Woodlands The
Inspection history, citations, penalties and survey trends for this long-term care facility in Muncie, Indiana.
- Location
- 3820 W Jackson St, Muncie, Indiana 47304
- CMS Provider Number
- 155229
- Inspections on file
- 34
- Latest survey
- May 7, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Woodlands The during CMS and state inspections, most recent first.
A staff member did not report a suspected abuse incident involving a cognitively impaired resident who was combative and refused medication. An LPN, after being unable to administer medication, handed over the task to an RN and a QMA, who entered the resident's room and closed the door. The resident was heard yelling in protest, and the QMA later stated they managed to administer some medication despite resistance. The LPN did not report the incident, and facility leadership was unaware until interviewed, in violation of the facility's abuse reporting policy.
The facility removed seating and furniture from common areas, including the nurses' station and TV lounge, disrupting residents' established routines and preferred gathering spaces. Staff and family members reported increased confusion, stress, and a rise in falls among residents with cognitive impairments following these changes. The actions were taken without soliciting staff feedback and did not align with care plans emphasizing consistent routines for residents with dementia.
A resident with Alzheimer's disease and moderate cognitive impairment was involuntarily secluded when a DDCS directed her to sit alone in the activities room, deviating from her usual routine of sitting near the nurse's station. The resident became confused and distressed by the unexplained change, and staff observed her emotional upset before assisting her back to a communal area.
A cook at the facility was observed engaging in unsanitary food handling practices, including using the same gloves to touch various surfaces and food items, potentially impacting all 69 residents receiving meals. Despite washing hands and changing gloves, the cook continued to contaminate food by touching meal tickets, countertops, and food items with soiled gloves. The cook admitted to not following proper food handling procedures.
The facility failed to manage funds for two residents using acceptable accounting principles. Envelopes with money were improperly stored in the medication room, and hand-written money logs were found in the narcotic reconciliation book. The residents had a history of misplacing money, and the Business Office Manager was unaware of the nursing-controlled logs. The facility lacked a policy for keeping resident funds outside the trust.
A resident at risk for pressure ulcers did not have the prescribed low air loss mattress in place, despite ongoing pain and a care plan indicating its necessity. Staff interviews confirmed the absence of the mattress, and the clinical record lacked documentation for this oversight, violating the facility's policy on skin integrity and pressure ulcer prevention.
The facility failed to properly label and dispose of insulin pens on the Hickory Hall 2 medication cart. An undated NovoLog Flexpen and an expired lispro KwikPen were found during an observation. The LPN acknowledged the error, noting that insulin should be dated when opened and is only good for 28 days. The DON confirmed the expectation for staff to date and check insulin pens to prevent expired medication use. Nine diabetic residents were affected by this oversight.
The facility failed to follow infection control practices during medication administration for two residents, as an LPN did not perform hand hygiene or use gloves. Additionally, the facility did not implement enhanced barrier precautions for a resident with a wound and urinary catheter, as staff did not wear gowns or follow EBP protocols. The facility's policy required EBP for residents with wounds or indwelling devices, but staff were unaware and did not implement these precautions.
The facility failed to consistently update the daily nurse staffing information, as required by policy. Observations showed that the staffing boards were not updated on multiple occasions, displaying outdated information. The DON, responsible for this task, acknowledged the oversight due to the recent addition of this responsibility and the absence of a scheduler.
The facility failed to employ a qualified Food Services Director, impacting all 70 residents. The director, employed since 2020, lacked necessary certifications and qualifications. The Assistant Dietary Manager was also not certified, and the Registered Dietician visited only weekly. Facility policy requires a qualified individual to oversee food services, which was not met.
A resident's morphine medication was misappropriated by an LPN, who admitted to taking the pills due to personal stress. The incident was discovered during a shift change medication count, and the resident was assessed for pain but reported no concerns. The facility initiated an investigation, and the LPN was suspended and later terminated.
The facility failed to ensure anti-depressant and mood stabilizer medications were not started without proper indication for a resident diagnosed with dementia and agitation. Following an incident where the resident allegedly pushed another resident, the facility prescribed Depakote and Celexa without adequate documentation or non-pharmacological interventions, contrary to their policy on unnecessary medication.
Failure to Report Suspicion of Abuse for Cognitively Impaired Resident
Penalty
Summary
A staff member failed to report a suspicion of abuse involving a resident with severe cognitive impairment. The incident occurred when an LPN was unable to administer medication to the resident, who was combative and refused the medication. The LPN informed an RN of the situation, who, along with a QMA, took over the medication administration. The QMA and RN entered the resident's room, closed the door, and the resident was heard yelling that she did not want the medication. Afterward, the QMA reported that they were able to get some medication into the resident, despite her fighting and spitting it out. The LPN did not witness the interaction but did not report the incident to facility leadership. The facility's abuse policy required any staff member with a suspicion of abuse or mistreatment to immediately notify the Executive Director. However, the LPN did not report the incident, and facility leadership, including the Regional President, Regional Clinical Director, and DON, were unaware of the event until the survey interview. This failure to report delayed the initiation of an investigation and notification to the appropriate agencies, as required by facility policy.
Failure to Support Resident Choice and Routine by Removing Common Area Seating
Penalty
Summary
The facility failed to honor and support resident self-determination and choice by removing furniture from common areas, including the nurses' station, dining room, activities room, and TV lounge, which had previously served as gathering spaces for residents. The Divisional Director of Clinical Services (DDCS) directed staff to return residents to their rooms after meals or activities and discouraged them from gathering at the nurses' station. Staff reported that these changes caused confusion and stress among residents, as they were accustomed to using these areas for socialization and rest. The removal of seating also led to residents being redirected when they attempted to move chairs to their preferred locations. Multiple staff interviews indicated that the changes disrupted established routines and increased resident confusion. Certified Nursing Assistants (CNAs) observed that residents viewed the area around the nurses' station as a communal living space and that the lack of seating caused distress. The previous Director of Nursing (DON) and other staff noted an increase in falls following the removal of seating, particularly among residents who were known to rest at the nurses' station after meals. The clinical records of four residents with cognitive impairments, histories of falls, and other medical conditions documented falls occurring in their rooms after the changes were implemented. Care plans for these residents emphasized the importance of consistent routines and environments to reduce confusion. Interviews with family members and staff further confirmed that the removal of furniture negatively impacted residents' ability to socialize and maintain their routines. The Regional Director of Clinical Services (RDCS) and DDCS acknowledged that the changes were part of a pilot project to encourage engagement with activity stations, but admitted they had not solicited or followed up on staff feedback regarding the impact of these changes. Facility policy reviewed during the survey affirmed residents' rights to self-determination and a dignified existence, which were not upheld in this instance.
Involuntary Seclusion of Resident Due to Unexplained Change in Routine
Penalty
Summary
A resident with Alzheimer's disease, severe protein-calorie malnutrition, and a history of stroke was involuntarily secluded when the Divisional Director of Clinical Services (DDCS) directed her into the activities room, left her alone, and did not provide an explanation for the change from her usual routine. The resident, who had moderate cognitive impairment and was accustomed to sitting outside the nurse's station as part of her preferred daily activities, was found confused and distressed by the change, expressing concern about what she had done wrong and whether she was in trouble. Staff members observed the resident's confusion and emotional distress, and one CNA eventually assisted her back to a communal area with other residents. The facility's care plan for the resident emphasized maintaining a consistent routine due to her cognitive impairment. The facility's policy, as reviewed, prohibits involuntary seclusion and requires residents to be free from such practices. The DDCS indicated a preference for not having chairs around the nurse's station due to fall risks but did not provide a specific reason to the resident for the change in her routine or her placement in the activities room alone.
Unsanitary Food Handling Practices Observed
Penalty
Summary
The facility failed to ensure food was prepared and served using safe sanitary food preparation and handling methods, potentially impacting all 69 residents who received meals from the kitchen. During lunch meal preparation and service, a cook was observed engaging in several unsanitary practices. The cook touched the refrigerator door with gloved hands, then used the same gloves to handle hot dogs and plates. She also used her gloved hands to adjust her clothing before continuing to handle food items. The cook washed her hands and donned new gloves but continued to engage in unsanitary practices by touching meal tickets, countertops, trays, lids, and utensil handles with the same gloves. She then left the meal service area, retrieved a bag of hot dog buns, and handled the buns and hot dogs with the same soiled gloves. The cook continued to touch various food items, including hamburger buns and tartar sauce packets, with contaminated gloves. During an interview, the cook acknowledged that she was not supposed to handle or serve food with her gloved hands, indicating a lack of adherence to the facility's safe food handling policy.
Improper Management of Resident Funds
Penalty
Summary
The facility failed to manage resident funds using acceptable accounting principles for two residents. During observations, it was noted that small labeled and dated envelopes containing dollar bills were left in plain view on a storage shelf in the medication room. These envelopes were labeled with the names of two residents and dated from previous months. Additionally, hand-written money logs for these residents were found in the narcotic reconciliation book. Interviews revealed that these logs and envelopes were interventions put in place by the business office due to the residents' history of misplacing money. The clinical records of the two residents indicated that both had a history of misplacing personal items and required money for personal use during offsite hours and weekends. Despite having signed Resident Fund Management Service agreements, their funds were improperly stored in the medication storage room. The Business Office Manager was unaware of the money logs controlled by nursing, and the facility lacked a policy regarding the keeping of resident funds outside the trust. The facility's Resident Trust Policy and Procedures outlined the proper management of resident funds, which was not adhered to in this case.
Failure to Implement Pressure Ulcer Prevention Interventions
Penalty
Summary
The facility failed to implement preventative interventions for a resident at risk for pressure ulcers. The resident, who was cognitively intact and dependent on staff for various activities, was observed in a wheelchair and later in bed without the prescribed low air loss mattress. Despite having an order for an airflow mattress and a care plan indicating the need for a pressure-reducing device, the resident's bed was equipped with a standard mattress. The resident reported ongoing pain in the buttocks, and a hydrocolloid dressing was applied to a skin impairment that had healed and then reopened due to friction and shear. Interviews with staff, including an LPN and a Corporate Nurse Consultant, confirmed that the low air loss mattress was not in place as ordered, and there was no documentation explaining its absence. The facility's policy on skin integrity and pressure ulcer prevention was not adhered to, as the clinical record lacked an order to ensure the mattress was in place and functioning. The deficiency was identified through observations, record reviews, and staff interviews, highlighting a failure to follow the care plan and implement necessary interventions to prevent pressure ulcers.
Failure to Properly Label and Dispose of Insulin Pens
Penalty
Summary
The facility failed to ensure proper labeling and disposal of insulin pens on the Hickory Hall 2 medication cart. During an observation, it was found that a NovoLog Flexpen with 10 units remaining was undated, and a lispro KwikPen, which was dated, had expired with 185 units remaining. The LPN present during the observation acknowledged that insulin should be dated when opened and is only good for 28 days. The expired lispro insulin should not have been administered to residents. There were nine diabetic residents receiving medication from this cart. The Director of Nursing confirmed that the facility's expectation is for staff to date all insulin pens and vials upon opening and to check these dates before each use to ensure they are not expired. The facility's policy, as provided by the Administrator, states that medications should be dated when opened and discarded according to manufacturer guidelines, specifically within 28 days for multi-dose vials unless otherwise specified. This oversight in medication management could potentially impact the care of diabetic residents relying on these medications.
Infection Control Deficiencies in Medication Administration and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to infection prevention and control practices during medication administration for two residents. During an observation, an LPN did not perform hand hygiene after administering nasal sprays and insulin to a resident. The LPN also failed to don gloves during these procedures, which was against the facility's policy. The LPN acknowledged the oversight during an interview, and the Director of Nursing confirmed that gloves and hand hygiene were required for these procedures. In another instance, the facility did not implement enhanced barrier precautions (EBP) for a resident with a wound and an indwelling urinary catheter. The resident's clinical record lacked an order for EBP, and the care plan did not include interventions for EBP. During a wound care observation, staff did not wear gowns or follow EBP protocols, despite the resident having a wound and a urinary catheter. Interviews with staff revealed a lack of awareness and implementation of EBP for residents with wounds or indwelling devices. The facility's policy on EBP indicated that such precautions should be used for residents with wounds or indwelling medical devices, even if they are not known to be infected with a multi-drug resistant organism. However, the staff did not follow these guidelines during the care of the resident. The staff development coordinator and other staff members acknowledged the absence of EBP signs and PPE canisters, which are required to indicate the need for enhanced precautions.
Failure to Update Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post the daily facility census number and actual hours worked of licensed and unlicensed nursing staff directly responsible for resident care per shift daily. During observations and record reviews, it was noted that the Nursing Staff Directly Responsible for Resident Care boards were not updated consistently. On multiple occasions, the boards displayed outdated information, failing to reflect the current staffing and census numbers. For instance, on 3/4/25 and 3/5/25, the boards were not updated until later in the day, showing incorrect staffing information from previous days. Interviews revealed that the Director of Nursing (DON) was responsible for updating the staffing information daily, a task recently added to her responsibilities due to the absence of a scheduler. The DON acknowledged the oversight, indicating that she tried to update the information before leaving work on Fridays to cover the weekend but missed updates on certain days. The facility's policy requires that nurse staffing information be posted daily at the beginning of each shift in a prominent place accessible to residents and visitors, which was not adhered to in this instance.
Facility Lacks Qualified Food Services Director
Penalty
Summary
The facility failed to employ a qualified Food Services Director, which had the potential to impact all 70 residents. The Food Services Director had been employed since August 2020 and assumed the director position in May 2022. However, she was not a Certified Dietary Manager nor ServSafe Management certified, lacking the required qualifications for her role. The Administrator acknowledged that the Food Services Director had enrolled in a dietary manager program but failed to obtain certification, although she had re-enrolled. The Assistant Dietary Manager also lacked ServSafe Management certification, and the Registered Dietician only visited the facility once a week. The facility's policy, revised in April 2024, mandates that the Food and Nutrition Services department be directed by a qualified individual with the necessary competencies and skills. In the absence of a full-time dietician, a qualified person should be designated to oversee the department with regular consultations from a dietician. Despite this policy, the facility did not have a qualified individual in the Food Services Director role, as confirmed by the Administrator during the survey conducted from February 4 to February 6, 2025.
Misappropriation of Resident's Medication by LPN
Penalty
Summary
The facility failed to prevent the misappropriation of a resident's medication, specifically involving Resident C. During a shift change, it was discovered that two morphine sulfate IR 15 mg tablets were missing from Resident C's medication supply. LPN 5 later admitted to taking the medication, citing personal stress as the reason for ingesting the pills at home. The incident was reported to the local police, and an investigation was initiated immediately. Resident C, who had diagnoses including intervertebral disc degeneration, pain, and malignant neoplasm of the liver, was assessed for any signs of distress or pain following the incident and denied any concerns. The resident's clinical records indicated a physician's order for morphine sulfate 15 mg to be administered as needed for pain, which was discontinued on the day of the incident. The resident was discharged home with all remaining morphine tablets on the same day. The facility's investigation involved verifying the medication count by additional nurses, notifying the DON and Administrator, and conducting a urine drug screen on LPN 5, which tested positive for opiates. The facility's policy on abuse and misappropriation of resident property was reviewed, highlighting the definition of misappropriation as the wrongful use of a resident's property without consent. LPN 5 was suspended and subsequently terminated following the investigation.
Inappropriate Initiation of Psychotropic Medications
Penalty
Summary
The facility failed to ensure that anti-depressant and mood stabilizer medications were not started without proper indication for use for Resident D. Resident D, who was diagnosed with unspecified dementia with agitation, anxiety disorder, insomnia, and depression, was involved in an incident where he allegedly pushed a female resident, resulting in her being sent to the emergency room. Following the incident, Resident D was placed on one-on-one supervision, and psychiatric services were contacted. Despite the lack of clear documentation indicating the necessity for the medications, Resident D was prescribed Depakote and Celexa shortly after the incident. Resident D's clinical records and care plans indicated that he was severely cognitively impaired and exhibited territorial behavior, particularly over a table and its contents. Multiple behavior notes documented his agitation and verbal aggression towards other residents, but there was no clear evidence of physical aggression prior to the incident. Interviews with staff members, including the Social Service Director, CNAs, and the DON, revealed that Resident D was generally grumpy and territorial but had not shown prior physical aggression. The decision to prescribe Depakote and Celexa was made without adequate documentation of the underlying condition or non-pharmacological interventions. The psychiatric nurse practitioner and the Medical Director both indicated that the medications were prescribed to manage Resident D's behaviors and prevent further incidents. However, the facility's policy on unnecessary medication requires documentation of adequate indications for medication use and the implementation of non-pharmacological approaches before initiating pharmacological treatment. The facility's failure to adhere to this policy resulted in the inappropriate initiation of psychotropic medications for Resident D without proper indication or documentation.
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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