Westminster Village Kentuckiana
Inspection history, citations, penalties and survey trends for this long-term care facility in Clarksville, Indiana.
- Location
- 2210 Greentree N, Clarksville, Indiana 47129
- CMS Provider Number
- 155191
- Inspections on file
- 42
- Latest survey
- January 20, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Westminster Village Kentuckiana during CMS and state inspections, most recent first.
A resident with chronic pain and other conditions did not receive a prescribed narcotic pain medication after a pharmacy delivery was signed for by an LPN and reportedly handed off to another LPN. The medication was not found in the medication cart during subsequent counts, and staff interviews revealed confusion about its whereabouts. The LPN last in possession of the medication left her position and refused a drug screen, and the missing medication was reported to the DON for investigation.
A resident with chronic pain and other conditions received PRN oxycodone with acetaminophen from a QMA on multiple occasions without the required assessment or authorization from a licensed nurse, and without the nurse's co-signature on the controlled drug record, contrary to facility policy and QMA scope of practice.
A resident with a diagnosis of fibromyalgia received prescribed oxycodone with acetaminophen as needed for pain, but the administration of this narcotic was not consistently documented on the medication administration record (MAR) as required. Staff interviews and facility policy confirmed that all administered medications should be recorded on the MAR, but this was not done for multiple instances, resulting in incomplete medical records.
The facility failed to maintain a clean and sanitary kitchen, affecting all 59 residents receiving food. Rodent droppings and a rodent trap with a rodent were found in the kitchen and storage areas. The Dietary Manager admitted there was no cleaning schedule for January 2025, and the deep cleaning schedule for December 2024 was missing. A sanitization policy from 2008 was not being followed.
A facility failed to ensure timely availability of medications for a resident discharged with multiple health conditions, including heart failure and diabetes. Despite attempts to fax the medication list to the pharmacy, it was not received, and the family had to visit the facility to obtain medications. The facility's policy required a physician's order for sending medications home, which was not in place for this resident.
The facility failed to maintain a sanitary environment for two residents, as rodent droppings were found in their personal storage areas. A resident with diabetes, hypertension, and anemia reported believing the mouse problem was resolved, but droppings were found in his drawers. Another resident with hemiparesis, diabetes, and multiple sclerosis reported seeing a mouse, and droppings were also found in her drawers. Despite pest control services, the issue persisted.
The facility failed to maintain proper dishwasher temperatures, adhere to infection control practices during dining, and keep a resident snack refrigerator sanitary. The dishwasher's rinse temperature was consistently below the required 180 degrees, and a CNA did not wash her hands while serving meals. Additionally, the resident snack refrigerator contained undated and expired food items, contrary to facility policy.
The facility failed to keep heater vents clean in six resident rooms, with a black substance observed on the vents. A resident reported sneezing due to suspected black mold, but the Maintenance Supervisor identified it as dirt buildup. There was no cleaning schedule, and staff were unaware of the issue, relying on maintenance to address it when informed.
The facility failed to complete discharge MDS assessments for two residents who were discharged with no anticipated return. The MDS Coordinator acknowledged the oversight, which was contrary to the facility's policy requiring timely assessments by the Interdisciplinary Assessment Team.
A resident with a history of stroke and incontinence developed a skin impairment due to improper brief placement or incorrect sizing. Despite treatment, the wound persisted, and staff interviews revealed a lack of training on proper brief management. Facility policies emphasized skin protection, but there was no system for ensuring correct brief sizes.
An LPN failed to prime insulin kwikpens before administering doses to two residents, resulting in incorrect insulin administration. Resident 160 received an incorrect dose due to lack of priming, and Resident 56's high blood sugar was not properly addressed due to similar errors. The facility's DON was unaware of the priming requirement, contributing to the deficiency.
The facility failed to document meal consumptions for two residents as required by their care plans, with multiple instances of missing records across several months. This deficiency was confirmed by a CNA and related to a specific complaint, highlighting issues with adherence to documentation standards.
The facility failed to provide appropriate dinnerware for two residents, both diagnosed with left-sided hemiplegia and hemiparesis, who were served meals in styrofoam containers with plastic utensils. This made it difficult for them to eat, impacting their dignity and ability to exercise their rights.
The facility failed to complete quarterly smoking assessments for two residents as required by their care plans. Both residents had their last assessments in August 2023, with no documentation for November 2023. The Director of Nursing acknowledged the oversight, which was identified during a complaint investigation.
Failure to Prevent Misappropriation of Resident's Narcotic Medication
Penalty
Summary
The facility failed to prevent the misappropriation of a resident's property, specifically a narcotic pain medication prescribed for a resident with diagnoses including diabetes, depression, and chronic pain. The resident had a physician's order for Hydrocodone-Acetaminophen to be administered as needed. According to pharmacy records, a delivery of 30 tablets was made and signed for by an LPN, who reported handing the medication to another LPN responsible for the resident's medications. However, the medication was not found in the medication cart during subsequent counts, and staff interviews revealed confusion and lack of clarity regarding the medication's whereabouts. The LPN who was last reported to have received the medication left her position shortly after the incident and refused a drug screen when requested. Multiple staff members, including a QMA and several LPNs, were involved in the medication ordering, delivery, and counting process, but none could account for the missing medication. The narcotic count sheets and medication cards were reported as correct during one count, but the medication was still unaccounted for. The incident was reported to the Director of Nursing, and an investigation was initiated after it was discovered that the resident's narcotic pain medication had disappeared between the time of delivery and the next scheduled administration.
Failure to Obtain Nurse Assessment and Authorization for PRN Narcotic Administration
Penalty
Summary
A deficiency occurred when a resident with diagnoses including fibromyalgia, depression, and pain received as needed (PRN) narcotic pain medication, specifically oxycodone with acetaminophen, without the required assessment and authorization from a licensed nurse. The clinical record review showed that a Qualified Medication Aide (QMA) administered the PRN narcotic pain medication on multiple occasions, but there was no documentation of a licensed nurse assessment or co-signature on the controlled drug record for these administrations. Facility policy and the QMA Scope of Practice require that a licensed nurse assess the resident's need for PRN narcotic pain medication, provide authorization, and co-sign the medication administration record. Interviews confirmed that QMAs are expected to obtain permission from a licensed nurse and document this in the resident's record, including the nurse's co-signature by the end of the shift. However, these steps were not followed, as evidenced by the lack of assessment and authorization documentation for the resident who received the PRN narcotic pain medication.
Failure to Document Narcotic Administration on Medication Record
Penalty
Summary
The facility failed to ensure that a resident's medication administration record (MAR) accurately reflected the administration of a prescribed narcotic pain medication. Specifically, for a resident diagnosed with fibromyalgia and prescribed oxycodone with acetaminophen to be given every four hours as needed for pain, the August controlled drug record showed multiple instances where the medication was administered. However, the corresponding MAR lacked documentation of these administrations on the listed dates and times. Interviews with staff confirmed that when as-needed pain medication is given, it should be documented both on the controlled drug record and the MAR. The facility's own policy, provided by the Director of Nursing, requires that all medications administered be immediately documented on the MAR, including the signature and title of the person administering the medication. The failure to document the administration of the narcotic medication on the MAR constituted a deficiency in maintaining accurate and complete medical records in accordance with professional standards.
Facility Fails to Maintain Sanitary Kitchen Conditions
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen, which had the potential to affect all 59 residents receiving food from the kitchen. During an inspection, rodent droppings and jelly packets were found behind shelves in the dry storage area, and a rodent trap containing a rodent was observed under a shelf with large canned foods. Additionally, rodent droppings were found near the ice machine in the kitchen area. The Dietary Manager admitted there was no cleaning schedule for January 2025, as they were transitioning to a new system with more detailed forms, which had not yet been implemented. Furthermore, the deep cleaning schedule for December 2024 could not be located. The Executive Director provided a sanitization policy dated October 2008, which stated that food service areas should be clean and free from rodents, but this policy was not being followed.
Failure to Provide Timely Medication Upon Discharge
Penalty
Summary
The facility failed to ensure that a resident's medications were available in a timely manner upon discharge. Resident B, who had multiple diagnoses including congestive heart failure, acute respiratory failure with hypoxia, heart disease, diabetes, hypertension, and atrial fibrillation, was discharged to her home. The facility's progress notes indicated that the resident's medication orders were faxed to the pharmacy of choice. However, the complainant reported that the medication list was not sent to the pharmacy, and despite multiple attempts to fax the list, the pharmacy did not receive it. The family member had to visit the facility to obtain some medications that were still in stock. The Director of Nursing was unable to provide fax confirmation for the medication list being sent to the pharmacy. The facility's policy required a physician's order for medications to be sent home with Medicare residents, which Resident B did not have. The facility's policy also stated that medications would be sent with a discharged resident only under conditions that protect the resident and comply with the law. Despite these policies, the family was not provided with the necessary medications in a timely manner, leading to a deficiency in the discharge process.
Rodent Droppings Found in Residents' Drawers
Penalty
Summary
The facility failed to maintain a sanitary environment for two residents, identified as Resident F and Resident G, as evidenced by the presence of rodent droppings in their personal storage areas. Resident F, who has diagnoses including diabetes, hypertension, and anemia, reported that he believed the mouse problem had been resolved, although rodent droppings were found in multiple drawers of his nightstand and chest during an observation. Staff Member 7 confirmed that there had been a rodent issue for a couple of months and had previously cleaned and organized the residents' drawers. Resident G, with diagnoses including left dominant side hemiparesis, diabetes, and multiple sclerosis, also reported seeing a mouse in the bathroom, indicating an ongoing issue. Observations revealed rodent droppings in the drawers of Resident G's nightstand. Despite pest control services being provided on 11 occasions between November and January, the problem persisted, leading to the citation related to Complaint IN00449149.
Deficiencies in Dishwasher Temperatures, Infection Control, and Refrigerator Maintenance
Penalty
Summary
The facility failed to adhere to guidelines regarding dishwasher temperatures, infection control during dining, and maintaining a sanitary resident snack refrigerator. During an observation, the dishwasher's rinse temperature was found to be consistently below the required 180 degrees, with records showing this issue persisted throughout November. The Dietary Manager acknowledged the problem and indicated that the staff had been instructed to stop washing dishes until the issue was resolved. The facility's policy required dishwashing machine rinse temperatures to be at least 180 degrees, which was not met. In another observation, a CNA was seen handling food trays without washing or sanitizing her hands after touching various surfaces and adjusting her clothing. This occurred during meal service, where the CNA served multiple residents without adhering to proper hand hygiene practices. The facility's policy mandated that employees wash their hands after activities that could contaminate them, which was not followed in this instance. Additionally, the resident snack refrigerator contained several undated and expired food items, including a pumpkin pie and a pecan pie with use-by dates that had passed. The facility's policy required perishable foods to be discarded after three days, and the night shift staff were responsible for cleaning the refrigerators on specific days. However, this policy was not followed, as evidenced by the presence of outdated food items in the refrigerator.
Facility Fails to Maintain Cleanliness of Heater Vents in Resident Rooms
Penalty
Summary
The facility failed to maintain cleanliness in resident rooms, specifically regarding the heater vents in six of the 26 rooms reviewed. During a tour, a black spotty substance was observed covering the heater vents in rooms 105, 107, 111, 114, 115, and 120. A resident reported experiencing sneezing upon waking, attributing it to black mold on the heater vents. However, the Maintenance Supervisor later identified the substance as dirt buildup, not black mold. Despite this, there was no established cleaning schedule for the vents, and maintenance relied on staff to report when vents needed cleaning. Interviews with staff revealed a lack of awareness and responsibility regarding the cleanliness of the heater vents. A CNA stated that nursing staff did not clean the vents but would inform maintenance if cleaning was needed, although she was unaware of any vents requiring attention. Similarly, an RN indicated that staff could clean the vents if they noticed dirt, but they would also notify maintenance. The RN was not aware of the dirty vents. The Maintenance Director's job description emphasized maintaining the facility's physical environment, but the absence of a cleaning schedule contributed to the oversight.
Failure to Complete Discharge MDS Assessments for Two Residents
Penalty
Summary
The facility failed to complete discharge Minimum Data Set (MDS) assessments for two residents, identified as Residents 14 and 25, out of 19 MDS records reviewed. Resident 14 was admitted to the facility and discharged with no anticipated return on July 1, 2024, yet the MDS listings lacked a completed discharge assessment. Similarly, Resident 25 was admitted and discharged on the same date, also without a completed discharge assessment. During an interview, the MDS Coordinator acknowledged that discharge assessments for these residents had been missed and should have been completed. The facility's policy, titled 'Resident Assessment Instrument' and revised in September 2021, states that the Assessment Coordinator is responsible for ensuring timely resident assessments by the Interdisciplinary Assessment Team.
Improper Brief Management Leads to Resident Skin Impairment
Penalty
Summary
The facility failed to prevent a skin impairment for a resident who was reviewed for quality of care. The resident, who was cognitively intact, had a history of stroke, anemia, hemiplegia/hemiparesis, and depression, and was always incontinent of bowel and bladder. An open area was reported on the resident's upper right posterior thigh, which was attributed to trauma from the brief. The wound was initially noted by a CNA and measured 2.5 cm by 1.0 cm by 0.2 cm. A Wound MD classified the wound as non-pressure and initiated a treatment order. Despite the treatment, the wound persisted, and the care plan included interventions such as medication administration, physician contact as needed, and regular turning and repositioning. Interviews with staff revealed that the wound was believed to be caused by improper brief placement or incorrect sizing. The Infection Preventionist/Wound Nurse and the DON acknowledged the issue but indicated that staff had not been in-serviced on proper brief placement or sizing. CNAs reported that they were unsure about education on correct brief placements, and there was no list available for staff to reference the correct brief sizes for residents. The facility's policies on urinary continence and perineal care emphasized maintaining dignity, comfort, and skin protection, but the deficiency highlighted a gap in staff training and awareness regarding brief management.
Failure to Prime Insulin Kwikpens Leads to Dosage Errors
Penalty
Summary
The facility failed to ensure proper administration of insulin for two residents, leading to deficiencies in pharmaceutical services. During an observation, an LPN administered insulin to Resident 160 without priming the needle of the Humalog kwikpen, which is necessary to remove air and ensure the correct dose is delivered. The LPN initially administered 3 units of insulin when the resident's blood sugar reading required 4 units according to the physician's sliding scale order. The LPN then administered an additional unit without priming the needle again. The physician's order specified the insulin dosage based on blood sugar levels, but the LPN did not follow the correct procedure for priming, as outlined in the manufacturer's instructions. Similarly, for Resident 56, the LPN administered insulin without priming the needle. The resident's blood sugar reading was significantly high, and the LPN attempted to administer 12 units of insulin. However, the kwikpen only contained 5 units, which were administered without priming. The LPN then retrieved another kwikpen to administer the remaining 7 units, again without priming the needle. The facility's Director of Nursing incorrectly believed that priming was not necessary for the kwikpens, despite the manufacturer's instructions indicating otherwise. The facility's insulin administration policy required verification of the insulin type, dosage, and method of administration, but these procedures were not followed, leading to the deficiency.
Failure to Document Meal Consumptions for Residents
Penalty
Summary
The facility failed to document meal consumptions for two residents, Resident B and Resident C, as required by their care plans. Resident B's clinical record review revealed multiple instances in August and September 2024 where meal consumptions were not documented. Specifically, there were missing records for various meals, including breakfast, lunch, and dinner on several dates. This lack of documentation was confirmed during an interview with a CNA, who stated that all resident meals should be documented in the system. Similarly, Resident C's clinical record review showed numerous undocumented meal consumptions across August, September, and October 2024. The resident's care plan required setup assistance with meals and documentation of the percentage eaten, but this was not consistently followed. The missing documentation spanned multiple meals and dates, indicating a pattern of non-compliance with the care plan requirements. The facility's failure to document meal consumptions was further highlighted by the provision of two documents by the Director of Nursing and the Infection Preventionist. These documents outlined the protocol for documenting dietary intake and preparing residents for meals, emphasizing the importance of maintaining accurate records. The deficiency was related to a specific complaint, indicating a broader issue with the facility's adherence to documentation standards.
Failure to Provide Appropriate Dinnerware for Residents
Penalty
Summary
The facility failed to ensure that residents were served meals on appropriate dinnerware, impacting their dignity and ability to eat comfortably. Resident B, diagnosed with left-sided hemiplegia and hemiparesis, was observed eating from a styrofoam container with plastic utensils, which made it difficult for her to cut food due to her condition. She expressed that she had been receiving meals in this manner for over a year and found it challenging to eat with the provided utensils. The Assistant Dietary Manager and the Executive Director confirmed that the use of styrofoam and plastic utensils was due to a supply issue after their contracted company left, taking the dishware with them. They were waiting on new supplies, including plate warmers and tray carts, which had been delayed due to other expenditures and supply chain issues. Similarly, Resident C, also diagnosed with left-sided hemiplegia and hemiparesis, was observed with styrofoam meal containers on his bedside table. He reported difficulties eating from the high-edged containers. The facility's meal service policy indicated that disposable dining dishes and flatware should only be used during emergency meal service, which was not the case here. The Executive Director provided a document outlining resident rights, which included the right to a dignified existence and dignity, highlighting the facility's failure to uphold these rights in meal service. This deficiency was related to Complaint IN00428146.
Failure to Complete Quarterly Smoking Assessments
Penalty
Summary
The facility failed to ensure quarterly smoking assessments were completed for two residents, Resident B and Resident C, as required by their care plans. Resident B, diagnosed with left-sided hemiplegia, hemiparesis, bipolar disorder, and major depressive disorder, had a care plan indicating the need for quarterly smoking assessments. However, the last assessment was completed in August 2023, and there was no documentation of a quarterly assessment for November 2023. The Director of Nursing acknowledged that the smoking assessments were not included when the quarterly assessments were set up in the new system, despite the facility policy requiring them to be completed quarterly. Similarly, Resident C, diagnosed with left-sided hemiplegia, hemiparesis, and dementia, also had a care plan indicating the need for quarterly smoking assessments. The last assessment for Resident C was also completed in August 2023, with no documentation for November 2023. The Director of Nursing provided a copy of the facility's smoking policy, which stated that residents' ability to smoke safely should be re-evaluated quarterly. This deficiency was identified during a complaint investigation.
Latest citations in Indiana
Surveyors observed that dietary staff repeatedly worked in kitchen and meal service areas with uncovered facial hair, despite facility policy and state sanitation requirements mandating effective hair restraints. Two dietary aides with short beards or mustaches were seen walking through food preparation areas, taking food temperatures, handling food, and plating meals at steamtables in dining rooms without any facial hair coverings, while the current policy required all hair, including facial hair, to be restrained to prevent contamination.
The facility failed to consistently provide and document required bed-hold policy notices when several residents were transferred to the hospital. In multiple cases, residents with dementia, psychotic disorders, COPD, chronic respiratory failure, altered mental status, and cerebral infarction were sent out for acute changes in condition, and while transfer notes reflected physician and family notifications, they lacked documentation that the bed-hold policy was discussed with the resident or responsible party. Notices of Transfer or Discharge often indicated a copy of the bed-hold policy was sent with the resident, but the records did not show signed and dated acknowledgment by the resident or appropriate representative, including in situations where a resident had moderate cognitive impairment, short-term memory issues, or a documented need for a proxy and a financial POA authorizing an agent for health care decisions.
Surveyors found that the facility failed to provide trauma‑informed and culturally competent care by not incorporating two residents’ extensive trauma histories and specific behavioral triggers into their care plans. One resident with documented homelessness, polysubstance abuse, severe accidents with multiple fractures, viral encephalitis with coma, physical and sexual abuse, loss of family contact, and a past suicide attempt had multiple behavior‑focused care plans that referenced identifying triggers but listed none and did not mention their physical, sexual, medical, or psychosocial trauma. Another resident with TBI from being struck by a truck, an 11‑month coma, long‑term state hospital residence, alleged shooting of a parent, and diagnoses including intermittent explosive disorder and borderline personality disorder had a PASRR identifying a specific trigger and notes of inappropriate sexual behavior, yet their care plans omitted these traumatic events, the identified trigger, and the sexual behavior. Staff interviews confirmed that residents were screened for trauma, but the trauma histories and triggers were not reflected in the individualized plans of care.
A resident with schizophrenia, post‑stroke hemiparesis, and mild cognitive impairment expressed feeling down and wanting to kill himself, but staff did not document asking about a specific plan, did not notify the physician or psychiatric NP as expected, and did not develop or update a care plan addressing depression or suicidal ideation. The SSD documented offering support and initiating 15‑minute checks once, but there was no further follow‑up or documentation of interventions after subsequent suicidal statements made in a care plan meeting with the resident’s father. The DON and Administrator reported that facility policy requires immediate notification of key staff, assessment for a plan and means of self‑harm, and thorough documentation, which were not carried out or reflected in the medical record for this resident.
A resident with schizophrenia, post-stroke hemiparesis, and mild cognitive impairment verbalized suicidal ideation, but the care plan did not address depression or suicidal thoughts, and required assessments and services were not accurately or timely documented. An SSD note recorded the resident saying he wanted to kill himself and referenced 15‑minute checks and a care plan update, yet the active care plan lacked depression/suicidal ideation interventions. Multiple late-entry Social Services notes were later added, describing follow-up visits and the resident denying suicidal ideation, but the SSD later reported she did not typically ask about a suicide plan and did not personally provide individual follow-up visits as described. These practices conflicted with the facility’s policy requiring factual, first-hand, and timely documentation of assessments and services.
A resident was observed with an Albuterol inhaler on an overbed table and later reported keeping the inhaler in a nightstand drawer, with no staff present during these observations. Record review showed the resident had no cognitive impairment on the admission MDS but lacked any documented self-medication administration assessment. The DON acknowledged that the required assessment had not been completed, despite facility policy requiring staff and the practitioner to evaluate each resident’s mental and physical abilities before allowing self-administration of medications.
Surveyors found that the facility submitted inaccurate direct care staffing data to CMS through the PBJ system over multiple days in a quarter. CASPER reports showed apparent gaps in 24-hour licensed nurse coverage, low weekend staffing, and a 1-star staffing rating, while internal staffing sheets documented that licensed nurses were present and the facility was fully staffed on those days. The Administrator reported that the discrepancies were due to PBJ data entry errors, despite a facility policy requiring all PBJ entries to be accurate, auditable, and verifiable against payroll, invoices, or contracts.
Surveyors found that the facility did not provide or document required written transfer/discharge notices and bed-hold policy information for four residents who were sent to the hospital, including individuals with conditions such as dementia, CHF, chronic respiratory failure, and CKD. In each case, progress notes showed that the resident was transferred for acute issues, but the clinical records lacked evidence that written notices were given to the residents or their representatives, and in one case lacked documentation that required information was sent to the receiving provider. Facility leadership, including the ADON, DON, and Administrator, acknowledged that the records did not contain the required documentation, despite a written policy requiring such notices and information exchange.
A resident with Alzheimer’s disease and depression, previously on an antidepressant, exhibited intermittent refusals of medications and care, occasional yelling at staff, and reports of unusual perceptions, such as believing men were in or near her room. Nursing notes over several months documented these refusals and complaints but did not show that the behaviors were evaluated or recorded as dangerous, non-redirectable, or causing significant distress, nor did they document specific non-pharmacological interventions attempted or their outcomes. Despite this, a psychiatric NP later added new diagnoses of schizoaffective disorder, borderline personality disorder, and delusional disorder and ordered an antipsychotic (Seroquel) without a comprehensive evaluation in the record to support these diagnoses. The facility’s psychotropic medication policy, which requires identification and documentation of target behaviors, use of nonpharmacological interventions, and ongoing behavior monitoring, was not followed for this resident.
The facility failed to keep PASARR Level I screenings accurate and current for three residents when new mental health diagnoses and psychoactive medications were initiated. One resident’s PASARR omitted a PTSD diagnosis and an added antidepressant, despite documentation of PTSD on the MDS and care plan and a physician order for Pristiq. Another resident’s PASARR listed only depression and dementia, even after additional diagnoses such as borderline personality disorder, delusional disorder, and schizoaffective disorder were added and an antipsychotic (quetiapine) was ordered, with the MDS later reflecting psychotic disorder, schizophrenia, and depression with antipsychotic and antidepressant use. A third resident’s PASARR did not include a depression diagnosis or newly ordered escitalopram and lorazepam, although the admission MDS documented depression with antianxiety and antidepressant use. These omissions occurred despite facility policy requiring a new Level I review after significant mental status changes, including new mental health diagnoses or new psychotropic medications.
Uncovered Facial Hair During Food Preparation and Meal Service
Penalty
Summary
The deficiency involves the facility’s failure to ensure that food was served in a sanitary and safe manner in accordance with professional standards and facility policy during multiple kitchen and meal service observations. During an initial kitchen observation, two dietary aides were seen walking through the kitchen food preparation area with uncovered facial hair. One aide had facial hair above and below the lip and along the jaw line, approximately one-fourth inch in length, and the other had a mustache of similar length; neither used any facial hair covering. These observations occurred while staff were present in the kitchen area where food was stored and prepared. During subsequent observations on the same day, the same two dietary aides were again observed with uncovered facial hair while directly involved in meal preparation and service. One aide walked through the kitchen while the noon meal was being prepared and placed into a transport cart for service in the south dining room, and later was observed plating the noon meal at the steamtable in that dining room, still without a facial hair covering. The other aide walked through the kitchen while the noon meal was being prepared and placed into the steamtable for the north dining room, took food temperatures, assisted with plating meals at the steamtable, and retrieved food items and supplies from the kitchen, all while having an uncovered mustache approximately one-fourth inch in length. The Dietary Manager stated that staff hair was to be covered when in the kitchen and during meal service, and the facility’s written policy and the cited Indiana Food Establishment Sanitation Requirements both required effective hair restraints, including for facial hair, to prevent contamination of food, equipment, and utensils.
Failure to Provide and Document Bed-Hold Policy at Time of Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure that required bed-hold policy information was provided and documented for four residents transferred to the hospital. For a resident with dementia, psychotic disorder, and autistic disorder who had a BIMS score of 0 indicating severe cognitive impairment, progress notes documented physician notification and guardian notification when the resident was sent to the hospital, but there was no documentation that the bed-hold policy was provided to the responsible party. A Notice of Transfer or Discharge later indicated a copy of the bed-hold policy was sent with the resident. Another resident with COPD and chronic respiratory failure, cognitively intact with a BIMS score of 13, experienced a decline in condition and was transferred to the hospital by ambulance; progress notes documented family notification but did not document any discussion of the bed-hold policy, although a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident. A third resident with altered mental status and cerebral infarction, with a BIMS score of 10 indicating moderate cognitive impairment and documented short-term memory impairment, experienced changes in condition and was transferred to the hospital. Progress notes stated the resident was their own responsible party and that no other notification was completed, and transfer documentation did not include the bed-hold policy, although an untimed Notice of Transfer or Discharge indicated a copy of the bed-hold policy was signed by the resident. A financial power of attorney document in the record showed the resident had designated an agent to act in consent or refusal of health care. For a fourth resident with dementia and osteomyelitis, transfer documentation and a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident, and the transfer form noted the resident required a proxy for decision making. The facility’s policy required that at the time of transfer to a hospital, written notice specifying the duration of the bed-hold policy and information on return to the next available bed be provided, and that a signed and dated copy of the bed-hold notice given to the resident or representative be kept in the resident file, which was not consistently documented for these residents.
Failure to Integrate Trauma Histories and Behavioral Triggers Into Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to identify and incorporate residents’ trauma histories and specific behavioral triggers into their care plans, despite documented histories of significant trauma and behavioral health issues. For one resident, extensive social service and progress notes documented homelessness, polysubstance abuse, major depressive and anxiety disorders, chronic pain, a history of severe car accidents with multiple fractures, viral encephalitis resulting in a three‑month coma, loss of child custody, multiple divorces, physical abuse by a spouse, the death of a fiancé who was struck by a car while in a wheelchair, lack of family contact, and a past suicide attempt by Valium overdose. Additional documentation noted a history of rape by a brother at age eight and prior placement under direct supervision and 15‑minute checks related to suicidal ideation. Despite these documented traumatic events and behavioral health concerns, the resident’s care plans did not identify a history of physical trauma, sexual trauma, homelessness, substance abuse, medical trauma, or attempted suicide. For this same resident, the MDS showed no cognitive deficit and identified behaviors such as verbal aggression and rejection of care, along with diagnoses including seizure disorder, depression, chronic pain syndrome, homelessness, and anxiety disorder. Multiple care plans addressed behaviors such as drug‑seeking, pretending to have seizures for attention or medication, making false allegations, verbal aggression when unable to smoke, and a desire for intimate relationships with consenting male residents. These care plans referenced goals such as effective coping skills, seeking staff support, and compliance with the smoking policy, and they called for identification and reduction of behavioral triggers. However, none of these care plans actually listed any specific triggers. The care plan addressing the resident’s right to consensual intimate relationships focused on assessment and education regarding consent but did not integrate the resident’s extensive trauma history. Staff interviews indicated the resident had displayed sexual behaviors since admission, including an incident where the resident expressed anger at another resident for not buying a soda after engaging in sexual acts. A second resident with a documented history of traumatic brain injury (TBI), dementia, seizure disorder, borderline personality disorder, anxiety, intermittent explosive disorder, tobacco use, and other behavioral/emotional disorders was also affected by the same deficiency. Social history and progress notes documented that this resident sustained a TBI after being hit by a semi‑truck while riding a bicycle at age 18, resulting in an 11‑month coma, followed by 13 years in a state hospital and subsequent residence in a group home. Additional documentation indicated the resident allegedly shot their father at age 26 after being sworn at and had a PASRR identifying TBI, intermittent explosive disorder, and borderline personality disorder, with a specific trigger of hearing the name of the current U.S. President. Progress notes also described inappropriate sexual behavior toward staff, including touching themselves intimately during personal care and refusing to stop when redirected. Despite this, the resident’s care plans, which addressed explosive disorder and history of altercations, risk for decreased psychosocial well‑being, and refusal to bathe or shower, did not list any specific behavioral triggers, did not reference the traumatic events such as being hit by a truck or shooting their father, and did not document the inappropriate sexual behavior. The Administrator and Social Service Director acknowledged that residents were to be screened for trauma and that trauma responses and PTSD should be added to care plans, but the specific trauma histories and triggers for these two residents were not incorporated into their plans of care.
Failure to Assess and Care Plan for Resident Suicidal Ideation
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess, investigate, and care plan for a resident’s suicidal ideation in accordance with its own policy and staff expectations. The resident had diagnoses including schizophrenia, cerebral edema, and hemiparesis/hemiplegia following a cerebral infarction, and a current MDS showed mild cognitive impairment (BIMS score 12). A progress note documented that the resident told the Social Services Director (SSD) he was feeling down and wanted to kill himself; the SSD offered assistance, activities, and initiated 15‑minute checks, and the note stated the care plan was updated. However, the note did not indicate that the SSD asked whether the resident had a plan to kill himself, and there were no additional notes regarding suicidal ideation or follow‑up. Review of the current care plan showed no problem, goal, or interventions addressing depression or suicidal ideation, and progress notes over the following month contained no documentation of physician notification related to the suicidal statement. Further record and interview evidence showed that the care plan conference summary did not document interventions for suicidal ideation, and the SSD acknowledged she did not normally ask residents expressing suicidal ideation if they had a plan. The SSD reported that the resident had admission paperwork mentioning suicidal ideation related to depression after a stroke and that the resident again vocalized suicidal ideation during a care plan meeting with his father, after which emotional support was offered and the father took the resident out on a leave of absence; no further visits or follow‑up were done. The DON stated that, upon notification of suicidal verbalization, staff should assess the resident, ask if there is a plan, remove potential means of self‑harm, immediately notify the psychiatric NP, and document the occurrence, and that a detailed progress note and updated care plan were expected but not present for this resident. The Administrator similarly stated that staff should ask about a plan, document interventions, notify the physician and family, and update the care plan, and indicated the resident should have had a care plan addressing depression with suicidal ideation. The facility’s written policy required immediate notification of the DON, SSD, and physician, an interview including asking about a plan and assessing mood and means for self‑harm, and thorough documentation of mood, behavior, and all actions taken, which were not reflected in the resident’s record.
Incomplete and Inaccurate Documentation of Suicidal Ideation and Follow-Up
Penalty
Summary
The facility failed to ensure accurate, complete, and timely documentation of assessments and services for a resident who verbalized suicidal ideation. Resident 6, who had schizophrenia, cerebral edema, and right-sided hemiparesis/hemiplegia following a cerebral infarction, had a BIMS score of 12 indicating mild cognitive impairment. The resident’s admission paperwork mentioned suicidal ideation related to depression after a stroke, and a Social Services note on 3/11/2026 documented that the resident was feeling down and said he wanted to kill himself. The Social Services Director (SSD) documented that she talked with the resident, coordinated with Activities, advised the resident to contact SSD or nursing if he wanted to talk, and that the resident was scheduled for 15-minute checks and the care plan was updated. However, the current care plan initiated on 2/26/2026 did not address depression or suicidal ideation. Multiple Social Services progress notes were later entered as late entries in April, with effective dates in March, stating that the resident had no plan and no longer had suicidal ideation, that he felt much better after 1:1 time, and that he continued his daily routine and therapy. These late entries described follow-up visits and reassessments of suicidal ideation on several consecutive days, but in interviews the SSD stated she did not normally ask residents about having a plan when they verbalized suicidal ideation and did not recall any other occurrences beyond the initial event. She further indicated she did not personally provide individual follow-up visits with this resident regarding suicidal ideation, despite the late-entry notes describing such visits. The DON acknowledged that late entries had been added to address concern about suicidal verbalization, and the Administrator stated that upon suicidal statements staff should ask about a plan, notify the physician and family, and update the care plan, and that this resident should have had a care plan addressing depression with suicidal ideation. The facility’s documentation policy required factual, first-hand, timely documentation, which was not followed in this case.
Failure to Complete Required Self-Administration Assessment for Inhaler Kept at Bedside
Penalty
Summary
Surveyors identified that a resident was allowed to keep and access an Albuterol inhaler without the facility completing the required self-administration medication assessment. During an initial tour, the resident was observed sitting in a wheelchair with a handheld Albuterol inhaler on the overbed table and no staff present in the room or hallway. On a subsequent observation, the resident again was in a wheelchair and reported that the Albuterol inhaler was stored in the top drawer of the nightstand, where it was found. Review of the clinical record showed an admission MDS indicating no cognitive impairment, but there was no documentation of a self-medication administration assessment. In an interview, the DON confirmed that the resident did not have the required self-medication assessment, despite the facility’s policy stating that staff and the practitioner must assess each resident’s mental and physical abilities to determine whether self-administering medications is clinically appropriate. This failure to complete and document a self-administration medication assessment for a resident who had an Albuterol inhaler kept at bedside constituted noncompliance with the facility’s own policy and with 410 IAC 16.2-3.1-11(a).
Inaccurate PBJ Staffing Data Submission to CMS
Penalty
Summary
The deficiency involves the facility’s failure to electronically submit complete and accurate direct care staffing information to CMS through the Payroll-Based Journal (PBJ) system for 22 days in a fiscal quarter. A CASPER report review on 4/6/26 showed that, according to PBJ data, the facility did not have licensed nursing coverage 24 hours per day on multiple specific dates across three months, had low weekend staffing, and held a 1-star staffing rating. However, review of the facility’s internal staffing sheets for that quarter indicated the facility was fully staffed and had licensed nurse coverage on all of the dates in question. During an interview, the Administrator stated that the PBJ information must have contained data entry errors, as she had verified licensed staff coverage on the timesheets. The facility’s PBJ policy in effect stated that all staffing data entered into the PBJ system would be auditable and verifiable through payroll, invoices, or contracts, but the submitted PBJ data did not accurately reflect the facility’s actual licensed nurse staffing as documented on internal records. No specific residents or clinical conditions were mentioned in the report, and the deficiency centers solely on inaccurate staffing data submission rather than direct resident care events.
Failure to Provide and Document Required Transfer/Discharge and Bed-Hold Notices
Penalty
Summary
The deficiency involves the facility’s failure to provide and document required written notices of transfer/discharge and bed-hold policies, as well as required information to receiving providers, for four residents who were transferred or discharged to the hospital. For a resident with generalized anxiety disorder, major depressive disorder, and dementia, progress notes showed that the resident was sent to the hospital via 911 for chest pain, lower back pain, and shortness of breath and later returned to the facility, but the clinical record lacked documentation that a written Notice of Transfer/Discharge and the bed-hold policy were provided to the resident or representative, and lacked documentation that required information was conveyed to the receiving facility. The ADON and the Administrator both confirmed there was no documentation that these written notices were provided. For a resident with congestive heart failure and muscle weakness who was sent to the emergency room for painful urination and bloody urine, the clinical record lacked documentation that a Notice of Transfer/Discharge or bed-hold policy was given to the resident or representative, which the DON confirmed. Another resident with chronic respiratory failure and diabetes was discharged to the hospital for respiratory failure, and a resident with chronic kidney disease and dementia was discharged to the hospital, but in both cases there was no documentation that a written notice of transfer/discharge or bed-hold policy was provided to the residents or their representatives. Review of the facility’s Transfer and Discharge policy, dated 1/15/26, showed that the policy required the facility to provide written transfer/discharge notices and bed-hold information to residents and representatives and to provide specified information to receiving providers, but the records for these four residents did not contain the required documentation.
Failure to Document Target Behaviors and Non-Pharmacological Interventions Before Initiating Antipsychotic
Penalty
Summary
The deficiency involves the facility’s failure to document how a resident’s behaviors presented danger or distress to self or others, and failure to document non-pharmacological interventions attempted prior to initiating an antipsychotic medication. Resident 6 had documented diagnoses of Alzheimer’s disease, depression, and severe cognitive impairment, and was receiving sertraline for depression. A PASSAR identified only depression and dementia, and the admission MDS listed Alzheimer’s disease and depression as active diagnoses. Over several months, nursing progress notes documented that the resident intermittently reported unusual perceptions, such as believing there were men causing trouble, a man in her room, or a man wanting to marry her and yelling through the walls, but there was no documentation that these episodes caused danger to the resident or others or that they resulted in unmanageable distress. From late April through mid-July, nursing notes primarily described the resident’s frequent refusals of evening and morning medications, blood sugar checks, blood pressure checks, insulin administration, hygiene care, and showers. Staff documented that the resident sometimes yelled at staff, said “Get out!”, was visibly upset by a room move, was leery of staff and asked to see name badges, and became upset about a pillow under her head until it was removed, after which she calmed down. The notes also recorded instances where the resident believed housekeeping had not cleaned her room or that she had not received medications when she had. However, there were no progress notes or assessments indicating that these behaviors were evaluated as dangerous, non-redirectable, or causing significant distress or functional impairment, and no detailed behavior monitoring logs were present as required by facility policy. On a psychiatric NP visit for initial psychotropic medication management, new mental health diagnoses of schizoaffective disorder, borderline personality disorder, and delusional disorder were added, and Seroquel 25 mg, an antipsychotic, was ordered. The clinical record did not contain a comprehensive evaluation to support these new diagnoses, and there was no documentation of target behaviors meeting the facility’s policy criteria for psychotropic use, such as behaviors representing danger to self or others, causing distress and impairment in functional abilities, or clearly attributable to psychosis or mania. The resident’s representative reported that the resident had no prior history of mental health disorders or psychiatric hospitalization and was unaware of the new diagnoses. The facility’s own psychotropic medication policy required identification and documentation of specific target behaviors, use and documentation of nonpharmacological interventions, and ongoing monitoring of behaviors and interventions, which were not reflected in the record for this resident.
Failure to Update PASARR Screens for New Mental Health Diagnoses and Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that Preadmission Screening and Resident Review (PASARR) Level I screenings were accurate and updated when new mental health diagnoses and psychoactive medications were initiated for multiple residents. For one resident with dementia, anxiety, depression, and post-traumatic stress disorder (PTSD), the PASARR completed on admission listed anxiety, depression, and dementia with sertraline and quetiapine, but did not include the PTSD diagnosis or the antidepressant Pristiq, despite the admission MDS and care plan documenting PTSD and a subsequent physician’s order for Pristiq. For another resident with Alzheimer’s disease, borderline personality disorder, delusional disorder, schizoaffective disorder, and depression, the PASARR only reflected depression and dementia with sertraline, even though additional mental health diagnoses were added later and an antipsychotic (quetiapine) was ordered for borderline personality disorder, and the quarterly MDS documented psychotic disorder, schizophrenia, and depression with antipsychotic and antidepressant use. A third resident had diagnoses including Alzheimer’s disease, depression, anxiety disorder, irritability and anger, and nonrheumatic aortic valve stenosis. The PASARR for this resident listed dementia and anxiety with Risperdal but omitted the diagnosis of depression and the medications escitalopram and lorazepam, although physician’s orders were in place for escitalopram for depression and lorazepam for anxiety, and the admission MDS documented depression with antianxiety and antidepressant use. Interviews with the Assistant Director of Nursing confirmed that new Level I PASARR screens should have been completed when new mental health diagnoses and psychoactive medications were added, and that the PASARR for one resident, completed prior to arrival, should have included all mental health diagnoses and medications. The facility’s own policy required notification of the state mental health authority within 14 days after a significant change in mental condition and specified that a new Level I screen is required for new mental health diagnoses or newly prescribed psychotropic medications, which was not followed in these cases.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
