consistency. The facility’s menu and diet ticket for a lunch meal listed roasted Brussels sprouts that were to be served chopped for this dysphagia advanced diet. On the day of the incident, a CNA observed the resident during lunch rapidly shoving food into her mouth, not chewing, and pocketing food in her cheeks, which was unusual for the resident who typically fed herself slowly. The CNA moved the plate out of reach to slow the resident’s intake and address the food already in her mouth, then noted the resident’s lips turning bluish and believed she was choking. The CNA performed the Heimlich maneuver while the resident was seated, resulting in expulsion of a whole Brussels sprout, after which an LPN assumed care. The Corporate Risk Management Nurse later confirmed the resident had been served whole Brussels sprouts instead of chopped Brussels sprouts as required by the ordered dysphagia advanced diet and the facility’s texture policy.
Failure to Notify Resident Representative of Significant Change and Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s emergency contact of a significant change in condition, transfer to the hospital, and subsequent initiation of life-sustaining interventions. The resident had diagnoses including a personal history of transient cerebral ischemic attack (TIA) and seizure disorder. On the date of the incident, documentation showed the resident was observed by a CNA at approximately 5:00 a.m. and was up and talking at that time. Around 5:35 a.m., the resident’s roommate activated the call light and reported the resident was on the bathroom floor. The resident was found unresponsive with right-sided facial drooping and inability to raise the right arm, 911 was called, and the resident was transferred by ambulance to a local hospital emergency room. A Transfer to Hospital form listed the resident’s sister as the emergency contact and indicated she was not aware of the transfer, and the clinical record contained no documentation that the emergency contact was notified of the fall, acute change in condition, or hospital transfer. The resident’s family member, identified as the emergency contact, reported that she and the resident communicated often and that the family had planned to visit for the resident’s upcoming birthday. She stated she made three calls to the resident that day, each transferred to the nurse’s station without being answered, and on a fourth call around 9:00 p.m. a staff member informed her that the resident had been sent to a local hospital that morning and later transferred to a hospital in Indianapolis, where the resident was in the ICU on a ventilator receiving life-sustaining interventions. The family member stated that, in her opinion, the resident had suffered while alone in the hospital and that, had the facility contacted her as required, she might have been able to be present during his last lucid moments. The resident subsequently died without regaining consciousness. The facility’s own Notification of Change in Condition policy required prompt notification of the resident’s representative for significant changes in condition, life-threatening conditions, and transfers to the hospital, but this notification did not occur as required for this resident.
Failure to Monitor and Provide Nighttime Care Resulting in Resident Neglect
Penalty
Summary
The facility failed to protect a resident's right to be free from neglect by not providing adequate monitoring and care during the night shift. A resident with multiple medical conditions, including COPD, congestive heart failure, diabetes, and atherosclerotic heart disease, required supervision or assistance with activities of daily living (ADLs) and was at risk for falls. Care plans indicated the need for staff to check for incontinence, provide assistance with transfers, and ensure the call light was within reach, but there was no documentation that the resident was independent with ADLs or refused care. On the night in question, staff did not enter the resident's room or visualize her for the entire 8-hour night shift, relying instead on the assumption that the resident would come out or use the call light if assistance was needed. Staff statements and interviews revealed that the nurse and CNA assigned to the resident's unit did not physically check on the resident during the night, with the CNA last seeing her between 9:00 p.m. and 10:00 p.m. and the nurse not seeing her at all. The QMA assigned to the unit opened the resident's door but did not fully enter or confirm the resident's presence, only assuming she was in bed. Documentation in the resident's records, including progress notes and care logs, lacked entries indicating care or monitoring was provided after late evening, and there was no evidence the resident refused care or requested privacy that would have precluded staff checks. Staffing levels were reported as typical for the facility but were described by multiple staff as insufficient to allow for regular two-hour checks, especially during night shifts. The resident was found deceased on the floor between her bed and wheelchair by the oncoming shift nurse the next morning, with rigor mortis present, indicating she had been dead for several hours. The coroner and police were notified, and the preliminary autopsy indicated death from natural cardiac causes with no suspicious trauma. Staff interviews confirmed that routine two-hour checks were expected but not performed, and the resident's care plan did not document any preference to avoid such checks. The facility's policies required regular monitoring for safety and care needs, but these were not followed, resulting in the resident not being observed or assisted throughout the night.
Failure to Provide Sufficient Night Shift Staffing Resulting in Resident Death
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs and ensure the supervision of residents, resulting in a deficiency related to inadequate staffing. On the night in question, only one nurse was on duty for the entire building, with one QMA assigned to three units and one CNA assigned to two units. This staffing pattern was not unusual for the facility, despite a census of approximately 93 to 97 residents. Staff interviews revealed that residents were not checked on every two hours as expected, and some staff did not physically enter certain residents' rooms, relying instead on residents to seek help if needed. Documentation and care records for one resident showed a lack of entries for toileting and other care after a certain time, indicating that required checks and assistance were not provided throughout the night. A resident with multiple chronic conditions, including COPD, congestive heart failure, diabetes, and heart disease, was found deceased on the floor between the bed and wheelchair during morning rounds. The resident had previously indicated a desire for CPR in the event of cardiac arrest, but was found with irreversible signs of death, and CPR was not initiated. Staff statements confirmed that the resident was not checked on during the night shift, and the last known interaction was the previous evening. The CNA assigned to the resident's unit had worked a double shift and did not perform the expected two-hourly checks, citing difficulty managing the workload. Other staff corroborated that night shift staffing was consistently low, making it challenging to provide timely care and supervision. The facility's own assessment and staffing model indicated a need for more licensed nurses and nurse aides per unit than were actually scheduled, and the assessment lacked documentation of how policies and procedures were evaluated or updated. Multiple staff and residents reported that the number of staff on night shift was insufficient to meet care needs, with delays in response to call lights and medication requests. Staffing schedules showed frequent instances of only one nurse on duty, with no documentation of efforts to secure replacements when staff called in. The deficiency was identified as immediate jeopardy due to the failure to provide adequate care and supervision, resulting in a resident not being checked on all night and subsequently being found deceased.
Failure to Conduct and Document Thorough Abuse Investigations
Penalty
Summary
The facility failed to conduct thorough investigations and maintain complete records for abuse allegations involving three residents. In one incident, two residents with cognitive impairments were involved in an altercation in the dining room, where one resident pushed another's wheelchair. Although staff separated the residents and initiated an investigation, the incident file lacked documentation of resident interviews and did not include statements from other residents to determine if there were additional concerns. Furthermore, the electronic health records for both residents did not contain any documentation of the incident. In another case, a resident with severe dementia reportedly sustained a skin tear to the right forearm after contact with a CNA. The CNA was suspended pending investigation, but the facility's documentation was incomplete. There was no skin assessment performed on the date of the incident, and subsequent skin check forms and nurse progress notes did not document the injury. The investigation file included an undated statement from the CNA and a resident interview, but lacked individual, signed, and dated statements from all staff present at the time of the incident. Additionally, the facility could not locate a statement from the nurse on duty during the incident. The facility's policy required obtaining statements from all involved parties and documenting facts and findings in each resident's medical record. However, in both incidents, the required documentation was missing or incomplete, including resident and staff statements, and proper recording of the incidents in the residents' health records. These deficiencies were confirmed through record review and interviews with the Executive Director and Regional Director of Clinical Operations.
Deficient Documentation of Wound Care and Insulin Administration
Penalty
Summary
The facility failed to accurately document wound descriptions upon admission and did not ensure medication administration was documented according to physician orders for two residents. For one resident with paraplegia and type 2 diabetes, the medical record review revealed inconsistencies in wound measurement documentation. The wound was measured in centimeters, but the recorded size did not match the measurements from an outside wound center, which showed significant changes in wound size before and after the resident's stay. Interviews with staff indicated uncertainty about proper wound staging and measurement protocols, despite facility policy requiring measurements in centimeters. For another resident with type 2 diabetes and moderate cognitive deficit, the facility did not document insulin administration according to physician orders. The medication administration record (MAR) showed multiple instances where insulin doses were recorded as given at times significantly different from the prescribed schedule. Staff interviews revealed that nurses sometimes delayed documentation, making it appear as though medications were administered late, and that time management challenges contributed to the issue, especially when nurses had to cover for medication aides who could not administer insulin. Facility policies required timely and accurate documentation of both wound care and medication administration, including adherence to the five rights of medication administration and real-time charting. However, the observed practices did not align with these policies, as evidenced by the discrepancies in wound documentation and the inconsistent timing of insulin administration entries in the MAR.
Failure to Administer and Document Insulin According to Physician Orders
Penalty
Summary
The facility failed to ensure that insulin and other diabetes medications were administered and documented according to physician orders for four residents. Multiple observations, record reviews, and interviews revealed that insulin doses were frequently given outside of the prescribed time frames, with some doses being administered several hours late or not documented at all. Residents reported inconsistent administration times, with some indicating they received insulin before meals as ordered, while others were unsure of the timing or reported significant delays. Staff interviews confirmed that medications were sometimes administered late due to workload and that documentation was not always completed at the time of administration. Medical record reviews for the affected residents showed repeated instances where insulin was administered well outside the one-hour window before or after the scheduled time, as required by facility policy. For example, insulin doses scheduled for early morning or before meals were often given in the late morning, afternoon, or even evening. In some cases, there was a complete lack of documentation for certain insulin administrations, including STAT orders for hyperglycemia. The medication administration records (MARs) reflected numerous late entries and missing documentation for both scheduled and sliding scale insulin doses. The residents involved had diagnoses of type 2 diabetes mellitus, some with complications such as diabetic neuropathy or chronic kidney disease, and were assessed as requiring regular insulin injections. Care plans for these residents included interventions to administer diabetes medications as ordered, but these interventions were not consistently followed. Staff interviews indicated that high workload and the need to cover multiple halls contributed to the delays. The facility's medication administration policy required medications to be given within a specific time frame and for documentation to be current, but these standards were not met for the residents reviewed.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to ensure proper implementation of enhanced barrier precautions during a dressing change for a resident with pressure ulcers. During a continuous observation, an LPN performed hand hygiene, donned gloves and a gown, and completed a dressing change to the resident's sacrum. Near the end of the procedure, a CNA entered the room to assist but did not perform hand hygiene upon entry, donned gloves without a gown, and removed the dressing from the resident's left heel. The CNA continued to hold the resident's leg and did not perform hand hygiene or change gloves after removing the dressing. The LPN later confirmed that the CNA should have performed hand hygiene before donning gloves, worn a gown, and not removed the dressing from the resident's heel. The resident involved had a diagnosis of a stage four pressure ulcer of the sacral region and required enhanced barrier precautions for wound care, as indicated by physician orders. Facility policy required the use of gowns and gloves, as well as hand hygiene, during high-contact care activities such as wound care for residents with wounds. The Nurse Consultant confirmed that the facility's current policies required these precautions but stated there was no specific policy for dressing changes.
Inadequate Staffing Leads to Missed Insulin Administration
Penalty
Summary
The facility failed to ensure adequate nurse staffing across multiple units, leading to missed administration of critical insulin medications for residents. Resident K, who resides on the 400 unit and has a diagnosis of type 2 diabetes mellitus, reported not receiving her insulin doses as prescribed. The review of the nursing staff schedule and medication administration records (MAR) for December 2024 revealed multiple instances where no nurse or Qualified Medication Aide (QMA) was scheduled, resulting in missed doses of Lispro and Glargine insulin on several days. The Regional Director of Clinical Operations (RDCO) suggested that the nurses might have administered the medications but failed to document them. Similarly, Resident F, residing on the 2A unit, also reported missing insulin doses, particularly during the evening shifts. The review of the staffing sheets and MAR indicated that on several occasions, there was a lack of documentation for the administration of Fiasp, Exenatide, and Basaglar insulin, as well as accu checks. The staffing schedule often lacked clarity on which nurse was responsible for covering the QMA, leading to confusion and potential oversight in medication administration. Interviews with staff members highlighted the challenges faced due to the confusing schedule and the need for nurses to cover multiple units simultaneously. The facility's staffing issues were further compounded by the practice of having one nurse oversee multiple QMAs across different units, which overwhelmed the staff and led to inadequate coverage. On several occasions, the schedule lacked evidence of nurse coverage for specific halls, leaving residents without proper care. The RDCO acknowledged the documentation issues and the need for re-education of the nursing staff, but the facility did not have a formal policy for staffing, contributing to the ongoing deficiencies.
Insulin Administration Deficiencies
Penalty
Summary
The facility failed to ensure that insulin medications were administered as ordered for three residents, leading to significant medication errors. Resident F, who was diagnosed with systemic lupus erythematosus and diabetes mellitus, did not receive several doses of her prescribed insulin medications, including Fiasp, Exenatide, and Basaglar, as documented in the December 2024 Medication Administration Record (MAR). Additionally, there were missing records of blood glucose monitoring (accu checks) for Resident F. During an interview, Resident F confirmed that she missed doses of her insulin, particularly during the evening shift. The Regional Director of Clinical Operations (RDCO) acknowledged the documentation issues and mentioned ongoing re-education of the nursing staff. Resident K, diagnosed with type 2 diabetes mellitus with hyperglycemia, also experienced missed doses of insulin medications, including Glargine and Lispro, as indicated by the December 2024 MAR. There was no documentation of the resident's refusal to take the medication. The RDCO believed that the nurses administered the insulin but failed to document it properly. This lack of documentation and administration was consistent across multiple dates. Resident H, who had multiple diagnoses including COPD, type 2 diabetes, and congestive heart failure, also had missing documentation for the administration of Lantus and Lispro insulin. The MAR for December 2024 showed that several doses were not recorded as administered. Resident H did not recall missing any insulin doses but mentioned refusing insulin when her blood sugar was too low. The facility's policy on injectable medication administration required documentation of the administration site and any reactions, which was not consistently followed. Interviews with staff revealed challenges in overseeing multiple halls and ensuring proper administration and documentation of insulin medications.
Deficiencies in Hand Hygiene and Dishwashing Temperatures
Penalty
Summary
The facility failed to ensure proper hand hygiene during dining and kitchen observations. Staff members, including a Central Supply Aide, a CNA, and an LPN, were observed washing their hands and then using a commercial size roll of paper towels to dry their hands. This practice led to contamination of the paper towel roll with water, as staff touched the roll with wet hands. Additionally, staff used the same paper towel to turn off the faucet and then proceeded to serve food to residents, further compromising hand hygiene standards. The facility also failed to maintain adequate dishwashing temperatures during kitchen observations. The dish machine's wash and rinse temperatures were observed to be below the required levels, with the wash temperature at 148 degrees Fahrenheit and the rinse temperature at 155 degrees Fahrenheit, both of which are below the manufacturer's recommended temperatures. The issue was attributed to significant lime buildup and faulty temperature gauges, which were later inspected and replaced. Interviews with staff revealed that the facility had a supply issue with paper towels, leading to the use of commercial rolls instead of the appropriate sheets for dispensers. The Director of Nursing and the Regional Director of Clinical Operations were unaware of the use of commercial rolls and acknowledged that it was not suitable for proper hand hygiene. The Dietary Manager confirmed the dish machine's temperature issues and had contacted the dish machine company for repairs.
Failure to Document and Communicate Resident's Code Status
Penalty
Summary
The facility failed to ensure that the code status of a resident was documented and readily available to staff. Resident 152, who had severe cognitive deficits and a history of heart disease, did not have an established code status documented in their electronic medical record (EMR) or in the physician's orders. During a review of the resident's records, it was found that the code status was not easily accessible, and the Licensed Practical Nurse (LPN) had difficulty locating it. Eventually, the LPN found the resident's POST (Physician Orders for Scope of Treatment) document in the hard chart, indicating a Do Not Resuscitate (DNR) status. Interviews with facility staff, including the Regional Director of Clinical Operations (RDCO) and the Director of Nursing (DON), revealed that the expectation was for the code status to be a physician's order and appear on the first page of the EMR. The POST form should have been scanned into the EMR and easily accessible to staff. However, the resident's code status was not documented as expected, leading to confusion and difficulty in accessing this critical information. The facility's policy on advanced directives emphasized the importance of documenting and communicating the resident's choices regarding life-sustaining treatment, which was not adhered to in this case.
Failure to Notify Ombudsman of Resident's Hospital Discharge
Penalty
Summary
The facility failed to notify the Ombudsman of a resident's discharge to the hospital, which was required as part of the discharge process. This deficiency was identified during a review of the records for a resident who was hospitalized. The resident, who had diagnoses including hemiplegia and hemiparesis following a stroke, COPD, and CHF, experienced a change in condition with new or worsening abdominal pain and shortness of breath. The resident was transferred to the hospital for evaluation and treatment on the physician's order. However, the facility's records did not include documentation that the Ombudsman was notified of this discharge. Interviews with facility staff revealed that the Social Services Director, who had recently assumed her position, had not sent the required notification for October 2024. The Regional Director of Clinical Operations confirmed that the notification had not been completed. The Ombudsman also confirmed not receiving the discharge notification for October 2024. The facility's Bed Hold Policy required that a copy of the Acute Transfer Letter be sent to the Ombudsman, but this procedure was not followed in this instance.
Delayed MDS Assessments for Discharged Residents
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) resident assessments were completed in a timely manner for two residents whose records were reviewed. Resident 42 was discharged with no anticipated return, yet her discharge MDS assessment was not completed until several months later, on 12/9/24, after being identified by the corporate office. Employee 19, responsible for audits, was unaware of the oversight until notified by the corporate office, which maintained an audit log, unlike the facility. Similarly, Resident 2 was discharged with no anticipated return, but her discharge MDS assessment was not completed until 12/2/24 and accepted on 12/3/24, again identified by the corporate office. Employee 19 was not familiar with the specifics of Resident 2's case but acknowledged the corporate office's role in discovering the delay. The Regional Director of Clinical Operations provided documentation from the CMS RAI Manual, which mandates that discharge assessments be completed within 14 days of discharge and submitted within 14 days of completion.
Failure to Implement Timely Pressure Ulcer Treatment
Penalty
Summary
The facility failed to obtain and implement treatment orders upon admission for a stage 4 pressure ulcer for Resident K. The resident was admitted with a stage 4 pressure ulcer on the sacrum, but the facility did not start the prescribed wound vacuum treatment until two days after the order was obtained. The medical record lacked documentation of wound treatment for five days, and the care plan did not reflect the presence of a stage 4 pressure wound or the necessary medical treatment. The wound vacuum was discontinued due to contamination issues, and there was a lack of documentation indicating that the treatment was completed as ordered. Interviews with staff revealed that the admitting nurse did not contact the physician or nurse practitioner to receive orders for wound care at the time of admission. The wound vacuum order was obtained on 10/28/24, but the treatment was not started until 10/30/24, following the schedule of Monday, Wednesday, and Friday. The facility's policy required obtaining a physician's order and documenting treatment in the Treatment Administration Record, but these steps were not followed, leading to the deficiency.
Insufficient Weekend Staffing in Facility
Penalty
Summary
The facility failed to ensure sufficient weekend staffing during the third fiscal year quarter from April 1, 2024, to June 30, 2024. This deficiency was identified through a review of staffing data and interviews with facility staff. On December 2, 2024, the staffing data report revealed low weekend staffing during this period. Interviews with a Certified Nursing Assistant (CNA) and a Licensed Practical Nurse (LPN) on December 4, 2024, highlighted that staff were unable to complete their daily assignments due to insufficient staffing levels. The CNA mentioned being frequently asked to work overtime, which she declined to avoid burnout, while the LPN noted that each CNA was responsible for up to two halls during day and evening shifts, with even fewer staff available on weekends. Further investigation on December 9, 2024, revealed that the facility's staffing schedules for April, May, and June 2024 lacked information on census, required number of staff, and assigned number of staff. The Nurse Staff Scheduler acknowledged the issue of low weekend staffing and mentioned efforts to hire more staff, particularly for the night shift. However, the facility did not have a policy related to staffing, as confirmed by the Regional Director of Clinical Operations. The deficiency was primarily attributed to a shortage of CNAs on weekends.
Deficiencies in Medication Administration and Infection Control
Penalty
Summary
The facility failed to ensure that staff was competent in medication administration for two residents, leading to deficiencies in care. For Resident 51, an LPN used a glucometer machine without proper cleaning and placed it on a bedside table without a barrier. The nurse also left medication carts unlocked and a computer screen open with resident information visible. The LPN was unsure about the correct procedure for cleaning the glucometer and admitted that residents shared the machines. Another staff member confirmed that bleach wipes should be used for cleaning and that a barrier should be used when placing the glucometer on surfaces. Additionally, the lancet was improperly disposed of in the trash instead of a sharps container. For Resident M, a QMA administered medications in coffee, which was not an approved method. The QMA was unaware that crushing Depakote ER, a medication on the do-not-crush list, was inappropriate. The QMA had been administering medications in coffee since starting at the facility, following advice from another staff member whose identity she could not recall. The resident's medical records indicated cognitive impairment and a history of dementia and major depressive disorder. The QMA had been working in the facility for a short period and was not fully aware of the proper medication administration procedures. The facility's policy on staff education and competency testing emphasized safety and required competency testing through various methods. However, the incidents with Residents 51 and M highlighted lapses in adherence to these policies, resulting in improper medication administration and infection control practices. The Regional Director of Clinical Operations acknowledged the errors and indicated that the staff involved would receive further education on proper procedures.
Deficiencies in Antipsychotic Medication Management
Penalty
Summary
The facility failed to ensure the correct supporting diagnosis was used to prescribe an antipsychotic medication for one resident. The resident's records indicated a prescription for Invega, an antipsychotic medication, for schizophrenia, despite lacking a documented diagnosis of schizophrenia. The Regional Director of Clinical Operations acknowledged the error, noting that the incorrect diagnosis was perpetuated by successive nursing staff following an initial incorrect entry. Additionally, the facility did not attempt a Gradual Dose Reduction (GDR) or provide evidence to support the denial of a GDR for another resident. This resident had a complex medical history, including schizoaffective disorder and other mental health conditions, and was on antipsychotic medication. Despite pharmacy reviews and team discussions, the facility's records lacked documentation of behaviors justifying the continued use of psychotropic medication or evidence of clinical GDR attempts. Interviews with facility staff revealed that previous GDR attempts were considered failed due to the resident's family discontinuing medications when taking the resident home. The psychologist and nursing staff acknowledged the lack of supporting documentation for the resident's continued medication use. The facility's policy required GDR attempts unless clinically contraindicated, but the documentation did not adequately support the decision to forgo these attempts.
Improper Labeling of Insulin Pen
Penalty
Summary
The facility failed to ensure proper labeling of medication for one of the medication carts reviewed. During an observation, an undated and opened Novolog insulin pen was found in the 200 B hall medication cart, which was labeled for a resident. The insulin pen did not have an open date, and the LPN interviewed was unaware of how long the pen had been opened. Another LPN confirmed that insulin pens should have an open date and are good for 28 days once opened. The resident associated with the insulin pen had a diagnosis of type 2 diabetes mellitus with diabetic neuropathy. A physician's order indicated the resident was to receive 15 units of Novolog insulin before meals. The facility's policy on medication storage required that an open date sticker be placed on medications with a specified usable duration after opening, which was not adhered to in this instance.
Infection Control Lapses in Medication Administration and Laundry Room
Penalty
Summary
The facility failed to ensure proper infection control practices during medication administration for a resident with type II diabetes mellitus. During an observation, an LPN used a glucometer without following the correct cleaning protocol. The LPN wiped the glucometer with an alcohol pad instead of using bleach wipes as required by the facility's policy. Additionally, the glucometer was placed on the resident's bedside table without a protective barrier, and a used lancet was improperly disposed of in the trash can instead of a sharps container. The facility's policy mandates the use of bleach wipes for cleaning glucometers and the use of barriers when placing them on surfaces, which was not adhered to in this instance. In a separate incident, the facility failed to maintain proper separation of clean and dirty items in the laundry room. During an observation, clean mechanical lift slings and mop heads were found in the soiled linen area, contrary to the facility's infection control policy. The Laundry Supervisor acknowledged that the clean items were improperly stored in the soiled area. The facility's policy requires that clean linens and equipment be stored separately from soiled items to prevent cross-contamination, which was not followed in this case.
Failure to Supervise Dementia Resident Leads to Altercation
Penalty
Summary
The facility failed to adequately supervise and implement effective interventions for a resident with dementia, known for intrusive wandering behaviors, which led to an altercation with another resident. Resident B, who had a history of pacing, fighting with staff, and invading personal space, entered Resident C's room, resulting in Resident C hitting Resident B. At the time of the incident, Resident B was under one-on-one observation, but the staff was unable to redirect her effectively. This incident resulted in a physical altercation, causing a reddened area on Resident B's right temple. Resident B had a complex medical history, including Alzheimer's dementia, schizoaffective disorder, and bipolar disorder, which contributed to her challenging behaviors. Despite being on a secured unit and having a care plan in place, the interventions lacked specificity and personalization to address her needs effectively. The care plans did not include detailed, person-centered interventions, and there was a lack of documentation regarding the efficacy of the interventions implemented. Staff were aware of Resident B's behaviors, such as touching other residents and not understanding personal space, but the interventions were not sufficient to prevent the incident. The facility's documentation indicated that Resident B had been exhibiting aggressive behaviors towards staff and other residents, with multiple incidents of physical aggression noted in the weeks leading up to the altercation. Despite being on one-on-one supervision, the facility did not have adequate measures in place to prevent Resident B from entering other residents' rooms or to manage her manic episodes effectively. The lack of specific interventions and documentation of their effectiveness contributed to the failure to prevent the incident, highlighting deficiencies in the facility's approach to managing residents with complex behavioral needs.
Failure in Narcotic Reconciliation Leads to Drug Diversion
Penalty
Summary
The facility failed to maintain a system for the reconciliation of narcotic medications, resulting in two separate occasions of drug diversion for a resident. The first incident involved a missing card of Norco, a narcotic medication prescribed to Resident C for moderate to severe pain. The facility's investigation could not determine who took the missing medication card, despite suspending two staff members, QMA 6 and RN 5, pending investigation. The investigation revealed discrepancies in the narcotic count sheets and the facility's inability to track the medication accurately. Resident C was informed of the missing medication, but this was not documented in the electronic health record. The second incident involved a missing card of tramadol, another narcotic medication prescribed to Resident C. Again, the facility could not determine the whereabouts of the medication card, leading to the suspension of QMA 6 and LPN 13. The investigation included a facility-wide search and interviews with staff, but the missing medication card and count sheet could not be located. The facility's documentation practices were found lacking, as there was no discharge medication documentation for Resident C's discharge to home. The facility's policy on medication controlled drugs and security was not adhered to, as evidenced by the discrepancies in narcotic counts and the failure to maintain accurate records. The facility's procedures for handling narcotic keys and conducting narcotic counts were not followed, leading to the inability to account for the missing medications. The facility's failure to maintain a proper system for narcotic reconciliation resulted in the misappropriation of resident property and a breach of regulatory compliance.
Failure to Ensure Dignified Transfer to Medical Appointment
Penalty
Summary
The facility failed to ensure that Resident B was transferred to a doctor's appointment in a dignified manner. Resident B, who has multiple diagnoses including volvulus, neuropathic bladder, autistic disorder, and profound intellectual disabilities, was transported to a urology appointment by an ambulance service. Upon arrival at the urology office, Resident B was found wrapped in a sheet covered in feces, wearing only an adult diaper, with a catheter falling out and a full, leaking colostomy bag. His skin was red and excoriated around his stoma and back. The record review indicated that Resident B was dependent on staff for care and had no documented episodes of rejecting care or pulling out his catheter or colostomy bag. However, the care plan did not address these behaviors or provide strategies for managing them. Interviews with staff revealed that Resident B was known to be resistive to care, often pulling off his colostomy bag and catheter. On the day of the appointment, staff attempted to clean him but were unsuccessful, and the transport team did not allow further cleaning before departure. The Director of Nursing confirmed that it was the facility's expectation for residents to be properly clothed and cleaned before appointments, and that extra clothing was available if needed. However, this protocol was not followed in Resident B's case. The report highlights a significant lapse in the facility's duty to provide dignified care and proper preparation for medical appointments, resulting in Resident B being transported in an undignified and unhygienic state.
Failure to Accurately Document IV Medication Administration
Penalty
Summary
The facility failed to ensure accurate documentation of medical records for Resident D, who was receiving intravenous (IV) medication administration. Resident D had multiple diagnoses, including metabolic encephalopathy, acute kidney failure, and type 2 diabetes. A physician's order dated 1/29/24 indicated that cefazolin sodium injection solution was to be administered intravenously every 8 hours until 2/9/24. However, the February 2024 medication administration record (MAR) lacked documentation of IV medication administration on several occasions, including 2/3/24 at 10:00 p.m., 2/9/24 at 2:00 p.m., and 2/17/24 at 11:00 p.m. There was no documentation for omission or resident refusal for these missed doses. Additionally, the MAR lacked documentation for heparin sodium lock flush and sodium chloride flush on the same dates and times. A nurse's note dated 2/14/24 indicated that Resident D's wife was concerned about missed doses of IV antibiotics. The Registered Nurse (RN) changed the administration times to avoid shift changes and ensure doses were not missed. Licensed Practical Nurses (LPNs) interviewed on 4/3/24 indicated they did not understand the blanks in the MAR and that it should not have been blank. The Director of Nursing (DON) indicated that if the resident was out of the facility during the scheduled administration time but returned within two hours, he should have received his medications. If a dose was missed, they were required to call telehealth, notify the family, and document the reason. Leave of absence records indicated Resident D signed out on 2/3/24 and 2/9/24, but there was no documentation for a leave of absence on 2/17/24. The facility's medication administration policy indicated that medications should be charted when given, and any refused or withheld medications should be documented. The policy also required follow-up with the physician for critical medications that were refused. The facility failed to adhere to these policies, resulting in incomplete documentation of Resident D's IV medication administration.
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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