Sycamore Care Strategies
Inspection history, citations, penalties and survey trends for this long-term care facility in Loogootee, Indiana.
- Location
- 12802 East Us Hwy 50, Loogootee, Indiana 47553
- CMS Provider Number
- 155263
- Inspections on file
- 23
- Latest survey
- December 5, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Sycamore Care Strategies during CMS and state inspections, most recent first.
A shared shower room and a resident bathroom were found with musty odors, visible mold, discolored tiles, dust buildup, exposed sticky traps with dead insects, and debris. Uncovered urine collection hats and resident care items were improperly stored in the bathroom. Staff confirmed the presence of mold and improper storage practices, and there was no policy in place for maintaining the environment in these areas.
The facility failed to maintain resident dignity and timely meal service, as observed during dining. A resident waited 12 minutes for water, and another was fed without interaction. Understaffing led to meal delays, with only one CNA passing trays on two halls. Promised coffee was not delivered to a resident, and another was served without a clothing protector. The DON acknowledged the need for more staff during meals.
The facility failed to ensure accurate resident assessments, with side rails incorrectly marked as restraints and discrepancies in medication records. Observations showed that side rails intended for mobility were documented as restraints for several residents. Additionally, a resident was marked as taking a hypnotic, but records showed no such medication was administered. Another resident was noted to have been prescribed opioids, yet no opioids were given during the review period. The DON acknowledged these errors, citing incorrect MDS entries and reliance on the RAI manual.
The facility failed to implement comprehensive care plans for residents, leading to unmet needs. A resident with mobility issues had their call light and reaching device out of reach, despite orders for accessibility. Another resident, requiring assistance with eating, was left unattended in the dining room. Additionally, a resident on antipsychotic medication lacked a care plan for its use. These deficiencies indicate a failure to adhere to care plans and physician orders.
The facility failed to maintain proper infection control practices, including not disinfecting equipment between residents, inadequate hand hygiene during incontinence and wound care, and improper use of PPE for a resident on Enhanced Barrier Precautions. These deficiencies involved multiple residents and staff, highlighting lapses in maintaining a safe and sanitary environment.
The facility was found deficient in maintaining a safe and sanitary environment, with issues such as soiled grout and leaking fixtures in the shower room, cracked and sharp plastic on a room door, and flaking leather on resident wheelchairs. Additionally, a resident's recliner had a strong urine odor, and loose carpeting created an uneven floor surface. These deficiencies were observed over several days, indicating a lack of timely maintenance and cleaning.
A facility failed to clarify a resident's code status, resulting in a mismatch between the physician's order and the signed POST form. The resident, with severe cognitive impairment, had a physician's order for full code status, while the POST form indicated DNR. Staff interviews revealed reliance on the EHR, which showed the incorrect status, and the discrepancy was not corrected, violating the facility's Advance Directives Policy.
The facility failed to provide Advanced Beneficiary Notices (ABN) to two residents whose Medicare Part A services were terminated, leaving them unaware of potential financial liabilities for non-covered services. Staff interviews revealed a lack of awareness and policy regarding ABN issuance.
A resident with dementia, at high risk for falls, repeatedly attempted to leave her chair, triggering alarms and becoming agitated. Despite expressing needs such as wanting water and needing the bathroom, staff did not offer activities or environmental changes to address her needs. The care plan lacked details on her preferences, and facility policies on dementia care were not followed.
A resident with dementia exited a facility through an unsecured window, walking 2.4 miles before being found by law enforcement. The resident, at risk for elopement, was not adequately supervised, and the facility failed to secure windows, contributing to the incident. The resident sustained injuries from falls during the elopement.
Failure to Maintain Sanitary and Homelike Resident Bathrooms and Shower Room
Penalty
Summary
The facility failed to maintain a safe, sanitary, and homelike environment in both a shared resident bathroom and a shared shower room. Observations revealed that the shared shower room had a persistent musty odor, visible mold-like dark circular areas around ceiling vents, discolored and possibly moldy or mildewed shower tiles, missing paint on walls, a displaced shut-off valve cover exposing a sticky trap with dead insects and droppings, dust accumulation on an overhead heater, and debris behind the commode. Staff interviews confirmed the presence of mold and cleanliness issues in the shower room, and the Housekeeping Manager stated that despite daily cleaning and deep cleaning efforts, the tile discoloration persisted. Maintenance staff were identified as responsible for the overhead vents. In the shared restroom between resident rooms, two uncovered urine collection hats were stored between the handrail and wall on each side of the commode, and two packages of briefs along with a pack of wipes were left on the floor next to the commode. The Infection Preventionist confirmed that urine sample hats should be stored in a facility storage closet until use and that resident care items should not be stored on the bathroom floor. The DON indicated there was no policy related to the resident environment in shared shower rooms and bathrooms. These findings were based on direct observation, staff interviews, and record review.
Failure to Maintain Resident Dignity and Timely Meal Service
Penalty
Summary
The facility failed to treat residents with respect and dignity during dining observations over two days. On one occasion, a resident in the main dining room requested water and had to wait 12 minutes before receiving it. Another resident, Resident 29, was fed by a CNA who did not engage in conversation with her throughout the meal. The CNA was observed attending to multiple residents simultaneously, which included picking up a roll from the floor, cueing another resident to eat, and addressing other residents' needs, all while feeding Resident 29 without any interaction. Additionally, the facility was understaffed during meal service, leading to delays in serving food. CNA 15 was the only staff member passing trays on two halls, while a nurse was present at the nurse's station but did not assist. In the main dining room, there were periods when no staff were present to pass trays, and the Administrator and other staff members did not assist in serving meals. This resulted in residents waiting for extended periods before receiving their meals. Specific incidents included Resident 1 being promised coffee, which was not delivered, and Resident 8 being served pureed food without a clothing protector, only a napkin. The Director of Nursing acknowledged that there should have been at least two staff members in the dining room during meals and that the delays and lack of attention to residents' needs were not acceptable. The facility's policies on dignity and assistance with meals were not adhered to, as evidenced by the observations.
Inaccurate Resident Assessments and Medication Documentation
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected their status, particularly concerning the use of physical restraints and unnecessary medications. Observations and record reviews revealed that side rails, intended for mobility, were incorrectly documented as physical restraints for several residents. For instance, Resident 7, who had severe cognitive impairment, was noted to use side rails daily as a physical restraint, despite assessments indicating they were for mobility enhancement. Similarly, Residents 23, 25, and 28 were observed with side rails marked as restraints, although assessments suggested they were for promoting independence and mobility. Additionally, discrepancies were found in medication administration records. Resident 23 was marked as taking a hypnotic, but the medication administration record showed no hypnotic was given during the review period. Instead, the resident was on Remeron for insomnia, which was incorrectly categorized. Resident 30 was noted to have been prescribed opioids, yet the medication administration record indicated no opioids were administered during the specified timeframe. The Director of Nursing acknowledged these errors, attributing them to incorrect entries on the MDS assessments and a lack of a specific policy for completing these assessments, relying instead on the Resident Assessment Instrument manual.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for several residents, leading to deficiencies in care. Resident 9, who had diagnoses including chronic obstructive pulmonary disease, impaired mobility, and diabetes mellitus type II, was observed multiple times with his call light and reaching device out of reach, despite physician orders and a fall risk care plan indicating these should be accessible. Resident 9 confirmed that he had difficulty finding these items, which were essential for his safety and communication needs. Resident 1, diagnosed with dementia, hallucinations, and depression, was observed in the dining room with her meal tray untouched and without assistance, despite a care plan indicating she required help with eating due to impaired mobility. Staff did not assist her, and she was seen feeding herself very slowly without support. Additionally, Resident 30, who was on an antipsychotic medication, lacked a care plan addressing the use of this medication, contrary to the facility's policy as stated by the Director of Nursing. These observations highlight the facility's failure to adhere to care plans and physician orders, resulting in unmet needs for the residents.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to maintain a safe and sanitary environment, leading to the potential transmission of communicable diseases and infections. During observations, staff did not adhere to proper infection control protocols. For instance, a Licensed Practical Nurse (LPN) and a Registered Nurse (RN) used a wrist blood pressure cuff and pulse oximeter on multiple residents without disinfecting the equipment between uses. This occurred during medication administration and vital sign checks, involving Residents 2 and 22, and during a random observation with Residents 29 and 26. Incontinence care procedures were also found lacking in infection control practices. Certified Nurse Aides (CNAs) were observed not changing gloves or sanitizing hands between dirty and clean tasks. For example, during incontinence care for Residents 1 and 25, CNAs did not change gloves or sanitize hands after handling soiled incontinence pads and before assisting with clean tasks, such as wiping the perineal area and adjusting clean incontinence pads. Additionally, staff failed to use proper Personal Protective Equipment (PPE) when interacting with a resident on Enhanced Barrier Precautions (EBP). CNA 26 entered Resident 30's room without wearing PPE, despite the presence of an EBP sign and a PPE cart outside the room. This resident had a wound on the buttock and was diagnosed with moderate dementia with behavioral disturbance. Furthermore, during wound care for Resident 30, RNs did not perform adequate hand hygiene, with handwashing lasting less than the recommended 20 seconds, and failed to sanitize hands between glove changes.
Facility Fails to Maintain Safe and Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe, sanitary, and homelike environment for its residents, as evidenced by multiple deficiencies observed in various areas. In the shower room, there was a missing tile at the entrance, soiled grout on the floor and walls, white buildup on the floor and handrails, and a leaking handheld shower head. Additionally, the toilet paper holder was missing, leaving the toilet paper exposed on the back of the toilet. These issues persisted over several days of observation. In resident rooms, several deficiencies were noted, including a cracked and sharp plastic cover on a room door, duct tape on a footboard, and loose carpeting causing an uneven floor surface. Resident wheelchairs and a Broda chair had flaking leather on the armrests, exposing the foam padding. A resident's recliner emitted a strong urine odor and had stained cushions. These conditions were observed repeatedly over multiple days, indicating a lack of timely maintenance and cleaning, as confirmed by the Director of Nursing during an interview.
Failure to Clarify Resident's Code Status
Penalty
Summary
The facility failed to clarify the code status for a resident, leading to a discrepancy between the physician's order and the signed Indiana Physician Orders for Scope of Treatment (POST) form. The resident, who had severe cognitive impairment due to dementia, had a physician's order indicating a full code status for cardiopulmonary resuscitation (CPR), while the POST form and the code status care plan indicated a Do Not Attempt Resuscitation (DNR) status. This inconsistency was not addressed, and the electronic health record (EHR) reflected the full code status, which was not updated to match the POST form. Interviews with staff revealed that the Registered Nurse (RN) relied on the EHR for the resident's code status, which showed the incorrect full code status. The Social Services Director (SSD) indicated that during care plan conferences, the resident's advance directive was discussed, and she checked for consistency between the code status care plan and the POST form. However, the discrepancy remained uncorrected, and the facility's Advance Directives Policy required that the plan of care be consistent with the resident's documented treatment preferences, which was not adhered to in this case.
Failure to Provide Advanced Beneficiary Notices
Penalty
Summary
The facility failed to provide appropriate notice of charges for services covered and not covered under Medicare for two residents. Both residents were discharged from Medicare Part A services but remained in the facility without receiving an Advanced Beneficiary Notice (ABN) for future services. Resident 5's Medicare Part A benefits ended on January 17, 2025, and Resident 14's benefits ended on January 31, 2025. Despite this, neither resident received the required ABN notice, which is necessary to inform them of their potential financial liability for services not covered by Medicare. Interviews with facility staff revealed a lack of awareness and policy regarding the issuance of ABN notices. The Social Services Director indicated that the therapy department was responsible for completing ABN notices, but the Business Office Manager and the Senior Administrator were unaware that such notices should have been issued for the residents in question. The Senior Administrator acknowledged the absence of a policy but stated that it would be their policy to follow the regulation for beneficiary notices.
Failure to Provide Appropriate Dementia Care
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident diagnosed with dementia, who was at high risk for falls. The resident was observed multiple times attempting to get out of a recliner, triggering the chair alarm, and becoming agitated. Despite these repeated attempts, the staff, including an LPN, did not offer any activities or changes in environment to address the resident's needs. The resident expressed needs such as wanting a drink of water and needing to use the bathroom, but these were not promptly addressed by the staff. The resident's clinical records indicated severe cognitive impairment and dependence on staff for daily activities. The dementia care plan lacked specific details about the resident's likes and dislikes, which could have been used to engage her and prevent agitation. Interviews with staff revealed some knowledge of the resident's preferences, such as enjoying mint ice cream sandwiches and music, but these were not utilized during the observed incidents. The facility's policies on quality of life and dementia care emphasized addressing the root causes of behavior and supporting residents in daily activities, which were not followed in this case.
Resident Elopement Due to Inadequate Supervision and Unsecured Windows
Penalty
Summary
The facility failed to ensure adequate supervision and a secured environment, resulting in a resident with dementia exiting the facility and leaving the property. The resident, who was at risk for elopement and wore a WanderGuard bracelet, managed to exit through a window in the dining room. The resident was last seen by staff at 8:00 P.M. and was not noticed missing until 8:45 P.M. The resident was found by local law enforcement approximately 2.4 miles away from the facility, having sustained a facial laceration and minor head injury from multiple falls. The resident's medical history included Alzheimer's Disease, altered mental status, anorexia, insomnia, and dementia, with a risk for elopement assessment completed prior to the incident. The resident's care plan included interventions for elopement risk and intrusive wandering, but did not document adequate supervision measures to prevent elopement. The resident had shown increased exit-seeking behavior, which was noted in nurse's notes, but no additional non-pharmaceutical interventions or increased supervision were implemented. The facility's investigation revealed that the resident was able to unlock and open a window in the dining room, which was not equipped with window stops, allowing the resident to climb out. The facility's policy on wandering and elopements required strategies and interventions to maintain resident safety, but these were not effectively implemented. The facility's failure to secure windows and provide adequate supervision contributed to the resident's elopement and subsequent injuries.
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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