Willows Of Richmond
Inspection history, citations, penalties and survey trends for this long-term care facility in Richmond, Indiana.
- Location
- 2070 Chester Blvd, Richmond, Indiana 47374
- CMS Provider Number
- 155228
- Inspections on file
- 23
- Latest survey
- October 15, 2025
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Willows Of Richmond during CMS and state inspections, most recent first.
A resident with cognitive intactness and hemiplegia reported a lost cell phone to staff, but no grievance form was completed or forwarded to the grievance official as required by policy. The resident received no follow-up and had to use the nurse's station phone, despite her care plan noting the importance of phone communication. Staff interviews confirmed the grievance process was not followed.
Surveyors identified unsanitary conditions in the kitchen, including a black substance along the dish sink area and significant ice buildup throughout the walk-in freezer. The Dietary Manager was aware of these issues but had not yet addressed them, and the Director of Maintenance was unaware until notified during the survey. These deficiencies affected the environment where food was prepared and stored for nearly all residents.
A resident with dementia and protein-calorie malnutrition, who required assistance with ADLs and was unable to obtain fluids independently, was repeatedly observed without water or fluids at the bedside. Despite care plan interventions and facility policy requiring fluid availability and encouragement, staff did not ensure fluids were accessible, as confirmed by the DON.
A resident with dementia and protein-calorie malnutrition, who was assessed as needing assistance with eating, was repeatedly left alone during meals without staff support. Observations showed the resident either sleeping with a full tray, confused about how to use utensils, or struggling to feed herself, despite care plans and assessments indicating the need for one-person assistance.
A resident with a documented acetaminophen allergy was administered the medication multiple times after admission, despite clear hospital discharge records and verbal reports from the resident and her family. The allergy was not added to the care plan until months later, and staff interviews confirmed that the allergy was not recognized or addressed as required by facility policy.
A resident with CHF and COPD was found to have an oxygen concentrator at the bedside and reported using oxygen at night, but there was no physician order for oxygen therapy. The DON confirmed the oxygen may have been started during a CHF episode and was not discontinued, contrary to facility policy requiring a physician's order for oxygen administration.
A resident did not receive their prescribed Xanax medication upon returning from the hospital due to a transcription error. The facility failed to resume the medication as ordered, despite hospital discharge instructions. The resident, with a history of seizures and Xanax usage, experienced a possible seizure and change in mental status, leading to another hospitalization. The facility's policy for verifying medication orders was not properly followed.
The facility failed to accurately document meal intakes and oral hygiene for three residents. Meal records showed multiple instances of undocumented or incorrectly marked meals, while oral care documentation was inconsistent. Interviews revealed confusion in the EHR system, contributing to these deficiencies.
The facility failed to accurately encode various aspects of the MDS for five residents, leading to discrepancies in their medical records. Errors included incorrect smoking status, GDR contraindication dates, life expectancy, discharge planning, and use of a BiPap machine. The MDS Coordinator acknowledged these errors and indicated plans to modify the assessments accordingly.
The facility failed to timely complete and transmit an entry tracking record for a resident admitted with cerebrovascular disease. The MDS Coordinator confirmed the record was not completed and would be late, contrary to the facility's policy requiring submission within 7 days.
The facility failed to develop and implement care plans for three residents with specific medical needs, including the use of a bipap machine, insulin for diabetes, anticonvulsant medication for seizures, and pain management. The deficiencies were confirmed by the MDS Coordinator and the Administrator.
The facility failed to assess and document bruising on a resident's forearms, despite the resident being on medication that increases bruising risk and having no prior skin issues. The bruising was observed on 4/15/24, but no documentation or assessment was made until 4/18/24, contrary to the facility's Skin Management policy.
A facility failed to implement a physician's order for a resident's left hand contracture. The resident, with multiple diagnoses including dementia and heart failure, was observed multiple times without the prescribed splint/carrot. The care plan required the carrot to be worn for 4-6 hours daily, but it was not consistently applied, and staff were unable to locate it in the resident's room.
Failure to Forward and Address Resident Grievance Regarding Lost Personal Item
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident's grievance regarding a lost cell phone was properly forwarded to the grievance official and addressed according to policy. The resident, who was cognitively intact and had diagnoses including hypertension and flaccid hemiplegia, reported to nursing staff that her cell phone had been missing for a couple of months. Despite informing staff, the resident did not receive any follow-up regarding the lost item and had to use the nurse's station phone to make or receive calls. The resident's care plan indicated that she enjoyed talking with her family on the phone, highlighting the importance of the missing item to her daily life. Interviews with staff revealed that a CNA was aware of the missing phone and verbally informed the Social Service Director (SSD), but no grievance form was completed or forwarded as required by facility policy. The SSD could not recall being told about the missing phone and confirmed that no grievance form was filled out. The facility's grievance policy specified that staff receiving a grievance must document it on a designated form and forward it to the grievance official, who is responsible for tracking and resolving grievances. This process was not followed in the case of the resident's lost cell phone.
Sanitation Deficiencies in Kitchen and Walk-In Freezer
Penalty
Summary
The facility failed to maintain the kitchen in a sanitary condition, as evidenced by the presence of a black substance along the dish sink area beside the dishwasher and underneath the soap dispenser. This substance had been present for approximately two weeks, and the Dietary Manager was aware of it but had not yet arranged for cleaning or re-caulking, instead waiting for maintenance to address the issue. The Director of Maintenance was unaware of the problem until it was pointed out and acknowledged that the area needed to be bleached and re-caulked. Additionally, the walk-in freezer was observed to have significant ice buildup on the ceiling, walls, fans, floor, bags of food, and door handle. The Dietary Manager explained that a recently repaired fan had previously allowed water condensation to accumulate, which then froze after the repair. The ice on the floor created a slick surface, and the Dietary Manager expressed concern about safely entering the freezer. The Director of Maintenance was also unaware of the ice buildup and stated that a plan was needed to remove all items from the freezer to allow it to thaw. The facility's sanitation inspection policy required daily and weekly inspections of food service areas, including the freezer and pot wash areas.
Failure to Ensure Bedside Fluid Availability for Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure the availability of fluids at the bedside for a resident with diagnoses including dementia and protein-calorie malnutrition. Multiple observations over several days revealed that the resident, who was severely cognitively impaired and required assistance with activities of daily living, did not have water or fluids accessible at the bedside. On several occasions, the resident was observed lying in bed without any fluids available, and at one point, only an empty cup was present. The resident's care plan specifically indicated the need for staff to encourage fluid consumption and ensure fluid availability at the bedside due to the resident's risk for altered nutrition and inability to initiate fluid intake independently. The facility's hydration policy also required that beverages be available and within reach of residents. During an interview, the DON confirmed that staff were expected to offer fluids to the resident whenever entering the room, acknowledging that the resident could not obtain fluids on her own.
Failure to Assist Resident with Eating
Penalty
Summary
The facility failed to provide necessary assistance with eating for a resident who was unable to perform this activity independently. The resident, who had diagnoses including dementia and protein-calorie malnutrition, was observed on multiple occasions lying in bed with a full lunch tray in front of her, either sleeping or appearing confused and unable to use eating utensils properly. No staff were present to assist her during these times. On another occasion, the resident was seen attempting to feed herself but had difficulty getting food onto her utensils, missed her mouth, and dropped food onto herself. Clinical documentation indicated that the resident was severely cognitively impaired and required partial to moderate assistance with eating, as well as cueing at meals. The care plan specified that she needed one-person assistance with eating and should be up out of bed for all meals. Despite these documented needs, staff failed to provide the required assistance, leaving the resident without support during mealtimes.
Failure to Address Documented Medication Allergy
Penalty
Summary
A resident with a diagnosis including congestive heart failure was admitted to the facility with a documented allergy to acetaminophen (Tylenol), as noted in her hospital discharge records. Despite this, the facility's physician orders included acetaminophen for general discomfort, and the medication was administered to the resident on multiple occasions over a two-month period. The allergy was not added to the resident's care plan until several months after her admission, even though both the resident and her daughter had informed staff of the allergy, and the hospital discharge documentation clearly indicated it. Interviews with the Director of Nursing (DON) revealed that staff failed to recognize and address the documented acetaminophen allergy upon the resident's return from the hospital. The DON acknowledged that the allergy should have been documented and addressed earlier, especially after the resident reported her inability to take acetaminophen during a care plan meeting. The facility's Medication Administration policy required verification of allergies before administering medications, but this protocol was not followed in this case.
Oxygen Therapy Provided Without Physician Order
Penalty
Summary
A resident with diagnoses including congestive heart failure and chronic obstructive pulmonary disease (COPD) was observed with an oxygen concentrator at the bedside and reported using oxygen at bedtime. Multiple observations confirmed the ongoing presence of the oxygen equipment in the resident's room. Review of the clinical record and order summary revealed that there was no physician's order for oxygen therapy for this resident at the time of the observations. The resident's care plan identified a risk for shortness of breath and included an intervention to administer oxygen per physician's order. However, the DON confirmed that the oxygen may have been initiated as a nursing measure during a CHF flare-up and was not discontinued or removed when no longer needed. Facility policy required that oxygen be administered only under a physician's order, which was not followed in this case.
Medication Error: Failure to Administer Xanax as Prescribed
Penalty
Summary
The facility failed to ensure that a resident received their prescribed medication, Xanax, as ordered by the physician. The resident was admitted with a 7-day order for Xanax 2 mg twice daily, which was not properly resumed upon their return from the hospital. Despite hospital discharge instructions indicating the continuation of Xanax, the medication was not restarted due to a prior stop date. The medication administration record (MAR) did not reflect the administration of Xanax after the resident's return, and the facility was unaware of the error until a staff member followed up with the hospital. The resident, who had a long history of seizure activity and Xanax usage, experienced a possible seizure and change in mental status, leading to another hospitalization. The neurologist noted that the abrupt withdrawal from Xanax likely contributed to the seizures. The facility's policy required verification of medication orders upon a resident's return from the hospital, but this was not properly executed, resulting in the medication error. The facility's administrator acknowledged the oversight and the failure to resume the Xanax order as prescribed.
Inaccurate Documentation of Meal Intakes and Oral Hygiene
Penalty
Summary
The facility failed to maintain accurate documentation of meal intakes and oral hygiene for three residents, identified as Residents B, C, and D. For Resident B, the electronic health record (EHR) showed multiple instances of undocumented meal intakes, with several meals marked as 'not available' instead of 'resident refused' when meals were declined. Additionally, oral care was inconsistently documented, with some days showing incomplete or missing records. Interviews with the Regional Nurse Consultant and the MDS Coordinator revealed confusion regarding the documentation process and the representation of meal intake data in the EHR. Resident C's records also exhibited similar issues, with several meals marked as 'not available' and some meals left undocumented. Oral care documentation for Resident C showed inconsistencies, with some days having fewer than the required three instances of oral care. The MDS Coordinator's interview highlighted a lack of clarity in the EHR's meal intake graph, which did not clearly identify meal times, leading to potential inaccuracies in documentation. For Resident D, the documentation of meal intakes was unclear, with entries made at inconsistent times and some meals not documented at all. The EHR did not specify which meal was being recorded, leading to further confusion. Oral care documentation for Resident D was also inconsistent, with some days showing incomplete records or no documentation at all. The facility's policies on meal serving and oral care were not effectively implemented, as evidenced by the discrepancies in the EHR documentation.
Inaccurate MDS Encoding for Multiple Residents
Penalty
Summary
The facility failed to accurately encode various aspects of the Minimum Data Set (MDS) for five residents, leading to discrepancies in their medical records. Resident 30, diagnosed with chronic obstructive pulmonary disease, was inaccurately recorded as a non-smoker despite a smoking care plan indicating otherwise. Resident 41, with vascular dementia and schizoaffective disorder, had an incorrect date for the contraindication of a gradual dose reduction (GDR) for antipsychotic medication. The correct date was 12/27/2023, but the MDS recorded it as 6/30/2023. Resident 50, who had a stroke and was utilizing hospice services, was not recorded as having a life expectancy of less than six months, contrary to the hospice certification. Resident 51, with a displaced comminuted fracture of the patella, was incorrectly documented as having an unplanned discharge, despite care plans and progress notes indicating a planned discharge. Resident 103, with multiple diagnoses including obstructive sleep apnea, was not recorded as using a BiPap machine, although physician orders and observations confirmed its use. The MDS Coordinator acknowledged these errors and indicated plans to modify the assessments accordingly. These inaccuracies in the MDS assessments were identified through interviews and record reviews conducted by surveyors. The MDS Coordinator admitted to the errors and stated that modifications would be made to correct the records. The facility's policy for MDS 3.0 Completion emphasizes the importance of accurate and comprehensive assessments to identify care needs and develop appropriate care plans. However, the deficiencies in encoding critical information for these residents highlight lapses in adhering to this policy, affecting the accuracy of the residents' medical records and potentially their care plans.
Failure to Timely Complete Entry Tracking Record
Penalty
Summary
The facility failed to timely complete and transmit an entry tracking record for one resident, identified as Resident 154, who was admitted with a medical diagnosis of cerebrovascular disease. Upon review of the clinical record on 4/17/2024, it was found that no MDS assessment or entry tracking record had been completed for this resident. An interview with the MDS Coordinator confirmed that the entry tracking record was not completed and would be late, with the latest anticipated date of completion being 4/9/2024. The facility's policy requires entry tracking to be completed and submitted within 7 calendar days of entry into the facility.
Failure to Develop and Implement Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement care plans for three residents with specific medical needs. Resident 103, who had diagnoses including acute on chronic congestive heart failure, heart disease, high blood pressure, type 2 diabetes mellitus with diabetic nephropathy and diabetic retinopathy with macular edema, and obstructive sleep apnea, did not have care plans for the use of a bipap machine or insulin for diabetes mellitus. Despite physician's orders for the use of a bipap machine and specific insulin dosages, these were not reflected in the resident's care plan. The MDS Coordinator acknowledged the absence of these care plans and indicated they would be added later. Resident 41, diagnosed with vascular dementia and schizoaffective disorder, had a physician's order for the anticonvulsant medication Keppra to manage seizures. However, there was no care plan in place for the seizure disorder or the use of Keppra. The Administrator confirmed the lack of a care plan for this resident's seizure management. Additionally, Resident 5, who had chronic pancreatitis, coronary heart disease, arthritis, chronic kidney disease, and dementia, frequently experienced pain and required repositioning for relief. Despite these observations and a progress note indicating severe back pain, there was no care plan addressing the resident's pain management. The MDS Coordinator confirmed the absence of a pain management care plan for Resident 5 and indicated that one was implemented later.
Failure to Assess and Document Bruising
Penalty
Summary
The facility failed to assess and document bruising on Resident 29, who was observed to have dark purple bruises on both forearms on 4/15/24. The resident, who has diagnoses including heart disease, lung disease, transient ischemic attacks, and long-term atrial fibrillation, indicated she did not know how the bruising had occurred. A review of Resident 29's record on 4/18/24 showed no documentation of the bruising or any assessment of how it occurred, despite the resident being cognitively intact and having no prior skin issues as per the Quarterly Minimum Data Set (MDS) assessment dated 3/22/24. The current physician's orders included Clopidogrel Bisulfate, a medication that can increase bruising risk, but there was no documentation addressing the bruising in the progress notes or nursing assessment dated [DATE]. On 4/19/24, the Administrator provided a follow-up investigation document dated 4/18/24, which included measurements and descriptions of the bruises but no known cause for the injury. The facility's Skin Management policy requires skin assessments upon admission and no less than weekly, with any new bruises to be documented in the medical record. However, the policy was not followed as the bruising was not documented or assessed in a timely manner. The Administrator indicated that the bruising was first noticed on 4/18/24, contradicting the observation made on 4/15/24.
Failure to Implement Physician's Order for Hand Contracture
Penalty
Summary
The facility failed to implement a physician's order for a resident's left hand contracture. The resident, who had diagnoses including dementia, major depression, heart failure, and hypertension, was observed multiple times without the prescribed splint/carrot in place. Observations on four different days revealed that the resident did not have the splint/carrot in place while sitting in a wheelchair or lying in bed. During an interview, a Qualified Medication Aide (QMA) was unable to locate the carrot in the resident's room and later found it at the nursing station. The Assistant Director of Nursing (ADON) indicated that Certified Nursing Assistants (CNAs) were responsible for ensuring the carrot was in place. The resident's care plan, dated November 2019, specified that the resident should wear the left hand carrot for 4-6 hours a day. Additionally, the care plan dated February 2024 indicated the resident was at risk for skin breakdown and moisture-associated skin disorder due to the contracture. The Quarterly Minimum Data Set (MDS) assessment from February 2024 noted the resident was severely cognitively impaired and had limited range of motion in both upper extremities. The April 2024 physician recapitulation reiterated the need for the resident to wear the carrot for four hours a day or as tolerated. The facility's Range of Motion (ROM) policy required nurses to monitor the consistent implementation of care plan interventions, but this was not adhered to in this case.
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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