Transcendent Healthcare Of Boonville - North
Inspection history, citations, penalties and survey trends for this long-term care facility in Boonville, Indiana.
- Location
- 305 E North St, Boonville, Indiana 47601
- CMS Provider Number
- 155801
- Inspections on file
- 39
- Latest survey
- February 17, 2026
- Citations (last 12 mo.)
- 20 (2 serious)
Citation history
Health deficiencies cited at Transcendent Healthcare Of Boonville - North during CMS and state inspections, most recent first.
A resident with early onset Alzheimer's, anxiety, and COPD, assessed as at risk for elopement, exited the facility unsupervised by using a keypad code on an exterior door. The resident was not discovered missing until a shift change, and was later found by law enforcement near a previous residence. The facility failed to provide adequate supervision and did not implement effective interventions to prevent the elopement.
A resident with an indwelling Foley catheter did not receive catheter care and monitoring as ordered by the physician, including missed catheter changes, saline flushes, and output documentation. Staff interviews revealed uncertainty about the resident's catheter care orders, and facility policy requirements for catheter care and documentation were not consistently followed.
The facility did not ensure that an RN was present for at least eight hours on two separate days, as required by policy. On those days, RN coverage was limited to less than eight hours, and the DON was not present in the building, though on call. This resulted in noncompliance with the facility's staffing requirements.
A resident with chronic conditions developed a stage III pressure ulcer on the coccyx due to the facility's failure to document and provide timely treatment. Despite being at risk and on a repositioning program, the resident's care plan was not updated promptly, and interventions were inconsistently documented. The ulcer worsened and became colonized with MRSA, highlighting a gap in the facility's pressure ulcer management.
The facility failed to maintain proper temperature controls for medications in the storage room. The refrigerator's temperature log had not been updated since May, and the freezer was covered in ice. Medications, including insulin pens, were stored at 46°F, outside the acceptable range of 33-41°F. The DON was unaware of the lapse in daily temperature checks, contrary to the facility's policy.
The facility failed to maintain infection control standards, as observed during a medication pass and review of Enhanced Barrier Precautions (EBP) for residents with indwelling devices and open wounds. A QMA administered a pill dropped on a cart with bare hands, violating protocols. Residents with MRSA, surgical incisions, and catheters lacked EBP signage and PPE. Staff interviews revealed a lack of awareness and training on EBP, contributing to these deficiencies.
A resident admitted on hospice care was found to lack physician orders for hospice and oxygen, despite being observed using oxygen and having a complex medical history. The resident's care plan noted hospice care needs and symptoms like restlessness and agitation. The MDS Coordinator confirmed the need for these orders, which were not documented, contrary to facility policy.
A facility failed to complete a comprehensive assessment within 14 days for a resident admitted with dementia, aphasia, depression, and gastrostomy status. The admission MDS assessment was still in progress past the required timeframe. The MDS Coordinator acknowledged the two-week completion requirement, and the facility's policy outlined the responsibility for timely submission to CMS.
The facility failed to develop specific care plans for two residents, one with significant weight loss and another dependent on staff for ADLs. Despite assessments indicating high nutritional risk and substantial assistance needs, the care plans were not updated to address these issues, as confirmed by the MDS nurse.
A resident was diagnosed with schizophrenia without proper diagnostic evaluation, despite being cognitively intact and showing no symptoms. The diagnosis was made by a former NP and physician, leading to the prescription of Latuda. The ADON acknowledged the inappropriate diagnosis and indicated it would be addressed.
A resident experienced significant weight loss without a prescribed regimen, and the facility failed to document a review or create a care plan following a high-risk nutritional assessment. Despite weight monitoring and dietary orders, the resident's care plan was not updated, and the RD did not document the weight loss review. The resident's medical history included bipolar disorder, anxiety, and major depression, and she often disposed of food despite encouragement to eat.
The facility failed to ensure CNAs were certified within 120 days of hire. Three CNAs were found not certified within the required timeframe. One CNA worked in dietary before starting as a CNA without certification, another was not certified, and a third was certified in another state but not locally. The DON confirmed the 120-day certification requirement, and the MDS Coordinator noted the absence of a specific policy, relying on state guidelines.
The facility did not ensure RN coverage for at least 8 hours a day on three weekends, as required by policy. The nursing schedule lacked RN coverage on specific dates, and the Administrator confirmed the deficiency.
Failure to Prevent Elopement of At-Risk Resident
Penalty
Summary
A deficiency occurred when a resident with a history of exit-seeking and elopement risk was able to leave the facility unsupervised. The resident, diagnosed with early onset Alzheimer's disease, anxiety, depression, and COPD, had recently been admitted and was assessed as at risk for elopement based on prior behaviors and assessment scores. Despite this, the resident was able to exit the building through a keypad-controlled door by entering the correct code, which was accessible due to a label indicating the code format. The resident left the facility at approximately 5:30 A.M. and was not discovered missing until 7:15 A.M. during a shift change, resulting in a significant delay before a search was initiated and law enforcement was notified. The resident's care plan included monitoring for sleep issues and mood, but there was no evidence of specific interventions to address the elopement risk beyond routine checks. Staff observations and documentation indicated the resident had been awake and in her room earlier in the morning, but there was no continuous supervision or targeted monitoring for exit-seeking behavior. The facility's policies required routine checks every two hours, but the resident was able to leave undetected between checks, and the absence of an alarm or notification system on the exit door further contributed to the failure to prevent the elopement. Interviews with staff and the resident's Power of Attorney revealed that the resident had memory issues and a desire to return to a previous home, which was a known risk factor. The resident was found by law enforcement approximately 1.2 miles from the facility, near a former residence, after being missing for several hours. The incident demonstrated a lack of adequate supervision and failure to implement effective interventions for a resident assessed as at risk for elopement, resulting in the resident's unsupervised departure from the facility.
Removal Plan
- Completed audits of clinical records for residents at risk for exit-seeking behavior or elopement.
- Removed labels indicating keycodes from keypads.
- Provided in-service training to staff on the elopement exit seeking policy and establishing interventions for residents assessed to be at risk for wandering/elopement.
Failure to Implement and Document Physician-Ordered Catheter Care
Penalty
Summary
The facility failed to implement and document physician-ordered catheter care and related interventions for a resident with an indwelling Foley catheter. The resident, who had diagnoses including neuromuscular dysfunction of the bladder, prostatic hyperplasia with lower urinary tract symptoms, and dementia, was observed with a catheter drainage bag attached to their wheelchair. Review of the resident's medical record revealed multiple physician orders for catheter care, including daily catheter changes, regular saline flushes, and monitoring of catheter output each shift. The resident's care plan also required catheter care as ordered, intake and output monitoring, and emptying the catheter bag at least three times daily. Documentation on the Treatment Administration Record (TAR) showed that several catheter care orders were not completed or documented on multiple occasions, including missed catheter changes, saline flushes, and output monitoring on specified dates. Interviews with facility staff indicated uncertainty and lack of awareness regarding the resident's catheter care orders and the required documentation. Facility policy required observation and documentation of urine output and adherence to catheter care procedures, but these were not consistently followed for the resident.
Failure to Provide Required RN Coverage for Eight Hours Daily
Penalty
Summary
The facility failed to provide Registered Nurse (RN) coverage for at least eight hours daily as required. Review of the nursing schedule showed that on two specific days, RN coverage did not meet the eight-hour minimum: on one day, an RN was scheduled from midnight to 7:00 A.M., and on another day, from 6:30 P.M. to midnight, resulting in less than eight hours of RN presence each day. An LPN who worked those weekends confirmed that the Director of Nursing (DON) was not present in the building during those shifts, although the DON was on call. Facility policy requires an RN to provide services for at least eight consecutive hours every 24 hours, seven days a week, which was not met on these occasions.
Failure to Prevent and Manage Pressure Ulcer
Penalty
Summary
The facility failed to prevent the development of a pressure ulcer in a resident who initially had no pressure-related skin impairment. Resident 12, who had chronic kidney disease, vitamin deficiency, atrial fibrillation, and chronic obstructive pulmonary disease, developed a stage III pressure ulcer on the coccyx while in the facility. The resident was at risk for pressure injuries as indicated by a Braden scale assessment and was on a turning and repositioning program. However, after the ulcer developed, there was no initial assessment documented, and no treatment was provided for four days. The care plan was not updated promptly to reflect the new condition, and interventions were not consistently documented as completed. The resident's care plan included interventions for potential skin breakdown due to decreased mobility and incontinence, but these were not effectively implemented. The resident experienced a decline in abilities, increased incontinence, and was occasionally incontinent of bladder and frequently incontinent of bowel. Despite these risk factors, the facility did not document any wound treatment or assessment until several days after the ulcer was first noted. The resident's wound was eventually assessed and treated, but the delay in care contributed to the development and worsening of the ulcer. Observations and interviews revealed that the resident was on a pressure-reducing air mattress and had a history of loose stools, which increased the risk of skin breakdown. The facility's failure to document and address the pressure ulcer promptly resulted in the wound becoming colonized with MRSA. The Assistant Director of Nursing could not explain the lack of documentation and treatment during the initial days of the ulcer's development, highlighting a gap in the facility's response to pressure ulcer prevention and management.
Improper Medication Storage Temperature Control
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored under proper temperature controls in the medication storage room. During an observation on November 13, 2024, it was noted that the refrigerator's temperature log had not been updated since May 28, 2024, and the freezer area was covered in ice. Medications, including insulin pens, were stored in this refrigerator. The Director of Nursing (DON) indicated that nursing staff should check and document the refrigerator temperature daily, but she was unaware of why this was not being done. At the time of observation, the refrigerator temperature was 46 degrees Fahrenheit, which was outside the acceptable range of 33-41 degrees Fahrenheit as indicated on the log sheet. A current Medication Labeling and Storage Policy provided by the MDS Coordinator stated that medications requiring refrigeration should be stored in a refrigerator located in the medication room at the nurse's station.
Infection Control Deficiencies in Medication Handling and EBP Implementation
Penalty
Summary
The facility failed to maintain a safe and sanitary environment to prevent the transmission of infections, as observed during a medication pass and review of Enhanced Barrier Precautions (EBP) for several residents. One incident involved a Qualified Medication Aide (QMA) who dropped a pill on the medication cart, picked it up with a bare hand, and administered it to a resident. This action violated infection control protocols, which require medications to be discarded if contaminated and not to be touched with bare hands. Additionally, the facility did not implement EBP for residents with indwelling devices and open wounds. Resident 12, who had a wound positive for MRSA, initially lacked signage and PPE indicating EBP. Similarly, Resident 44, with a surgical incision and a PICC line, and Resident 205, with a gastrostomy tube, were not placed on EBP, and there was no signage or PPE available. Resident 2, with an indwelling urinary catheter and a pressure ulcer, also lacked EBP orders and signage. Interviews with staff revealed a lack of awareness and training regarding EBP. The Infection Preventionist admitted that the facility was unaware of the need for EBP for residents with open wounds and indwelling devices. The facility's policies on administering medications and EBP were not effectively communicated or implemented, leading to these deficiencies in infection prevention and control.
Lack of Physician Orders for Hospice and Oxygen
Penalty
Summary
The facility failed to obtain physician orders for a resident's immediate care upon admission, specifically lacking orders for hospice and oxygen. This deficiency was identified for a resident who was admitted on hospice care and was observed using oxygen at 2 liters per minute via nasal cannula. Despite the resident's complex medical history, including liver cell carcinoma, chronic obstructive pulmonary disease, and hypertension, the necessary physician orders for hospice care and oxygen were not documented in the resident's clinical records. The resident's care plan indicated they were on hospice care and experiencing symptoms such as restlessness, agitation, and chronic confusion, requiring 1:1 supervision and frequent cues. The resident also had ongoing pain, which contributed to their agitation and restlessness. During an interview, the MDS Coordinator confirmed that the resident should have had physician orders for hospice and oxygen. The facility's policy stated that orders for a resident's immediate care should be provided by a physician upon admission, highlighting the oversight in this case.
Failure to Complete Timely Comprehensive Assessment
Penalty
Summary
The facility failed to complete a comprehensive assessment within 14 days of admission for one of the five residents reviewed who were admitted in the last 30 days. Resident 205, who was admitted with diagnoses including unspecified dementia, aphasia, depression, and gastrostomy status, did not have their admission MDS assessment completed within the required timeframe. The assessment, dated 10/24/24, was still in progress and should have been completed by 11/7/24. During an interview, the MDS Coordinator acknowledged the two-week timeframe for completing the admission MDS assessment. The facility's policy, provided by the MDS Coordinator, outlined the responsibility for ensuring timely submission of assessments to CMS' QIES ASAP system according to federal and state guidelines.
Failure to Develop Resident-Specific Care Plans
Penalty
Summary
The facility failed to develop a resident-specific care plan for two residents, leading to deficiencies in addressing their needs. Resident 25, diagnosed with bipolar disorder, anxiety, and major depression, experienced a significant weight loss of over 10% from March 7 to March 27, 2024. Despite a nutritional assessment indicating high risk and the significant weight loss, the care plan was not updated to address these nutritional concerns. The existing care plan only noted a potential for nutritional problems without any specific interventions following the assessment or weight loss. Resident 44, observed to be a bilateral lower leg amputee, required substantial assistance for activities of daily living (ADLs) such as toileting, bathing, and transfers. The care plan for this resident included interventions related to the amputations but failed to address the resident's dependency on staff for completing ADLs. The MDS nurse confirmed that care plans should have been developed to address these specific needs, as per the facility's policy on comprehensive, person-centered care plans.
Inappropriate Schizophrenia Diagnosis Without Proper Evaluation
Penalty
Summary
The facility failed to ensure that a new diagnosis of schizophrenia for a resident followed the professionally accepted diagnostic process. The resident, who was over the age of 65 and cognitively intact, was diagnosed with schizophrenia without documented screening, testing, or symptoms. The resident's medical history included bipolar disorder, anxiety disorder, post-traumatic stress disorder, and major depressive disorder. Despite the absence of behaviors, hallucinations, or delusions, the resident was prescribed Latuda for schizophrenia. During an observation and interview, the resident appeared alert, oriented, and well-groomed, answering questions appropriately. A review of the resident's records showed that the schizophrenia diagnosis was added in December of the previous year, and the medication Latuda was started in September of the same year. However, there was no diagnostic examination or evidence supporting the schizophrenia diagnosis in the resident's records. The Assistant Director of Nursing (ADON) indicated that the diagnosis was inappropriately given by a nurse practitioner and physician who were no longer affiliated with the facility. The ADON acknowledged that the facility attempted to inform the practitioners that a new diagnosis of schizophrenia requires meeting specific diagnostic criteria, but the diagnosis was still added. The ADON believed the diagnosis had been removed and indicated it would be addressed.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to ensure adequate nutrition for a resident who experienced significant weight loss. The registered dietitian did not document a review of the resident's weight loss, nor was a care plan created following a nutritional assessment that indicated the resident was at high risk. The resident, who was not on a prescribed weight loss regimen, reported losing weight and was observed sitting on the edge of her bed. Her medical history included bipolar disorder, anxiety, and major depression. The resident's weight records from March to July showed a significant decrease from 170.9 lbs to 126.6 lbs. Despite this, no new nutritional care plans were developed after a significant weight loss was noted on March 27. The resident's physician orders included a regular diet and weekly weight monitoring, but the house supplement for weight loss was discontinued. The resident's care plan only noted a potential for nutritional problems without further updates following the assessment or weight loss. Nurse's progress notes indicated the resident's lack of desire to eat, weakness, and confusion. The resident was treated for Helicobacter pylori and had a BMI of 23.9. Despite attempts to encourage eating and offering supplements, the resident often disposed of food. Interviews with the MDS nurse and ADON revealed that the RD forgot to document the weight loss review, although the facility was addressing the issue through medication adjustments and supplements. The facility's policy required immediate notification of the dietitian for significant weight changes, but this was not followed effectively.
Failure to Ensure CNA Certification Within 120 Days
Penalty
Summary
The facility failed to ensure that Certified Nurse Aides (CNAs) were certified within 120 days of their hire date, as required. During a review of employee records, it was found that three CNAs were not certified within the stipulated time frame. One CNA, hired on April 14, 2023, worked in dietary until July 3, 2024, when she started working as a CNA but was not certified. Another CNA, hired on July 3, 2024, was also not certified. A third CNA, hired on October 5, 2023, was certified in Illinois but not in Indiana. The Director of Nursing confirmed that CNAs have 120 days after their hire date to become certified. Additionally, the Minimum Data Set Coordinator indicated that there was no specific policy on CNA certification, and the facility followed state guidelines.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide registered nurse (RN) coverage for at least 8 hours a day, as required, on three out of five weekends reviewed. The nursing schedule, reviewed on September 3, 2024, for the period from August 2, 2024, to September 3, 2024, showed a lack of RN coverage for at least 8 hours on the dates of August 3, August 17, and August 31, 2024. During an interview on September 3, 2024, the Administrator acknowledged that the schedule did not meet the requirement for RN coverage. Additionally, the facility's current policy for departmental supervision in nursing mandates that an RN provides services for at least eight consecutive hours every 24 hours, seven days a week.
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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