St Elizabeth Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Delphi, Indiana.
- Location
- 701 Armory Rd, Delphi, Indiana 46923
- CMS Provider Number
- 155290
- Inspections on file
- 27
- Latest survey
- March 11, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at St Elizabeth Healthcare Center during CMS and state inspections, most recent first.
The facility did not provide required written discharge notices and bed hold policy information, including cost details, to residents and their representatives during hospital transfers. Documentation and staff interviews confirmed that, despite facility policy, there was no evidence that this information was given to multiple residents with complex medical conditions at the time of their transfer.
Staff administered and read Mantoux TB skin tests without documented training and failed to record required times for test administration and reading, resulting in tests being read too early or without proper documentation. Residents with complex medical conditions were affected, and facility policy requiring trained staff and complete documentation was not followed.
Staff did not obtain a follow-up weight or document refusals for a resident who experienced significant weight loss and gain, and failed to notify the physician, dietitian, or family representative as required by facility policy. Interviews indicated inconsistent practices and lack of documentation regarding weight refusals and follow-up.
The facility did not resolve ongoing grievances from residents about delayed call light response times, as documented in multiple resident council meetings and confirmed by resident interviews. Despite repeated complaints and facility policies requiring follow-up, there was no evidence that specific concerns were addressed or resolved, and documentation of actions taken was lacking.
The facility failed to document the progress of a non-pressure skin wound, monitor and document edema for a resident with a splint, and notify physicians of elevated blood sugar readings. Additionally, the facility did not follow physician's orders for medications for multiple residents, as confirmed through observations, record reviews, and staff interviews.
The facility failed to ensure proper respiratory care for three residents, leading to deficiencies in oxygen administration. Observations revealed inconsistencies in oxygen flow rates and undated oxygen tubing, contrary to physician's orders. Interviews with staff indicated a lack of adherence to prescribed oxygen levels.
The facility failed to ensure staff followed infection control standards, including handwashing during food service, using enhanced barrier precautions during wound care, and proper handling of soiled linens. Staff members acknowledged these lapses during interviews.
The facility failed to address and document resident council concerns about call light response times over several months. Residents reported long wait times for call light responses, sometimes up to an hour, and had to provide their own care due to staff inaction. The facility's policies on grievance resolution were not followed, leading to unresolved and undocumented concerns.
The facility failed to provide the required 48-hour Notice of Medicare Non-Coverage (NOMNC) for two residents, giving only a 24-hour notice instead. The Executive Director could not explain the reason for the insufficient notice period, as the responsible staff member was on leave. The facility's policy mandates a 2-day notice prior to Medicare discharge.
The facility failed to complete a revised PASARR level I for a resident after prescribing duloxetine for depression. The oversight was confirmed by the Executive Director and Clinical Support Nurse, who noted the facility did not have a specific PASARR policy.
The facility failed to remove expired medications and ensure proper labeling in the 500 back hall medication cart. Expired bottles of Robitussin DM and Geri tussin Liquid were found, along with unlabeled Tums, Diclofenac gel, and Children's Tylenol. A QMA was unaware of which residents were receiving the unlabeled medications and acknowledged the expired medications should have been removed.
The facility failed to maintain resident rooms and hallways in good repair and free of odors. Observations showed missing carpet and loud, old beds. Several rooms had strong urine odors, and staff were unaware of actions being taken to address the issue. The facility did not provide an environmental policy at the time of the exit conference.
Failure to Provide Written Discharge and Bed Hold Policy Information During Hospital Transfers
Penalty
Summary
The facility failed to provide required written documentation regarding the reason for discharge and the bed hold policy, including cost information, to residents and their representatives during hospital transfers. For four residents with complex medical histories, including conditions such as spina bifida, diabetes, congestive heart failure, dementia, and stroke, there was no evidence in the clinical records that written notices or bed hold policy details were given at the time of transfer. In several cases, nursing notes documented the transfer to the hospital but did not indicate that the residents or their representatives received the necessary information. One resident specifically reported not recalling receipt of discharge or bed hold policy documents. Interviews with facility staff, including the DON and Clinical Support Nurse, confirmed that while discharge paperwork was typically sent with the resident to the hospital, there was no documentation in the electronic health record to show that the required information was provided to the residents or their representatives. Facility policies required advance communication of bed hold options and charges, but the records reviewed did not demonstrate compliance with these requirements for the residents transferred to the hospital.
Failure to Document Training and Proper Administration of TB Skin Tests
Penalty
Summary
The facility failed to ensure that staff administering and reading Mantoux skin tests for tuberculosis (TB) had documented training, and did not consistently document all required elements of the TB testing procedure. Specifically, there was no documentation of the time the second step Mantoux test was administered or read for one employee, making it impossible to confirm the required 48-hour interval before reading the test. Additionally, for three residents, clinical records showed that TB skin tests were administered and read by nurses without documentation of required training, and in some cases, the tests were read before the 48-hour minimum had elapsed. The facility's own policies required that Mantoux tests be administered and read by staff with documented training and that the date and time of administration and reading be recorded. Residents involved had complex medical histories, including conditions such as spina bifida with hydrocephalus, type 2 diabetes mellitus, paraplegia, cerebral palsy, chronic respiratory failure, dementia, and other significant diagnoses. The records for these residents showed missing documentation of the time of TB test administration and reading, and in some cases, the tests were read too early. Interviews with the Infection Prevention Nurse and the Director of Nursing confirmed that the required training documentation was missing for several nurses, and that the facility could not verify training for some staff members.
Failure to Re-Weigh and Notify on Significant Resident Weight Changes
Penalty
Summary
Staff failed to obtain a follow-up weight for a resident who experienced significant fluctuations in weight, including a 23.65% loss in one month followed by a 27.49% gain the next month. There was no documentation of any re-weighing to confirm these significant changes, nor was there evidence that the physician, dietitian, or family representative were notified of the weight variances. The facility's own policy required re-weighing for weights outside the normal range and notification of significant weight changes, but these steps were not documented as completed. Interviews with staff revealed inconsistent practices regarding resident refusals to be weighed, with some staff stating they would attempt multiple times and inform management if a resident refused. However, there was no documentation of refusals or follow-up attempts for this resident, and some staff indicated the resident did not typically refuse to be weighed. The facility lacked a clear documentation policy for these situations, despite having written guidelines for weight tracking and management.
Failure to Resolve Resident Council Grievances Regarding Call Light Response
Penalty
Summary
The facility failed to resolve ongoing resident council concerns and grievances related to call light response times for three of five residents reviewed. Resident council meeting minutes over several months documented repeated complaints about long call light wait times, with no evidence of resolution. Residents reported waiting from 30 minutes to over an hour for assistance, including instances where a resident remained in soiled conditions for extended periods. Interviews with residents confirmed that the issue persisted over time, and the facility's documentation did not show specific actions taken to address or resolve these concerns. Facility staff, including the Clinical Support Nurse and Activity Director, indicated that grievances were recorded and reviewed by management, but could not provide evidence of specific concerns or their resolution. The only available call light audits covered a limited period, and facility policies required that grievances and recommendations be brought to the attention of leadership and reported back to the resident council, which was not demonstrated in practice. The deficiency was identified through interviews, record reviews, and examination of facility policies and procedures.
Failure to Document Wound Care and Notify Physicians of Abnormal Conditions
Penalty
Summary
The facility failed to assess and document the progress of a non-pressure skin wound for Resident 23. Despite having a physician's order to clean and dress the wound every five days, there was no documentation in the electronic health record (EHR) after the initial measurement on 2/25/24. The Director of Nursing Services (DNS) confirmed that the wound should have been assessed and measured weekly but was not. This lapse in documentation and follow-up care was evident during observations and interviews conducted on 4/16/24 and 4/17/24. Resident 37 had a left hand/wrist splint device in place, and her left wrist, hand, and fingers were swollen. Despite a physician's order to monitor for blanching, color, and odor three times a day, there was no documentation of the edema in the EHR. The DNS confirmed that there was no care plan in place for the resident's fracture and that the swelling and open skin area should have been documented. This deficiency was observed and confirmed during interviews on 4/18/24 and 4/19/24. The facility also failed to notify physicians of elevated blood sugar readings and to follow physician's orders for medications for multiple residents. For example, Resident 31 had blood glucose levels significantly above the normal range, but there was no documentation of physician notification. Similarly, Resident 29 received insulin despite blood sugar levels being below the threshold specified in the physician's order. Resident 16 was given digoxin despite having a pulse rate below the threshold, and there was no documentation of physician notification. These deficiencies were confirmed through record reviews and interviews with staff on 4/18/24 and 4/19/24.
Deficiencies in Respiratory Care
Penalty
Summary
The facility failed to ensure proper respiratory care for three residents, leading to deficiencies in oxygen administration. For Resident 23, observations revealed that the oxygen tubing was not dated, and the oxygen flow rate was inconsistently set at 1.5 liters, 2 liters, and 3 liters per minute, contrary to the physician's orders. The resident's care plan indicated a need for supplemental oxygen to manage chronic conditions such as congestive heart failure and chronic obstructive pulmonary disease, but the prescribed oxygen levels were not maintained consistently. Resident 31 was observed using an empty portable oxygen tank on multiple occasions, and the oxygen flow rate was set incorrectly at various times. The oxygen tubing was also not dated. Despite the physician's order for 2 liters of continuous oxygen, the flow rate was observed to be set at 2.5 liters and just under 3 liters. Interviews with staff indicated a lack of adherence to the prescribed oxygen flow rate, with only nurses authorized to adjust the flow rate. Resident 20's oxygen flow rate was observed to be set at 4 to 5 liters, contrary to the physician's order of 3 liters. The oxygen tubing was not dated, and the resident reported frequently asking staff to increase the oxygen flow when experiencing difficulty breathing. The resident's care plan and physician's orders were not followed, leading to inconsistent oxygen administration. Interviews with staff revealed a lack of awareness of the updated oxygen order, resulting in the incorrect flow rate being administered.
Infection Control Lapses
Penalty
Summary
The facility failed to ensure staff followed infection control standards in several instances. The Assistant Food Director was observed serving food to residents without washing his hands between serving plates on multiple occasions. Additionally, Guest Relations staff was seen touching her face and arm and then serving food without washing her hands. Both staff members acknowledged their lapses in hand hygiene during interviews. The Director of Health Services (DHS) and an RN did not follow enhanced barrier precautions while providing wound care and handling a urinary catheter for a resident with stage 3 and unstageable pressure ulcers, paraplegia, and osteomyelitis. Despite a physician's order requiring the use of gloves and gowns during high-contact care activities, both staff members only wore gloves. The DHS admitted they should have worn gowns during the procedure. Other infection control lapses included a Qualified Medication Aide (QMA) not changing gloves after performing incontinence care and then touching the resident's blankets and call light. A resident's catheter bag was found on the floor, and another resident had personal items and linens improperly stored on the floor and chair. Additionally, a soiled brief was left on a resident's bed, and a CNA was observed carrying soiled linens down the hall without placing them in a trash bag first. Staff members acknowledged these lapses during interviews, and the facility's policies on infection control were not followed in these instances.
Failure to Address and Document Resident Council Concerns
Penalty
Summary
The facility failed to ensure resident council concerns and grievances were addressed and documented in the meeting minutes for four of the twelve months reviewed. Specifically, concerns about call light response times were repeatedly raised by residents during council meetings in July 2023, January 2024, February 2024, and March 2024, but these concerns were not documented as reviewed or resolved in subsequent meeting minutes. Residents reported that call lights often went unanswered for extended periods, sometimes up to an hour or more, and in some cases, residents had to provide their own care due to the lack of timely response from staff. The Activity Director, who assisted residents in filling out grievances, was unaware of why the call light concerns had not been addressed, and the Director of Nursing Services confirmed that there was no documentation of call light audits being completed. The facility's policies on resident council meetings, resident rights, and the resident concern process were not followed. These policies require that grievances and recommendations be brought to the attention of the Executive Director, who should forward them to the appropriate department leader for attention and response. The resolutions should be documented and reported back to the Resident Council at the next meeting. However, this process was not adhered to, as evidenced by the lack of follow-up and resolution documentation in the meeting minutes. This failure to address and document resident concerns about call light response times indicates a significant lapse in the facility's grievance resolution process.
Failure to Provide 48-Hour Notice of Medicare Non-Coverage
Penalty
Summary
The facility failed to ensure the Notice of Medicare Non-Coverage (NOMNC) was given 48 hours prior to the end of Medicare benefits for two residents. For Resident 38, the NOMNC indicated that Medicare services would end on 3/13/24, but the resident signed the notice on 3/12/24, providing only a 24-hour notice. Similarly, for Resident 101, the NOMNC indicated that Medicare services would end on 3/5/24, but the resident signed the notice on 3/4/24, also providing only a 24-hour notice. During an interview, the Executive Director (ED) was unable to explain the reason for the insufficient notice period, as the staff responsible for completing the notices was on leave. The facility's current policy, last reviewed on 12/31/23, requires the NOMNC to be issued 2 calendar days prior to the actual discharge from Medicare.
Failure to Complete Revised PASARR Level I After Prescribing Psychotropic Medication
Penalty
Summary
The facility failed to ensure a revised Preadmission Screen and Resident Review (PASARR) level I was completed after psychotropic medications were prescribed for a resident. The clinical record for the resident indicated diagnoses including depression, anxiety disorder, dementia, congestive heart failure, and hypertension. A PASARR level I, dated earlier in the month, indicated the resident did not require a level II and was not taking any mental health medications. However, a physician's order later in the month prescribed duloxetine, an antidepressant, for the resident's depression. The care plan was updated to reflect the risk of adverse effects from the antidepressant medication, but a new PASARR level I was not completed within the required 14-day period after the medication was prescribed. The facility's Executive Director and Clinical Support Nurse confirmed the oversight during interviews, noting that the facility did not have a specific PASARR policy and relied on the Indiana PASARR Standard Operating Procedure Revenue & Collections.
Expired and Unlabeled Medications Found in Medication Cart
Penalty
Summary
The facility failed to ensure expired medications were removed from the medication cart and that medications were properly labeled. During an observation, a partial bottle of Robitussin DM with an expiration date of 2/22/24 and a partial bottle of Geri tussin Liquid 100/5 with an expiration date of 3/18/24 were found in the 500 back hall medication cart. Additionally, the bottom drawer contained a partial bottle of Tums and two tubes of Diclofenac sodium topical gel 1%, all of which were unlabeled. A partial bottle of Children's Tylenol was also found with a resident's name written in marker but not properly labeled. During an interview, a Qualified Medication Aide (QMA) indicated she did not know which resident(s) were receiving the Tums and Diclofenac gel and acknowledged that the expired medications should have been removed. She subsequently took the expired medications to the Director of Nursing Services for destruction. The facility's current policy on medication storage, received from the Clinical Support Nurse, indicated that outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or with insecure closures should be immediately removed from inventory and disposed of according to procedures for medication disposal. Another policy on medication administration guidelines emphasized the importance of checking the label, container, and contents for integrity and comparing them against the medication administration record before administering any medication. The facility's failure to adhere to these policies resulted in the presence of expired and unlabeled medications in the medication cart, posing a potential risk to resident safety.
Facility Fails to Maintain Clean and Odor-Free Environment
Penalty
Summary
The facility failed to ensure that resident rooms and hallways were in good repair and free of odors. Observations revealed that the doorway of one room was missing approximately 18 inches of carpet, and the hallway between two rooms had missing pieces of carpet around gold floor plates. Additionally, one room's bed was very loud when moving up and down due to dried grease on the bed frame, and the beds were old with the manufacturer no longer in business. The Maintenance Director confirmed that there were no purchase orders for the carpet or the beds. Several rooms had a strong urine odor that extended into the hallway. Interviews with staff indicated that the 500 hall always had a strong odor, and the Assistant Director of Nursing Services was unaware of any actions being taken to address the issue. The Maintenance Support mentioned that exhaust fans had been changed, but the odor persisted, possibly due to a resident spilling urine on the carpet. The facility did not provide an environmental policy at the time of the exit conference, although a policy on Resident Rights indicated that residents have the right to a safe, clean, comfortable, and homelike environment.
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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