Wedgewood Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Clarksville, Indiana.
- Location
- 101 Potters Ln, Clarksville, Indiana 47129
- CMS Provider Number
- 155265
- Inspections on file
- 50
- Latest survey
- November 18, 2025
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Wedgewood Healthcare Center during CMS and state inspections, most recent first.
A facility failed to ensure indwelling urethral catheter orders were in place for a resident with an indwelling catheter. The resident, with diagnoses including obstructive and reflux uropathy, was observed with a catheter, but the clinical record lacked documentation of catheter orders from late July to mid-November. The Director of Nursing indicated the orders were missed due to staff transition during the resident's readmission.
A facility failed to maintain accurate medication administration records for a resident prescribed Oxycodone for pain management. Discrepancies were found between the controlled drug administration record and the medication administration record over two months, with significantly fewer administrations documented in the latter. An LPN confirmed the procedure for documenting narcotic administration, which was not followed, as per the facility's policy.
The facility failed to address ongoing grievances from the Resident Council, including issues with room cleanliness, medication accuracy, and staff responsiveness. Residents reported repeated concerns about inadequate cleaning, insufficient snacks, and inconsistent meal services. Communication issues were also noted, with residents not being informed about the outcomes of their grievances or their rights. These deficiencies indicate a systemic failure to resolve resident concerns.
The facility's kitchen was found to be unsanitary during multiple inspections, with issues such as food debris, ice accumulation, and expired food items. Cleaning logs indicated tasks were completed, but observations contradicted this, and the Dietary Manager lacked policies for leftovers and cleaning.
The facility failed to secure smoking materials in a locked area when not in use, as observed in five residents. Smoking materials were found unsecured in residents' rooms and personal belongings, contrary to the facility's policy. The Social Services Director confirmed that residents were allowed to keep their smoking materials in their rooms, and lighters were not locked up, despite the policy requiring them to be secured.
A facility failed to monitor a resident's dialysis access site and notify the physician as required. The resident, with chronic kidney disease, had orders for monitoring the dialysis site for infection and assessing thrill and bruit every shift. However, documentation was missing for several shifts, and the resident reported swelling at the AV fistula site without immediate physician notification. Interviews confirmed the monitoring lapses and failure to follow the facility's policy for hemodialysis care.
A facility failed to follow infection control practices during incontinence care for a resident with severe cognitive impairment. An LPN and a CNA used the same area of wipes multiple times and did not apply barrier cream or dry the resident, contrary to the care plan and facility policy. The resident's wound dressing was also observed to be loose.
The facility failed to follow medication administration parameters and treatment orders for several residents, leading to deficiencies in care. A resident with hypertension was given medication without required blood pressure checks, and another resident's surgical incision treatment was not consistently documented. Additionally, a resident's blood pressure was not monitored as ordered, and another resident received medication despite readings outside prescribed parameters.
A facility failed to provide proper catheter care for a resident with a condom catheter, as documented in the treatment administration records for March and April 2024. The resident, diagnosed with a stage 4 sacral region pressure ulcer, required catheter care every shift and a weekly drainage bag change. However, records showed multiple instances of incomplete care and missed drainage bag changes. An LPN confirmed that completed treatments should be signed off, which was not done. The facility's policy required catheter care at least twice daily, highlighting a failure to adhere to this standard.
A CNA was observed exiting a resident's room with soiled items in gloved hands, violating the facility's infection prevention program. The program requires soiled items to be bagged separately and gloves removed before leaving the room.
Lack of Indwelling Catheter Orders for Resident
Penalty
Summary
The facility failed to ensure that indwelling urethral catheter orders were in place for a resident with an indwelling urethral catheter. Resident D, who had diagnoses including indwelling urethral catheter and obstructive and reflux uropathy, was observed with an indwelling catheter in place. The care plan for Resident D, dated 8/6/24, included interventions such as changing the catheter per medical provider orders and providing catheter care every shift. However, the clinical record lacked documentation of any indwelling catheter orders from 7/26/24 until 11/13/24. During an interview, the Director of Nursing indicated that the orders were missed due to the transition of staff when the resident was readmitted. The Regional Director of Clinical Operations provided a document titled Catheter Care, which stated the facility's policy to provide resident-centered care. Despite this policy, the absence of documented orders for the indwelling catheter care for Resident D from late July to mid-November represents a deficiency in the facility's adherence to its own care protocols.
Inaccurate Medication Administration Record for Pain Management
Penalty
Summary
The facility failed to ensure the accuracy of a resident's medication administration record for pain management. Resident C, who had diagnoses including osteomyelitis and a stage 4 pressure ulcer to the sacrum, was prescribed Oxycodone 10 mg every 4 hours as needed for pain. However, discrepancies were found between the controlled drug administration record and the medication administration record for September and October 2024. In September, the controlled drug record indicated the medication was given 90 times, while the medication administration record showed it was documented only 13 times. Similarly, in October, the controlled drug record showed 38 administrations, but the medication administration record documented only 19. During an interview, an LPN confirmed that when a narcotic pain medication is administered, it should be signed out on the controlled drug administration record and also documented on the medication administration record. The facility's policy, as provided by the Regional Director of Clinical Operations, stated that medications should be charted when given, indicating a failure to adhere to this policy. This deficiency was related to a specific complaint, highlighting a lapse in maintaining accurate medical records for Resident C.
Unresolved Resident Grievances in LTC Facility
Penalty
Summary
The facility failed to promptly resolve grievances and recommendations made by the Resident Council during multiple meetings. Over the course of several months, residents consistently reported ongoing issues that were not addressed by the responsible departments. These issues included inadequate cleaning of rooms, insufficient snacks, lack of communication regarding medication changes, and problems with medication accuracy. Additionally, residents expressed concerns about the attitude and responsiveness of nursing staff, including aides not answering call lights in a timely manner and not knocking before entering rooms. Further grievances were raised regarding the maintenance and cleanliness of the facility, such as unclean bathrooms, broken furniture, and inconsistent laundry services. Residents also reported issues with meal services, including inconsistent serving times, incorrect meal tickets, and a lack of diabetic-friendly options. The facility's failure to address these concerns was evident as the same issues were repeatedly brought up in subsequent meetings without resolution. The Resident Council meetings also highlighted problems with communication and transparency. Residents were not informed about the outcomes of their suggestions or grievances, and there was a lack of awareness about their rights and the facility's rules. Additionally, residents were not provided with the necessary information to make complaints to the State Department of Health. These deficiencies indicate a systemic issue in addressing and resolving resident concerns, leading to ongoing dissatisfaction and unmet needs within the facility.
Sanitation Deficiencies in Kitchen Observed
Penalty
Summary
The facility failed to maintain the kitchen in a sanitary manner, as observed during multiple inspections. During the initial tour of the kitchen, several issues were noted, including crumbs and debris under food shelves in the dry storage room, a small blue cup improperly left in a sugar bin, and a heavily soiled seasoning storage bin. In the walk-in freezer, a significant amount of ice was found under the milk crates, and the walk-in refrigerator contained expired food items. The kitchen itself had various cleanliness issues, such as food crumbs and debris under tables, heavily soiled sinks, and a buildup of grease and food particles on kitchen equipment. A second observation confirmed that the issues identified earlier in the day remained unaddressed. Further inspections revealed persistent problems, including ice accumulation in the walk-in freezer, expired food in the refrigerator, and unclean kitchen surfaces. Additionally, inappropriate storage of cleaning supplies was noted, with bleach wipes found next to china cups in the dining room serving area. The facility's cleaning logs indicated that all tasks had been completed as assigned, yet the observed conditions contradicted these records. The Dietary Manager admitted to not having policies in place for handling leftovers and cleaning the kitchen, highlighting a lack of procedural guidance contributing to the unsanitary conditions.
Failure to Secure Smoking Materials
Penalty
Summary
The facility failed to ensure that smoking materials were secured in a locked area when not in use, as observed in five residents who were reviewed for accident hazards. Resident 6 was observed multiple times with cigarettes and a lighter on her bedside table, both while asleep and after meals. She admitted to hiding her lighter under her leg when leaving her room. Resident 54 kept her cigarettes and lighter in her purse, which she kept in bed with her. Resident 46 stored his smoking materials in his dresser or pocket without locking them up. Resident 86 kept her lighter on a picnic table while smoking outside, and Resident 72 stored her smoking materials in her purse, which she slept with due to the lack of a locking mechanism. The Social Services Director confirmed that residents were allowed to keep their smoking materials in their rooms and that lighters were not locked up, although residents were supposed to turn them in at bedtime. The facility's smoking policy required smoking materials to be secured in a locked area when not in use, but this was not being followed. The review identified 25 residents who smoked, including 8 with dementia, highlighting a significant oversight in securing potentially hazardous materials.
Failure to Monitor Dialysis Access Site and Notify Physician
Penalty
Summary
The facility failed to ensure proper monitoring and physician notification for a resident requiring dialysis care. The resident, who had a history of chronic kidney disease and other related conditions, was supposed to have their dialysis access site monitored for signs of infection and for the presence of thrill and bruit every shift, as per physician orders. However, the clinical records showed a lack of documentation indicating that these assessments were consistently performed. On multiple occasions throughout June, the Medication Administration Record (MAR) lacked documentation of the required monitoring of the resident's dialysis site and the assessment of bruit and thrill. This included several shifts where no records were made, indicating a failure to adhere to the physician's orders for monitoring. Additionally, there was an incident where the resident reported swelling at the AV fistula site, but the nurse did not notify the physician immediately, instead allowing the resident to decide when to inform the Nurse Practitioner. Interviews with facility staff, including an LPN and the Regional Director of Clinical Operations, confirmed that the monitoring was not conducted as required and that the physician was not notified of the edema at the fistula site. The facility's Hemodialysis Care and Monitoring policy outlined the need for immediate physician contact in such cases, but this protocol was not followed, leading to the deficiency.
Infection Control Deficiency in Incontinence Care
Penalty
Summary
The facility failed to adhere to proper infection control practices during incontinence care for a resident with multiple diagnoses, including severe cognitive impairment and frequent incontinence. During an observation, a Licensed Practical Nurse (LPN) used the same area of a wipe multiple times to clean the resident's genital area and performed improper hand hygiene by turning off the faucet with her bare hand. Additionally, the LPN did not dry the resident or apply barrier cream as required by the care plan. In a separate observation, a Certified Nurse Aide (CNA) also used the same area of a wipe multiple times during incontinence care and failed to apply barrier cream, citing it was out of stock. The resident was not dried, and the wound dressing was observed to be loose. The facility's policy on perineal care was not followed, as it required thorough washing, rinsing, and drying of the perineal and rectal areas.
Medication Administration and Treatment Deficiencies
Penalty
Summary
The facility failed to adhere to medication administration parameters for several residents, leading to deficiencies in care. Resident B, diagnosed with diabetes, hypertension, and morbid obesity, was prescribed Carvedilol and Hydralazine with specific blood pressure parameters. However, on multiple occasions in May and June 2024, these medications were administered without obtaining the required blood pressure or pulse readings. Additionally, Resident B's treatment for skin integrity issues was not consistently completed as ordered, with several missed applications of Nystatin cream. Resident D, who had hypertension and a surgical incision, also experienced similar issues with medication administration. The resident was prescribed Metoprolol Tartrate with specific parameters for blood pressure and pulse, yet the medication was administered multiple times in June and July 2024 without obtaining the necessary readings. Furthermore, the resident's surgical incision treatment was not documented as completed on several days in June 2024. Resident F, diagnosed with hypertension, had a care plan requiring daily blood pressure checks due to elevated levels. However, there was a lack of documentation for these checks from June 23 to June 26, 2024. Similarly, Resident H, with a diagnosis of hypertension, was administered Coreg despite blood pressure and pulse readings being outside the prescribed parameters or not obtained at all on several occasions in May, June, and July 2024. These failures in following physician orders and documenting care led to the identified deficiencies.
Failure in Catheter Care for Resident
Penalty
Summary
The facility failed to ensure proper indwelling catheter care for a resident with a condom catheter, as documented in the treatment administration records (TAR) for March and April 2024. The resident, who had a diagnosis including a stage 4 sacral region pressure ulcer, required catheter care every shift and a weekly change of the drainage bag. However, the TAR indicated multiple instances where catheter care was not completed on various dates and shifts, and the drainage bag was not changed as ordered on specific dates. During an interview, an LPN confirmed that any completed treatment should be signed off on the TAR, which was not done in this case. The facility's policy, as provided by the Regional Director of Clinical Operations, stated that catheter care should be performed at least twice daily for residents with catheters. This deficiency was related to a specific complaint, indicating a failure to adhere to the facility's catheter care policy.
Infection Control Breach by CNA
Penalty
Summary
The facility failed to ensure proper infection control practices were followed by a staff member during one of five observations related to infection control. Specifically, a Certified Nursing Aide (CNA 4) was observed exiting a resident's room while wearing gloves and carrying a soiled brief in one gloved hand and a soiled pair of pants in the other. This action was contrary to the facility's infection prevention program, which requires soiled briefs and clothing to be placed in separate bags and soiled gloves to be removed before exiting a resident's room. The Regional Director of Clinical Operations provided a copy of the facility's Infection Prevention Program, which emphasizes the importance of reducing the risk of infections among residents and employees.
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.
