Allison Pointe Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Indianapolis, Indiana.
- Location
- 5226 E 82nd Street, Indianapolis, Indiana 46250
- CMS Provider Number
- 155272
- Inspections on file
- 52
- Latest survey
- February 25, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Allison Pointe Healthcare Center during CMS and state inspections, most recent first.
A resident with metastatic breast cancer, who was cognitively intact, was approached by an LPN about selling her vehicle after the LPN noticed it had not been moved for some time. The resident felt the inquiry was inappropriate and was upset that staff were discussing her personal matters. Facility leadership confirmed that staff soliciting to purchase items from residents is not acceptable and violates resident rights policies.
A controlled substance medication delivered for a resident was not properly processed or secured after being signed for by an LPN and handed to an RN. The medication was not entered into the narcotic log, was delivered in an incorrect bag, and was never located, with staff unable to account for its disposition. Facility policies requiring dual nurse verification and secure storage were not followed.
Surveyors found that the facility failed to properly document and reconcile controlled medication administration, resulting in missing or illegible records, inconsistent narcotic counts, and incomplete staff signatures for several residents. Additionally, some residents did not receive IV antibiotics and antifungal medications as ordered, with delays in order entry and missed doses. These deficiencies were identified through interviews, record reviews, and examination of facility policies.
Two residents did not receive their prescribed medications and treatments as ordered upon admission, due to delays and errors in entering and transmitting orders to the pharmacy. One resident missed several doses of critical medications, while another did not receive IV antibiotics and TPN as required, resulting in unmanaged symptoms and distress. Nursing staff interviews revealed issues with the admission process and order entry, leading to these deficiencies.
A resident with a history of intestinal perforation and peritoneal abscess did not receive ordered TPN upon admission due to a medication ordering error and lack of follow-up with the pharmacy. The resident experienced pain and vomiting while waiting for the TPN, which was not administered until the following day after staff intervention and a STAT pharmacy delivery.
A resident admitted with significant pain and an order for oxycodone did not receive her pain medication until the day after admission, despite repeated requests and the medication being available in the emergency drug kit. Nursing staff were aware of the resident's pain but did not administer the ordered medication in a timely manner.
A resident with complex pain management needs received incorrect narcotic pain medications on multiple occasions due to failure to follow physician orders and inconsistent medication administration. The resident was given oxycodone without an active order and did not consistently receive the prescribed Percocet, resulting in significant medication errors.
A resident with significant neurological impairments and nonverbal status did not receive appropriate pain management, as staff failed to document pain levels prior to administering PRN oxycodone, did not attempt or record non-pharmacological interventions, and inconsistently assessed the effectiveness of pain medication. Family concerns about the resident's pain and inability to self-report were not adequately addressed in the clinical documentation.
Staff did not follow enhanced barrier precautions when providing personal care to a resident with a tracheostomy, gastric tube, and wounds, as a CNA failed to wear a gown during perineal care and placed feces-soiled linen directly on the floor instead of bagging it, contrary to facility policy.
The facility failed to address grievances reported during resident council meetings, as concerns about staff not answering call lights timely were not documented or addressed. The Activities Director indicated grievances were only recorded if the entire group reported a concern, and residents were encouraged to fill out individual grievance forms for quicker resolution. The facility's policy required administrators to attend meetings and document concerns, but this was not followed.
The facility failed to serve food at appropriate temperatures for four cognitively intact residents with various medical conditions. Residents reported that hot items were cold and cold items were warm. A test tray confirmed food temperatures below the required 135 degrees Fahrenheit. The Dietary Manager was unaware of the need to maintain this temperature until delivery, contrary to facility policy.
The facility failed to ensure accurate MDS assessments for two residents, leading to deficiencies in communication and PASRR documentation. One resident's communication abilities were misrepresented, while another's PASRR condition was not accurately documented, despite prior evaluations. Staff interviews confirmed these inaccuracies.
The facility failed to provide adequate nail care and lotion application for two residents, leading to deficiencies in their personal hygiene. A resident with cognitive impairment had long fingernails despite requiring assistance with bathing, while another resident with diabetes and malnutrition had dry, flaky skin and lacked lotion in his room. Staff interviews confirmed the need for better hygiene care and appropriate lotion use.
A resident with a history of traumatic brain injury and dementia did not receive timely podiatry services despite a signed consent form. Observations showed the resident had extremely thick, long, yellowish toenails, and there was no documentation of podiatry consultations in the resident's health record. Interviews confirmed the absence of podiatry services, and the facility's Foot Care policy was not followed.
A resident at risk for falls was observed multiple times without a required mat at the bedside, as specified in their care plan. Despite the care plan's interventions, including a mat on the floor, being initiated, they were not consistently implemented. A CNA was unaware of the reason for the missing mat, highlighting a failure to adhere to the facility's Fall Prevention and Management Policy.
A facility failed to adhere to infection control protocols when a respiratory therapist provided care to a resident with acute respiratory conditions without wearing a gown, as required by the Enhanced Barrier Precaution policy. The resident was under enhanced barrier precautions due to conditions like acute respiratory distress syndrome and tracheostomy. The Regional President of Risk Management acknowledged the lapse in PPE usage.
Two residents experienced environmental deficiencies in their rooms, including a leaky commode, brownish ceiling spots, and a dirty grab bar. The Maintenance Director was unaware of these issues, and cleaning attempts by a CNA were ineffective, highlighting a lack of communication and oversight in maintaining a clean and safe environment.
A resident on anticoagulant therapy for lung cancer and pulmonary embolism was not properly monitored, as the facility failed to conduct daily INR tests as ordered. Despite receiving enoxaparin and warfarin, the resident's medical record lacked a care plan and INR test results. Interviews revealed a missed INR test and a lack of documentation for a delay in testing, leading to a deficiency.
The facility failed to document urine outputs for two residents with urinary catheters, despite physician orders to record every shift. Resident G, with paraplegia and bladder dysfunction, and Resident F, with a neurogenic bladder, both had multiple instances of missing documentation in September 2024. The Assistant DON confirmed the requirement for staff to document outputs every shift, indicating a lapse in care protocols.
A resident with a below the knee amputation reported a verbal altercation with an LPN over pain medication, where the LPN allegedly used offensive language and called the resident a drug addict. The resident's roommate confirmed hearing the argument. The LPN denied the accusations but admitted to calling the resident drug-seeking to another staff member. The incident followed a reduction in the resident's pain medication, which he believed was due to the LPN.
A resident with diabetes and other health conditions experienced elevated blood glucose levels on two occasions, but the facility failed to notify the physician as required. The resident reported self-administering insulin due to missed doses by the facility. Discrepancies in blood glucose readings were also noted without explanation.
A resident with paraplegia experienced swelling in the left thigh/leg, later identified as a hip fracture. The facility delayed reporting the incident to the State Survey Agency, despite policy requiring immediate reporting of such incidents. The fracture was confirmed on an x-ray, but the report was not made until days later, constituting a failure to comply with timely reporting requirements.
A facility failed to thoroughly investigate an abuse allegation involving a resident with fractures and pain. The resident reported that an LPN responded inappropriately to his pain complaints. The investigation lacked statements from key staff, including CNAs and the assigned nurse, violating the facility's abuse policy.
A facility failed to administer medications as ordered for a resident with a leg skin graft, leading to incorrect dosages of oxycodone and early application of a fentanyl patch. Another resident with paraplegia and a fracture experienced delays in scheduling a DEXA scan and orthopedic consultation due to transportation issues and lack of communication, resulting in significant delays in follow-up care.
A resident with multiple fractures experienced inadequate pain management due to the facility's failure to assess and address their pain needs. Despite a care plan outlining both pharmacological and non-pharmacological interventions, the facility did not consistently implement these measures. The resident reported significant pain and dissatisfaction with the nursing staff's response, and the clinical record lacked documentation of pain assessments and interventions.
A resident with a below-the-knee amputation experienced issues with narcotic medication reconciliation and documentation. The facility's records showed discrepancies in oxycodone tablet counts and missing nurse signatures and times. Interviews confirmed errors in the narcotic count sheets, with the administering nurse admitting to forgetting to sign and incorrectly counting remaining tablets.
A facility failed to maintain accurate clinical records for two residents, leading to deficiencies in care. One resident's enteral feeding residuals were incorrectly documented, while another resident's insulin administration and blood glucose readings were inconsistently recorded. The facility did not adhere to its Medication Administration policy, resulting in incomplete records and gaps in care documentation.
Staff Inappropriately Solicits Resident's Personal Property
Penalty
Summary
A facility failed to honor a resident's rights when a staff member, specifically an LPN, approached a resident to inquire about purchasing the resident's personal vehicle. The LPN had noticed a car in the facility parking lot that had not been moved for some time and, after learning it belonged to the resident, directly asked if the vehicle was for sale, stating it was for her daughter to use for college. The resident, who was cognitively intact and had a diagnosis of metastatic breast cancer, expressed concern about staff discussing her personal matters and felt the inquiry was inappropriate, especially given her medical condition. The resident reported feeling upset by the interaction and questioned the appropriateness of staff discussing her situation among themselves. The Executive Director and Director of Nursing confirmed that the action of a staff member attempting to purchase an item from a resident was inappropriate and not in line with resident rights policies. The facility's policy requires that residents be treated with respect and dignity, including the right to retain and use personal possessions. The LPN acknowledged in a written statement that she had inquired about the car and stated she meant no harm. The incident was identified through interviews and record review, and it was determined that the resident's rights to dignity and self-determination were not upheld in this situation.
Failure to Properly Process and Secure Controlled Substance Medication
Penalty
Summary
A controlled substance medication, oxycodone, intended for a resident was delivered to the facility by the contracted pharmacy, but the medication was not properly processed or safely stored. The medication was signed for by an LPN and then handed over to an RN, but there was no subsequent record of the medication in the facility's narcotic logbook. The facility's policies required that controlled substances be processed by two nurses, with a count and proper documentation, but this procedure was not followed. Additionally, the medication was delivered in a white gift bag instead of the facility's standard purple plastic bag used to visually identify controlled substances, which may have contributed to the confusion. The RN who received the medication could not specifically recall receiving it, as he was reportedly distracted by sending another resident to the hospital at the time. Two staff members recalled seeing the RN receive the medication from the LPN, but the medication and associated paperwork were never located. The pharmacy's manifest documentation showed signatures from both the LPN and a second, illegible staff member, but the medication was never entered into the narcotic log or secured as required by policy. The resident for whom the medication was intended did not miss any doses of pain medication, according to the Director of Nursing, and was later sent to the hospital for unrelated medical issues. The facility's investigation found multiple failures to follow established procedures for the receipt and handling of controlled substances, including lack of proper documentation, failure to secure the medication, and deviation from standard delivery protocols.
Deficient Documentation and Administration of Controlled Medications and IV Antibiotics
Penalty
Summary
The facility failed to document and administer controlled medications and intravenous (IV) antibiotics in accordance with physician orders and regulatory requirements for several residents. For one resident with end stage renal disease and opioid dependence, controlled drug administration records for oxycodone were incomplete and illegible, with missing dates, times, and staff signatures. The records showed inconsistencies with the prescribed dosing interval and as-needed administration, and the medication counts did not reconcile with the documented administrations. Similar documentation issues were found for another resident receiving oxycodone, where the count correction lacked a date, time, and signature, and the administration record contained illegible and crossed-out entries. For another resident with hypertension and lymphedema, the facility failed to ensure timely and complete administration of IV ceftriaxone, resulting in two missed doses out of fourteen ordered. Additionally, a newly admitted resident with multiple bowel perforations and intra-abdominal abscesses did not receive timely IV antibiotics and antifungal medications upon admission. Orders for these medications were not entered until the day after admission, leading to missed doses. The resident and her family reported delays in medication administration, and the medication administration record did not reflect the administration of all ordered medications. The facility's controlled drug administration records also lacked proper reconciliation for medications delivered and administered, including missing documentation for narcotic counts and administration of pain medications and sedatives. The facility's policy required shift-to-shift narcotic counts and immediate investigation of discrepancies, but the records reviewed did not consistently meet these requirements. These deficiencies were identified through interviews, record reviews, and review of facility policies.
Failure to Timely and Accurately Administer Admission Medications and Treatments
Penalty
Summary
The facility failed to ensure that admission orders for medications and treatments were entered timely and accurately for two residents. For one resident with diagnoses including anxiety disorder and a right upper humerus fracture, the clinical record showed that several prescribed medications were not administered as ordered upon admission. Specifically, aspirin was initially given at the wrong frequency, clonazepam was not administered at all, and both paroxetine and lorazepam were not started until several days after admission. The resident reported difficulty obtaining medications over the weekend, resulting in missed doses of several prescribed drugs. Another resident, admitted with multiple complex medical needs including bowel perforations, intra-abdominal abscess, candidemia, and requiring total parenteral nutrition (TPN) and IV antibiotics, also experienced delays and omissions in medication administration. The hospital discharge instructions included a comprehensive list of medications and treatments, but upon admission, some orders such as IV antibiotics and TPN were not entered or transmitted to the pharmacy in a timely manner. The resident and her family reported that medications and treatments were not provided as expected, and the resident experienced pain and vomiting while waiting for her medications. Interviews with nursing staff revealed that there were issues with the admission process, including missing pages from the hospital medication list, confusion about which medications needed to be entered, and errors in how orders were entered into the system, resulting in some orders not being sent to the pharmacy. The facility's policy required nurses to execute physician orders or ensure a safe hand-off, but this was not consistently followed, leading to delays and omissions in medication and treatment administration for both residents.
Failure to Timely Obtain and Administer TPN for Resident
Penalty
Summary
A deficiency occurred when the facility failed to timely obtain and administer Total Parenteral Nutrition (TPN) for a resident with diagnoses including perforation of intestine and peritoneal abscess. Upon admission, the resident was alert and oriented and had orders for Clinimix (a form of TPN) and Clinolipid to be administered intravenously. Despite these orders being entered on the day of admission, the TPN was not available or administered until the following day. The resident reported asking staff about her medications and experiencing pain, vomiting, and crying during this period. The resident’s family member also inquired about the missing TPN and IV antibiotics, prompting a nurse to review the medication list and obtain one antibiotic from the emergency drug kit, while the TPN was delivered via STAT order later. The delay was traced to a failure in the medication ordering process, where the TPN order was entered incorrectly and not transmitted to the pharmacy, resulting in no delivery or follow-up communication from the facility to the pharmacy. Interviews with staff and the pharmacy representative confirmed that the pharmacy did not receive the TPN order due to this error, and no notes indicated a STAT request was made on the evening of admission. The facility did not have a policy specific to TPN administration, relying instead on standard practice.
Failure to Timely Address Resident Pain Using Available Medication
Penalty
Summary
A resident with diagnoses including perforation of intestine and peritoneal abscess was admitted to the facility and had an order for oxycodone immediate release 10 mg as needed every six hours for moderate to severe pain. Upon arrival, the resident repeatedly requested her pain medication, reporting significant pain, vomiting, and crying, but was informed by staff that the pharmacy delivery was pending. The resident did not receive her ordered pain medication until the following day, despite continued complaints of pain. Nursing staff were aware of the resident's pain and the outstanding medication order, with one LPN reporting the need to follow up with the pharmacy or utilize the emergency drug kit, which contained the required medication. However, documentation shows that the pain medication was not administered on the day of admission, and the first dose was given the next day after a STAT order was placed. Facility policy required that residents receive pain management in accordance with professional standards, but staff did not utilize available resources to address the resident's pain in a timely manner.
Failure to Ensure Resident Remained Free from Significant Medication Errors
Penalty
Summary
A resident with diagnoses including end stage renal disease, opioid dependence, and chronic pain was not consistently administered the correct narcotic pain medication as ordered by the physician. The resident's care plan required medication to be provided per physician's orders to manage pain. However, review of medication administration records revealed that after an order for oxycodone-acetaminophen (Percocet) was initiated, the resident continued to receive oxycodone 5 mg tablets, for which there was no active order during that period. The records showed 28 administrations of oxycodone 5 mg without a valid order, while the ordered Percocet was not administered as prescribed. Additionally, when the order for oxycodone 5 mg was reinstated, the resident was inconsistently administered the medication as ordered, and there were instances where Percocet was given despite the absence of an active order for it. The facility's policy on controlled drugs required proper removal and destruction of discontinued medications, but the records indicated ongoing administration of discontinued medications. These actions resulted in the resident receiving incorrect narcotic medications on multiple occasions.
Failure to Document Pain Assessments and Non-Pharmacological Interventions
Penalty
Summary
The facility failed to provide safe and appropriate pain management for a resident with significant medical conditions, including cerebral infarction, aphasia, and hemiplegia. The resident was nonverbal and unable to request pain medication independently. Physician orders were in place to monitor pain every shift and to administer oxycodone as needed for moderate to severe pain, and acetaminophen as needed for mild pain. The care plan included the use of non-pharmacological interventions and required pain assessments upon admission, quarterly, with significant changes, and as needed. However, the clinical record did not document the use of non-pharmacological interventions, nor did it consistently record pain levels prior to the administration of as-needed pain medication. Medication Administration Records (MAR) and Controlled Drug Administration Records showed that oxycodone was administered multiple times, but there was a lack of documentation regarding the resident's pain level before administration and the effectiveness of the medication after administration, except for a few instances. There was also no documentation that acetaminophen was ever administered. The care plan interventions, such as repositioning, diversional activities, and other non-pharmacological measures, were not documented as being attempted prior to administering narcotic pain medication. Interviews with the resident's family member and nursing staff revealed that the family had requested scheduled pain medication due to the resident's inability to verbalize pain, and had observed nonverbal signs of pain such as lip biting, grimacing, and tensing up. The staff indicated they relied on family input and observation of facial expressions to assess pain. Despite these observations and requests, the facility did not document the required pain assessments or non-pharmacological interventions, leading to a deficiency in pain management practices for the resident.
Failure to Follow Enhanced Barrier Precautions and Proper Linen Handling
Penalty
Summary
Staff failed to maintain proper infection control practices for a resident who was under enhanced barrier precautions (EBP) due to a tracheostomy, gastric tube, and wounds. During an observation, a certified nurse aide (CNA) provided perineal care to the resident while only wearing disposable gloves and did not don a required disposable gown. The CNA stated she was unaware of the need to wear a gown during incontinent care for this resident, despite the physician's order specifying EBP for activities such as dressing, bathing, transferring, changing linen, providing hygiene, and toileting assistance. Additionally, soiled linen contaminated with feces was observed placed directly on the floor in the resident's room, rather than being properly bagged as required by facility policy. The resident involved was non-verbal, dependent on staff for bed mobility and toileting, and had significant medical conditions including cerebral infarction, aphasia, hemiplegia, and a tracheostomy. Facility policies provided by the clinical nurse consultant confirmed the requirements for gown and glove use during high-contact care and proper handling of soiled linens to prevent infection transmission.
Failure to Address Resident Council Grievances
Penalty
Summary
The facility failed to address grievances reported during resident council meetings for nine residents who attended a meeting. The resident council minutes from November 2024, December 2024, and January 2025 did not reflect any concerns discussed with various departments such as nursing, housekeeping, laundry, business office, activities, and maintenance. During a resident council meeting on January 29, 2025, residents expressed concerns about staff not answering call lights in a timely manner, an issue that had been ongoing without improvement. This concern had not been documented in previous resident council meetings. An interview with the Activities Director revealed that grievances were only recorded in the meeting minutes if the entire group reported a concern. Residents were encouraged to fill out individual grievance forms available throughout the facility for quicker resolution, rather than waiting for the next resident council meeting. The facility's policy, provided by the Regional President of Risk Management, stated that administrators should attend resident council meetings to assure residents that their grievances are important and should document any concerns on a Concern Form to be distributed to the appropriate department head. However, this procedure was not followed, leading to the deficiency.
Failure to Serve Food at Palatable Temperatures
Penalty
Summary
The facility failed to serve food at palatable temperatures for four residents, all of whom were cognitively intact and had various medical conditions such as heart failure, chronic obstructive pulmonary disease, and anxiety disorder. These residents reported that their meals were not served at appropriate temperatures, with hot items being cold and cold items being warm. This issue was confirmed through interviews conducted with the residents, who consistently expressed dissatisfaction with the temperature of their meals. Further investigation revealed that a test tray from the Cambridge Hall food cart had food items at temperatures below the required 135 degrees Fahrenheit. The Dietary Manager (DM) acknowledged that food was served from the steam table at a minimum of 135 degrees Fahrenheit but was unaware that this temperature should be maintained until the food was delivered to the residents' rooms. The facility's policy on food quality and palatability emphasized that food should be prepared and served at safe and appetizing temperatures, but this was not adhered to, leading to the deficiency.
Inaccurate MDS Assessments for Communication and PASRR
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for two residents, leading to deficiencies in communication assessment and Preadmission Screening and Resident Review (PASRR) documentation. For Resident E, the Annual MDS assessment inaccurately indicated that the resident was rarely or never able to understand or make himself understood, despite interviews with the Unit Manager and Social Service Assistant confirming that Resident E could communicate his needs, albeit inconsistently. The Float MDS Coordinator acknowledged that the assessment could have been coded differently to reflect the resident's actual communication abilities. For Resident 28, the facility did not accurately document the resident's PASRR condition in the MDS assessment. Although a PASRR Level II evaluation had been conducted, indicating the presence of a PASRR condition, the Admission MDS assessment failed to reflect this, marking that the resident had not been evaluated by PASRR Level II and did not identify any PASRR conditions. The Corporate MDS Coordinator confirmed the inaccuracy in the MDS assessment, which was not aligned with the facility's policy of using the Resident Assessment Instrument (RAI) for completing MDS assessments.
Deficiencies in Nail Care and Lotion Application for Residents
Penalty
Summary
The facility failed to provide adequate nail care and lotion application for two residents, leading to deficiencies in their personal hygiene. Resident B, who was cognitively impaired and required substantial assistance with bathing, was observed on multiple occasions with long fingernails, indicating a lack of proper nail care. Despite the care plan specifying shower days, the resident's representative expressed concerns about the quality of hygiene care provided. An LPN acknowledged that nail care should be performed on shower days and committed to trimming the resident's nails. Resident E, diagnosed with diabetes and malnutrition, required maximum assistance with personal hygiene and had a history of chronic wounds. Observations revealed dry, flaky skin on his legs and arms, and the resident expressed a desire for lotion, which was not available in his room. Although a care plan included the use of emollient for skin dryness, there was no physician's order for lotion application. A CNA confirmed that Resident E required total assistance with ADL care and did not refuse care. An RN suggested that a different type of lotion might be needed, but the deficiency remained unaddressed.
Failure to Provide Timely Podiatry Services
Penalty
Summary
The facility failed to provide timely foot care to a resident with a history of traumatic brain injury, dementia, chronic pain, and chronic obstructive pulmonary disease. The resident required substantial assistance with activities of daily living, including putting on and taking off footwear. Despite a podiatry consent form signed in May 2023 requesting podiatry services for thickened and painful nails, there was no documentation of any podiatry consultations in the resident's electronic health record. Observations revealed the resident had extremely thick, long, yellowish toenails, with the right big toenail raised a quarter inch from the base, indicating a lack of necessary foot care. Interviews with the Social Services Assistant and Unit Manager confirmed the absence of podiatry consultations for the resident, despite the facility's procedure of faxing consent forms to the podiatry provider. The Unit Manager was unaware of the resident's foot condition and acknowledged the need for podiatry referral. The facility's Foot Care policy indicated that foot care, including trimming of nails, should be performed by nursing personnel or a professional when necessary. However, the facility was unable to verify that the resident received the required podiatry services after signing the consent form.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement care planned fall interventions for a resident identified as being at risk for falls. The resident, who had a history of transient ischemic attack, muscle weakness, and abnormal posture, was observed multiple times without a mat on the floor at the bedside, which was a specified intervention in their care plan. The care plan, dated April 4, 2024, included placing a mat on the floor at the bedside, keeping the bed in the lowest position, and ensuring bed locks were engaged. These interventions were initiated on July 25, 2022, but were not consistently followed. On several occasions, the resident was observed lying in bed without the mat in place, despite the care plan's requirements. A Certified Nurse Aide (CNA) interviewed during the survey was unaware of why the mat was not in use and confirmed that if it was part of the care plan, it should have been implemented. The facility's Fall Prevention and Management Policy, provided by the Regional President of Risk Management, emphasized the importance of care plans to address fall risks, including environmental and medical factors. However, the facility did not adhere to these guidelines, resulting in a deficiency.
Infection Control Breach During Respiratory Care
Penalty
Summary
The facility failed to maintain proper infection control practices during the provision of respiratory care for a resident. Resident 75, who had diagnoses including acute respiratory distress syndrome, tracheostomy, and acute respiratory failure, was under enhanced barrier precautions as per a physician's order. During an observation, a respiratory therapist was seen providing care to the resident without wearing a gown, which is a required component of personal protective equipment (PPE) under the facility's Enhanced Barrier Precaution policy. This policy mandates the use of gowns and gloves during high-contact resident care activities, such as tracheostomy or ventilator care, to prevent the transmission of multi-drug resistant organisms. The Regional President of Risk Management confirmed that the respiratory therapist should have been wearing PPE while providing care.
Environmental Deficiencies in Resident Rooms
Penalty
Summary
The facility failed to maintain a clean and well-repaired environment for two residents, leading to deficiencies in their living conditions. Resident 60's room was observed to have several issues, including a restroom floor initially lacking tile or flooring, brownish spots on the ceiling above her bed, and a ceiling vent cover pulling away from the ceiling. Despite the placement of new flooring, a puddle of water was present due to a leaky commode, which Resident 60 had reported to staff but remained unfixed. The Maintenance Director was unaware of these issues, indicating a lack of communication and oversight in addressing the environmental concerns. Resident 47's room also exhibited cleanliness issues, with a dried tan substance on the grab bar beside her bed. This substance, likely dried food, was not removed despite attempts by a CNA, indicating inadequate cleaning practices. The facility's Resident Rights policy emphasizes providing safe and secure housing and attending to residents' needs, which was not upheld in these instances, leading to the noted deficiencies.
Failure to Monitor Anticoagulant Therapy
Penalty
Summary
The facility failed to ensure proper monitoring of a resident on anticoagulant medications, specifically enoxaparin and warfarin, for one of the three residents reviewed. Resident B, who was diagnosed with lung cancer and a pulmonary embolism, was admitted to the facility with orders to receive enoxaparin injections twice daily and warfarin daily, with daily INR tests to monitor therapeutic levels. However, the resident's medical record lacked a developed care plan for anticoagulant usage and did not include the INR test results as ordered. Interviews with the Assistant Director of Nursing and the Nurse Consultant revealed that the Nurse Practitioner intended for the resident to receive the medications for at least a week before obtaining INR test results, but there was no documentation to support this delay. An order for a daily INR test was placed on 9/19/24 but was missed by the lab technician, leading to a STAT INR test order on 9/20/24. The facility's warfarin monitoring policy outlined procedures for INR monitoring and communication, but these were not followed, resulting in the deficiency.
Failure to Document Urine Output for Residents with Catheters
Penalty
Summary
The facility failed to record urine outputs for two residents utilizing urinary catheters, leading to a deficiency in care. Resident G, diagnosed with paraplegia and neuromuscular dysfunction of the bladder, had orders to measure and record urine output every shift for both a Foley catheter and a urostomy bag. However, the September 2024 Medication and Treatment Administration Records (MAR/TAR) showed multiple instances where urine outputs were not recorded across various shifts. This lack of documentation was noted despite specific physician orders to do so. Similarly, Resident F, who had a neurogenic bladder and a suprapubic catheter, also experienced lapses in urine output documentation. The care plan for Resident F included recording urine output every shift, yet the September 2024 TAR indicated several shifts where this was not done, with some entries marked as not applicable. An interview with the Assistant Director of Nursing confirmed that staff should have been documenting urine output for both residents every shift, highlighting a failure in adhering to the prescribed care protocols.
Failure to Maintain Resident Dignity During Medication Dispute
Penalty
Summary
The facility failed to maintain the dignity of a resident, identified as Resident F, who was cognitively intact and had a diagnosis including below the knee amputation. The incident involved a night shift LPN, referred to as LPN 3, who allegedly used inappropriate language towards Resident F during an interaction about pain medication. Resident F reported that LPN 3 had called him a drug addict and used offensive language, which led to a verbal altercation between them. Resident F's roommate, who has hearing difficulties, confirmed overhearing an argument about pain medication but could not discern all the words exchanged. LPN 3 denied using offensive language directly to Resident F but admitted to referring to him as drug-seeking to another staff member, which Resident F might have overheard. The issue arose after Resident F's pain medications were reduced following a medical procedure, leading to his belief that LPN 3 was responsible for the changes. Another LPN, identified as LPN 11, corroborated that Resident F had expressed concerns about LPN 3's attitude towards him. The Regional Nurse emphasized the importance of staff being respectful when a resident is upset.
Failure to Notify Physician of Elevated Blood Glucose Levels
Penalty
Summary
The facility failed to notify a resident's physician of elevated blood glucose readings as required by the physician's order. Resident C, who has a medical history including diabetes type I, end-stage renal disease, major depressive disorder, and neuropathy, reported that the facility did not administer her insulin on numerous occasions, leading her to use her own supply. The physician's orders specified that the resident should receive Glargine insulin twice daily and Humalog insulin according to a sliding scale, with instructions to call the physician if blood glucose levels exceeded 400 or fell below 70. On two occasions, the facility did not follow these instructions. On July 12, 2024, Resident C's blood glucose reading was recorded at 461, and on July 20, 2024, it was recorded at 425. Despite these elevated readings, there was no documentation indicating that the physician was notified. Additionally, discrepancies in the recorded times and values of blood glucose readings were noted, with no explanations provided. The facility's medication administration policy requires documentation of medication administration and physician contact for critical medications like insulin, which was not adhered to in this case.
Failure to Timely Report Resident's Hip Fracture
Penalty
Summary
The facility failed to report a resident's unusual swelling and subsequent hip fracture to the State Survey Agency in a timely manner. Resident P, who has paraplegia and requires assistance for transfers, experienced swelling in the left thigh/leg, which was later identified as a left hip fracture. The swelling was first noted on 1/29/24, and an x-ray on 1/30/24 confirmed a moderately displaced subtrochanteric hip fracture. Despite this, the facility did not report the incident until 2/2/24, after the fracture was confirmed and Resident P had been sent to the emergency room for evaluation and treatment. The facility's policy requires immediate reporting of incidents that threaten the welfare, safety, or health of a resident, including fractures, within 24 hours of discovery. However, the fracture was identified on 1/31/24, and the report was delayed until 2/2/24. An interview with the Regional Nurse confirmed that the facility should have reported the fracture when the x-ray results were available. This delay in reporting constitutes a failure to comply with the facility's policy and regulatory requirements for timely reporting of significant incidents.
Incomplete Investigation of Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving Resident N, who was cognitively intact and had been admitted with diagnoses including a fractured mandible and fourth metatarsal bone, as well as pain. The incident in question occurred when Resident N reported that a nurse, LPN 3, allegedly responded inappropriately to his complaints of pain by telling him to get back in bed and later refusing to give him his pain medication. The investigation into this incident was incomplete, as it did not include statements from all relevant staff members, such as the certified nursing assistants (CNAs) and the resident's assigned nurse, LPN 6, who was on break during the incident. The investigation file contained several statements, including one from LPN 3, who described Resident N as agitated and aggressive, and claimed that she did not touch the resident but instructed him to return to bed. LPN 3 also mentioned that the resident's pain medication was adjusted, which upset him. Another statement from an unnamed nurse indicated that they did not witness any yelling and had left before the incident occurred. Additionally, MDS staff documented that Resident N expressed concerns about the night shift nurse being rude and refusing medication, which was explained as a result of the facility's admission process. Despite these statements, the investigation was deemed insufficient because it lacked input from CNAs and LPN 6, who was the assigned nurse for Resident N that night. LPN 6 later provided a statement indicating that she was unaware of the interaction between Resident N and LPN 3, as she was on break at the time. The facility's abuse policy requires comprehensive statements from all involved parties, including witnesses, which were not obtained in this case, leading to the deficiency citation.
Medication Administration and Follow-Up Care Deficiencies
Penalty
Summary
The facility failed to administer medications as ordered for Resident F, who had a below-the-knee amputation and underwent a leg skin graft procedure. Despite a physician's order for Resident F to receive 15 milligrams of oxycodone, three tablets, twice a day for pain, the resident only received one tablet at various times. Additionally, the administration of a fentanyl patch was not conducted according to the prescribed schedule, leading to an early application of the patch. These discrepancies were brought to the attention of the staff by Resident F, who reported not receiving the correct dosage of pain medication. For Resident P, who was diagnosed with paraplegia and had an acute distal tibial and fibula fracture, the facility failed to schedule necessary follow-up appointments in a timely manner. Despite orders for a DEXA scan and an orthopedic consultation, there was no evidence that these appointments were scheduled or completed promptly. The DEXA scan was delayed due to transportation issues and lack of communication, resulting in a significant delay in completing the order. The orthopedic appointment was also not scheduled until much later, despite the urgency indicated by the physician's order. These deficiencies were identified during a review of the clinical records and interviews with the residents and staff. The lack of timely medication administration and follow-up care coordination for Residents F and P highlights the facility's failure to adhere to physician orders and ensure appropriate treatment and care for its residents.
Inadequate Pain Management for Resident with Fractures
Penalty
Summary
The facility failed to adequately assess and address the pain management needs of Resident N, who was admitted with multiple fractures and reported significant pain. Upon admission, Resident N was noted to have a pain level of 8 out of 10, with pain occurring every four hours, particularly in the morning and at night. Despite having a care plan that included both pharmacological and non-pharmacological interventions, the facility did not consistently implement these measures. The resident's clinical record lacked documentation of pain assessments, including the location and intensity of pain, and there was no evidence that non-pharmacological interventions were attempted or offered. On the night of admission, Resident N experienced an interaction with LPN 3, where the resident requested pain medication but was told it was not time for the next dose. The resident reported being in pain and expressed dissatisfaction with the response from the nursing staff. The medication administration record indicated that pain medication was administered at 4:00 a.m., but there was no documentation of any pain assessment or alternative interventions being offered prior to this time. The facility's pain management policy emphasizes the importance of resident-centered care and the need for comprehensive pain assessments. However, the staff did not adhere to these guidelines, as evidenced by the lack of documentation and the resident's report of inadequate pain management. The Regional Nurse acknowledged that the staff should have addressed the resident's pain more effectively, highlighting a deficiency in the facility's pain management practices.
Narcotic Medication Reconciliation and Documentation Errors
Penalty
Summary
The facility failed to ensure accurate reconciliation of narcotic medications and proper documentation on the narcotic control record for a resident. The clinical record for a resident, who had a below-the-knee amputation and was cognitively intact, showed a physician's order for 15 milligrams of oxycodone every 4 hours for pain, which was discontinued on a specific date. However, discrepancies were found in the controlled drug administration record, including incorrect tablet counts and missing nurse signatures and times for medication administration. Interviews revealed that the narcotic count sheets were not accurately filled out, with errors in the total remaining tablet counts and missing signatures from the administering nurse. The nurse admitted to forgetting to sign her name after administering the medication and acknowledged an incorrect count of remaining tablets. The facility's medication administration policy required narcotics to be signed out when given, which was not adhered to in this case.
Deficiencies in Clinical Record Documentation for Two Residents
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for two residents, Resident E and Resident C, leading to deficiencies in their care. For Resident E, the clinical records were reviewed and revealed discrepancies in the documentation of enteral feeding residuals. The Medication Administration Record (MAR) showed that staff recorded 'NA' (nonapplicable) for several days instead of actual residual amounts, which was incorrect. Additionally, the recorded amounts on certain days were mistakenly documented as formula totals rather than residuals, indicating errors in the documentation process. For Resident C, the facility did not consistently administer insulin as per the physician's orders, and there were multiple instances where blood glucose readings were not recorded or documented correctly. Resident C, who had a history of diabetes type I and other medical conditions, reported administering her own insulin due to missed doses by the facility. The MAR indicated several instances where blood glucose readings were marked as 'NA' or left blank, and there were no corresponding notes in the clinical record to explain these omissions. This lack of documentation and failure to administer insulin as prescribed led to significant gaps in Resident C's medical records. The facility's Medication Administration policy requires that medications be charted when given, and any medications that are refused, withheld, or not given must be documented. However, the facility did not adhere to these standards, resulting in incomplete and inaccurate records for both residents. These deficiencies were identified during a survey related to specific complaints, highlighting the facility's failure to follow accepted standards of nursing practice in maintaining accurate clinical records.
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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