Waters Of Huntington Skilled Nursing Facility, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Huntington, Indiana.
- Location
- 1500 Grant St, Huntington, Indiana 46750
- CMS Provider Number
- 155059
- Inspections on file
- 39
- Latest survey
- November 24, 2025
- Citations (last 12 mo.)
- 43 (1 serious)
Citation history
Health deficiencies cited at Waters Of Huntington Skilled Nursing Facility, The during CMS and state inspections, most recent first.
Two residents with severe cognitive impairment and high fall risk experienced repeated falls and injury due to the facility's failure to consistently implement and communicate fall prevention interventions. Despite care plans outlining specific measures such as safety checks, anti-tippers, and floor mats, these were often missing or not in place, and staff were unclear about responsibilities and interventions, leading to inadequate supervision and preventable accidents.
Two residents experienced documented falls that were not accurately reflected in their MDS assessments, as progress notes described multiple incidents of residents being found on the floor, but the corresponding MDS assessments indicated no falls since the prior assessment. The MDS Coordinator relied only on active risk management reports and was unaware of how to access historical data, and there was no specific facility policy for MDS assessments.
The facility did not complete required assessments for three residents with respiratory illness and falls. One resident with COPD and other conditions did not have documented respiratory assessments or vital signs after starting treatment for an infection. Two residents with cognitive impairment and multiple unwitnessed falls had incomplete neurological checklists, with missing entries and no documentation of refusals or reasons for missed checks. Staff and DON interviews confirmed that assessments and documentation were not completed as required by facility policy.
The facility failed to maintain a clean and homelike environment, with stained and worn carpeting, unclean floors, and bathrooms with brown matter around toilets. The Administrator acknowledged the unclean conditions, and the Housekeeping Director was developing a new cleaning plan. Observations indicated that cleaning procedures were not effectively implemented.
A facility failed to conduct weekly skin assessments for a resident at risk for skin breakdown, as required by their care plan and facility policy. The resident, with multiple diagnoses including dementia and hypertension, had not received a skin assessment since March, despite being identified as at risk for pressure ulcers. The care plan and facility policy both mandated weekly assessments, which were not performed, as confirmed by the ADON and MDS Coordinator.
A facility failed to immediately report a resident-to-resident altercation involving two residents with dementia, leading to a delayed submission to the Indiana Department of Health. The incident occurred when one resident, agitated, entered another's room, resulting in a physical confrontation. Staff interviews revealed a failure to follow the facility's abuse reporting policy, as the incident was not reported to the Administrator until weeks later.
The facility failed to implement individualized non-pharmacological interventions for two residents with dementia, leading to incidents of wandering, agitation, and aggression. Despite behavior monitoring orders, care plans lacked specific interventions, and staff were uncertain about documentation responsibilities. The facility's policy on behavior management was not adequately followed.
A cognitively impaired resident at high risk for falls was inadequately supervised, with room doors often closed, impairing staff's ability to monitor. Despite multiple unwitnessed falls, some resulting in injury, the care plan was not updated with new interventions. Staff interviews revealed a lack of communication and awareness of the resident's fall history and interventions, and post-fall monitoring reports were incomplete.
A resident with type 2 diabetes mellitus received expired Humalog insulin from a medication cart in an LTC facility. The insulin, opened on May 1st, was administered multiple times after its expiration on May 29th. Despite nightly checks, the expired insulin was not removed, and the facility's policy on insulin expiration was not followed.
The facility did not ensure that daily nurse staffing data was complete and available at the beginning of each shift. Observations showed that the posted information lacked the number of hours worked per shift for RNs, LPNs, and CNAs, as well as the resident census. Interviews confirmed that these details were filled out the following day, contrary to facility policy.
A resident with dementia was moved to a memory care unit without proper notification or involvement in the decision-making process, leading to confusion and distress. The facility cited a non-existent flood as the reason for the move, failing to follow its own policy on room changes and neglecting to document the necessity of the move in the resident's clinical record.
Failure to Implement and Communicate Fall Prevention Interventions for High-Risk Residents
Penalty
Summary
The facility failed to provide adequate supervision and implement fall prevention interventions for two residents with known high fall risk, resulting in repeated falls and injury. One resident, with diagnoses including dementia, repeated falls, and severe cognitive impairment, experienced multiple falls over a period of time. Despite a care plan outlining numerous fall prevention interventions such as safety checks, anti-tippers for the wheelchair, non-skid footwear, and floor mats, these interventions were inconsistently implemented. After each fall, there was a lack of immediate new interventions to prevent further incidents, and required equipment such as anti-tippers and floor mats were often missing or on backorder. The resident sustained injuries including a left ankle fracture and a gash to the face, with documentation showing that staff and interdisciplinary team meetings did not result in timely or effective changes to the care plan or its implementation. Another resident, also with severe cognitive impairment and multiple comorbidities, was similarly identified as a high fall risk. The care plan for this resident included interventions such as anti-rollbacks for the wheelchair, floor mats, and non-skid strips. However, observations revealed that these interventions were not in place at the time of survey, and the resident experienced several falls, often found on the floor without the prescribed safety equipment. Staff interviews indicated confusion about who was responsible for implementing new interventions, and communication about fall interventions was inconsistent. Maintenance was sometimes responsible for installing equipment, but there was no clear process to ensure timely implementation. Throughout the report, staff interviews and observations highlighted a lack of awareness and understanding of the residents' fall interventions among CNAs, LPNs, and other staff. Communication about changes to care plans and interventions was primarily verbal during shift changes or huddles, and documentation was not always updated promptly. The facility's failure to ensure that fall prevention interventions were consistently implemented and that staff were adequately informed and trained contributed directly to repeated falls and injuries for residents at high risk.
Inaccurate Coding of Falls on MDS Assessments
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for two residents. For one resident, multiple progress notes documented incidents where the resident was found on the floor, including being observed sitting or lying on the floor in his room or doorway, sometimes with minor redness noted but no significant injuries. Despite these documented falls, the resident's quarterly MDS assessment indicated that there had been no falls since the prior assessment. Similarly, another resident's record showed two separate incidents where the resident was found on the floor, one time after sliding out of a wheelchair and another after attempting to stand and losing balance. Both incidents were documented in progress notes, with no significant injuries reported. However, the resident's quarterly MDS assessment also indicated no falls since the prior assessment. Interviews with the MDS Coordinator revealed that she only reviewed active risk management reports and was unaware that historical reports could be accessed, while the DON clarified that prior reports were available under a different tab. The facility did not have a specific policy for MDS assessments.
Failure to Complete Required Assessments for Respiratory Illness and Falls
Penalty
Summary
The facility failed to ensure that appropriate assessments were completed for residents with respiratory illnesses and those who experienced falls. For one resident with chronic obstructive pulmonary disease (COPD), anemia, and hypertension, there was a lack of documented respiratory assessments and vital signs after the initiation of treatment for an upper respiratory infection. Despite physician orders for antibiotics and steroids, and a care plan that included monitoring for respiratory symptoms, there were no recorded assessments or temperature readings for an extended period, contrary to facility policy and staff expectations. For two other residents with cognitive impairment and mobility issues, there were multiple unwitnessed falls documented in their records. However, neurological checklists initiated after these falls were incomplete, with missing entries, blank spaces, and no documentation of refusals or reasons for missed assessments. In some cases, the checklists were not continued as required, and there were inconsistencies and illegible entries in the documentation. Staff interviews confirmed that neurological checks should be completed after unwitnessed falls or head injuries, and any missed assessments should be explained in the progress notes, which was not done. Facility policies required ongoing assessments for both respiratory illnesses and post-fall incidents, including specific monitoring and documentation protocols. The Director of Nursing acknowledged the missing documentation and incomplete neurological check forms for the affected residents. The deficiencies were identified through record review and staff interviews, and were related to complaints received by the facility.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, homelike environment for its residents, as observed during a facility tour. The carpeting in the hallways was stained and worn, and the floors in resident rooms and bathrooms were unclean, with dark debris and brown matter around the base of toilets. The bathrooms also had yellowish-brown stains on the outside surfaces of the toilets. The Administrator acknowledged the unclean conditions and noted that housekeeping was in the process of mopping floors and cleaning rooms. However, the Administrator was unsure of the last time the floors had been stripped, and the housekeeping supervisor had only been in the position for four days. During the tour, further observations revealed sticky bathroom floors, discolored baseboards, and dried brown matter inside and around toilets. The Housekeeping Director mentioned developing a new cleaning plan for the facility. A review of the facility's deep cleaning schedule indicated that at least one room was to be deep cleaned daily, in addition to normal cleaning tasks. The facility's cleaning policies outlined procedures for cleaning resident bathrooms and rooms, but the observed conditions suggested these procedures were not being effectively implemented.
Failure to Conduct Weekly Skin Assessments for At-Risk Resident
Penalty
Summary
The facility failed to provide weekly skin assessments for a resident identified at risk for skin breakdown, as outlined in their care plan. Resident D, who has diagnoses including depression, dementia, anxiety, hypothyroidism, delusions, hypertension, insomnia, and hypoglycemia, had not received a skin assessment since March 10, 2024. The most recent quarterly Minimum Data Set (MDS) assessment indicated that the resident was at risk for pressure ulcers and required assistance for transfers and repositioning. The care plan, dated November 10, 2023, specified that the resident was at risk for skin breakdown due to incontinence and required weekly skin assessments by a nurse. However, this was not adhered to, as confirmed by the Assistant Director of Nursing and the MDS Coordinator during an interview. The facility's policy, dated May 28, 2023, also required weekly skin assessments, which were not conducted for Resident D.
Delayed Reporting of Resident Altercation
Penalty
Summary
The facility failed to report a resident-to-resident altercation to the Administrator immediately, which delayed the submission of the incident to the Indiana Department of Health. The incident involved Resident B and Resident C, both diagnosed with anxiety, depression, and dementia. On the night of the altercation, Resident B was agitated and entered Resident C's room, leading to a physical confrontation. Despite the altercation occurring on 7/9/24, the Administrator was not made aware until 7/29/24, resulting in a late report to the health department. Interviews with staff revealed a lack of immediate reporting of the incident. LPN 3, who was notified of the altercation, did not report it because she did not witness it herself. The facility's policy requires immediate reporting of such incidents to the Administrator or the person in charge. However, the delay in reporting was attributed to the staff's failure to follow the chain of command and the facility's abuse reporting policy. The Administrator only became aware of the incident when it was reported to him on 7/29/24, which was the date he used for the self-reportable submission.
Failure to Implement Individualized Dementia Care Interventions
Penalty
Summary
The facility failed to develop and implement individualized non-pharmacological interventions for residents with dementia, specifically for Resident B and Resident C. During observations, Resident B was noted to wander around the unit, intruding into other residents' spaces, and was involved in incidents of agitation and aggression. Despite these behaviors, Resident B's care plan lacked specific interventions to address his increased agitation and aggression. Resident B's clinical record indicated diagnoses of depression, dementia, anxiety, and seizures, with medication orders including sertraline, memantine, Vimpat, lorazepam, and donepezil. Behavior monitoring was ordered for intrusive wandering, anxiety, non-compliance, and pacing, yet the care plan did not reflect these needs. Resident C, diagnosed with dementia with behavioral disturbances, major depressive disorder, and anxiety, was also involved in altercations with Resident B. Despite a history of aggression towards Resident B, Resident C's care plan lacked interventions related to his behavior. His clinical record showed medication orders for sertraline, lisinopril, and donepezil, with behavior monitoring for depressive mood, anxiety, agitation, and non-compliance. However, no behaviors were documented under the behavior monitoring order for July 2024, indicating a lack of proper documentation and intervention planning. Interviews with staff revealed confusion and inconsistency in documenting and addressing the residents' behaviors. LPNs and CNAs noted Resident B's wandering and Resident C's protective behavior towards female residents, yet there was uncertainty about who was responsible for documenting behavior monitoring. The Social Services Director acknowledged that the care plans should have been updated with new interventions, and the Administrator and DON confirmed the need for summarization in progress notes and updated care plans. The facility's Behavior Management Program policy emphasized the need for identifying causal factors and appropriate interventions, which were not adequately implemented in this case.
Inadequate Supervision and Fall Prevention for Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure adequate supervision to prevent falls for a cognitively impaired resident, identified as Resident C. Observations revealed that Resident C's room door was often closed or slightly ajar, which impaired the ability of staff to provide proper supervision. The resident, who was cognitively impaired and at high risk for falls, was frequently found on the floor after unwitnessed falls. Despite the resident's repeated calls for assistance, staff response was delayed, and the resident's preference for an open door was not consistently honored. Resident C's medical history included unspecified dementia, polyneuropathy, and other conditions that contributed to her high fall risk. The resident required moderate to maximum assistance for transfers and mobility and was dependent on staff for certain activities of daily living. Despite these needs, the care plan was not updated with new interventions following multiple unwitnessed falls, some of which resulted in injuries, including a head injury that required an emergency room visit. Interviews with staff indicated a lack of communication and awareness regarding the resident's fall history and the interventions in place to prevent falls. The facility's policy required specific monitoring and documentation following falls, but the post-fall monitoring reports lacked detailed information, and there was no evidence of consistent monitoring. The deficiency was further highlighted by the facility's failure to update the care plan with new interventions after each fall, as required by their policy.
Expired Insulin Administered to Resident
Penalty
Summary
The facility failed to remove and destroy expired insulin from a medication cart, affecting one resident who received medications from this cart. During an observation, it was noted that a Humalog Kwikpen, which was opened and expired, was stored in the medication cart. The insulin had been opened on May 1st and expired on May 29th, yet it was administered to the resident on multiple occasions after its expiration date. The resident, who had a diagnosis of type 2 diabetes mellitus with diabetic nephropathy, received expired insulin doses on several dates, totaling six expired doses. The facility's policy and the manufacturer's instructions both indicated that the insulin should have been discarded 28 days after opening. Interviews with the LPN and ADON revealed that the expired insulin should have been disposed of during nightly checks and prior to administration. The Third Shift Insulin Expiration Review Sheets, which were supposed to ensure expired insulins were removed, were signed daily but failed to result in the removal of the expired insulin. The DON acknowledged that signatures on these sheets should have indicated that insulins were checked for expiration, but this was not effectively done. The facility's policy on insulin pens was not adhered to, leading to the administration of expired insulin to the resident.
Incomplete Daily Nurse Staffing Data Posting
Penalty
Summary
The facility failed to ensure that the posted daily nurse staffing data was completed at the beginning of each shift and was readily available for residents and visitors. During observations on three separate days, the posted staffing information in the main lobby lacked the number of hours worked per shift for each RN, LPN, and CNA, as well as the resident census for that day. The observations revealed discrepancies in the documentation, such as missing hours and census data, which were only completed the following day after calculating hours from timecards. Interviews with facility staff, including the Business Office Manager, Medical Records personnel, and the Administrator, confirmed that the staffing postings were incomplete. The Medical Records staff indicated that the resident census and nurse staffing hours were left blank initially and filled out the next day. The Administrator stated that the daily nurse staffing sheet was filled out according to facility policy, except for the resident census and nurse staffing hours, which were completed the following day. The facility policy required that the staffing data, including the total number of hours worked and the current census, be posted daily at the beginning of each shift.
Failure to Involve Resident in Room Change Decision
Penalty
Summary
The facility failed to involve Resident B in the decision-making process prior to a room change, which led to her experiencing anxiety about her personal belongings and confusion about her new environment. Resident B, who was diagnosed with major depressive disorder and unspecified dementia, was moved to a memory care unit after her previous room allegedly flooded. However, it was later revealed that there was no actual flood, and the move was initiated without proper notification or involvement of the resident or her representative. Resident B's clinical records indicated she was moderately cognitively impaired and had a history of wandering. Despite this, the facility did not provide prior written notice of the room change to her or her representative. Interviews with staff revealed that the decision to move Resident B was made hastily, with management informing her of a non-existent flood to justify the relocation. This lack of communication and transparency contributed to Resident B's confusion and distress, as she struggled to adjust to her new surroundings and missed her previous social interactions. The facility's policy on room changes requires that residents and their responsible parties be notified and oriented to new rooms prior to any change. However, this protocol was not followed in Resident B's case. The absence of a Notification of Room Change evaluation and the failure to document the necessity of the move in her clinical record further highlight the facility's oversight in managing the transition appropriately. Interviews with various staff members, including the ADON, DON, and Social Service Director, confirmed that the move was not handled in accordance with established procedures, leading to Resident B's unnecessary distress.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
