Westminster Village Health & Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Terre Haute, Indiana.
- Location
- 1120 E Davis Dr, Terre Haute, Indiana 47802
- CMS Provider Number
- 155221
- Inspections on file
- 26
- Latest survey
- March 13, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Westminster Village Health & Rehab during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, stroke history, muscle weakness, and respiratory failure, who was dependent on staff for transfers, was being moved from a wheelchair to a bed using a mechanical lift with assistance from two CNAs. The care plan required use of a mechanical lift with two staff, and facility policy required secure attachment and double-checking of sling straps before lifting. During the transfer, the resident was raised in the lift, one CNA pulled the wheelchair away, a lift strap became detached, and the resident fell to the floor, striking the shoulder and head and sustaining a clavicle fracture and scalp laceration. The Administrator later determined that a strap likely had not been fully engaged on the lift, contrary to the facility’s mechanical lift procedure.
A resident admitted with multiple medical conditions was cognitively intact and had signed a POST form indicating Full Code status. However, the facility incorrectly entered a DNR order at admission and failed to maintain the POST form in the medical record as required by policy, resulting in a discrepancy between the resident's documented wishes and the orders present in the record.
A resident with COPD and CHF was discharged home with Home Health Care, but the facility did not transmit the discharge MDS assessment to the State within the required timeframe. The MDS Coordinator was on leave and was uncertain about transmission requirements, leading to the deficiency.
Two residents with significant dental issues, including broken or missing teeth and loose dentures, were not accurately represented in their MDS assessments. Staff observations and care plans documented these dental problems, but the MDS failed to reflect them, despite ongoing awareness among staff and family members.
A resident with multiple mental health diagnoses, including dementia, did not have a care plan addressing dementia care or specific interventions for their condition. Although care plans were in place for general mental health needs and behaviors, there was no documentation of dementia-specific strategies, despite facility policy requiring such a plan for individuals with confirmed dementia.
Surveyors identified that two residents did not receive appropriate catheter care: one experienced a delay in UTI treatment due to late physician notification and medication procurement, while another was repeatedly observed with a Foley catheter drainage bag and tubing in contact with the floor, contrary to infection control policy.
A resident with heart failure and other complex conditions experienced multiple significant overnight weight gains, but staff did not notify the physician as required by orders and facility policy. Nursing staff and the DON acknowledged lapses in monitoring and reporting these discrepancies.
A resident with chronic respiratory conditions did not have their oxygen tubing and nebulizer equipment consistently dated or properly stored, as required by physician orders and facility policy. Observations showed undated and unbagged equipment left on surfaces, despite staff stating that equipment should be cleaned, dried, and stored in dated bags.
A resident with cognitive impairment and behavioral health needs exhibited ongoing aggression and care refusals, but the facility failed to develop or implement individualized interventions. Care plans and documentation remained generic, and staff did not consistently attempt or record resident-specific strategies during behavioral episodes, leading to the resident's transfer to the ER without evidence of tailored behavioral management.
The facility failed to maintain sanitary conditions in food preparation and service, with employees not adhering to proper hygiene practices, such as not covering mustaches, handling food without gloves, and turning off water faucets with bare hands after washing. The kitchen was also found to be in an unsanitary condition, with debris on the floor and unclean equipment.
The facility failed to obtain a supporting diagnosis for an indwelling Foley catheter for a resident who had the catheter placed during a hospital stay. The resident's medical record lacked documentation of a supporting diagnosis and notification to the physician. Additionally, there was no care plan for the catheter, and the facility's policy on catheter care was not followed.
A facility failed to address a significant weight discrepancy for a resident with multiple health conditions. The resident's weight fluctuated notably over several days, but the discrepancies were not documented or addressed as required by physician orders and facility policy. Staff interviews revealed issues with scale calibration and a lack of proper documentation.
The facility failed to ensure post-dialysis assessments were completed for a resident with end-stage renal disease, despite physician orders and facility policy. The deficiency was confirmed through record reviews and interviews with the resident, an LPN, and the DON.
The facility failed to ensure verbal physician's orders were counter-signed per pharmacy recommendations for two residents. Multiple instances of missing physician counter-signatures were noted, including medication changes and dosage reductions. Both residents had limited cognition and multiple diagnoses, highlighting the importance of proper medication management.
The facility failed to ensure that verbal physician's orders for psychotropic medications were signed by the physician for two residents. Both residents had multiple verbal orders for psychotropic medications that were not countersigned by the physician, despite pharmacy recommendations for dosage reductions.
The facility failed to ensure proper storage and labeling of medications, including undated and expired insulin pens for two residents. LPNs and the DON confirmed that insulin should be dated when opened and refrigerated until use, with a 28-day usage period post-opening. Facility policies on medication storage and expiration were provided.
The facility failed to maintain a separation between clean linen and the soiled linen area. An employee acknowledged that clean linens were left uncovered in the soiled laundry area, contrary to the facility's policy.
Injury from Improper Mechanical Lift Transfer
Penalty
Summary
The facility failed to ensure a resident was mechanically transferred safely, resulting in a fall from a mechanical lift and subsequent injuries. The resident involved had diagnoses including metabolic encephalopathy, history of stroke, muscle weakness, and respiratory failure, was severely cognitively impaired per a recent MDS, and was dependent on staff for transfers and non-ambulatory. The resident’s care plan required maximum assistance of two staff with a mechanical lift for transfers. During an evening transfer from a wheelchair to a bed using a mechanical lift, two CNAs assisted the resident. According to nursing documentation, the resident fell to the ground, striking her left shoulder on the base of the lift and the back of her head, and exhibited pain behaviors such as grimacing, moaning, and crying. Written statements from both CNAs indicated that they had attached the resident’s sling straps to the lift prior to initiating the transfer. One CNA reported that three straps were hooked on the resident and that she had attached the two bottom straps and one top strap, while the other CNA attached the remaining top strap. When the lift was operated and the resident was in the air, one CNA pulled the wheelchair away, and a strap came undone, causing the resident to fall; the other CNA attempted to catch the resident but was unsuccessful. The Administrator’s investigation concluded that one of the straps likely had not fully engaged on the lift, which was the only explanation offered for why a strap would come loose. The facility’s mechanical lift policy required staff to ensure sling straps were securely attached, properly balanced, double-checked for security before lifting, and that all hooks, clips, fasteners, and strap stability be examined, indicating these procedural steps were not effectively followed during the transfer that led to the fall and injuries.
Failure to Accurately Document and Honor Resident Code Status on Admission
Penalty
Summary
A deficiency occurred when the facility failed to accurately document and honor a resident's code status upon admission. The resident, who was cognitively intact and admitted with diagnoses including infection related to a joint prosthesis, methicillin susceptible staphylococcus aureus infection, and hypertension, had a POST (Physician Orders for Scope of Treatment) form signed at admission indicating Full Code status. However, the physician order entered at the time of admission incorrectly documented the resident as DNR (Do Not Resuscitate), and the POST form was not present in the medical record as required. The care plan referenced the existence of advanced directives and DNR documentation, but did not reflect the resident's actual wishes as indicated on the POST form. The discrepancy was identified during a review of the medical record and confirmed through interviews with facility staff, including the medical record nurse and the DON. The facility's policy required the POST form to be maintained at the front of the resident's medical record, but this was not done, resulting in a failure to ensure the resident's treatment preferences were accurately recorded and accessible.
Failure to Timely Transmit Discharge MDS Assessment
Penalty
Summary
The facility failed to ensure the timely transmission of a discharge Minimum Data Set (MDS) assessment for one resident. The resident had been admitted with diagnoses including chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF), and was discharged back to his home with Home Health Care. The admission MDS assessment indicated no cognitive deficit and a plan for discharge. The discharge MDS assessment was completed on the date of discharge, but there was no documentation that it had been transmitted to the State within the required timeframe. During the investigation, the Administrator stated that the MDS Coordinator was on a leave of absence and, when contacted, was unsure about the transmission requirements for regular Medicare versus Managed Medicare residents. The facility's policy, based on the CMS RAI Version 3.0 Manual, requires that discharge assessments be transmitted no later than 14 calendar days after completion. The lack of timely transmission for the discharge MDS assessment constituted the deficiency.
Inaccurate MDS Coding for Dental Status
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were accurately coded regarding the dental status of two residents. For one resident, observations revealed broken and missing teeth, but the significant change MDS assessment did not document the presence of obvious cavities or broken natural teeth. The resident's care plan had previously identified a risk for oral and dental problems due to missing teeth and a need for assistance with oral care. Staff interviews confirmed the presence of missing and broken teeth, which were not reflected in the MDS documentation. For another resident, observations during a meal showed that her upper dentures were very loose, frequently falling off her gums and requiring her to push them back with a spoon. Despite this, both the significant change and quarterly MDS assessments failed to document the issue of broken or loosely fitting dentures. The resident had a history of severe cognitive deficit, type 2 diabetes, and protein-calorie malnutrition. Staff interviews indicated that the loose denture had been a persistent problem, known to both staff and the resident's family, but not accurately coded in the MDS. The facility's DON acknowledged awareness of the issue but was unsure why the MDS was not completed correctly, despite the facility's use of the CMS RAI manual for assessment guidance.
Failure to Implement Dementia-Specific Care Plan
Penalty
Summary
The facility failed to develop and implement a care plan specifically addressing dementia care and resident-specific interventions for a resident with multiple mental health diagnoses, including unspecified dementia, psychotic disturbance, mood disturbance, and anxiety. The resident's medical record showed care plans for verbally abusive behaviors and mental health needs, but there was no care plan that directly addressed dementia or Alzheimer's disease, nor was there mention of a bipolar diagnosis. The interventions listed in the existing care plans focused on general mental health support, such as assessing needs, providing supportive counseling, and involving family, but did not include dementia-specific strategies. A review of the resident's Minimum Data Set (MDS) assessment confirmed cognitive impairment, yet the medical record lacked evidence of a care plan tailored to dementia care. During an interview, the Social Services Director acknowledged the absence of a dementia care plan and stated that one should have been implemented at admission. The facility's current policy requires the interdisciplinary team to create a resident-centered care plan for individuals with confirmed dementia, but this was not done for the resident in question.
Delayed UTI Treatment and Improper Catheter Care Identified
Penalty
Summary
The facility failed to provide timely treatment for a urinary tract infection (UTI) for a resident with a history of severe cognitive impairment and an indwelling catheter. Laboratory results indicating the presence of two types of bacteria in the urine were received by the facility, but there was no documentation that the physician was notified or that antibiotics were ordered until several days later. Interviews with staff revealed that the process for notifying the physician and obtaining antibiotics was not followed as expected, resulting in a delay of four days before treatment was initiated. The delay was attributed to a lack of immediate action to obtain the medication from the emergency drug kit or through a back-up pharmacy service, despite facility policy requiring timely access to medications. Additionally, the facility failed to ensure proper catheter care for another resident with an indwelling Foley catheter. Multiple observations over several days showed the resident's catheter drainage bag and tubing in direct contact with the floor while the resident was in a recliner. This was confirmed by the Director of Nursing, who acknowledged that the drainage bag and tubing should not be on the floor, in accordance with the facility's infection control policy. The deficiencies were identified through record review, staff interviews, and direct observation. The issues included both a lack of timely medical intervention for a UTI and repeated failures to maintain catheter equipment in a sanitary manner, as required by facility policy and standard infection control practices.
Failure to Notify Physician of Significant Weight Changes
Penalty
Summary
The facility failed to address significant weight discrepancies for one resident with multiple medical conditions, including heart failure, a femur fracture, and vascular parkinsonism. The resident was under physician orders for daily weights and required notification to the physician if there was a weight gain of 3 pounds or more overnight or 5 pounds in one week. Despite this, multiple instances were documented where the resident experienced weight gains ranging from 3.6 to 12 pounds in less than 24 hours, and there was no evidence in the record that the physician was notified as required by the orders. Interviews with nursing staff and the Director of Nursing revealed that while staff were generally aware of the need to re-weigh residents or notify the physician in the event of significant weight changes, these actions were not consistently documented or performed. The DON acknowledged that monitoring of weight discrepancies had lapsed due to other responsibilities, and the facility's policy required reporting significant weight changes to the nurse supervisor and in accordance with professional standards, which was not followed in these instances.
Improper Storage and Management of Respiratory Equipment
Penalty
Summary
The facility failed to ensure proper storage and management of respiratory equipment for a resident with significant respiratory diagnoses, including COPD, chronic respiratory failure, and pulmonary fibrosis. Multiple observations revealed that oxygen tubing and nebulizer equipment were not consistently dated or stored in accordance with facility policy and physician orders. Specifically, oxygen tubing was found undated and unbagged, draped over the concentrator, and nebulizer equipment was repeatedly observed unbagged and left on the bedside or overbed table. Some equipment was found in bags, but the bags or tubing were not always dated as required. Review of the resident's medical record confirmed orders for regular changing and proper storage of oxygen tubing and nebulizer equipment, with specific instructions to change tubing and humidifier bottles weekly and to document these changes. Interviews with LPNs indicated that equipment should be cleaned, air dried, and stored in dated bags, but observations did not consistently reflect this practice. The facility's policy also required tubing to be replaced per manufacturer and facility schedule, documented, and stored in plastic bags with dates, which was not consistently followed for this resident.
Failure to Develop and Implement Resident-Centered Behavioral Health Interventions
Penalty
Summary
The facility failed to develop and implement a resident-centered behavior management care plan and did not identify or attempt individualized interventions during behavioral episodes for a resident with a history of behavioral health needs. The resident, who had diagnoses including encephalopathy, mood disorder, and mild cognitive impairment, exhibited ongoing agitation, verbal and physical aggression, and care refusals from the time of admission. Documentation repeatedly lacked evidence of specific interventions tailored to the resident’s needs, and staff notes often did not describe what was attempted or the effectiveness of any interventions during episodes of aggression or care refusal. Care plans and progress notes reviewed for the resident were generalized and did not include individualized strategies to address the resident’s behaviors, despite frequent incidents of aggression, care refusal, and false accusations towards staff. Interventions listed, such as care in pairs, reapproaching after 10-15 minutes, and offering to call the resident’s wife, were not tailored to the resident’s specific triggers or needs. Staff interviews confirmed that interventions were not effective, and there was uncertainty among staff about where to find or how to implement appropriate interventions. The intervention binder referenced by the facility contained only generic strategies and was not helpful in managing the resident’s behaviors. Despite the resident’s escalating behaviors, including physical aggression towards staff, the facility did not document the development or implementation of new, resident-specific interventions prior to transferring the resident to the emergency room for psychiatric evaluation. The records also lacked documentation that the resident was a danger to himself or others, as the behaviors were directed solely towards staff. The facility’s policy required individualized assessment and care planning for behavioral health needs, but this was not reflected in the care provided or documented for the resident.
Failure to Maintain Sanitary Conditions in Food Preparation and Service
Penalty
Summary
The facility failed to prepare and serve food in a sanitary manner, as observed during multiple kitchen and dining room inspections. Employees were found not adhering to proper hygiene practices, such as not covering their mustaches with beard covers, handling food without gloves, and turning off water faucets with bare hands after washing. Additionally, the kitchen was observed to be in an unsanitary condition, with debris on the floor, unclean equipment, and missing dishwasher temperature logs for specific periods. During dining observations, several employees, including the Dietary Director and CNAs, were seen washing their hands for less than the required 20 seconds and turning off the water faucet with their bare hands. This improper hand hygiene practice was repeated multiple times, even after touching potentially contaminated surfaces like hair. The Dietary Director and other staff members were also observed serving food without gloves and touching the inside of plates with bare hands. The facility's policies on sanitation and hand hygiene were not followed, as evidenced by the unsanitary conditions in the kitchen and improper handwashing techniques. The Dietary Director acknowledged the lack of proper cleaning and was unable to provide a cleaning schedule. The facility's handwashing policy, which requires using a paper towel to turn off the faucet, was not adhered to by multiple staff members, leading to potential contamination during food preparation and service.
Failure to Obtain Supporting Diagnosis for Indwelling Foley Catheter
Penalty
Summary
The facility failed to obtain a supporting diagnosis for an indwelling Foley catheter for one resident. The resident indicated that the catheter was placed during a hospital stay but could not recall the reason for its placement. Upon return from the hospital, the facility did not obtain a supporting diagnosis because they were waiting for a follow-up appointment with urology. The Director of Nursing confirmed that the physician referred them to urology for the diagnosis, and there was no documentation of a supporting diagnosis in the resident's medical record. Additionally, the medical record lacked documentation of notification to the physician requesting a supporting diagnosis for the catheter. The resident's medical record included various diagnoses such as a displaced fracture of the lower end of the right femur, chronic respiratory failure with hypoxia, atrial fibrillation, major depressive disorder, urine retention, and dysuria. However, there was no care plan for the indwelling Foley catheter, and the Minimum Data Set indicated the resident did not have a diagnosis of neurogenic bladder, renal failure, or urinary obstruction. The facility's policy on catheter care required documentation of clinical indications for catheter use, which was not followed in this case.
Failure to Address Significant Weight Discrepancy
Penalty
Summary
The facility failed to address a significant weight discrepancy for a resident with multiple health conditions, including unspecified diastolic heart failure, cerebral infarction, and chronic obstructive pulmonary disease. The resident's weight fluctuated significantly between 3/18/24 and 3/22/24, with weights recorded as 175.4 pounds, 153.8 pounds, 154.8 pounds, 155.4 pounds, and 153.2 pounds, respectively. Despite a physician's order to notify the doctor of a 3-pound weight gain in 24 hours or a 5-pound gain in one week, the record lacked documentation that these discrepancies were addressed. The most recent dietary/nutrition note was dated 12/16/23 and did not reflect the recent weight changes. During interviews, staff indicated that residents were usually weighed by nursing staff and that significant weight differences should be re-weighed and reported. One LPN mentioned that one of the scales needed recalibration, but it was unclear which one. The Assistant Director of Nursing acknowledged that the weight difference should have been documented and re-weighed, attributing the discrepancy to a potential error due to scale issues. The facility's policy on weighing and measuring residents, revised in March 2011, emphasized the importance of calibrated scales and reporting significant weight changes to the nurse supervisor.
Failure to Complete Post-Dialysis Assessments
Penalty
Summary
The facility failed to ensure a post-dialysis assessment was completed for a resident who required dialysis services. Resident 23, who had diagnoses including end-stage renal disease, type 2 diabetes mellitus, and hemiplegia, was noted to be on dialysis as per a quarterly Minimum Data Set (MDS) assessment. The resident had physician orders for dialysis three times a week and for checking the bruit and thrill in the right upper arm every shift. Despite these orders, the review of dialysis communication forms for February and March 2024 revealed that post-dialysis assessments were not completed on multiple dates. Interviews with the resident, an LPN, and the Director of Nursing (DON) confirmed that the post-dialysis assessments were not consistently performed, and the DON was unaware of this lapse in procedure. The resident indicated that while an assessment was done on the day of the interview, it was not always performed when returning from dialysis. The facility's policy, revised in February 2023, required documentation of the catheter's location, condition of the dressing, whether dialysis was done, any report from the dialysis nurse, and observations post-dialysis. The failure to complete these assessments as per the policy and physician orders led to the deficiency noted in the report.
Failure to Ensure Physician Counter-Signatures on Verbal Orders
Penalty
Summary
The facility failed to ensure verbal physician's orders were counter-signed per pharmacy recommendations for two residents. For Resident 37, the pharmacist recommended a dose reduction for Effexor, but the form lacked documentation of a counter signature by the physician. Resident 37 had multiple diagnoses, including type 2 diabetes, vascular dementia, epilepsy, hypertension, and hypothyroidism, and was on several medications. The quarterly Minimum Data Set indicated the resident had limited cognition, highlighting the importance of proper medication management and oversight. For Resident 11, multiple instances of missing physician counter-signatures were noted. These included changes in medication from Omeprazole to Pantoprazole, a reduction in Prozac dosage, instructions for Pulmicort use, and linking a bipolar diagnosis with an order for Seroquel. Resident 11 had diagnoses including COPD, type 2 diabetes, anxiety disorder, hyperlipidemia, hypothyroidism, and major depressive disorder. The annual Minimum Data Set also indicated limited cognition. The facility's policy on verbal orders, dated February 2020, stated that verbal orders should be counter-signed by the physician during their next visit, which was not adhered to in these cases.
Failure to Ensure Physician's Signature on Verbal Orders for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that verbal physician's orders for psychotropic medications were signed by the physician for two residents. Resident 47, who had diagnoses including Parkinson's disease, major depressive disorder, anxiety disorder, and borderline personality disorder, had several verbal orders for psychotropic medications that were not countersigned by the physician. These included orders for olanzapine, buspirone, and sertraline, with pharmacy recommendations for dosage reductions that were verbally disagreed upon but lacked the necessary physician's counter signature. Similarly, Resident 16, who had diagnoses including anxiety disorder, depression, and chronic respiratory failure with hypoxia, also had multiple verbal orders for psychotropic medications that were not countersigned by the physician. These included orders for sertraline and Xanax, with pharmacy recommendations for dosage reductions that were verbally disagreed upon but lacked the required physician's counter signature. During an interview, the Administrator indicated a lack of awareness regarding a policy for pharmacy recommendations and verbal orders. The facility's policy, provided by the Administrator, stated that verbal orders should only be given in emergencies or when the attending physician is not immediately available, and that the practitioner should review and countersign verbal orders during their next visit. However, this policy was not followed in the cases of Residents 47 and 16.
Improper Medication Storage and Labeling
Penalty
Summary
The facility failed to ensure medications were stored and labeled properly and did not dispose of expired medications for two of three medication carts reviewed. On one occasion, an undated and opened Lispro insulin pen and a Lantus insulin pen with an open date of 2/22/24 were found in the 200 hall second medication cart, both labeled for Resident 47. The Lantus insulin pen should have been discarded as it was past the 28-day usage period. LPN 7 confirmed that insulin pens should be dated when opened and discarded after 28 days. Resident 47's records indicated a diagnosis of type 2 diabetes mellitus and included physician orders for Humalog and Lantus insulin pens with specific administration instructions. In another instance, an unopened and non-refrigerated Lispro insulin pen labeled for Resident 14 was found in the 200 hall first cart. LPN 10 acknowledged that unopened insulin should be refrigerated until used but was unaware of how long the pen had been in the cart. The DON confirmed that insulin should be dated once opened and refrigerated until then, with a 28-day usage period post-opening. Resident 14's records also indicated a diagnosis of type 2 diabetes mellitus with a physician order for insulin Lispro injection solution to be administered per sliding scale with meals. The facility's policies on medication storage and expiration dating were provided, indicating insulin should be refrigerated until opened and discarded 28 days after opening.
Failure to Maintain Separation Between Clean and Soiled Linen
Penalty
Summary
The facility failed to maintain a separation between clean linen and the soiled linen area. During an observation of the soiled laundry area, several barrels containing linens were uncovered and placed against the wall in front of the washing machines, which were in use with soiled laundry. An employee indicated that the linens and clothing within the barrels had been washed and were clean, and she was waiting to put them into the dryer. The employee acknowledged that the lids had not been placed on the barrels to protect the clean linen and that the barrels containing the washed clean linen were within the soiled laundry area. The facility's policy, titled 'Laundry and Bedding, Soiled,' dated September 2022, indicated that clean linen should be protected from dust and soiling during transport and storage and should be stored separately from soiled linens at all times.
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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