Willows Of Shelbyville
Inspection history, citations, penalties and survey trends for this long-term care facility in Shelbyville, Indiana.
- Location
- 2309 S Miller St, Shelbyville, Indiana 46176
- CMS Provider Number
- 155022
- Inspections on file
- 29
- Latest survey
- December 23, 2025
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Willows Of Shelbyville during CMS and state inspections, most recent first.
Three residents with cognitive and physical impairments did not have their fall prevention interventions in place as specified in their care plans. One was observed without required non-skid footwear, another lacked non-skid strips in front of her chair, and a third was missing a pommel cushion in her wheelchair, with staff either unaware of the intervention or unable to provide it.
A resident with multiple health conditions and significant weight loss did not receive a physician-ordered nutritional supplement at lunch, and her family was not consistently given the opportunity to complete weekly menus as care planned. The resident was served foods she did not like, and the dietary staff failed to ensure the supplement was provided, despite clear instructions on the meal ticket.
A resident with dementia and a history of skin picking was observed with untreated facial wounds, but her care plan was not updated to address this behavior, and staff failed to document or monitor the issue as required by facility policy.
Three residents with indwelling urological devices were observed multiple times with their drainage bags and tubing in direct contact with the floor, contrary to care plans and infection control protocols. Despite orders for daily care and enhanced barrier precautions, staff did not prevent the devices from touching the floor, as confirmed by observations and interviews with the Infection Prevention Nurse.
The facility failed to maintain kitchen equipment cleanliness and proper sanitization levels, affecting all residents. The Dietary Manager lacked test strips to verify sanitization bucket chemical levels due to expired strips and supplier backorder. Additionally, a brown fuzzy substance was found on refrigerator racks, which remained uncleaned despite available supplies. Facility policies did not adequately address these issues.
The facility failed to properly store food and maintain hygiene in the kitchen, affecting all residents. Observations included improperly stored silverware, inadequately sealed food packages, and open syrup bottles. A staff member was seen without a beard cover while serving food. The kitchen environment was unclean, with cobwebs, debris, and dead insects in light fixtures, indicating a failure to adhere to cleanliness standards.
The facility failed to maintain the kitchen in a clean and well-repaired state, affecting all residents. Observations included missing baseboards, cracked wall covers, and missing tiles in various areas. The dry storage room had significant dirt and debris, and the walk-in cooler had spills and possible rust. Weekly cleaning logs showed several areas were not signed off as cleaned, and logs for early August were missing. The facility's cleaning policy was not followed.
The facility failed to redirect residents with dementia who wandered into others' rooms, compromising privacy. Despite care plans for managing wandering behaviors, staff did not consistently intervene, and there were no structured activities to engage residents. Interviews revealed a lack of regular activity staff and inadequate supervision, leading to repeated incidents of uninvited room entries.
A facility failed to accurately document a resident's code status, resulting in a discrepancy between the POST form and physician orders. The resident's POST form indicated CPR was to be administered, while the physician's orders stated otherwise. Interviews revealed procedural gaps, including a lack of proper explanation to the resident and failure to maintain an updated binder of code statuses.
The facility failed to accurately encode MDS assessments for two residents, leading to documentation errors. One resident's MDS inaccurately indicated no hospice services despite continuous hospice care, while another's MDS incorrectly noted anticoagulant use without corresponding physician orders. The MDS Coordinator confirmed these errors.
A facility failed to conduct timely care plan meetings for a resident with Parkinson's disease, COPD, and major depressive disorder. The resident, who was cognitively intact, did not recall having care plan meetings, and records showed a gap between meetings from December to July. The Social Service Director could not find records of these meetings, despite being responsible for scheduling them quarterly and as needed, as per the facility's policy.
A resident with a history of falls experienced an unwitnessed fall, resulting in incomplete neurological checks by the facility. Despite the policy requiring frequent assessments, documentation showed gaps, and the resident was later sent to the hospital unresponsive.
The facility failed to implement and evaluate a resident's behavioral health care plan, leading to multiple incidents of physical aggression towards staff and other residents. The care plans were outdated, and there was inadequate documentation and follow-up on the aggressive behaviors. Additionally, the facility did not report these incidents to the Indiana Department of Health.
The facility failed to ensure a resident with dementia had a care plan with specific interventions for inappropriate behaviors, leading to repeated incidents of inappropriate touching of other residents. Despite being on medication and having a history of such behaviors, the resident's actions were not adequately monitored or documented, compromising the safety of other residents.
The facility failed to ensure narcotic medication was administered per physician orders for two residents. One resident with Huntington's disease had multiple instances of undocumented diazepam administration, while another resident reported issues with receiving scheduled pain medication, with several instances of undocumented Norco administration.
Failure to Implement Fall Prevention Interventions per Care Plans
Penalty
Summary
The facility failed to implement fall prevention interventions as outlined in the care plans for three residents. One resident with osteoporosis, Alzheimer's disease, and chronic pain had a history of unwitnessed falls, including one resulting in a hip fracture. Despite a care plan intervention requiring appropriate footwear, the resident was observed wearing regular socks without non-skid features or shoes while in the dining room. Staff confirmed the absence of non-skid socks and acknowledged the resident should have been wearing tennis shoes. Another resident with Alzheimer's disease and multiple psychiatric diagnoses had a care plan intervention for non-skid strips to be placed both beside her bed and in front of her chair. Observation revealed that while strips were present beside the bed, they were missing in front of the recliner, and the weekend supervisor was unaware of this requirement. A third resident with dementia and heart failure, who required substantial assistance with transfers and had a recent fall with injury, had a care plan intervention for a pommel cushion to prevent leaning and potential falls. Observations showed the resident was seated in a wheelchair without the pommel cushion, and staff were either unaware of what the cushion was or stated it was unavailable due to being soiled. The DON later indicated that hospice was responsible for providing the cushion, but it had not been supplied, and an alternative cushion was used without proper documentation in the care plan. These findings demonstrate that the facility did not ensure fall prevention interventions were consistently in place as specified in residents' care plans.
Failure to Provide Ordered Nutritional Supplement and Honor Resident Menu Preferences
Penalty
Summary
A resident with diagnoses including dysphagia, dementia, depression, malnutrition, and anxiety experienced a significant weight loss of 16 pounds over 180 days. The resident was on hospice services, required total assistance with feeding, and had a physician's order for a regular diet with thin consistency, finger foods as needed, and a magic cup nutritional supplement at lunch. During a lunch observation, the resident did not receive the ordered magic cup, and the CNA assisting her did not notice its absence. The meal ticket clearly indicated the need for the supplement, but the kitchen did not send it, and the dietary aide responsible for reading the ticket and placing supplements on trays did not ensure it was provided. Additionally, the resident's care plan included having a family member complete weekly menus to honor her food preferences and intolerances. However, the family member reported that he had not been given the opportunity to fill out menus recently, resulting in the resident being served items she did not like or would not eat. The Dietary Manager confirmed that menu packets were not consistently provided to the family member as agreed, missing at least three times, including the current week. The facility's policy required providing nutritional and dietary supplements consistent with assessed needs, but this was not followed for the resident.
Failure to Revise Care Plan and Monitor Self-Injurious Behavior in Dementia Resident
Penalty
Summary
The facility failed to revise the care plan and adequately monitor a resident diagnosed with dementia who exhibited skin picking and scratching behaviors. The resident, who had diagnoses including Alzheimer's disease, chronic pain, depression, and dementia, was observed with quarter-sized, reddish areas with partially scabbed centers on both cheeks. Despite these visible injuries, there were no progress notes, assessments, or care plans referencing the areas on her cheeks or her picking/scratching behavior. Staff interviews revealed that the behavior had been noticed previously, but it was not documented or addressed in the resident's care plan. The Memory Care Facilitator, responsible for care planning, acknowledged that the resident's skin picking should have been included in her care plan. The DON and other staff confirmed that the behavior was observed but not documented, and the areas on the resident's cheeks were not assessed or treated as needed. Review of the facility's behavior monitoring reports and progress notes showed no documentation of the resident's self-injurious behaviors, despite staff being aware of the issue. The facility's policy required care planning and intervention for problematic behaviors, but this was not followed for the resident in question.
Failure to Maintain Infection Control for Indwelling Urological Devices
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices for residents with indwelling urological devices. For three residents with urostomies or indwelling urinary catheters, observations revealed that their drainage bags and tubing were in direct contact with the floor on multiple occasions. Specifically, one resident with a urostomy was observed twice with the drainage bag and tubing touching the floor, despite care plans and physician orders indicating the need for daily urostomy care and enhanced barrier precautions. Another resident with a suprapubic urinary catheter was seen in a wheelchair with the catheter bag contacting the floor during two separate observations, even though the care plan required catheter care every shift and enhanced barrier precautions. A third resident with an indwelling urinary catheter was observed in the dining room with the catheter bag directly on the floor, despite similar care plan interventions for infection prevention. Record reviews confirmed that all three residents had diagnoses requiring indwelling urological devices and were dependent on staff for various activities of daily living. Interviews with the Infection Prevention Nurse confirmed that staff were expected to keep catheter drainage bags and tubing off the floor to promote infection control. The repeated failure to prevent these devices from contacting the floor constituted a breach of established infection control measures as outlined in the residents' care plans and facility protocols.
Deficiency in Kitchen Sanitization and Equipment Maintenance
Penalty
Summary
The facility failed to maintain kitchen equipment in a clean manner and ensure proper sanitization levels in sanitizing buckets, potentially affecting all 71 residents. During a kitchen tour, it was observed that the Dietary Manager (DM) did not have test strips to verify the chemical levels in the sanitization buckets, as the existing strips had expired. The DM had informed the Executive Director (ED) about the expired strips, but due to a backorder from their supplier, new strips had not yet arrived. This lack of testing capability meant that the sanitization solution's effectiveness could not be confirmed. Additionally, the walk-in refrigerator was found to have a brown fuzzy substance on the storage racks, which the DM had been aware of since assuming her position. Despite attempts to clean it, the substance remained, and although cleaning supplies and a power washer were available, the cleaning had not been completed. The facility's policies did not adequately address the sanitization requirements for the buckets, and the cleaning policy indicated that the walk-in refrigerator and racks should be cleaned regularly, which was not adhered to.
Improper Food Storage and Hygiene Practices in Kitchen
Penalty
Summary
The facility failed to adhere to proper food storage and hygiene practices in the kitchen, potentially affecting all 57 residents. During a kitchen tour, it was observed that silverware was improperly stored with handles facing downward, contrary to the facility's policy. In the dry storage room, opened packages of food items were inadequately sealed with non-sticking masking tape, and bottles of syrup were left open without lids, exposing them to air. In the walk-in cooler, an opened bag of celery was improperly stored with the celery resting directly on the shelf. Additionally, a staff member was observed not wearing a beard cover while serving food, which is against the facility's dress code policy. The kitchen environment was also found to be unclean, with a large cobweb on the stove hood and fuzzy debris on the sprinkler heads. Debris was hanging from the ceiling around a vent over the food preparation counters, and the light fixtures above these counters were covered in thick debris, with some containing dead insects. The Dietary Supervisor indicated that attempts to clean the ceiling resulted in flaking, and there was uncertainty about the cleaning of light fixtures. These observations highlight a failure to maintain cleanliness and hygiene standards in food preparation and storage areas, as outlined in the facility's policies.
Kitchen Maintenance Deficiency
Penalty
Summary
The facility failed to maintain the kitchen in a clean and well-repaired state, potentially affecting all 57 residents. During a tour of the kitchen, several issues were observed, including missing baseboards behind the ice chest, a cracked wall corner cover by the handwashing sink, and missing tiles in various areas such as underneath the dishwasher counter, the three-compartment sink, and in front of the back kitchen door. The dry storage room was found to have a significant amount of dirt and debris, including macaroni, on the floor against the baseboards underneath the food storage racks, with the baseboard peeling away from the wall in the corner. Additionally, a solidified brown liquid substance was found on the floor underneath one of the racks, which the Dietary Supervisor (DS) suggested might be from previous banana boxes. The walk-in cooler had spills all over the floor, with one area possibly being old rust with liquid over it, and there were cracked and missing floor tiles underneath the steamer. The facility's weekly kitchen cleaning logs from August 2024 to the present were reviewed, revealing that several areas had not been signed off as cleaned for multiple weeks. These areas included the walls and baseboards from the walk-in cooler to around the back door, both prep tables in the back area, the cook's help table on the serving line, the walls and baseboards behind all dish carts on the clean side of the dish area, and the refrigerator/freezer next to the sink. Furthermore, the cleaning logs for the first three weeks of August 2024 were missing entirely. The facility's Cleaning Equipment Policy and Procedures, provided by the Director of Nursing, stated that the walk-in refrigerator floor should be swept and mopped at least once a week, and the racks should be removed, and the floors and walls scrubbed with a sanitizing agent at least once a year.
Inadequate Redirection of Wandering Residents in Memory Care Unit
Penalty
Summary
The facility failed to adequately redirect residents with dementia who exhibited wandering behaviors, leading to a lack of privacy for other residents. Specifically, five residents with dementia were observed entering other residents' rooms uninvited, which was not addressed by staff. For instance, Resident 22, diagnosed with dementia, frequently wandered into other residents' rooms, including Resident 157's room, without staff intervention. This behavior was noted to occur multiple times a day, causing distress to the residents whose privacy was invaded. The care plans for residents with wandering behaviors, such as Residents 22, 41, and 27, included goals and interventions to manage these behaviors. However, the interventions were not effectively implemented. For example, Resident 27 was observed wandering into an empty room without staff redirection, and there were no structured activities available to engage her. Similarly, Resident 41's care plan included interventions to protect the rights and safety of others, but these were not consistently applied, as evidenced by her intrusive wandering behavior. Interviews with staff revealed a lack of structured activities and inadequate supervision on the memory care unit. LPNs reported attempting to redirect residents with snacks or music, but there was no regular activity staff to provide consistent engagement. The facility's policies on elopement and dementia care emphasized the need for adequate supervision and person-centered care plans, but these were not effectively executed, resulting in repeated incidents of residents entering others' rooms uninvited.
Failure to Accurately Document Resident's Code Status
Penalty
Summary
The facility failed to accurately document a resident's code status in the clinical record, leading to a discrepancy between the resident's POST form and the physician's recapitulation orders. Resident 40's POST form, signed by both the resident and the physician, indicated that the resident was to receive CPR in the event of no pulse and no breathing. However, the physician's recapitulation orders stated that the resident was not to be resuscitated under the same circumstances. This inconsistency highlights a failure in the facility's documentation process. Interviews with the Director of Nursing (DON) and the Social Service Director revealed gaps in the facility's procedures for maintaining and communicating residents' code statuses. The DON indicated that the discrepancy might have occurred when Resident 40 was readmitted, and a floor nurse had the resident sign the POST form without proper explanation. Additionally, the Social Service Director admitted to not maintaining an ongoing binder with residents' current code statuses, contrary to the facility's policy. This lack of coordination and adherence to policy contributed to the failure in accurately documenting the resident's advanced directives.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to accurately encode Minimum Data Set (MDS) assessments for two residents, leading to deficiencies in their care documentation. For Resident 44, the clinical record review revealed a discrepancy in the MDS assessment dated 9/4/2024, which inaccurately indicated that the resident had a six-month or less life expectancy without receiving hospice services. However, the hospice plan of care showed that Resident 44 had been admitted to hospice on 7/31/2023 and had been receiving hospice services continuously since then. The MDS Coordinator confirmed the error during an interview, acknowledging that the MDS assessment was coded inaccurately. Similarly, for Resident 53, the Admission MDS assessment dated 8/13/2024 incorrectly indicated that the resident received anticoagulant medication in the seven days prior to the admission reference date. However, the physician orders provided by the facility did not include any order for anticoagulant medication for Resident 53. The MDS Coordinator confirmed that the resident had not been on an anticoagulant during the review period, and the assessment was coded in error. The facility's policy on conducting accurate resident assessments was not adhered to, resulting in these inaccuracies.
Failure to Conduct Timely Care Plan Meetings
Penalty
Summary
The facility failed to conduct care plan meetings for a resident, identified as Resident 10, who was reviewed for care plans. Resident 10's clinical record, reviewed on September 30, 2024, showed diagnoses including Parkinson's disease, chronic obstructive pulmonary disease, and major depressive disorder. During an interview on September 26, 2024, Resident 10, who was cognitively intact according to the Quarterly Minimum Data Set assessment dated August 27, 2024, indicated they did not recall having care plan meetings. The electronic health record revealed that the last comprehensive care plan meeting for Resident 10 was held on December 14, 2023, with no further meetings until July 1, 2024. The Social Service Director, interviewed on October 1, 2024, was unable to find records of care plan meetings for Resident 10 and stated that social services were responsible for setting up these meetings, which were supposed to be conducted quarterly and as needed. The facility's Comprehensive Care Plan policy, provided by the Director of Nursing, emphasized the resident's right to be informed of and participate in care planning, with care plan conferences scheduled regularly.
Incomplete Neurological Checks After Resident Fall
Penalty
Summary
The facility failed to conduct complete neurological checks, including vital signs, for a resident who experienced an unwitnessed fall. Resident B, who had a history of falls and required substantial assistance, was found on the floor with skin tears after a fall in the bathroom. Despite the facility's policy requiring neurological assessments after unwitnessed falls, the documentation showed gaps in the checks, with a missing entry on 8/3/24 at 10:45 p.m. and no vital signs recorded after 8/3/24 at 9:14 p.m. Resident B's clinical record indicated multiple health issues, including dementia and repeated falls, and the resident was noted to be alert only to person with impaired memory after the fall. The resident was later sent to the hospital due to being unresponsive, highlighting the incomplete neurological monitoring. The facility's policy required frequent neurological assessments post-fall, but these were not fully adhered to, as evidenced by the incomplete documentation and the resident's subsequent condition.
Failure to Implement and Evaluate Behavioral Health Care Plan
Penalty
Summary
The facility failed to ensure a resident's plan of care for behavioral health was implemented and evaluated after the resident exhibited physical behavioral symptoms towards staff and other residents. Resident E, diagnosed with Huntington's disease, schizophrenia, and other conditions, had multiple incidents of physical aggression that were not adequately documented or addressed. The care plans for Resident E had not been updated with new interventions since 2021 and 2023, despite ongoing aggressive behaviors. The facility also failed to document the reasoning for administering intramuscular injections of antianxiety and antipsychotic medications and did not report these incidents to the Indiana Department of Health. On multiple occasions, Resident E exhibited aggressive behaviors, including grabbing another resident's arm, causing a skin tear and bruising, and attempting to choke Resident F, resulting in redness and fear. These incidents were not followed up with appropriate documentation or root cause analysis. Additionally, there were no follow-up notes in Resident E's clinical record to indicate if the underlying cause of the physical contact was discussed or determined. The facility's behavior management policy was not effectively implemented, as evidenced by the lack of behavior tracking and interdisciplinary team discussions. Interviews with staff revealed concerns about Resident E's unpredictable behaviors and the difficulty in communicating with him. Observations showed that Resident E was often left unsupervised in common areas, increasing the risk of further incidents. The facility's failure to provide necessary behavioral health care and services, document interventions, and ensure the safety of other residents during behavioral episodes led to significant deficiencies in the care provided to Resident E and other residents involved.
Failure to Address Inappropriate Behaviors in Resident with Dementia
Penalty
Summary
The facility failed to ensure that a resident with dementia had a care plan with resident-specific interventions regarding inappropriate comments towards staff, monitoring of behaviors, and documentation of such behaviors in the clinical record. Resident H, who had a history of sexually inappropriate behavior, did not have a care plan that included interventions to address these behaviors. Despite being on medication for sexual behavior, Resident H continued to exhibit inappropriate behaviors, which were not adequately monitored or documented in the clinical record. Resident H was found to have touched another resident, Resident G, inappropriately on multiple occasions. The facility's response included placing Resident H on 1:1 supervision and moving him to a different room. However, the care plan for Resident H's sexually inappropriate behaviors was not revised to include effective interventions. Additionally, Resident H's behavior continued, leading to another incident involving Resident J, where Resident H attempted to touch her inappropriately. Interviews with staff indicated that Resident H had a history of sexually inappropriate behavior towards staff and other residents. The facility's policy on dementia care emphasized the need for individualized care plans and ongoing monitoring of interventions, but these were not effectively implemented for Resident H. The lack of appropriate interventions and monitoring led to repeated incidents of inappropriate behavior, compromising the safety and well-being of other residents.
Failure to Administer and Document Narcotic Medication
Penalty
Summary
The facility failed to ensure narcotic medication was administered per physician orders for two residents. Resident E, diagnosed with Huntington's disease and other conditions, had multiple instances where diazepam was not documented as administered according to the narcotic log sheets. Specific dates and times were noted where the medication was not recorded, indicating a failure in proper medication administration and documentation. Resident D, who was cognitively intact and diagnosed with heart failure, fibromyalgia, anxiety disorder, and low back pain, reported issues with receiving her scheduled pain medication. The narcotic log sheets for her Norco tablets showed several dates and times where the medication was not documented as administered. The facility's policies on controlled substance storage and medication administration were not followed, leading to these deficiencies.
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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