Waters Of Sullivan Nursing Facility, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Sullivan, Indiana.
- Location
- 505 W Wolfe St, Sullivan, Indiana 47882
- CMS Provider Number
- 155262
- Inspections on file
- 26
- Latest survey
- February 13, 2026
- Citations (last 12 mo.)
- 27
Citation history
Health deficiencies cited at Waters Of Sullivan Nursing Facility, The during CMS and state inspections, most recent first.
A resident with Type II DM had a standing order for mealtime Lispro insulin without any parameters for holding doses, yet nursing staff repeatedly held scheduled insulin at various times for blood glucose values ranging from the 50s to just over 100, and on some occasions failed to document any blood glucose value or whether insulin was given. The clinical record did not show MD notification or new orders for these held doses, and interviews with a QMA and the DON confirmed that no physician parameters for holding insulin had been provided and that staff did not contact the prescriber as required by facility policy.
The facility required CNAs and nursing staff to cover laundry duties in addition to resident care, resulting in longer call light response times, increased staff workload, and delays in meal tray delivery. The Administrator did not seek additional staffing or external support, and the actual staffing levels did not match the facility's assessment plan. Staff reported running out of linens and increased stress, with no additional staff scheduled to address the shortage.
The Administrator failed to address ongoing gnat infestations, unsafe environmental conditions, and staffing shortages, resulting in residents experiencing contaminated food, injuries from unrepaired fixtures, and inadequate laundry and housekeeping services. Staff and residents reported that the Administrator was not present on the floor and did not communicate about these issues, leading to unresolved problems affecting all residents.
A gnat infestation persisted throughout the facility, affecting all residents and multiple areas such as resident rooms and the dining room. Residents reported gnats contaminating food and beverages, and one developed maggots between her toes. Staff repeatedly reported the issue to administration, but responses were delayed and insufficient, with pest control measures failing to resolve the problem in a timely manner.
A resident admitted with orders for enoxaparin, Humalog, and Lantus did not receive scheduled doses because the required medications were unavailable in the Emergency Drug Kit and not obtained in time from the pharmacy. The Director of Nursing confirmed that staff should have used the EDK or arranged for emergency delivery, but the EDK was out of stock for the needed insulins and did not have the correct enoxaparin dose, resulting in missed medication administration.
Three residents, including those with cognitive impairments and special dietary needs, reported that their meals were frequently served cold and unappetizing. Observations confirmed that food was delivered on unheated carts without adequate warming devices, resulting in meal temperatures below the facility's policy requirements. The Dietary Manager acknowledged insufficient warming equipment, and complaints were noted about both food temperature and appearance.
The facility failed to manage food safety and storage, with incomplete temperature logs, expired food items, and improper storage practices. Bread lacked expiration dates, and sanitizer concentration levels were not properly tested or logged. Staffing shortages contributed to these deficiencies.
The facility did not conduct quarterly care plan meetings for two residents, as required by policy. One resident reported not attending a recent meeting, and records showed only one meeting in the past year. Another resident's records indicated only two meetings over a year, despite the quarterly requirement. The facility lacked a Social Service Director, which may have contributed to these oversights.
A resident with a history of prostate cancer and atrial fibrillation experienced edema in his feet and ankles, but the facility failed to notify the physician of this change in condition. Despite the resident's significant weight gain and the care plan's directive to monitor for edema, the facility did not document notifying the physician, resulting in a deficiency.
A resident was observed self-administering medications without supervision, contrary to facility policy requiring licensed nursing staff to administer medications or have physician authorization for self-administration. The resident's records lacked necessary assessments and orders, and staff interviews confirmed non-compliance with supervision protocols.
A facility failed to properly store and obtain physician orders for a resident's CPAP equipment. Observations showed the CPAP mask and tubing were unbagged and undated, and the resident's medical record lacked specific CPAP settings or humidification orders. An LPN confirmed the equipment should have been bagged and dated, and the facility's policy required a written physician's order for CPAP therapy, which was missing.
A facility failed to ensure proper physician documentation for a resident's continued use of Vesicare, despite a pharmacy recommendation to discontinue it. The resident, diagnosed with neuromuscular dysfunction of the bladder, had no documented rationale from the physician for continuing the medication, contrary to facility policy. This deficiency was confirmed by the Regional Nurse Consultant during an interview.
A facility failed to complete physician-ordered lab tests for a resident with multiple medical conditions, including heart failure and diabetes. Despite orders for various tests such as Digoxin levels, Hemoglobin A1C, and CBC, the records lacked documentation of their completion. The Regional Nurse Consultant confirmed the absence of lab results, highlighting a deficiency in following the facility's policy for nursing actions related to physician orders.
The facility failed to maintain infection prevention measures during meal service and medication administration. A CNA did not sanitize hands after touching her ear and hair while serving ice, and an LPN did not wash hands between checking blood sugar for two residents. Staff also did not follow hand hygiene guidelines, washing hands for less than 20 seconds and turning off faucets with bare hands.
Failure to Follow Insulin Orders and Obtain Parameters for Holding Doses
Penalty
Summary
The deficiency involves the facility’s failure to administer insulin as ordered by the physician and to obtain physician parameters or orders for holding insulin doses for a resident with Type II diabetes mellitus. Resident B had a current signed order for Lispro insulin, 25 units subcutaneously with meals, dated 12/4/25, with no parameters for when to hold doses. The eMAR showed multiple instances where scheduled insulin doses were held without corresponding physician orders or documented parameters: the 7:30 a.m. dose was held on several dates for blood sugar (BS) values of 46, 90, and 116; the 11:30 a.m. dose was held on multiple dates for BS values ranging from 54 to 80; and the 5:30 p.m. dose was held on one date for a BS of 105. The clinical record also lacked documentation of any BS value, progress note, indication of the resident being out of the facility, or indication that insulin was administered for certain scheduled doses. The record further lacked documentation that the physician was notified regarding the held insulin doses. A QMA reported obtaining BS values prior to insulin administration and stated that, on one occasion when the BS was 77 at 11:30 a.m., the nurse instructed her to document in the eMAR that the insulin was held due to that BS value. During interview, the DON confirmed that the physician had not provided parameters for holding mealtime insulin, that the hospital discharge records did not include such parameters, and that the facility physician had not added any. The facility’s medication administration policy stated that if a dosage is believed to be inappropriate or excessive, or associated with potential adverse consequences, the person administering the medication will contact the prescriber or attending physician, but the documentation did not show that this occurred for the held insulin doses.
Nursing Staff Shortage Due to Laundry Coverage
Penalty
Summary
The facility failed to ensure adequate nursing staff to meet resident needs while also requiring nursing assistants to cover laundry services since the end of October. Certified Nursing Assistants (CNAs) reported that they were assigned to laundry duties during their shifts, which resulted in them leaving the floor and being less available for direct resident care. Multiple CNAs and an LPN indicated that this dual responsibility led to longer call light response times, increased workload, and delays in meal tray delivery and pick-up. Staff also noted that there were occasions when only two aides, a nurse, and a QMA were present on night shift to care for all residents while also handling laundry, and that no additional staff had been scheduled to compensate for the increased workload. The Administrator acknowledged that only one full-time housekeeper/laundry person was employed after the termination of the Housekeeping Supervisor, and that CNAs had picked up extra hours to cover laundry. The Administrator had not reached out to regional leadership or considered external sources for laundry coverage, nor had she discussed the impact of the staffing shortage with residents or staff in detail. The Facility Assessment Tool indicated a staffing plan that included more housekeeping/laundry staff than were actually present. Staff reported running out of linens on night shift, necessitating laundry to be done during evenings and nights. One resident noted that staff appeared more stressed, though did not observe increased call light response times.
Failure to Address Bug Infestation, Staffing Shortages, and Unsafe Conditions
Penalty
Summary
The Administrator failed to manage the facility in a manner that ensured effective use of resources and quality of life for residents, as evidenced by ongoing issues with bug infestation, inadequate direct care staffing, and unsafe living conditions. Multiple confidential interviews with staff and residents revealed that the Administrator was not present on the floor, did not engage with staff or residents, and was perceived as indifferent to the facility's challenges. Staff morale was reported to be low, and concerns about vacancies and pest infestations were largely ignored by the Administrator. One resident reported sustaining a cut on his arm from a damaged bathroom door frame, which had not been repaired for over a month due to the absence of a Maintenance Director. The Administrator acknowledged the delay in repairs and indicated that the new Maintenance Director would address the issue when possible. The same resident described severe gnat infestations in his room and the dining area, with gnats contaminating food and beverages. Staff and residents reported that the gnat problem persisted for several weeks, and staff requests to use pest control devices were denied by the Administrator. Another resident reported developing maggots between her toes, which she attributed to the insect infestation in her room. The facility also experienced significant staffing shortages, particularly in housekeeping and laundry. The Administrator had terminated the Housekeeping Manager, leaving only one full-time housekeeper/laundry staff member, and CNAs were required to cover laundry duties, leading to frequent shortages of linens, especially during night shifts. The Administrator admitted to not seeking additional support or outside services to address the laundry staffing gap and had not communicated with staff or residents about the impact of these shortages. The Administrator was aware of the gnat issue but did not fully grasp its extent and did not escalate the problem to higher management or seek alternative pest control solutions.
Failure to Control Gnat Infestation Compromises Resident Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment by not controlling a gnat infestation that affected multiple areas, including resident rooms and the dining room. Residents reported significant issues with gnats over a period of several weeks to months, with gnats found in beverages and food, and residents taking measures such as covering drinks and personal items to avoid contamination. One resident described counting multiple gnats in his coffee, while another mistook gnats for pepper on her food. Staff interviews confirmed that the infestation was widespread and persistent, with reports that the issue was communicated to administration multiple times. Resident interviews revealed that the infestation caused considerable discomfort and annoyance, with one resident covering her face at night to avoid gnats and another developing maggots between her toes, which was documented in a Skin Integrity Issue report. The report noted that this resident had predisposing factors such as a preference for independence, incontinence, fragile skin, improper footwear, and resistance to care. Staff described the infestation as severe, with gnats present in food, beverages, and throughout the facility, and expressed concerns that the facility's response was insufficient and not timely. The Administrator acknowledged being aware of some gnats in her office but was not aware of the extent of the infestation throughout the facility. She had not spoken directly to residents or staff about the issue and relied on department heads for information. The pest control company was called for additional visits, but staff felt these measures were inadequate. The facility's pest control policy outlined responsibilities for prevention, monitoring, and control, but the actions taken did not prevent or resolve the infestation in a timely manner.
Failure to Timely Obtain and Administer Ordered Medications After Admission
Penalty
Summary
The facility failed to ensure that medications were obtained and administered in a timely manner for a newly admitted resident. Upon admission, the resident had physician orders for enoxaparin (an anticoagulant), Humalog (short-acting insulin), and Lantus (long-acting insulin). The Medication Administration Records (MAR) showed that scheduled doses of these medications were not administered as ordered, with documentation indicating to see nurse's notes for the reason. However, progress notes lacked documentation regarding the missed enoxaparin doses, and notes for the missed insulin doses indicated that Humalog and Lantus were not available in the Emergency Drug Kit (EDK) at the time they were needed. The Director of Nursing (DON) confirmed that if residents did not arrive with their medications, staff were expected to use the EDK, which is restocked with regular pharmacy runs. On the dates in question, the EDK was out of stock for Humalog and Lantus, and the available enoxaparin doses did not match the physician's order. The DON was unsure if staff should have contacted the physician regarding alternative dosing with the available enoxaparin. Facility policy required prompt initiation of therapy from the EDK or emergency delivery if needed, but this did not occur, resulting in the resident not receiving ordered medications as scheduled.
Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to ensure that food was served at a safe and appetizing temperature for three residents reviewed for dietary services. Resident C, who was cognitively intact and ate all meals in his room, reported that the food was always cold and not good. Observations revealed that meal trays were delivered on an unheated metal cart, with plates covered only by plastic covers and lacking warming pieces. The Dietary Manager checked the temperature of a test tray after all meals were served and found the barbeque sandwich meat at 107.3°F and baked beans at 117.4°F, both below the facility's policy requirement of 135°F. The Dietary Manager acknowledged there were not enough warming pieces for all trays, especially since most residents preferred to eat in their rooms, and none of the trays on the east wing had warming pieces during the observed lunch service. Additionally, the barbeque meat was noted to be an unnatural bright red color, and there had been complaints about the food's appearance. Resident B, who had moderate cognitive impairment and was on a mechanical soft diet, was reported by a family member to have poor food intake due to the food not being good, with meals also taken in her room. Resident G, cognitively intact, stated that the food was often cold when it arrived. The facility's policy required hot food to be held at 135°F or greater throughout service, which was not met during the observed meal service. These findings were based on interviews, observations, and record reviews, and were related to a specific complaint investigation.
Deficiencies in Food Safety and Storage Practices
Penalty
Summary
The facility failed to properly manage food storage and safety protocols, as observed during a kitchen tour. Temperature logs for the walk-in refrigerator and freezer were incomplete, lacking documentation for specific dates. The responsibility for maintaining these logs typically fell to the cook, but due to staffing shortages, this task was neglected. Additionally, thawed raw chicken was found with an outdated label, indicating it should have been discarded. The facility's policy required food to be labeled and dated, with expired items discarded, but this was not consistently followed. Further observations revealed that bread items in dry storage lacked manufacturer expiration dates or received dates. The Dietary Director was unaware of the specific policy regarding this issue, although bread shipments were received weekly and stored in the freezer for up to two weeks. Additionally, boxes of broccoli cuts and sheet cakes were found on the floor of the walk-in freezer, contrary to the facility's policy that required food to be stored at least six inches off the floor. The facility also failed to maintain a testing log for sanitizer concentration levels. A Dietary Assistant demonstrated incorrect testing procedures, initially holding the test strip in the solution for too long and repeating the process multiple times. The Dietary Director acknowledged the absence of a sanitation chemical testing log, although testing was believed to occur throughout the day. The facility's policy required adherence to the manufacturer's recommendations for sanitizer concentration, but this was not consistently monitored or documented.
Failure to Conduct Quarterly Care Plan Meetings
Penalty
Summary
The facility failed to conduct quarterly care plan meetings for two residents, as required by their policy. Resident 19, who was cognitively intact, reported not being invited to or attending a care plan meeting recently. A review of Resident 19's records showed that only one care plan meeting was documented over the past year, despite the requirement for quarterly meetings. The Regional Nurse Consultant confirmed the absence of additional quarterly care plan meetings for Resident 19 and noted the facility's lack of a Social Service Director, which may have contributed to this oversight. Similarly, Resident 30, also cognitively intact, indicated he had not participated in a care plan meeting. His medical records showed only two care plan meetings were conducted from May 2023 to June 2024, failing to meet the quarterly requirement. The facility's policy mandates that comprehensive care plans be reviewed and updated every quarter, but this was not adhered to for Resident 30. The Regional Nurse Consultant provided the facility's policy, which outlines the procedures for scheduling and documenting care plan meetings, highlighting the facility's failure to follow its own guidelines.
Failure to Notify Physician of Resident's Edema
Penalty
Summary
The facility failed to notify a physician of a resident's change in condition related to edema. Resident 46, who has a history of malignant neoplasm of the prostate and atrial fibrillation, was observed multiple times with edema in his bilateral feet and ankles. Despite the resident's observations of swelling and attempts to manage it by elevating his legs, there was no documentation of the physician being notified of this change in condition. The resident's care plan included monitoring for signs of atrial fibrillation, such as edema, but the facility did not follow through with notifying the physician as required. The resident's weight had increased significantly over the last 30 days, yet there was no record of the physician being informed of this weight gain, which was a critical indicator of the resident's condition. The facility's policy required notifying the physician of significant changes in a resident's condition, but this was not adhered to in the case of Resident 46. Interviews with staff revealed that some were aware of the swelling but did not take appropriate action to notify the physician, leading to a deficiency in the care provided to the resident.
Failure to Supervise Resident Medication Administration
Penalty
Summary
The facility failed to ensure adequate supervision for a resident self-administering medications, leading to a deficiency in accident prevention. During observations, the resident was seen taking medications without a nurse present, and the resident confirmed that nurses often left her medications in her room for her to take alone. The resident's records lacked documentation of an assessment for self-administration of medications, and there was no physician order authorizing self-administration. The resident's medical conditions included nonrheumatic aortic valve stenosis, congestive heart failure, chronic kidney disease, and a need for assistance with personal care. The facility's policy required medications to be administered only by licensed nursing staff and allowed self-administration only when authorized by a physician. Interviews with staff revealed that the nurses were aware of the policy but did not adhere to it, as one nurse left the resident to meet a pharmacy representative. The Regional Nurse Consultant confirmed that medications should not be left with residents without supervision. The facility's failure to follow its own policy and ensure proper supervision resulted in the deficiency.
Deficiency in CPAP Equipment Management and Physician Orders
Penalty
Summary
The facility failed to ensure proper storage and physician orders for a resident's CPAP equipment. During multiple observations, the CPAP machine of a resident with Parkinson's disease and obstructive sleep apnea was found with unbagged and undated tubing and mask. The resident indicated that staff assistance was required for using the CPAP, and the equipment had not been bagged since her admission. The resident's medical record lacked documentation of a physician order specifying the CPAP settings or humidification, despite a care plan indicating the need for CPAP use at bedtime and during naps. Interviews with facility staff revealed a lack of adherence to the facility's policy on CPAP equipment management. An LPN confirmed that the CPAP tubing and mask should have been bagged and dated, and acknowledged the absence of a storage bag in the resident's room. The LPN also noted that the CPAP machine was set at a different level than the resident believed it should be, and the electronic medical record did not include specific settings or humidification orders. The facility's policy required a written physician's order for CPAP therapy, including the level of CPAP and humidification if needed, which was not present in the resident's records.
Lack of Physician Documentation for Medication Continuation
Penalty
Summary
The facility failed to ensure proper physician documentation to justify the continuation of a medication against a pharmacy recommendation for a resident diagnosed with neuromuscular dysfunction of the bladder. The pharmacy had recommended discontinuing Vesicare, a medication used to treat overactive bladder symptoms, but the physician disagreed and simply noted 'Continue med' without providing further justification. This lack of documentation was confirmed during an interview with the Regional Nurse Consultant, who was unable to find any additional physician notes explaining the decision. The facility's policy requires that if a physician disagrees with a pharmacy recommendation, they must document the rationale in the resident's medical record, which was not adhered to in this case.
Failure to Complete Physician-Ordered Lab Tests
Penalty
Summary
The facility failed to ensure that physician-ordered laboratory tests were completed for a resident with multiple medical conditions, including congestive heart failure, atrial fibrillation, type 2 diabetes, hypertension, hyperlipidemia, and gastro-esophageal reflux disease. The resident's medical record indicated several physician-approved lab tests, such as Digoxin levels, Hemoglobin A1C, BMP, Magnesium levels, Lipid profiles, and CBC, were recommended and ordered at various intervals. However, the record lacked documentation that these tests were completed as ordered. During an interview, the Regional Nurse Consultant confirmed the absence of documentation for the lab results within the specified time frame. The facility's policy, as provided by the Regional Nurse Consultant, indicated that the Director of Nursing was responsible for following up on any nursing actions needed in response to the physician's orders. Despite this policy, the necessary lab tests were not documented as completed, leading to a deficiency in the facility's compliance with physician orders for lab testing.
Infection Control Deficiencies During Meal and Medication Administration
Penalty
Summary
The facility failed to maintain proper infection prevention measures during meal service and medication administration. During meal service observations, a Certified Nurse Aide (CNA) was seen touching her ear and hair and then continuing to pass ice to residents without sanitizing her hands. Additionally, the CNA placed the ice scoop back into the ice bucket instead of the designated container. The CNA also failed to sanitize her hands after adjusting oxygen tubing for one resident before assisting another. The facility's policy required staff to wash their hands before serving food and after assisting residents, which was not followed. During medication administration, a Licensed Practical Nurse (LPN) did not wash her hands between checking the blood sugar of two residents. The facility's policy required hand cleansing before contact with each resident, which was not adhered to. Furthermore, random observations revealed that staff did not wash their hands for the required 20 seconds and turned off the water faucet with bare hands, contrary to the facility's hand hygiene guidelines. These actions were inconsistent with the facility's policies on hand hygiene and infection control.
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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