Wellbrooke Of Carmel
Inspection history, citations, penalties and survey trends for this long-term care facility in Carmel, Indiana.
- Location
- 12315 Pennsylvania Street, Carmel, Indiana 46032
- CMS Provider Number
- 155833
- Inspections on file
- 32
- Latest survey
- January 21, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Wellbrooke Of Carmel during CMS and state inspections, most recent first.
A resident with dementia and a history of repeated falls sustained multiple injuries, including fractures and lacerations, after being left unattended in her room and bathroom despite care plan interventions requiring supervision. Staff failed to consistently follow and communicate the resident's fall prevention measures, leading to several unwitnessed falls and significant harm.
A resident with Parkinson's disease did not receive the correct dose of Rytary after an admitting nurse entered an incorrect order and the pharmacy, referencing an outdated profile, confirmed the lower dose. The error persisted until a nurse questioned the dosage, revealing that both nursing and pharmacy staff failed to verify the most current physician order, resulting in the resident receiving less medication than prescribed.
The facility did not ensure that pain assessments were completed and documented before and after administering narcotic pain medication to two residents, despite physician orders and EMAR requirements. An LPN administered Oxycodone on multiple occasions without the required assessments, and interviews confirmed that the residents had not recently requested such medication, with one preferring Tylenol.
Two residents with complex medical conditions received Oxycodone as indicated by narcotic count sheets, but the administration was not documented on the EMAR. Interviews revealed that neither resident had requested the medication on the dates in question, and staff failed to follow proper documentation procedures.
A facility failed to update a resident's code status to DNR in their electronic medical record after receiving a signed declaration and order. Despite the form being scanned into the system, the resident's status remained listed as full code. Interviews revealed that staff relied on incorrect information in emergencies, and the facility's policy on advanced directives was not followed.
The facility failed to conduct required care plan meetings for three residents, leading to a deficiency in care planning. A resident with depression and Alzheimer's disease missed a quarterly meeting, while another with Alzheimer's and hallucinations had not had a meeting since May. A third resident with cancer and malnutrition reported not being invited to a meeting since July. The Clinical Support Nurse cited employee turnover and focus on rehab residents as reasons for the oversight.
The facility failed to follow physician's orders for medication administration for three residents, leading to deficiencies in care. A resident received midodrine despite high blood pressure, another received carvedilol with a low heart rate, and a third had elevated blood sugar without physician notification. The facility lacked a policy for blood glucose monitoring.
The facility failed to accurately record urine output for two residents with suprapubic catheters, using vague terms like 'large', 'medium', and 'small' instead of precise measurements in milliliters. Staff interviews revealed that CNAs were responsible for charting output but often used imprecise terms, and the facility lacked a policy on documenting intake and outputs, leading to inconsistent recording practices.
A facility failed to document medication administration for a resident in the MAR, missing entries for several medications including buspirone, cholecalciferol, Cymbalta, docusate sodium, and gabapentin. The Corporate Support Nurse confirmed that medications should be documented post-administration, as per facility policy.
A resident's credit card was misappropriated by a staff member during her stay at the facility. The resident, with a history of chronic kidney disease and diabetes, reported the card missing after returning from activities and therapy. An investigation revealed that a housekeeper, who was under training, used the card at a McDonald's during her lunch break. The housekeeper left the facility and did not return, leading to her termination.
The facility failed to ensure that a staff member had the appropriate qualifications and current certification to perform the duties of a CNA and QMA. Employee 1 worked under another person's name and provided certifications that did not match his employment records. Additionally, his job-specific orientation checklists were incomplete and unsigned by the trainer. The deficiency was identified following an anonymous complaint and a news report.
Failure to Follow Care Plan and Provide Supervision Resulting in Multiple Resident Falls
Penalty
Summary
The facility failed to ensure that a resident's comprehensive care plan was followed and that adequate supervision was provided, resulting in multiple unwitnessed falls for a resident with significant cognitive impairment and a history of repeated falls. The resident, who had diagnoses including dementia, periprosthetic fracture, repeated falls, and major depressive disorder, experienced five falls within six months, each resulting in injury. These injuries included skin tears, bruises, lacerations, a fractured left hip, and a periprosthetic fracture around an internal prosthetic left hip joint. Despite documented care plan interventions specifying that the resident was not to be left unattended in her room or bathroom, staff failed to consistently implement these measures. Multiple incidents were documented where the resident was left alone, contrary to her care plan. In one instance, the resident was left alone in her bathroom and fell while attempting to self-transfer, resulting in a femur fracture. On another occasion, she was left alone in her room and fell, sustaining a head laceration that required sutures. In another event, a CNA left the resident in the bathroom to retrieve supplies, during which time the resident moved herself into her room and fell, resulting in facial lacerations and additional sutures. Staff interviews and documentation revealed that some staff were unaware of the resident's fall interventions, and there was a lack of consistent communication regarding care plan updates and interventions during shift reports. Observations confirmed the resident had visible injuries, including bruising and sutures on her face and forehead. Family members expressed concern about the resident being left alone despite assurances from management that this would not occur. Facility records and interviews indicated that care plan interventions were not reliably communicated or followed, contributing to the resident's repeated, injurious falls. The facility's policies required care plan updates and communication of interventions, but these were not effectively implemented for this resident.
Incorrect Medication Dosage Administered Due to Order Entry and Pharmacy Review Errors
Penalty
Summary
A deficiency occurred when a resident with diagnoses including Parkinson's disease, history of stroke, and weakness was not provided with the correct dosage of Rytary, a medication used to treat Parkinson's symptoms. The resident's physician orders for Rytary changed multiple times, with one order indicating four capsules four times daily, but due to an error by the admitting nurse, the order was incorrectly entered as one capsule four times daily. This incorrect dosage was then perpetuated when the pharmacy, upon review, referenced an older resident profile and confirmed the lower dose, leading to the resident receiving less medication than prescribed. The issue was identified after a weekend nurse questioned the medication dosage, prompting further review. Interviews with the DON and review of facility communications revealed that both nursing and pharmacy staff contributed to the error by relying on outdated information and not verifying the most current physician order. The facility's policy required an Immediate Medication Regimen Review (IMRR) by a licensed pharmacist upon request, but the review did not catch the discrepancy, resulting in the resident not receiving the intended medication dose for a period of time.
Failure to Document Pain Assessments Before and After Narcotic Administration
Penalty
Summary
The facility failed to ensure that pain assessments were completed both prior to and after the administration of narcotic pain medication for two residents. For one resident with diagnoses including dementia, chronic kidney disease, malignant melanoma, anxiety disorder, and chronic lumbar degeneration, there were multiple instances where Oxycodone was administered without documentation of a pain assessment before or after the medication was given, as required by the physician's order and the EMAR. Specific dates and times were identified where this documentation was missing. Another resident, with diagnoses such as dysarthria following cerebral infarction, right shoulder stiffness, type II diabetes with neuropathy, and major depressive disorder, also received Oxycodone without the required pain assessments being documented before and after administration. Interviews with both residents and a family member indicated that the residents had not requested strong pain medication recently, and one preferred Tylenol for pain. The Executive Director confirmed that the LPN should have completed pain assessments as required.
Failure to Document Administration of Narcotic Pain Medications
Penalty
Summary
The facility failed to ensure that narcotic pain medications administered to two residents were properly documented on the electronic medication administration record (EMAR). For both residents, the narcotic count sheets indicated that Oxycodone had been given on multiple occasions, but there were no corresponding signatures or documentation on the EMAR to confirm administration. Interviews with the residents revealed that they had not requested the as-needed narcotics on the dates in question, and one resident's family member confirmed a preference for non-narcotic pain relief. The lack of documentation was also confirmed during interviews with facility staff. The residents involved had significant medical histories, including dementia, chronic kidney disease, malignant melanoma, anxiety disorder, chronic lumbar degeneration, dysarthria following cerebral infarction, shoulder stiffness, type II diabetes with neuropathy, and major depressive disorder. Despite physician orders for as-needed Oxycodone, the absence of EMAR documentation for the administered doses constituted a failure to follow the facility's policy on the right documentation of medication administration.
Failure to Update Resident's Code Status in Medical Record
Penalty
Summary
The facility failed to update a resident's code status in their electronic medical record after receiving an out of hospital do not resuscitate (DNR) declaration and order. The resident, who had multiple diagnoses including Alzheimer's disease, hypertension, and chronic kidney disease, signed the DNR form, which was subsequently signed by the physician six days later. Despite the form being scanned into the electronic medical record, the resident's code status remained listed as full code in various parts of the medical record, including the top banner information and face sheet. Interviews with facility staff revealed that the Director of Nursing acknowledged the oversight in updating the charting system with the correct order. An LPN indicated that in an emergency, staff would rely on the computer's top banner information to determine whether to initiate CPR or honor a DNR request. The facility's policy on advanced directives emphasized the importance of obtaining and following residents' end-of-life care wishes, including confirming code status and obtaining a physician's order as part of the medical record. However, this policy was not adhered to in the case of the resident in question.
Failure to Conduct Required Care Plan Meetings
Penalty
Summary
The facility failed to ensure that care plan meetings were offered or held for three residents, leading to a deficiency in care planning. Resident 23, diagnosed with depression, anxiety disorder, and Alzheimer's disease, did not have a documented quarterly care plan meeting between April and December 2024. The Clinical Support Nurse confirmed that only two meetings were held during this period, missing the required quarterly meeting. Resident 29, with Alzheimer's disease, dementia, insomnia, and visual hallucinations, had not had a care plan meeting since May 2024. Despite experiencing increased hallucinations and being prescribed Risperidone, the facility missed the quarterly care plan meeting for this resident. The Clinical Support Nurse acknowledged the oversight during an interview. Resident 30, diagnosed with malignant neoplasm, severe protein-calorie malnutrition, and muscle weakness, reported not being invited to a care plan meeting for a long time. The facility had not conducted a care plan meeting for this resident since July 2024, and the Clinical Support Nurse admitted that the last quarterly meeting was missed due to significant employee turnover and a focus on rehab residents. The facility's policy requires quarterly meetings and communication with residents and their representatives, but these were not adhered to, resulting in a failure to meet care planning requirements.
Medication Administration Errors and Lack of Physician Notification
Penalty
Summary
The facility failed to adhere to physician's orders regarding medication administration for three residents, leading to deficiencies in quality of care. Resident 194, diagnosed with conditions including metabolic encephalopathy and type 2 diabetes, was prescribed midodrine with instructions to hold the medication if systolic blood pressure exceeded 120. Despite this, the medication was administered on multiple occasions when the resident's systolic blood pressure was above the specified threshold, without notifying the physician. Resident 4, with diagnoses including hypertension and type 2 diabetes, was prescribed carvedilol with instructions to hold the medication if the heart rate was below 65 beats per minute. The medication was administered several times when the resident's heart rate was below this parameter, contrary to the physician's order. The care plan indicated a potential for cardiovascular distress, yet the medication was not held as required. Resident 2, who had diabetes mellitus and other conditions, had a physician's order for insulin administration based on blood sugar levels, with instructions to notify the physician if blood sugar exceeded 400. On one occasion, the resident's blood sugar was recorded at 576, but there was no documentation of physician notification. The facility lacked a policy for blood glucose monitoring, and the Director of Nursing confirmed the physician was not notified as required.
Inaccurate Documentation of Urine Output for Residents with Catheters
Penalty
Summary
The facility failed to accurately record the urine output for two residents with suprapubic catheters. Resident 20's clinical record indicated a care plan to monitor urinary output and assist with catheter care, with a physician's order to monitor catheter output every shift. However, the Treatment Administration Record (TAR) showed that urine output was documented using vague terms like 'large', 'medium', and 'small' instead of precise measurements in milliliters. Interviews with staff revealed that CNAs were responsible for charting urine output, but often used these imprecise terms, which were not in line with the facility's expectations for accurate documentation. Similarly, Resident 1, who had a suprapubic catheter due to urethral stricture, had a physician's order to monitor urinary output three times a day. The TAR for this resident also showed urine output recorded in non-specific terms rather than in milliliters. Interviews with CNAs and LPNs confirmed that the output should have been documented in milliliters, but the facility lacked a policy on documenting intake and outputs, contributing to the inconsistency in recording practices. The Indiana State Department of Health Nurse Aide Curriculum emphasizes the importance of accurately measuring and recording urine output, as decisions regarding resident care may be based on these reports. The facility's failure to adhere to these guidelines and accurately document urine output in milliliters for residents with catheters represents a deficiency in providing appropriate care and monitoring for these residents.
Failure to Document Medication Administration
Penalty
Summary
The facility failed to ensure proper documentation of medication administration for a resident, identified as Resident 30, in the Medication Administration Record (MAR). The clinical record review revealed that on a specific day, there was no documentation indicating whether several medications were administered or not. These medications included buspirone for adjustment disorder, cholecalciferol as a supplement, Cymbalta for adjustment disorder, docusate sodium for constipation, and gabapentin for neuropathy. Additionally, there were seven other instances of missed documentation in the December MAR. During an interview, the Corporate Support Nurse confirmed that medications should be documented after administration. The facility's policy, revised in January 2017, states that if a dose of regularly scheduled medication is withheld, refused, not available, or given at a different time, it must be documented in the MAR or electronic health record. This lack of documentation indicates a failure to adhere to the facility's medication administration policy.
Resident's Credit Card Misappropriated by Staff
Penalty
Summary
The facility failed to ensure the safety and security of a resident's credit card during her admission, leading to its misappropriation. Resident B, who had a medical history including chronic kidney disease, hypertension, and diabetes, reported her credit card missing with unauthorized charges. The card was last seen in her phone case wallet before she left her room for activities and therapy. Upon returning, she discovered the card missing and found it had been used at a McDonald's. The incident occurred between the time she left her room and returned after lunch. An investigation revealed that Housekeeper 1, who was under training, was involved in the theft. Housekeeper 1 was observed eating McDonald's food during her lunch break, which coincided with the time the unauthorized transaction occurred. The housekeeper left the facility during her break and did not return, leading to her termination. The facility's investigation included reviewing employee records and interviewing staff, confirming the involvement of Housekeeper 1 in the theft of Resident B's credit card.
Failure to Verify Staff Credentials and Ensure Proper Orientation
Penalty
Summary
The facility failed to ensure that a staff member, Employee 1, had the appropriate qualifications and current certification to perform the duties of a Certified Nursing Assistant (CNA) and a Qualified Medication Aide (QMA). Employee 1 worked at the facility for a total of 34 days, during which he was suspended for a week due to a staff-to-staff incident and did not work for another week due to COVID-19. It was discovered that Employee 1 had worked under the name of another person and provided CNA and QMA certifications under a different name than his employment records. The facility did not verify the discrepancy in names, which Employee 1 attributed to a recent marriage, although no marriage license was found in his employee file. Additionally, Employee 1's job-specific orientation checklists for his CNA and QMA roles were incomplete and unsigned by the trainer, indicating a lack of proper orientation before he began working alone on the floor as a CNA and QMA. The facility's failure to ensure proper certification and orientation for Employee 1 led to his termination for poor job performance and unsatisfactory interactions with staff. The deficiency was identified following an anonymous complaint and a subsequent news report that revealed Employee 1 had worked under another person's LPN license. The facility's investigation confirmed that Employee 1 had used different names and provided certifications that did not match his employment records. The facility's oversight in verifying Employee 1's credentials and ensuring proper orientation contributed to the deficiency. The deficient practice was corrected on 5/18/24, prior to the start of the survey, and was therefore past noncompliance.
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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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.
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