Transcendent Healthcare Of Boonville
Inspection history, citations, penalties and survey trends for this long-term care facility in Boonville, Indiana.
- Location
- 725 S Second St, Boonville, Indiana 47601
- CMS Provider Number
- 155508
- Inspections on file
- 46
- Latest survey
- March 13, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Transcendent Healthcare Of Boonville during CMS and state inspections, most recent first.
Multiple deficiencies were identified, including uneven floors causing instability, persistent cigarette smoke odor in the main dining area due to inadequate door sealing, unclean resident rooms and restrooms, missing or damaged closet doorknobs, and the use of duct tape for repairs. Residents reported poor restroom cleanliness and issues with pests entering rooms through unrepaired areas.
A resident's care plan was not updated to reflect a change from Full Code to DNR status, despite documentation of the new advance directive and facility policy requiring such updates. The care plan continued to instruct staff to initiate CPR, and the issue was confirmed through record review and staff interviews.
A resident with a history of tobacco use, nicotine dependence, COPD, and other conditions was repeatedly observed and reported to have smoked inside the facility without supervision, in violation of facility policy. Staff and resident interviews, as well as record reviews, confirmed that the resident had access to smoking materials and smoked in his room, despite policies requiring supervision and restricting smoking to designated outdoor areas.
A resident with moderate cognitive impairment and multiple mental health diagnoses reported her wallet and debit card missing after falling asleep. Unauthorized transactions were later identified on her bank statement. Police investigation and surveillance footage confirmed that a CNA had taken the resident's debit card and made multiple unauthorized purchases. The facility lacked a written policy on staff making purchases for residents, though only department heads or the Activity Director were verbally permitted to do so with resident permission.
The facility did not ensure that physician orders for wound care were consistently followed and documented for two residents with complex wounds, resulting in missed treatments and incomplete records. Staff interviews confirmed that some wound care orders were not completed or documented, and facility policy requiring proper order execution and documentation was not adhered to.
A resident with multiple diagnoses did not receive a physician-ordered hemorrhoid cream for routine treatment, as the medication was not available in the facility and staff could not provide proof of pharmacy delivery. Despite repeated requests from the resident, the cream was not located in the treatment or medication carts, and there was no documentation of timely reordering as required by facility policy.
A resident with severe cognitive impairment and multiple diagnoses exited the facility through an unsecured window that had been left open after construction repairs. The resident was not identified as an elopement risk and was last seen during a routine bed check, with their absence discovered several hours later. The resident was found by police outside, wet and shivering, and required hospitalization. Staff were unaware of the window's unsecured status, and the facility's failure to provide adequate supervision and a secure environment led to the elopement.
A resident with severe cognitive impairment and multiple diagnoses eloped from the facility and was found outside by police, but the event and related notifications were not documented in the medical record as required by facility policy. Additionally, the MAR inaccurately showed that the resident received medications after leaving the facility, with staff later acknowledging the documentation error.
The facility failed to conduct timely care plan conferences for several residents, including a newly admitted resident who did not have an initial conference. Other residents did not have quarterly conferences as required, despite the facility's policy mandating such reviews. The Social Services Director acknowledged the oversight, and the Director of Nursing provided the relevant policy, highlighting the deficiency in facilitating resident participation in care planning.
The facility failed to ensure accurate MDS assessments for six residents, leading to discrepancies in clinical records. Errors included incorrect documentation of medication administration and failure to reflect completed level 2 PASARRs. The MDS Coordinator acknowledged these inaccuracies, indicating systemic issues in the assessment process.
The facility failed to implement comprehensive care plans for residents, leading to deficiencies. A resident's call light was repeatedly out of reach, another lacked a care plan for antidepressant use, and a third was without proper fall prevention measures. Staff acknowledged these oversights, which were contrary to the facility's policy requiring comprehensive, person-centered care plans.
The facility failed to provide adequate supervision and maintain a hazard-free environment for residents. A resident was observed smoking unsupervised, contrary to the facility's smoking policy, while another resident with cognitive impairment also smoked without supervision. Additionally, a resident with Alzheimer's disease and a high fall risk had an unsecured extension cord in his room, posing a hazard. These incidents highlight lapses in adherence to care plans and facility policies.
The facility failed to ensure a sanitary and homelike environment, with issues in refrigerator temperature logging, structural maintenance, and cleanliness. Observations revealed incomplete temperature logs, improper refrigerator temperatures, and structural deficiencies like cracked tiles and peeling paint. Interviews indicated a lack of clarity in cleaning responsibilities and awareness of issues by the Maintenance and Housekeeping Supervisor.
The facility failed to deliver mail to residents on Saturdays, as confirmed by eleven residents and the Activity Director. The mail was not delivered on two weekends each month due to the office being locked, despite the facility's policy requiring mail delivery within twenty-four hours of arrival.
The facility failed to update care plans for two residents experiencing declines in their conditions. One resident, with multiple diagnoses, was inaccurately documented as not taking a diuretic, while another resident showed a decline in ADLs without corresponding updates to their care plan. Staff interviews revealed inconsistencies in care and lack of restorative therapy due to staffing issues.
A resident with COPD, dementia, and stroke experienced a decline in ADLs, but the facility failed to update the care plan or provide recommended restorative therapy. Despite a discharge recommendation for a Restorative Nursing Program, staffing issues led to inconsistent implementation, and the resident's decline was not communicated effectively among staff.
A resident with dementia was not provided appropriate treatment and services, leading to a deficiency. The resident was observed roaming without eyeglasses or an ankle alarm, despite care plans indicating these were necessary. The facility failed to document the resident's wandering behavior and did not have a specific dementia care plan. Staff interviews revealed a lack of awareness and documentation of the resident's care needs, contributing to the deficiency.
A resident with hypotension and chronic pain was administered Midodrine HCl without proper blood pressure monitoring and outside prescribed parameters, and Norco was given excessively without clarification of orders. Facility staff failed to adhere to medication administration protocols, leading to unnecessary medication use.
The facility failed to ensure appropriate use of psychotropic medications for two residents. One resident was prescribed buspirone for anxiety without a required gradual dose reduction, and the facility did not implement a pharmacy recommendation for GDR. Another resident received quetiapine without a clinically indicated diagnosis, as the facility inaccurately listed Alzheimer's disease as the indication. The Administrator later acknowledged the error and provided a revised care plan, but the clinical record did not reflect the necessary information at the time of the survey.
The facility failed to securely store medications, as a medication cart contained a cup with loose pills, including a narcotic, intended for a resident who had left the hall. A QMA and RN indicated that medications are placed in the cart if the resident is unavailable, and narcotics should be double locked. Policies provided by the DON emphasized secure storage and proper packaging.
The facility failed to maintain infection control standards for two residents. A resident with severe cognitive impairment did not receive proper glove changes during wound care, and another resident with an indwelling catheter lacked Enhanced Barrier Precautions (EBP) signage and supplies. Interviews revealed inconsistencies in staff adherence to EBP protocols, highlighting lapses in infection prevention practices.
The facility failed to enforce its smoking policy, resulting in two residents smoking unsupervised and in undesignated areas. Smoking assessments were not conducted quarterly, and smoking supplies were improperly managed, leading to deficiencies in supervision and safety.
The facility did not ensure complete daily posting of nurse staffing sheets for seven days, missing the facility's name and specific hours worked. The DON indicated Medical Records handled postings, and the Administrator provided a policy requiring daily posting of staffing data, including the facility's name and actual hours worked.
The facility failed to ensure a safe, sanitary, and homelike environment in two resident halls. Observations included cracked and uneven flooring, a hole in the drywall, a persistent damp/mildew odor, and uncovered specimen collection items. The Maintenance Director acknowledged ongoing issues with leaking heating/air units and planned repairs. The facility's policy on maintaining a homelike environment was not followed.
The facility failed to securely store medications and syringes, as observed during a survey. A resident's medications and an unsealed sharps container with unused syringes were found in an unlocked conference room. Interviews with staff confirmed that these items should be stored in a locked medication room or cart, as per facility policy.
A resident with dementia and a history of elopement exited a facility through a tampered window, despite being identified as high risk for wandering. The resident's care plan lacked interventions to prevent wandering, and previous elopement attempts were not addressed. The resident was found 22 miles away by law enforcement.
Failure to Maintain Safe, Sanitary, and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, sanitary, and homelike environment in two of three resident halls, as evidenced by multiple observations and resident interviews. Uneven floors were noted in several locations, including soft spots, dips, and raised areas that caused instability and flooring to come up. In one instance, a resident lost balance when a bedside table slid on an uneven floor. The main dining room was affected by cigarette smoke odor due to gaps and lack of weather stripping in the doors leading to a designated smoking area, with residents and staff confirming the persistent smell. Resident rooms and restrooms were observed to be unkept, with spills left uncleaned and specimen collection equipment left uncovered on restroom floors. Multiple residents reported that restrooms were not cleaned well. Additional deficiencies included missing or damaged doorknobs on hall closets, bent or loose door handles, and the use of duct tape to repair coved base and door trim in resident rooms. One resident reported that duct tape was used to seal a hole behind the coved base to prevent mice from entering. Overhead lights in a resident room contained debris and dead insects. The facility administrator indicated there was no policy related to the physical environment. These findings were based on direct observation, resident and staff interviews, and record review.
Failure to Update Care Plan Following Change in Advance Directive
Penalty
Summary
The facility failed to update or revise the care plan for a resident after a change in the resident's advance directive status. Record review showed that the resident had completed an Advance Directive Form indicating a Do Not Attempt Resuscitation (DNR) preference. However, the resident's care plan continued to reflect a Full Code status, instructing staff to initiate CPR if the resident's heart or breathing stopped. The care plan was not updated to reflect the resident's DNR status, despite facility policy requiring that changes in advance directives be incorporated into the care plan and communicated to the interdisciplinary team. The deficiency was identified through interviews and record reviews, including documentation of the resident's death and confirmation from the Social Service Director that the care plan should have been updated at the time of the code status change.
Failure to Prevent Unsupervised Smoking and Smoking Hazards
Penalty
Summary
The facility failed to ensure adequate supervision and a hazard-free environment for residents who smoke, as evidenced by repeated incidents involving a resident smoking inside the building against facility policy. Multiple observations noted a cigarette smoke odor in a resident hall, and interviews with residents and staff confirmed that a resident had been smoking in his room without supervision. The resident admitted to smoking in his room, and another resident expressed frustration over the violation of smoking rules. Staff interviews confirmed that residents are not permitted to smoke inside the facility and should not possess cigarettes or lighters, with smoking materials to be distributed only during supervised, designated smoking times in the outdoor smoking area. Record review revealed that the resident involved had diagnoses including tobacco use, nicotine dependence, COPD, polyneuropathy, and an unspecified mental disorder, with no cognitive impairment noted on the most recent assessment. The resident's smoking safety assessment indicated prior burn marks on skin, clothing, or furniture, and required supervision per facility policy. Nurses' progress notes documented multiple instances of the resident smoking inside the facility and possessing smoking items, including taking cigarette butts from outside ashtrays. The facility's smoking policy explicitly prohibits smoking inside and requires all smoking materials to be kept at the nurse's station and distributed only at designated times.
Unauthorized Use of Resident's Debit Card by Staff
Penalty
Summary
A resident with diagnoses including dementia, anxiety, depression, and psychotic disorder, and assessed as having moderate cognitive impairment, reported that her wallet and debit card were missing after she had placed her purse at the foot of her bed and fallen asleep. Upon reviewing her bank statement, the resident identified several unauthorized transactions, including purchases at a local gas station and a phone bill payment that did not belong to her. The resident contacted local police, who reviewed surveillance footage and determined that a CNA was responsible for the unauthorized use of the debit card. The facility's investigation revealed that the CNA had taken the resident's debit card without consent and made multiple unauthorized purchases. The facility did not have a written policy regarding staff making purchases for residents, but the administrator stated that only department heads or the Activity Director were permitted to make purchases on a resident's behalf, and only with the resident's permission. The facility did have a policy requiring all reports of theft or misappropriation of resident property to be reported to appropriate agencies.
Failure to Follow and Document Physician Wound Care Orders
Penalty
Summary
The facility failed to ensure that physician orders for wound care were thoroughly followed and properly documented for two residents. For one resident with diagnoses including peripheral vascular disease, morbid obesity, and lymphedema, physician orders specified detailed wound care regimens for multiple areas of the right foot, including cleansing, application of various dressings, compression wraps, and weekly skin assessments. Record review revealed that several of these treatments and assessments were not documented as completed on specific dates, indicating a lack of adherence to the prescribed care plan. Another resident, admitted with a stage IV pressure ulcer to the right heel, type II diabetes, and edema, also had physician orders for daily wound care and regular checks of dressing placement. The resident's records showed multiple instances where wound care and dressing checks were not documented as completed on the required shifts. The care plan for this resident included monitoring and replacing dressings as needed, but the MAR/TAR lacked evidence that these interventions were consistently performed. Interviews with facility staff, including the DON and an LPN, confirmed that some treatments were missed or not documented, with the DON noting that some orders may have been completed by outside sources but could not account for all missed treatments. Facility policy requires that all medication and treatment orders be consistent with safe and effective practices, but the observed documentation gaps indicate that this standard was not met for the residents reviewed.
Failure to Provide Ordered Topical Medication Due to Lack of Pharmaceutical Services
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate pharmaceutical services to meet the needs of a resident who required a physician-ordered topical treatment. The resident, who had diagnoses including anxiety, irritable bowel syndrome, and hypertension, reported not receiving a routine hemorrhoid cream that had been ordered to reduce inflammation and pain related to a rectal fissure. Despite the resident's repeated requests, the medication was not available for administration. Facility staff, including the ADON and DON, were unable to locate the prescribed cream in the treatment or medication carts, nor could they provide documentation that the pharmacy had delivered the medication. The facility's policy required that drugs and biologicals be reordered at least three days before the last dose to ensure availability, but there was no evidence this process was followed for the resident's treatment.
Resident Elopement Due to Unsecured Window and Inadequate Supervision
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and a secure environment to prevent a resident with dementia from eloping. The resident, who had diagnoses including dementia, anxiety disorder, schizoaffective disorder, and heart failure, was assessed as not being at risk for elopement in a recent assessment. The care plan included interventions for cognitive impairment and required assistance with mobility, but did not identify elopement risk until after the incident. The resident was last seen by staff during a 2:00 A.M. bed check and was discovered missing around 5:00 A.M. during the next check. The resident exited the facility through a window that had been left unsecured after construction crews removed the screws during repairs. Staff were unaware that the window was not secured. The resident was found by local law enforcement in a field near the facility, wet and shivering in the rain, and required hospitalization for altered mental status and a urinary tract infection. Staff interviews confirmed that the resident had not previously exhibited wandering or exit-seeking behaviors, and the window's unsecured status was not known to staff prior to the incident. Facility policy required staff to initiate a search and notify appropriate parties if a resident was missing, which was followed after the resident was discovered absent. Documentation and interviews indicated that the resident's absence was not immediately recognized, and the unsecured window provided an unmonitored exit route. The incident was substantiated through observation, interviews, and record review, confirming a failure to ensure a safe and supervised environment for residents at risk.
Incomplete and Inaccurate Medical Records Following Resident Elopement
Penalty
Summary
The facility failed to ensure that resident records were complete and accurate for a resident with multiple diagnoses, including dementia, anxiety disorder, schizoaffective disorder, and heart failure. The resident, who had severe cognitive impairment and required assistance with ambulation, was assessed as not at risk for elopement in mid-January, but was later identified as at risk after an incident in March. On the morning of the incident, the resident was found missing during a bed check, and after a search by staff and notification to the police, was located outside the facility by local authorities and subsequently sent to the hospital for evaluation. There was no documentation in the resident's medical record regarding the elopement event or the notifications made to the police, despite facility policy requiring such documentation. Additionally, the resident's Medication Administration Record (MAR) for the day of the incident inaccurately indicated that multiple medications were administered during the morning medication pass, even though the resident was not present in the facility at that time. The staff member responsible for the documentation acknowledged that the medications were signed off in error and indicated an intention to correct the record. These failures resulted in incomplete and inaccurate medical records for the resident, contrary to accepted professional standards and facility policy.
Failure to Conduct Timely Care Plan Conferences
Penalty
Summary
The facility failed to facilitate care plan meetings with residents and/or their representatives, as required, for several residents. Specifically, a newly admitted resident did not have an initial care plan conference, and other residents did not have their care plan conferences held quarterly as mandated. This deficiency was identified through interviews and record reviews of six random clinical records. For instance, Resident 260, who was admitted with diagnoses including chronic obstructive pulmonary disease (COPD), schizophrenia, and alcohol dependence with alcohol-induced persisting dementia, lacked a care plan conference since admission. Similarly, other residents, such as Resident 11, Resident 35, Resident 3, Resident 26, and Resident 30, had not had their care plan conferences conducted quarterly, with the most recent conferences dating back several months. The Social Services Director (SSD) acknowledged responsibility for scheduling these care plan conferences and confirmed that they should have been conducted quarterly. The Director of Nursing (DON) provided a policy indicating that the interdisciplinary team is required to review and update care plans at least quarterly, in conjunction with the required quarterly MDS assessment. Despite this policy, the facility did not adhere to the required schedule for care plan conferences, resulting in a deficiency in ensuring resident participation in the development and implementation of their person-centered plans of care.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for six residents, leading to discrepancies in their clinical records. For Resident 31, the MDS assessment inaccurately indicated no cognitive impairment and diuretic use, while omitting the administration of an opioid and an antiplatelet, despite physician orders and the Medication Administration Record (MAR) showing otherwise. Resident 40's MDS assessment incorrectly noted an injection that was not administered during the lookback period. These inaccuracies were acknowledged by the MDS Coordinator, who admitted to errors in marking the antiplatelet and diuretic, and missing the opioid for Resident 31, as well as being unsure about the incorrect injection entry for Resident 40. Additionally, the facility failed to accurately document the completion of level 2 Preadmission Screening and Resident Review (PASARR) for Residents 20, 6, 23, and 30. Despite having completed level 2 PASARRs, their MDS assessments did not reflect this, indicating a lack of thoroughness in the assessment process. The MDS Coordinator confirmed that these residents should have been marked as having completed level 2 PASARRs, highlighting a systemic issue in the accuracy of resident assessments.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for four residents, leading to deficiencies in care. Resident 4, diagnosed with depression and schizophrenia, was observed on multiple occasions with a call light out of reach, despite a care plan intervention to keep it accessible. This oversight was confirmed by a CNA who acknowledged the call light should have been within reach at all times. Resident 54, with severe cognitive impairment and on an antidepressant, lacked a care plan addressing the medication, which was a responsibility of the MDS Coordinator. The absence of this care plan was noted during a review of the resident's clinical records. Resident 23, with multiple diagnoses including Parkinson's disease and vascular dementia, was observed without proper fall prevention measures in place. The resident's bed was not positioned against the wall, and a landing mat was missing, contrary to the care plan interventions. An LPN indicated that the bed and fall interventions should have been moved with the resident when they changed rooms, but this was not done. The facility's policy requires comprehensive, person-centered care plans to be developed and revised as residents' conditions change, but this was not adhered to in these cases.
Inadequate Supervision and Environmental Hazards in LTC Facility
Penalty
Summary
The facility failed to provide adequate supervision and maintain an environment free of accident hazards for several residents. Resident 32, who was cognitively intact but required supervision for certain activities, was observed smoking unsupervised on the patio, contrary to the facility's smoking policy. Despite having a smoking care plan that required staff supervision, Resident 32 kept smoking supplies on his person and exited the building to smoke alone. The resident admitted to keeping his lighter and cigarettes with him and preferred to smoke without supervision. Resident 22, who was also cognitively intact but had mild cognitive impairment and delusional disorders, was observed smoking unsupervised in front of the building. The facility's policy required that smoking supplies be stored in the social services office and that residents be supervised while smoking. However, Resident 22 was found with smoking supplies on his person and without staff supervision, indicating a failure to adhere to the smoking care plan and facility policy. Resident 54, diagnosed with Alzheimer's disease and at high risk for falls, was observed roaming without eyeglasses and had an unsecured extension cord in his room. The extension cord, used due to a malfunctioning electrical outlet, was not secured out of the resident's walking path, posing a fall risk. Despite the resident's severely impaired cognition and high fall risk, the facility did not ensure the environment was free from hazards, as required by their hazardous area policy.
Facility Fails to Maintain Sanitary and Homelike Environment
Penalty
Summary
The facility failed to maintain a sanitary and home-like environment across multiple areas, including resident rooms and a shower room. Observations revealed that temperature logs for resident personal refrigerators were not consistently completed, with some refrigerators showing signs of improper temperature control, such as ice buildup and expired food items. Interviews indicated that housekeeping was responsible for checking and logging refrigerator temperatures daily, but this was not consistently done, and there was a lack of clarity on cleaning responsibilities. In addition to issues with refrigerator maintenance, the facility had structural and cleanliness deficiencies. A call light was found out of the wall with exposed wires, and brown spots were observed on the walls of a resident's room, which the Maintenance Assistant dismissed as the texture of the bricks. The [NAME] Hall shower room had cracked tiles, peeling paint, and a vent caked with dust, among other issues. These conditions were not addressed promptly, and there was a lack of awareness from the Maintenance and Housekeeping Supervisor regarding these concerns. The facility's policies on maintaining a homelike environment and food storage were not effectively implemented. Privacy curtains were found with brown smudges, and a door was difficult to open and close due to rubbing against the threshold. The Maintenance and Housekeeping Supervisor acknowledged some of these issues but was unsure of the last deep cleaning for certain rooms. The facility's policies required safe, clean, and comfortable environments, but the observations and interviews indicated a failure to adhere to these standards consistently.
Failure to Deliver Mail on Saturdays
Penalty
Summary
The facility failed to deliver mail to residents on Saturdays, as reported by eleven anonymous residents during a resident council meeting. The Activity Director confirmed that mail should be delivered every day, but indicated that mail was not delivered on two weekends each month because the office was locked. The facility's current mail policy, revised in November 2010, states that mail should be delivered to residents within twenty-four hours of delivery on the premises. This discrepancy between policy and practice led to the deficiency identified by the surveyors.
Failure to Revise Care Plans for Residents with Declining Conditions
Penalty
Summary
The facility failed to revise the care plans for two residents, leading to deficiencies in their care. Resident 11, who has multiple diagnoses including COPD, dementia, and edema, was observed being fed by staff and was noted to be taking a diuretic, Lasix, as per physician's orders. However, the care plan inaccurately indicated that she was not taking a diuretic. The MDS Coordinator confirmed that Resident 11 was not capable of self-administering medication, contradicting the medication administration record that suggested otherwise. Resident 35, diagnosed with COPD, dementia, and stroke, was observed in a wheelchair and later in bed, showing signs of a decline in activities of daily living (ADLs). The most recent MDS assessment indicated a decline in his ability to eat and perform hygiene tasks, yet the care plan had not been updated to reflect these changes. Staff interviews revealed that Resident 35 had been less active and more withdrawn since the passing of a friend, and there was no restorative therapy being provided due to staffing issues. The facility's policies on functional impairment and care plan revisions were not adhered to, as evidenced by the lack of updates to the residents' care plans despite noticeable changes in their conditions. The MDS Coordinator acknowledged the expectation for care plans to reflect changes in residents' functioning, but this was not done for Residents 11 and 35, leading to deficiencies in their care management.
Failure to Provide Adequate Restorative Care for Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 35, was provided with the necessary treatment and services to maintain or improve his ability to perform activities of daily living (ADLs). Resident 35, who had diagnoses including COPD, dementia with behaviors, and stroke, experienced a decline in his functional abilities. The most recent MDS assessment indicated a decline in his ability to eat, dress, and perform hygiene tasks, yet the ADL Care Plan was not updated to reflect these changes, and restorative therapy was not provided as recommended. Observations and interviews revealed that Resident 35 was often found in bed or seated in a wheelchair, and he had slowed down on eating. The Director of Therapy Services noted that Resident 35 had been discharged from therapy after meeting his goals, with a recommendation for a Restorative Nursing Program (RNP) to maintain his functional level. However, the facility's restorative nursing program was inconsistent due to staffing issues, and the resident did not receive the recommended restorative therapy. Interviews with staff, including the Qualified Medication Aide and the MDS Coordinator, indicated a lack of communication and follow-through regarding Resident 35's decline. The MDS Coordinator was unaware of the decline and did not update the care plan, as the computer system did not trigger a significant change. The facility's policies on functional impairment and restorative nursing services were not effectively implemented, contributing to the resident's decline in ADLs.
Deficiency in Dementia Care for Resident
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident diagnosed with dementia, leading to a deficiency in care. The resident, identified as having Alzheimer's disease, was observed multiple times roaming the halls without eyeglasses and without an ankle alarm, which was supposed to be a preventative measure according to the resident's care plan. The resident's clinical record lacked a specific care plan for dementia, and there was no documentation of the resident's wandering behavior, which was a daily occurrence. The resident's care plans for vision, wandering, and elopement were not adequately implemented or documented. The Vision Care Plan required staff to ensure the resident wore eyeglasses, yet the resident was repeatedly seen without them. The Wandering Care Plan included interventions such as offering diversions and identifying patterns of wandering, but these were not documented or evaluated. Additionally, the Elopement Care Plan required a wander alert device, which was not observed on the resident during multiple instances. Interviews with staff revealed a lack of awareness and documentation regarding the resident's behavior and care needs. A CNA indicated the resident did not have a daily routine and was unaware of any specific interventions for dementia care. The Activities Director mentioned that one-on-one visits with dementia residents were not documented due to pending training. The Administrator acknowledged inaccuracies in the resident's clinical record regarding the diagnosis for antipsychotic medication and provided a revised Behavior Care Plan during the survey. Overall, the facility's failure to implement and document appropriate care plans and interventions for the resident's dementia care needs resulted in a deficiency.
Failure in Medication Administration and Monitoring
Penalty
Summary
The facility failed to ensure that medications were administered appropriately for a resident, leading to unnecessary medication use. The resident, who had diagnoses including hypotension and chronic pain, was administered a blood pressure medication, Midodrine HCl, without adequate monitoring and outside of the ordered parameters. The medication was given even when the resident's systolic blood pressure was above the prescribed limit of 120, and there was a lack of documentation explaining why the blood pressure was not taken prior to administration. Additionally, the resident was prescribed an opioid pain medication, Norco, which was administered excessively. The resident's clinical record showed that the Norco was given both as a routine dose and as needed, without clarification or discontinuation of the as-needed order when the routine dose was increased. This led to multiple instances of the medication being administered without proper documentation or monitoring for signs of excessive opioid use. Interviews with facility staff, including an LPN, the DON, and an RN, revealed a lack of adherence to medication administration protocols. The staff acknowledged that blood pressure should have been taken before administering Midodrine HCl and that the Norco order should have been clarified. The facility's policies on administering medications and pain management were not followed, contributing to the deficiency in medication administration for the resident.
Failure to Ensure Appropriate Use of Psychotropic Medications
Penalty
Summary
The facility failed to ensure the appropriate use of psychotropic medications for two residents. Resident 31, diagnosed with depression and diabetes mellitus, was prescribed buspirone for anxiety without a required gradual dose reduction (GDR). Despite a pharmacy recommendation for a GDR, the facility did not implement it correctly, and the Director of Nursing (DON) was unaware of who was responsible for reviewing the recommendations at the time. This oversight led to the continued use of the medication without the necessary GDR. Resident 54, with diagnoses including chronic obstructive pulmonary disease, Alzheimer's disease, and depression, was administered quetiapine, an antipsychotic medication, without a clinically indicated diagnosis. The facility's records inaccurately listed Alzheimer's disease as the indication for the antipsychotic, while the resident actually required it for major neurocognitive disorder with behavior disturbance and agitation psychosis. The Administrator acknowledged the error and provided a revised Behavior Care Plan to include the correct diagnosis, but at the time of the survey, the clinical record did not reflect this necessary information.
Medication Storage Deficiency
Penalty
Summary
The facility failed to maintain safe and secure storage of medications, as observed during a survey. A medication cart on the [NAME] Hall contained a clear medication cup with 10 loose pills, including an oxycodone 10mg tablet, intended for Resident 17. The Qualified Medication Aide (QMA) indicated that the resident had requested the pills but then left the hall. Registered Nurse (RN) 23 stated that if medications are prepared and the resident is unavailable, they are placed in the medication cart because they cannot be returned to the package. Additionally, RN 23 acknowledged that narcotics should be double locked in the medication cart. The Director of Nursing (DON) provided policies indicating that unused controlled substances should be securely locked until disposed of, and medications should be stored in their original packaging.
Infection Control Deficiencies in Wound and Catheter Care
Penalty
Summary
The facility failed to maintain a safe and sanitary environment to prevent the transmission of infections, as observed in the care of two residents. For Resident 26, who had severe cognitive impairment and required substantial assistance, the Wound Nurse did not change gloves after touching multiple items before starting wound care. The nurse performed hand hygiene and changed gloves only after the initial contact with the wound area, which is against the infection control protocol. Additionally, although Enhanced Barrier Precautions (EBP) were indicated for Resident 26 due to the presence of a stage 3 pressure ulcer and a catheter, the nurse did not follow the proper procedure for glove changes during the wound care process. Resident 3, who was cognitively intact but required assistance for activities of daily living and had an indwelling catheter, did not have EBP signs or supplies outside her room. This oversight was noted during multiple observations, indicating a lack of adherence to the facility's EBP policy. The absence of EBP signage and supplies suggests that staff may not have been adequately informed or reminded of the necessary precautions for residents with indwelling medical devices. Interviews with the Infection Preventionist and RN 23 revealed inconsistencies in the understanding and implementation of EBP. The Infection Preventionist confirmed that residents with indwelling devices or wounds should have EBP signs and PPE available, but this was not the case for Resident 3. RN 23's description of catheter care did not include the use of a gown, which is required under EBP guidelines. These deficiencies highlight lapses in the facility's infection prevention and control practices, as evidenced by the lack of proper glove use and EBP implementation.
Failure to Enforce Smoking Policy and Supervision
Penalty
Summary
The facility failed to adhere to its smoking policy for two residents, leading to deficiencies in supervision and safety. Resident 32 was observed smoking unsupervised on a patio, despite a care plan indicating the need for staff supervision. The resident's smoking assessments were not conducted quarterly as required, with a gap between June and November. The resident admitted to keeping smoking supplies on his person and smoking alone, contrary to the facility's policy. Similarly, Resident 22 was seen smoking without staff supervision in an undesignated area. The resident's care plan required supervision and storage of smoking supplies in the social services office, but these measures were not followed. The facility's smoking policy mandates that smoking assessments be conducted quarterly and that smoking materials be kept at the nurse's station, but these protocols were not consistently applied, leading to the observed deficiencies.
Incomplete Daily Nurse Staffing Sheets
Penalty
Summary
The facility failed to ensure that nurse staffing sheets were thoroughly completed and posted daily for seven consecutive days during the survey period. The posted staffing sheets included total hours worked by nursing staff but were missing the name of the facility and specific hours worked for each day. This deficiency was observed on January 21, 22, 23, 27, 28, 29, and 30, 2025. During an interview, the Director of Nursing (DON) stated that Medical Records was responsible for posting the nurse staffing sheets and that the facility followed state regulations. The Administrator provided a current, undated policy on posting direct care daily staffing numbers, which indicated that the facility would post daily nurse staffing data, including the facility's name and actual time worked during each shift for each category and type of nursing staff.
Facility Fails to Maintain Safe and Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe, sanitary, and homelike environment in two resident halls, as observed during a survey. The flooring in front of the nurse's station on [NAME] Hall was cracked and uneven due to leaking heating/air units, which had been inadequately repaired. In room [ROOM NUMBER]'s shared restroom, a hole in the drywall and a soft, depressed floor were noted, with the Maintenance Director unaware of the hole and acknowledging ongoing flooring issues. Additionally, the East Hall had a persistent damp/mildew odor, with a resident reporting a sewer-like smell, especially after rain. The Maintenance Director confirmed a significant water leak and planned repairs starting in January 2025, with heating and air units contributing to floor damage. Further observations revealed a soft spot in the floor of a service hall and damage to a doorway on [NAME] Hall. In room [ROOM NUMBER]'s shared restroom, an uncovered urine collection hat, an empty basin on the floor, and a full trash can with paper towels and briefs were found, with the resident indicating the restroom was typically messy. The Maintenance Director, also responsible for housekeeping, acknowledged that old briefs should not be left in trash and that bed pans and urine collection hats should be covered. The facility's policy on providing a safe, clean, and homelike environment was not adhered to, as evidenced by the conditions observed.
Unsafe Storage of Medications and Syringes
Penalty
Summary
The facility failed to ensure the safe and secure storage of medications and syringes, as observed during a survey. During a random observation, a cardboard box containing medications for Resident J was found in an unlocked conference room. The medications included Levofloxacin 500 mg, Vitamin D3 50,000 IU, Juven Oral Packets, and a Scopolamine Base Patch. Additionally, an unsealed sharps container with 30 unused syringes was accessible through an opening at the top of the box. This situation was confirmed during an interview with the Director of Nursing, who acknowledged the need to remove the medications from the conference room. Despite the removal of the medications, the unsealed sharps container with unused syringes remained in the conference room. Interviews with LPN 8 and the MDS Nurse confirmed that all medications and syringes should be stored securely in a locked medication room or cart. The MDS Nurse indicated that the syringes had been placed in the conference room the previous day and should not have been left unsecured. The facility's policy on medication labeling and storage, provided by the Facility Administrator, mandates that all medications and biologicals be stored in locked compartments, with access limited to authorized personnel.
Resident Elopement Due to Inadequate Supervision and Security Measures
Penalty
Summary
The facility failed to provide adequate supervision to prevent a resident with dementia and a history of elopement from exiting the facility. This deficiency resulted in an elopement incident involving a resident who was last seen by staff at 10:00 P.M. and was discovered missing at approximately 1:00 A.M. The resident managed to exit the facility through a window in their room, which had been tampered with, and was later found by local law enforcement at a previous residence 22 miles away. The resident involved had a history of mental health complications, including dementia and delusional disorder, and was under a court emergency protective services order due to being an endangered adult. Despite being identified as high risk for wandering, the resident's initial baseline care plan did not include interventions to minimize or prevent wandering. Previous incidents, such as an attempt to leave the facility during a smoke break, were noted, but no additional interventions were implemented following the resident's readmission to the facility. Interviews and observations revealed that the facility's windows were supposed to be secured with stops and latches to prevent them from fully opening. However, the resident was able to manipulate the window to exit the facility. The facility's policy on wandering and elopements required care plans to include strategies for residents at risk, but this was not adequately followed for the resident in question.
Removal Plan
- In-serviced the staff on elopement prevention
- Ensured all windows were secured with latches and window stops
- Monitor residents at risk for elopement
- Staff education and elopement drills
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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