Aperion Care Arbors Michigan City
Inspection history, citations, penalties and survey trends for this long-term care facility in Michigan City, Indiana.
- Location
- 1101 E Coolspring Ave, Michigan City, Indiana 46360
- CMS Provider Number
- 155156
- Inspections on file
- 48
- Latest survey
- February 10, 2026
- Citations (last 12 mo.)
- 26
Citation history
Health deficiencies cited at Aperion Care Arbors Michigan City during CMS and state inspections, most recent first.
A resident with multiple comorbidities and existing pressure ulcers to both buttocks and the left ischial area had care plan interventions and MD orders for nightly wound care that were not documented as completed on multiple consecutive days. On readmission, nursing documentation stated there were no changes in skin integrity, but the DON later confirmed that no skin assessment was performed that day, and a new wound care regimen ordered the following day was also not signed out on the TAR for two nights. The DON acknowledged that the readmission skin assessment should have been completed the day the resident returned and that ordered treatments should have been signed out.
A resident with severe cognitive deficits and a g-tube experienced a dislodged tube and received new antibiotic orders, but the facility failed to notify the family or representative of these significant changes, despite documentation that the family managed the resident's care.
Three residents did not receive antibiotics or wound care as ordered, including missed doses of prescribed antibiotics and incomplete or undocumented wound treatments. In each case, required documentation was lacking, and staff could not provide explanations for the omissions.
A dependent resident requiring maximal assistance with ADLs, including scheduled showers twice weekly, did not receive documented bathing over a nearly month-long period. The care plan required staff assistance for bathing, but records lacked evidence of completed showers, refusals, or rescheduling attempts when the resident was unavailable or declined care. The DON acknowledged gaps in staff documentation.
A resident with severe cognitive impairment and a right shin skin tear did not receive wound care as ordered when an LPN failed to apply skin prep during a dressing change, despite this being specified in the physician's order.
During a midnight shift, a CNA administered medications to five residents with cognitive impairments after the assigned LPN left due to a medical emergency. The CNA used the LPN's login credentials to document medication administration, despite facility policy requiring only licensed staff to perform this task. The incident was confirmed through staff statements, medication records, and video footage.
Staff on the memory care unit plated and served food using bare hands and transported uncovered food through hallways and dining areas, failing to follow sanitary protocols and facility policy. These actions affected all residents on the unit during multiple meal services.
All residents on the memory care unit experienced uncomfortably cold temperatures after the facility turned off the heat in May, as confirmed by resident and staff interviews and temperature readings as low as 68 degrees. Residents were observed bundled in extra clothing and blankets, and staff acknowledged ongoing difficulties maintaining comfortable temperatures during seasonal transitions.
Two residents with cognitive impairments and psychiatric diagnoses received PRN anti-anxiety medications without documentation that non-pharmacological interventions were attempted beforehand. Staff interviews confirmed that such interventions were expected, and facility policy required alternatives to be incorporated into care plans, but records did not reflect these actions.
A resident with cognitive impairment and physical dependency was repeatedly observed without engagement in activities or sensory stimulation, despite care plans specifying regular one-to-one and group activities. Documentation and observations confirmed missed activity opportunities and a lack of consistent implementation of the resident's activity program.
A wound nurse did not clean a resident's trauma wound with normal saline solution before applying a new dressing, as required by the physician's order. The resident had multiple medical conditions and a care plan specifying wound care procedures, but the nurse omitted the cleaning step during a scheduled dressing change.
A wound nurse applied skin prep to an open pressure ulcer on a resident's hip, contrary to physician orders and standard practice, after observing the wound was open and had dried bloody drainage. The resident had multiple medical conditions and was not cognitively intact, with care plans requiring treatments as ordered. The error was confirmed by clinical leadership, who noted the wound was now a Stage 2 ulcer.
Two residents with limited ROM did not have physician-ordered anti-contracture devices in place as required. One resident with a left hand contracture was repeatedly observed without a palm protector or rolled wash cloth, despite orders and documentation indicating otherwise. Another resident with a contracted hand had no care plan or documentation of the ordered hand guard being applied or refused, and staff confirmed there was no system to record refusals or alternative interventions.
Two residents requiring oxygen therapy did not receive care in accordance with physician orders and care plans, including incorrect flow rates, lack of documentation on the MAR, and failure to document titration as ordered. Observations showed one resident adjusting her own oxygen without documentation, and another resident's oxygen flow rate was not recorded as required.
Expired Admelog and Lantus insulin pens were found on two medication carts during surveyor inspection. An LPN and an RN confirmed the insulins were past the 28-day usage period and should have been discarded. The facility was unable to provide a policy for insulin storage.
Surveyors observed an LPN discarding used lancets into a regular trash can instead of a sharps container during blood glucose testing for a resident, contrary to facility policy. Additionally, a wound nurse placed clean wound care supplies on dirty bedside tables and handled gauze with bare hands without performing hand hygiene before treating two residents with complex medical needs. The nurse consultant acknowledged the concerns.
Staff did not remain in the dining room to supervise residents with dementia and swallowing difficulties during meals, leaving them unsupervised while eating. A resident with dysphagia required supervision or assistance with eating, but staff left the area after serving food, and multiple staff interviews confirmed that supervision was expected but not provided.
The facility failed to provide adequate pressure ulcer care, resulting in the deterioration of ulcers for several residents. A resident's stage two ulcer worsened to stage four due to lack of interventions and physician notification. Another resident experienced delayed antibiotic treatment due to pharmacy communication issues. Additionally, treatments were not consistently documented, and a resident's refusal of care was not addressed with education or physician notification. A quadriplegic resident was not regularly repositioned, contributing to the deficiencies.
The facility failed to provide adequate ADL support and personal care for several residents, leading to issues such as unkempt hair, lack of mobility assistance, and poor hygiene. Residents were observed with greasy hair, dirty fingernails, and wearing the same dirty clothes for days. Care plans were not followed, and refusals of care were not documented, indicating systemic deficiencies in maintaining hygiene and personal care standards.
The facility failed to complete treatments as ordered, assess and monitor bruises, and document hospital transfers. Residents experienced lapses in medication administration and bowel management, and there was inadequate documentation of skin conditions and hospitalizations.
The facility failed to maintain clean and sanitary conditions for medication storage, with multiple medication carts and a storage room found in disarray. Loose pills were observed in the carts, and the storage room had a dirty floor and spillage on cabinets. Staff were unclear about cleaning responsibilities, contributing to the unsanitary conditions.
The facility failed to provide snacks to residents who requested them, as reported by eight residents during a Resident Council meeting. Despite the Dietary Manager's claim that snacks were prepared and delivered daily, CNAs working the second shift indicated that snacks were rarely available, particularly on weekends. The DON confirmed that snacks should be available daily for all residents who requested them.
A LTC facility failed to implement proper infection control practices, including not cleaning equipment after use, improper hand hygiene, and inadequate use of PPE. A resident's pressure ulcers were treated with ointment applied by a gloved hand instead of a sterile applicator. An LPN did not perform hand hygiene or wear an isolation gown while assessing a PEG tube site. A CNA used a soiled washcloth for a resident's gastrostomy tube and urinary catheter care. Additionally, a wound nurse did not change a soiled gown before wound treatment. These actions violated the facility's infection control policies.
The facility failed to maintain the dignity of two residents by allowing them to remain in hospital gowns during the day and posting a personal care sign above one resident's bed. One resident, with a history of pressure ulcers and dementia, was observed in a gown with a sign detailing care instructions, without a care plan addressing these issues. Another resident, with limited clothing and a history of acute kidney failure and dementia, was also observed in a gown, lacking a care plan for clothing preferences. The DON was unaware of these situations.
A resident did not receive medications at their preferred time due to an LPN's failure to administer them after the resident's smoking period. The resident, with a history of high blood pressure, heart failure, and COPD, typically received medications before or after smoking. The LPN disposed of the medications and reported them as refused, without attempting to administer them after smoking, as confirmed by the resident and DON.
A facility failed to assess a resident for self-administration of medications and lacked necessary Physician's Orders for medications found in the resident's room. The resident, who was cognitively intact, had medications including Gas-X, Systane eye drops, and Jet-Alert pills without a recent self-administration assessment or physician authorization. The ADON was unaware of these medications, and the facility's policy requiring a physician's order and assessment was not followed.
A resident reported the loss of two cell phones, but the facility failed to file a grievance form for the first missing phone and did not thoroughly investigate the issue. The resident, who was cognitively intact and had multiple diagnoses, reported the first missing phone to staff, but no grievance was filed. The ADON was aware of the first missing phone but not the second until later. A grievance form for the second phone was eventually filed with social services, but the Director of Social Services only received it on the day of the interview. A Nurse Consultant confirmed that a grievance form should have been filed for the first missing phone.
A resident, who was cognitively intact, was not invited to participate in their care planning conference. Despite having a comprehensive medical history, including kidney disease and dementia, the resident did not attend the meeting, and there was no documentation of an invitation. The Director of Social Services and the DON confirmed the oversight.
A resident at risk for falls due to cognitive impairment and other conditions experienced multiple falls because the facility failed to ensure proper use of Dycem pads in the resident's wheelchair. Observations showed the Dycem was incorrectly placed under the cushion, contrary to care plan interventions and physician's orders. Staff interviews revealed uncertainty about the correct placement of the Dycem, and the facility's Fall Prevention Program was not effectively implemented.
A facility failed to document meal consumption for a resident with a history of weight loss. The resident, who was cognitively impaired and on a mechanically altered diet, lost 8.87% of their weight over three months. The care plan required monitoring and recording of meal intake, but logs lacked documentation for several meals. The DON confirmed that staff should document meal consumption, but no policy was provided.
The facility failed to properly monitor and assess feeding tube sites for two residents. One resident had a peg tube site with drainage and was diagnosed with cellulitis, but there was no documented assessment before or after a doctor's visit. Another resident had redness and irritation around the gastrostomy tube site, which a CNA failed to report to the LPN. The facility lacked a policy for assessing peg tube sites and did not ensure CNAs reported skin changes as required.
The facility failed to provide adequate pain management for two residents due to unavailability of prescribed medications. One resident, with multiple diagnoses including fibromyalgia, experienced missed doses of MS Contin and Oxycodone-Acetaminophen. Another resident, with conditions such as depression and anemia, did not receive Tramadol over a weekend due to a missing prescription script. Staff interviews confirmed the medication shortages, and the DON acknowledged the issue.
A significant medication error occurred when an LPN mistakenly prepared four tablets of Amlodipine instead of the prescribed Furosemide for a resident. The error was identified before administration, preventing the resident from receiving five times the ordered dose of Amlodipine. The resident had a history of high blood pressure, heart failure, and COPD. The facility's policy emphasizes the Five Rights and a triple check process during medication preparation.
The facility failed to manage constipation and wound care for four residents. A resident with dementia did not receive prescribed constipation medication, while another with a toe wound lacked a care plan and consistent treatment. A third resident at risk for skin tears had improperly positioned geri sleeves, and a fourth resident's surgical wound dressing was not changed as ordered. The DON acknowledged these lapses in care.
The facility did not maintain comfortable temperature levels in the main dining room, affecting 7 residents who were observed wrapped in blankets or wearing coats. The temperature varied from 70 to 63 degrees Fahrenheit throughout the room, and residents reported feeling cold. The Director of Maintenance acknowledged the issue and indicated the temperature should be around 70-71 degrees Fahrenheit.
The facility failed to provide adequate ADL assistance for several residents, including bathing, incontinence care, nail care, and oral care. A resident with COPD did not receive the preferred bed baths, while another was left in wet clothing due to inconsistent incontinence care. Additional residents experienced neglect in personal hygiene, such as long, dirty fingernails and infrequent oral care, despite needing assistance due to medical conditions.
A facility failed to ensure a resident had Physician's Orders and an assessment to self-administer medications. The resident was observed with Tums, Tagamet, and Bacitracin in his room without a Care Plan or self-administration assessment. The facility's policy requires written orders from the attending physician for self-administration, which was not followed.
The facility failed to follow wound care orders for two residents with pressure ulcers. An LPN did not apply the correct dressing for a resident with a sacral wound, and another resident's treatment was delayed, leading to worsening of the condition. The Regional Nurse Consultant and Corporate Wound Nurse confirmed these deficiencies.
A facility failed to document meal consumption for a resident with significant weight loss and multiple health conditions, including dementia and stroke. Despite a care plan indicating a nutritional problem, meal logs were incomplete for several dates. The DON confirmed that meal consumption should be documented after each meal.
A resident receiving enteral feeding through a PEG tube was improperly positioned in bed, with the head of the bed lowered to a flat position while the feeding was infusing. The CNA involved acknowledged the error and intended to pause the feeding. The resident's care plan and facility policy required the head of the bed to be elevated at least 30 degrees during feeding.
A resident receiving hemodialysis was not properly monitored for a fluid restriction, as required by their care plan. Despite physician's orders for a 1200 ml fluid restriction per day, the MAR for May and June showed multiple instances of non-compliance without documentation in the progress notes. The DON confirmed that the orders were to be followed, highlighting a failure in adherence to the care plan and documentation protocols.
A facility failed to administer sliding scale insulin and monitor blood sugars as ordered for a resident with type 2 diabetes. The resident's care plan required insulin administration based on a physician's sliding scale order. However, documentation in the MAR was missing for several dates and times. The DON confirmed that monitoring should have occurred as ordered.
The facility failed to maintain accurate records for two residents, leading to deficiencies in monitoring food intake and managing advance directives. One resident's meal logs were incomplete, despite requiring a mechanically altered diet. Another resident had conflicting code status orders, with a DNR preference mistakenly overridden by a full code order. The DON acknowledged these issues.
A facility failed to follow infection control practices when an LPN did not remove PPE before leaving a resident's room under enhanced barrier precautions. The LPN was observed wearing the same gown and gloves outside the room while retrieving supplies, and did not change the gown upon returning. The Regional Nurse Consultant confirmed that PPE should not be worn in the hallway.
The facility failed to administer pain medication as ordered for two residents receiving hospice care. One resident did not receive Tramadol and Norco as prescribed, with nurses citing the resident being asleep as the reason. Another resident received incorrect dosages of morphine sulfate, with improper documentation on the MAR and narcotic count accountability sheet. These deficiencies were confirmed through record reviews and staff interviews.
The facility failed to accurately document and reconcile controlled drugs for a resident receiving hospice care. Discrepancies were found in the documentation of morphine sulfate administration, with missing entries on the narcotic count accountability sheet and inconsistencies between the MAR and the accountability records. The Regional Nurse Consultant confirmed that staff should have documented the correct amount and times of medications administered on both records, as per the facility's policy.
The facility failed to ensure complete and accurate documentation for a resident who passed away under hospice care. Despite measures taken to stabilize the resident and communication with hospice and family, there was no further documentation regarding the resident's status or death. The facility's Regional Nurse Consultant and Administrator acknowledged the lapse in documentation.
Failure to Provide Ordered Pressure Ulcer Treatments and Timely Skin Assessment
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pressure ulcer treatments and to complete a timely skin assessment upon a resident’s readmission. The resident had multiple diagnoses including COPD, respiratory failure, diabetes, arthritis, heart failure, and a history of pressure ulcers, and had documented pressure ulcers to the left buttock, right buttock, and left ischial tuberosity related to immobility, incontinence, obesity, fragile skin, and prior ulcers. A care plan directed staff to provide wound treatments and nutritional supplements and to assist with offloading the lower extremities. Physician’s orders dated 12/11/25 required nightly cleansing of the left and right buttocks with soap and water, application of zinc barrier cream mixed with antifungal ointment, and coverage with bordered gauze. The December 2025 TAR showed these treatments were not signed out on three consecutive days, indicating they were not documented as completed. Upon the resident’s return to the facility on 1/1/26, a nurse’s note documented that the resident arrived via stretcher, could make needs known, and that there were no changes in skin integrity, but the DON later confirmed that a skin assessment was not performed that day. A subsequent physician’s order on 1/2/26 directed nightly wound care with Dakin’s solution, Dakin’s-soaked gauze, calcium alginate, and bordered gauze. The January 2026 TAR indicated this treatment was not signed out on two consecutive nights. During interview, the DON acknowledged that the skin assessment should have been completed on the day of readmission and that the wound treatments should have been signed out, confirming the failure to follow physician’s orders and to complete a timely skin assessment for the resident with pressure ulcers.
Failure to Notify Family of Changes in G-Tube Status and Treatment
Penalty
Summary
A deficiency occurred when the facility failed to notify a dependent resident's family or representative of significant changes related to a dislodged gastrostomy tube (g-tube) and new antibiotic orders. The resident in question had severe cognitive deficits, was dependent for bed mobility and transfers, and had a care plan indicating impaired cognition with the family managing her care. Despite this, the resident was listed as her own responsible party in the facility's records, and her family members were only listed as emergency contacts. On multiple occasions, nurse notes documented significant events, including the dislodgement of the g-tube and the initiation of antibiotic therapy for a g-tube site infection. While the nurse practitioner and physician were notified and the resident was noted as being aware, there was no documentation that the family or representative was informed of these changes. An interview with the Nurse Consultant confirmed that the resident should not have been listed as her own responsible party, as the family was managing her care.
Failure to Administer Antibiotics and Wound Care as Ordered
Penalty
Summary
The facility failed to provide necessary care and treatment as ordered for three residents with infections or wounds. For one resident with severe cognitive deficits and a g-tube, physician orders for two antibiotics were not followed, as the medications were not administered on a specified evening, and there was no documentation or explanation for the missed doses. The nurse consultant was unable to provide further information regarding the omission. Another resident, who was cognitively intact and admitted with a surgical hip wound, did not receive wound care and dressing changes as ordered. Documentation showed incomplete wound assessments, with missing details about the wound's condition and progress. The treatment administration record did not reflect that dressing changes were performed according to physician orders, and weekly wound assessments were not consistently completed as required by facility policy. The nurse consultant confirmed that orders and documentation were not followed as directed. A third resident, also cognitively intact and receiving IV antibiotics for an abdominal abscess, did not receive several scheduled doses of meropenem as ordered. The medication administration record indicated missed doses on multiple occasions, with no explanation or documentation provided for these omissions. The nurse consultant was unable to offer additional information regarding the missed antibiotic administrations.
Failure to Provide Scheduled Showers and Document ADL Care for Dependent Resident
Penalty
Summary
A dependent resident with diagnoses including diabetes, adult failure to thrive, and a chronic non-pressure skin ulcer, who was cognitively intact but required maximal assistance with activities of daily living (ADLs) and transfers, did not receive the required showers or baths as outlined in their care plan. The care plan specified that the resident needed assistance from 1-2 staff members to shower and was scheduled to receive a bath or shower twice weekly, on Tuesday and Friday evenings. Record review revealed a lack of documentation for bathing from July 1 to July 29, with no evidence of bathing or refusals on several scheduled dates, and no documented attempts to reschedule when the resident was unavailable or refused. During interview, the Director of Nursing acknowledged the need for staff education on documentation but did not provide further information.
Failure to Follow Physician's Wound Care Orders
Penalty
Summary
A deficiency was identified when a licensed practical nurse (LPN) failed to complete wound care treatment as ordered for a resident with a non-pressure related skin condition. During direct observation, the LPN cleansed and dressed the resident's right shin skin tear but omitted the application of skin prep, which was specified in the physician's order. The resident involved had diagnoses including dementia and cerebral infarction, was severely cognitively impaired, and was on hospice care. The physician's order required cleansing with normal saline or wound wash, patting dry, applying skin prep, xeroform, and a dry dressing on a set schedule. The LPN acknowledged during interview that the skin prep was not applied during the wound care procedure.
Unlicensed Staff Administered Medications on Midnight Shift
Penalty
Summary
The facility failed to ensure that only licensed and qualified personnel administered medications according to each resident's written plan of care for five memory care residents during the midnight shift. Multiple residents with diagnoses including dementia, hypothyroidism, psychotic disorder, and severe intellectual disabilities received medications that were prepared, poured, and administered by an unlicensed staff member, specifically a CNA, rather than a licensed nurse as required by facility policy and physician orders. Medication administration records showed that medications such as Levothyroxine, Omeprazole, and Carbidopa-Levodopa were signed out under the name of an LPN, but were actually administered by the CNA using the LPN's login credentials. The incident occurred when the assigned LPN on the 100 unit experienced a medical emergency and left the facility, leaving the medication cart keys with a CNA. The CNA contacted the on-call scheduler and was later told that another LPN from a different unit would oversee the 100 unit. The CNA then obtained the LPN's login credentials and proceeded to administer medications to five residents, documenting the administration under the LPN's name. The LPN in question denied providing her credentials, but the CNA's statement and camera footage confirmed that the CNA prepared, poured, and administered the medications. The residents involved were not cognitively intact for daily decision-making, as indicated by their Minimum Data Set (MDS) assessments, and required medications to be administered by licensed personnel according to physician orders. The facility's policy stated that only persons legally authorized could administer medications, but this policy was not followed during the incident. The Director of Nursing confirmed that no staff, including the scheduler, notified her of the situation, and the deficiency was identified through review of records, staff statements, and video evidence.
Food Service Lacked Sanitary Practices on Memory Care Unit
Penalty
Summary
Staff on the memory care unit failed to maintain sanitary conditions during food service, as observed during multiple meal times. Certified Nursing Assistants (CNAs) and a Qualified Medication Aide (QMA) were seen plating and serving food without using proper barriers, such as tongs or gloves, and handled toast with their bare hands. Additionally, food was transported uncovered through hallways and between dining areas, contrary to facility policy and professional standards. These practices were observed during both breakfast and lunch meal services, affecting all residents on the unit. The Dietary Food Manager confirmed that staff were instructed not to touch food with bare hands and that food should be covered during transport. The facility's policy requires all food to be covered when moved from the kitchen to other areas and for items to remain covered until they reach the resident. Despite these guidelines, staff continued to handle food improperly and transport it uncovered, impacting the sanitary conditions of food service for all 27 residents on the memory care unit.
Failure to Maintain Safe and Comfortable Temperatures on Memory Care Unit
Penalty
Summary
The facility failed to maintain comfortable and safe temperature levels for all 27 residents on the memory care unit. Residents reported that the unit had been very cold recently, and staff confirmed that the heat was turned off earlier in May. Observations showed residents in common areas and their rooms dressed in long sleeves, sweaters, and using blankets, with ambient air temperatures ranging from 68 to 71 degrees. The dining room and several resident rooms were specifically noted to be on the lower end of this range, with some rooms as cold as 68 degrees. Staff interviews confirmed that the heating system, which is a boiler system, was routinely shut off in May, and that the facility often struggles to maintain comfortable temperatures during transitional months. Despite staff ordering warming blankets for residents due to the cold weather, these had not yet arrived at the time of the survey. Staff also used a portable heating element behind the nursing station to address the cold, primarily for staff comfort. The Maintenance Director and Administrator acknowledged the limitations of the facility's heating and cooling system and the impact on resident comfort, especially when outside temperatures dropped overnight. The deficiency was identified during a complaint investigation and was substantiated by both resident and staff interviews as well as direct temperature measurements.
Failure to Document Non-Pharmacological Interventions Prior to PRN Psychotropic Medication Administration
Penalty
Summary
The facility failed to ensure that non-pharmacological interventions were documented and attempted prior to administering PRN anti-anxiety medications for two residents. For one resident with diagnoses including major depressive disorder, anxiety, psychotic disorder, dementia, and Parkinson's disease, records showed that Ativan was administered on two occasions without any documentation of non-pharmacological interventions being attempted beforehand. The care plan indicated the use of anti-anxiety medication as needed, but there was no evidence in the medication administration record that alternatives were tried prior to medication administration. The Director of Nursing confirmed that such documentation should have been completed. For another resident with a history of stroke, dementia, psychotic disorder, and other conditions, Lorazepam was administered multiple times for behaviors such as yelling, rambling, and increased anxiety. On each occasion, there was no documentation that non-pharmacological interventions were attempted before giving the medication. Staff interviews confirmed that interventions such as offering food, changing position, or checking for incontinence were expected prior to medication administration, but these were not documented. The facility's policy required that alternatives to psychotropic medication be incorporated into the care plan, but this was not reflected in the records reviewed.
Failure to Provide Ongoing Activity Program for Cognitively Impaired Resident
Penalty
Summary
The facility failed to implement an ongoing activity program to meet the needs of a cognitively impaired and dependent resident. Multiple observations over several days showed that the resident, who has diagnoses including Parkinson's disease and vascular dementia with behavioral disturbance, was frequently in bed with her eyes open, facing the wall, and without any sensory stimulation such as television or music. The resident was also observed seated in a broda chair near the nurses' station but again without engagement in activities. Documentation revealed that the resident was to receive one-to-one visits three times weekly and enjoyed activities such as watching birds, listening to music, coloring, and sensory programming. However, there was no evidence of consistent activity participation or documentation for several days, and the resident was not observed participating in scheduled group activities, such as glamour nails. The resident's care plan and activity assessments indicated a reliance on staff for social, physical, mental, and sensory stimulation, with specific interventions outlined to encourage participation in both group and one-to-one activities. Despite these plans, records and direct observation showed a lack of implementation, with gaps in activity documentation and missed opportunities for engagement. The Activity Director acknowledged the oversight and indicated an intention to address the lack of stimulation, but at the time of the survey, the deficiency remained unaddressed.
Failure to Follow Physician's Wound Care Orders
Penalty
Summary
A wound nurse failed to follow a physician's order for wound care for a resident with a trauma-related wound on the right anterior heel. During a bandage change, the nurse removed the dirty dressing and applied a new dry dressing without first cleaning the wound with normal saline solution (NSS) as specifically ordered by the physician. The resident's medical record indicated diagnoses including after care following joint replacement, COPD, seizures, and obstructive sleep apnea, and the resident was assessed as moderately intact for daily decision making. The physician's order required the wound to be cleaned with NSS, patted dry, covered with a non-adherent pad, and wrapped with kerlix dressing on a set schedule. The care plan also directed staff to administer treatments as ordered and follow facility protocols for skin breakdown prevention and treatment. The nurse indicated she believed she had completed the procedure correctly, despite omitting the required wound cleaning step.
Inappropriate Pressure Ulcer Treatment Provided
Penalty
Summary
A deficiency was identified when a wound nurse failed to provide appropriate treatment for a resident with an existing pressure ulcer. During a treatment observation, the nurse applied skin prep directly to an open pressure ulcer on the resident's right hip, despite skin prep being intended only for intact skin and not for open wounds. The nurse had removed a bandage with dried bloody drainage and noted the wound was red and open, then proceeded to clean the wound with normal saline, pat it dry, and apply the skin prep before covering it with a foam bandage. The nurse indicated this was the first time the wound was open. The resident involved had multiple diagnoses, including stroke, dementia, protein malnutrition, psychotic disorder, osteoporosis, and high blood pressure, and was not cognitively intact for daily decision making. The care plan required treatments to be administered as ordered. Physician orders specified different treatments for the left and right hips, with the right hip to be cleaned, dried, have barrier film applied, and then covered. However, the nurse applied skin prep to the open right hip wound, contrary to the order and standard practice. Interviews confirmed the wound was now a Stage 2 pressure ulcer and that skin prep should not have been used on the open area.
Failure to Provide Physician-Ordered Anti-Contracture Devices for Residents with Limited ROM
Penalty
Summary
The facility failed to ensure that residents with limited range of motion (ROM) had physician-ordered anti-contracture devices in place as required. For one resident with a contracture of the left hand and wrist due to hemiplegia following a stroke, observations on multiple occasions revealed the resident's left hand was closed in a fist without a palm protector or rolled wash cloth in use, despite a physician's order for a palm protector as tolerated. The care plan indicated the resident sometimes refused the splint but would accept a rolled wash cloth, yet neither device was observed in use. Documentation on the treatment administration record indicated the palm protector was applied, but this was not consistent with direct observations. The Director of Nursing confirmed that staff should not have documented the device as applied if it was not in use. For another resident with a history of dementia, osteoarthritis, and stroke, repeated observations showed the resident's left hand was tightly closed without an anti-contracture device in place. Although there was a physician's order for a hand guard as tolerated, there was no care plan addressing the contracted hand, and no documentation on the administration records of the device being applied or refused. Staff interviews confirmed the resident often refused the device, but there was no system in place to document refusals or alternative interventions. The Director of Nursing acknowledged attempts to use alternative devices in the past, but there was no documentation of their use.
Failure to Ensure Safe and Documented Oxygen Therapy
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents who required oxygen therapy. For one resident with diagnoses including psychotic disorder, dementia, COPD, and hypertension, observations showed she was using oxygen at four liters via nasal cannula, despite a physician's order for three liters continuously. The resident was seen adjusting her own oxygen levels, and this change was not documented. Additionally, the Medication Administration Records (MAR) from January through May did not show that oxygen therapy was signed out, and care plans indicated the need to monitor and administer oxygen as ordered. For another resident with diagnoses such as diabetes, asthma, dementia, and depression, observations revealed she was on three liters of oxygen via nasal cannula, with a physician's order to administer oxygen at three liters as needed and to titrate up to four liters to maintain oxygen saturation above 90%. The MAR indicated PRN oxygen was signed out, but there was no documentation of the flow rate as required by the titration order. The care plan required monitoring and use of oxygen as ordered, but the lack of documentation and adherence to the prescribed flow rates contributed to the deficiency.
Expired Insulin Pens Found on Medication Carts
Penalty
Summary
Surveyors observed that the facility failed to ensure proper storage and timely disposal of expired medications on two of five medication carts inspected. On one cart, two Admelog SoloStar insulin pens were found with open dates and expiration dates indicating they were past the 28-day usage period; the LPN present confirmed both pens were expired and should have been discarded. On another cart, a Lantus SoloStar insulin pen was also found to be expired, with the RN present acknowledging it should have been discarded. Additionally, the facility was unable to provide a policy related to the storage of insulins during the survey. These findings demonstrate that expired medications were not removed from active medication carts as required, and there was a lack of documented policy regarding insulin storage.
Infection Control Lapses in Sharps Disposal and Wound Care Supply Handling
Penalty
Summary
The facility failed to implement proper infection control practices during blood glucose monitoring and wound care procedures. In one instance, an LPN performed a blood sugar check for a resident and discarded used lancets into a regular garbage can instead of a designated sharps container, despite facility policy requiring sharps to be disposed of in a non-porous hazardous waste container marked with the biohazard symbol. The LPN acknowledged the error during an interview. Additionally, during wound care for two residents, a wound nurse placed clean treatment supplies directly onto dirty bedside tables that were littered with crumbs and personal belongings. In one case, the nurse handled clean gauze with bare hands and did not perform hand hygiene after leaving and returning to the treatment cart. Supplies were then placed on the unclean table before being moved to a clean drape. Both residents involved had significant medical histories, including pressure ulcers and chronic conditions, and required substantial assistance with mobility and care. The nurse consultant confirmed awareness of the concerns but did not provide further information.
Failure to Supervise Memory Care Residents During Meals
Penalty
Summary
Staff failed to provide adequate supervision to residents in the memory care unit during meal times, resulting in residents being left unsupervised while eating. On two separate lunch meal observations, staff members served food to the residents and then left the dining room, leaving all residents, including one with dysphagia and dementia, without supervision. At various times, staff such as CNAs, LPNs, and QMAs entered the dining room briefly but did not remain to supervise the residents as they ate. There were periods when no staff were present in the dining room while residents were consuming food and beverages. A review of the medical record for one resident revealed diagnoses of dysphagia and dementia, with an assessment indicating the need for supervision or assistance with eating. A family member reported concerns about the lack of supervision during meals, expressing fear that a resident could choke. Interviews with staff and administration confirmed that staff were expected to remain in the dining room during meals, but this did not occur on the observed dates.
Deficiencies in Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to provide effective pressure ulcer care and prevent the deterioration of existing ulcers for several residents. Resident F was readmitted with a stage two pressure ulcer on the coccyx, which deteriorated to a stage four ulcer requiring surgical debridements. The facility did not implement interventions for pressure relief, failed to notify the physician of the wound's deterioration, and did not ensure treatments were signed out as completed. Additionally, antibiotics for a wound infection were not started promptly, and the physician was not notified of treatment refusals. Resident E, who had a history of stroke and vascular dementia, had a stage four pressure ulcer on the coccyx that worsened. The facility delayed the initiation of an antibiotic treatment due to a lack of communication with the pharmacy regarding the availability of the medication. The treatment was not started until three days after it was ordered, and there was no documentation of the conversations with the pharmacy or the change in medication form. Resident T had multiple pressure ulcers, and the facility failed to document the completion of treatments on several occasions. Resident O, who was cognitively intact, refused wound treatments, but there was no documentation of physician notification or education provided to the resident about the importance of the treatments. Resident H, who was quadriplegic, was not regularly turned and repositioned, as indicated by the resident's statements and observations. The facility's inaction and lack of documentation contributed to the deficiencies in pressure ulcer care.
Deficiencies in ADL Support and Personal Care
Penalty
Summary
The facility failed to ensure that activities of daily living (ADLs) were adequately completed for several dependent residents, leading to various deficiencies in personal care. Resident Q was observed with greasy, unkempt hair and a strong urine odor, indicating a lack of timely incontinence care. Despite being cognitively impaired and requiring substantial assistance, the resident's care plan was not followed effectively, as evidenced by the resident's refusal of showers and the staff's failure to maintain hygiene standards. Resident P was observed in bed for several days without being assisted into her wheelchair, despite her care plan indicating the need for substantial assistance with transfers. This lack of mobility assistance was acknowledged by the Director of Nursing, who confirmed that the resident had not been helped out of bed all week. Similarly, Resident G was found with dirty fingernails and a dried substance on her face, highlighting a failure in personal hygiene care. The resident's care plan did not document any refusal of care, and the staff did not maintain cleanliness standards. Other residents, such as Resident C, had long fingernails digging into their palms, and Resident F had long facial hair, both indicating a lack of personal grooming. Resident H was given a bed bath without assistance, resulting in the resident's face hitting a call light, which was against the care plan's instructions to prevent injury during transfers. Resident R was observed wearing the same dirty shirt for several days, with greasy hair and dried blood under the nails, despite being cognitively intact and requesting a shower. These observations collectively demonstrate a systemic failure in providing adequate ADL support and personal care to the residents.
Deficiencies in Treatment, Medication Management, and Documentation
Penalty
Summary
The facility failed to ensure that treatments were completed as ordered and that bruises were assessed and monitored for several residents. For instance, a resident with a scabbed area below the right knee and discoloration on the right lower shin did not have the prescribed dressing applied, and there was no assessment of the discoloration. Additionally, medications were not signed out as administered on multiple occasions, indicating a lapse in medication management. Another resident experienced prolonged periods without bowel movements, yet the facility did not initiate the bowel protocol as required by their policy. This resident, who was on opioid medication, was at risk for constipation, but there was no documentation of any as-needed laxatives being administered during the periods of constipation. Similarly, other residents had bruises and skin conditions that were not assessed or documented, despite being on medications that increased the risk of such conditions. Furthermore, the facility failed to document the condition and reason for hospitalization for a resident who was transferred to the hospital multiple times. There was no record of assessments or notifications to family or physicians regarding the resident's condition prior to transfer. This lack of documentation and monitoring highlights significant deficiencies in the facility's care and record-keeping practices.
Improper Medication Storage and Sanitation Issues
Penalty
Summary
The facility failed to ensure medications were stored in clean and sanitary conditions across multiple medication carts and a storage room. Observations revealed that medication carts on the 200, 300, and 400 halls contained multiple loose pills of various sizes and colors in the bottoms of the drawers, indicating improper storage and potential contamination. Staff members, including an LPN, a QMA, and RNs, were observed with these carts and expressed uncertainty about who was responsible for cleaning them. This lack of clarity contributed to the unsanitary conditions observed. Additionally, the medication storage room on the 200 hall was found to be in a state of disrepair and uncleanliness, with a visibly dirty floor, missing tiles, exposed adhesive, trash, and dark-colored spillage on the cabinet doors. The QMA accompanying the surveyor was unaware of the cleaning responsibilities for the room, noting that housekeeping did not have access to it. The Director of Nursing and a Nurse Consultant were informed of these findings, with the DON expressing uncertainty about the cleaning responsibilities for the medication storage rooms.
Failure to Provide Snacks to Residents
Penalty
Summary
The facility failed to ensure that snacks were available for residents who requested them, affecting all eight residents who attended a Resident Council meeting. These residents, who were cognitively intact for daily decision-making, reported that they never received snacks when they asked for them. The Dietary Manager stated that snacks were prepared daily and delivered by 7:30 p.m., with enough for every resident, but CNAs working the second shift reported that snacks were rarely available, especially on weekends. The Director of Nursing confirmed that snacks should be available every day for all residents who requested them.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement proper infection control practices in several instances. During a random observation, a CNA used a Hoyer lift to transfer a resident without cleaning it afterward. Additionally, a wound nurse applied ointment to a resident's pressure ulcers using her gloved hand instead of a sterile applicator. The resident had multiple health issues, including morbid obesity, diabetes, and pressure ulcers. The nurse consultant acknowledged that the wound nurse should have used a different method to apply the ointment. In another instance, an LPN did not perform hand hygiene before and after glove removal while assessing a resident's PEG tube stoma site. The LPN also failed to wear an isolation gown as required by the facility's Enhanced Barrier Precautions policy. The resident had a PEG tube and was not cognitively intact, relying on the tube for nutrition. The Director of Nursing confirmed the LPN's awareness of the proper procedures but did not provide additional information. Further observations revealed a CNA using a soiled washcloth to clean a resident's gastrostomy tube site and urinary catheter, without changing gloves or water. The resident had quadriplegia and a stage 4 pressure ulcer. Additionally, a wound nurse did not change her soiled gown before starting a wound treatment after providing incontinence care to another resident. The nurse consultant expected a gown change, but the wound nurse was unaware of the soiling. These incidents highlight the facility's failure to adhere to infection control policies, as confirmed by staff interviews and policy reviews.
Failure to Maintain Resident Dignity in Attire and Personal Care
Penalty
Summary
The facility failed to maintain the dignity of two residents, identified as Residents P and F, by allowing them to remain in hospital gowns during the day while in bed, and by posting a personal care sign above Resident P's bed. Resident P was observed multiple times over several days wearing a hospital gown and having a sign above her bed that detailed specific care instructions. Her medical history included pressure ulcers, major depressive disorder, and dementia, and she required significant assistance with dressing. Despite these needs, there was no care plan addressing her attire or the presence of the sign, and the Director of Nursing acknowledged that the resident should have been dressed and the sign removed. Similarly, Resident F was observed in a hospital gown during the day on multiple occasions. This resident had a medical history of acute kidney failure, diabetes, and dementia, among other conditions, and required assistance with personal hygiene and dressing. The resident's care plan did not reflect any preference for wearing a hospital gown during the day. A CNA noted that the resident had limited clothing, which was provided by the social service department, and the Director of Nursing was unaware of the resident's attire situation, indicating a lack of a care plan for the resident's clothing preferences.
Failure to Administer Medications at Resident's Preferred Time
Penalty
Summary
The facility failed to ensure a resident's right to participate in his care by not administering medications during the resident's preferred time window. On the morning of December 11, 2024, an LPN prepared a set of medications for a resident who was outside smoking. The medications included Amlodipine Besylate, Furosemide, Losartan Potassium-HCTZ, Aspirin, Flomax, Metformin, Sertraline HCl, Trelegy Ellipta, Metoprolol Tartrate, and Potassium Chloride. The LPN attempted to deliver the medications to the resident at the smoking area, but the resident indicated he had just started smoking. Instead of waiting to administer the medications after the resident finished smoking, the LPN disposed of the medications and reported to the Nurse Practitioner that the resident had refused his morning medications. The resident's medical record indicated a history of high blood pressure, alcohol use, heart failure, COPD, and tobacco use. The Medication Administration Record for December 2024 noted the resident's refusal of morning medications on December 11, 2024, without evidence of an attempt to administer them after the smoking period. Interviews with the resident and the Director of Nursing revealed that the resident typically received medications before or after smoking, which was his preference. The Director of Nursing acknowledged the importance of the smoking time to residents and indicated that the nurse should have offered the medications before or after the designated smoking time.
Failure to Assess and Authorize Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident was properly assessed for self-administration of medications and lacked the necessary Physician's Orders for the medications observed in the resident's room. Resident 60, who was cognitively intact according to the Quarterly Minimum Data Set assessment, was observed with a package of Gas-X, Systane eye drops, and a bottle of Jet-Alert pills on a shelving unit in her room. Despite the resident's indication that she used the Systane eye drops and would use Gas-X as needed, there was no recent medication self-administration assessment completed to confirm her ability to safely self-administer these medications. The Medications Self-Administration Assessment dated several months prior indicated that the resident was unable to safely self-administer her medications. The Assistant Director of Nursing (ADON) was unaware of the medications in the resident's room and confirmed that there were no Physician's Orders for these medications. The facility's policy requires a written order from the attending physician and a completed self-administration assessment to permit a resident to administer or retain medications in their room, which was not adhered to in this case.
Failure to File and Investigate Grievances for Missing Personal Items
Penalty
Summary
The facility failed to properly file a grievance form, thoroughly investigate, and resolve grievances related to missing personal items for a resident. Resident S reported the loss of two cell phones, with the first phone reported to staff at the nurses' station. However, no grievance form was filed for the first missing phone. The resident was cognitively intact, as indicated by the Quarterly Minimum Data Set assessment, and had diagnoses including anxiety, respiratory failure, kidney disease, and depression. The Assistant Director of Nursing (ADON) on the 300 Unit was aware of the first missing phone but was not informed about the second missing phone until later. A grievance form for the second missing phone was eventually filed with social services. The Director of Social Services confirmed that she received the grievance form for the missing phone only on the day of the interview. A Nurse Consultant indicated that a grievance form should have been filed for the first missing phone, highlighting the facility's failure to adhere to its grievance policy.
Resident Not Invited to Care Plan Conference
Penalty
Summary
The facility failed to ensure that a resident was invited to attend and participate in their care planning conference. Resident U, who was cognitively intact for daily decision-making as indicated by the Quarterly Minimum Data Set (MDS) assessment, reported not attending a care plan meeting. The resident's medical history included kidney disease, asthma, respiratory failure, depression, and dementia. A Care Plan Progress Note documented a meeting between the Director of Social Services and the resident's son regarding the resident's quarterly assessment, but there was no evidence that the resident was invited to or attended the care conference. Interviews with the Director of Social Services and the Director of Nursing confirmed that the resident was not invited to the care plan conference, which was an oversight.
Failure to Implement Fall Precautions for Resident
Penalty
Summary
The facility failed to ensure fall precautions were in place for Resident J, who was at risk for falls due to cognitive impairment and other medical conditions such as hypertension, dementia, and depression. Observations revealed that the resident's wheelchair had a Dycem pad placed incorrectly underneath the cushion, rather than on top, which was intended to prevent the resident from sliding off the wheelchair. This improper placement of the Dycem pad was identified as the root cause of two previous falls, one of which resulted in a major injury. Despite a physician's order and care plan interventions specifying the use of Dycem in the wheelchair, staff were unsure of its correct placement, leading to inadequate fall prevention measures. Interviews with staff, including CNAs and an LPN, indicated a lack of clarity and education regarding the proper use of Dycem pads. The Director of Nursing acknowledged that staff did not consistently check the presence and correct placement of the Dycem pad, contributing to the resident's falls. The facility's Fall Prevention Program policy required safety interventions for residents at risk, but these were not effectively implemented or maintained, as evidenced by the repeated incidents involving Resident J.
Failure to Document Meal Consumption for Resident with Weight Loss
Penalty
Summary
The facility failed to ensure that food consumption logs were completed for a resident with a history of weight loss. Resident 3, who had diagnoses including dementia, hypertension, anxiety, bipolar disorder, and schizophrenia, was cognitively impaired and required partial to moderate assistance for eating. The resident was on a mechanically altered therapeutic diet. The care plan for the resident, which was revised on 12/22/21, included interventions to monitor and record meal intake and report any significant weight loss to the physician. Despite these interventions, the resident experienced an 8.87% weight loss over three months, dropping from 191.6 lbs to 174.6 lbs. The Task Nutrition-Amount Eaten Logs lacked documentation for several meals over the last 30 days, including breakfast and lunch on 12/3/24 and multiple dinners in November and December. During an interview, the Director of Nursing confirmed that staff should document the amount eaten for every meal, but no facility policy was provided for meal consumption logs.
Failure to Monitor and Report Feeding Tube Site Conditions
Penalty
Summary
The facility failed to ensure proper monitoring, assessment, and cleaning of feeding tube sites for two residents, Residents C and H. For Resident C, during an observation, it was noted that the peg tube stoma site had a bandage that was sticking to the skin, requiring saline to remove it. The stoma site was clean but had a moderate amount of drainage. The resident's care plan required monitoring and documentation of infection at the tube site, but there was no documented assessment of the peg tube stoma site before or after a doctor's visit for a possible infection. The resident was diagnosed with cellulitis at the gastrostomy tube site and was prescribed antibiotics, but the facility lacked a policy regarding assessing the peg tube site. For Resident H, during a bed bath, a CNA observed redness and irritation around the gastrostomy tube site but failed to report it to the LPN before leaving the building. The resident's care plan required CNAs to report any changes in skin status, and the facility's bed bath policy also required reporting of any reddened areas or skin discoloration. The Director of Nursing was informed of the findings but had no further information to provide.
Deficiency in Pain Medication Availability for Residents
Penalty
Summary
The facility failed to ensure the availability of pain medications for two residents, leading to deficiencies in pain management. Resident K reported issues with the facility running out of her scheduled pain medications. Her medical record indicated she had multiple diagnoses, including fibromyalgia and major depressive disorder, and was prescribed MS Contin and Oxycodone-Acetaminophen for pain management. However, the Medication Administration Record (MAR) showed instances where these medications were not administered due to unavailability, as confirmed by the Director of Nursing. Similarly, Resident 101 experienced a lack of pain medication over a weekend, resulting in unmanaged pain. Her diagnoses included depression, anxiety, and anemia, and she was prescribed Tramadol for pain. The MAR indicated that Tramadol was not administered on two consecutive days. Interviews with staff revealed that the medication was ordered but not available due to a missing prescription script, which required the physician's intervention. The Director of Nursing acknowledged the issue but had no further information to provide.
Significant Medication Error Due to Incorrect Drug Dispensing
Penalty
Summary
The facility failed to ensure medications were administered as ordered, resulting in a significant medication error for one resident. During a medication administration observation, an LPN prepared a dose of Furosemide 40 mg for a resident but mistakenly dispensed four tablets of Amlodipine 10 mg instead. The LPN realized the error before administering the medication, noting that she had prepared five times the resident's ordered dose of Amlodipine. The LPN then disposed of the entire cup of pills. The resident involved had a medical history that included high blood pressure, alcohol use, heart failure, COPD, and tobacco use. The resident's physician orders included Furosemide 40 mg, one tablet daily, and Amlodipine Besylate 10 mg, one tablet daily. The Director of Nursing was aware of the medication error and was following up with the LPN. The facility's medication administration policy emphasizes the importance of the Five Rights and recommends a triple check process during medication preparation.
Deficiencies in Constipation and Wound Care Management
Penalty
Summary
The facility failed to provide appropriate treatment and care for four residents, leading to deficiencies in managing constipation and wound care. Resident 20, who had multiple diagnoses including dementia and chronic pain, was at risk for constipation due to decreased mobility and opioid use. Despite having physician's orders for Milk of Magnesia and Docusate Sodium to manage constipation, the Medication Administration Record indicated that the Milk of Magnesia was not administered from June 17 to June 22, 2024. The Director of Nursing was unable to provide additional information regarding this lapse in care. Resident C, who was cognitively intact and had a new wound on his left great toe, did not have a care plan for his arterial ulcer. Although a treatment order for Bacitracin was obtained and later changed to Skin Prep, the Treatment Administration Record showed that the Skin Prep was not consistently applied as ordered. The Director of Nursing acknowledged that treatments were to be completed as ordered, but there were gaps in the administration of the prescribed care. Resident 45, who was at risk for skin tears and bruising, was observed multiple times with improperly positioned geri sleeves, and on one occasion, without any sleeves. The care plan indicated that geri sleeves should be provided to protect her fragile skin, but the records showed inconsistent documentation of their use. Additionally, Resident 329, who had a surgical wound on her head, reported that her dressing was not changed as ordered after returning from the hospital. Despite the Treatment Administration Record indicating daily dressing changes, observations confirmed the absence of a dressing. The Assistant Director of Nursing noted that the wound had closed, and the order should have been reconciled, while the Director of Nursing acknowledged the discrepancy in the treatment records.
Failure to Maintain Comfortable Temperature in Dining Room
Penalty
Summary
The facility failed to maintain comfortable and safe temperature levels in the main dining room, affecting 7 out of 14 residents during a random observation. On the specified date, the ambient air temperature in the dining room was observed to be cool, with several residents wrapped in blankets or wearing coats while waiting for their meal. The thermostat on the wall showed a temperature of 68 degrees Fahrenheit. The Director of Maintenance was asked to check the temperature, which registered 70 degrees Fahrenheit at the entrance, 68 degrees Fahrenheit five feet into the dining room, 65 degrees Fahrenheit an additional five feet in, and 63 degrees Fahrenheit at the back of the dining room. During interviews, seven residents expressed feeling cold, and the Director of Maintenance acknowledged the need to adjust the temperature, indicating it should be around 70-71 degrees Fahrenheit.
Deficiencies in ADL Assistance and Personal Hygiene Care
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL) for several residents, leading to deficiencies in care. Resident B, who required maximum assistance for bathing due to conditions such as COPD and an above-knee amputation, did not receive the preferred bed baths twice a week as documented. The bath sheets indicated that the resident only received a bath on three occasions in June, contrary to the care plan that specified a bed bath every Tuesday and Friday evening. Resident E, who was incontinent and required substantial assistance for toilet hygiene, was not changed promptly after incontinence episodes. Observations revealed that the resident was left in wet clothing for extended periods, and documentation of incontinence care was inconsistent and incomplete. The Director of Nursing acknowledged that the resident should have been checked or changed every two hours, but the task section for urinary incontinence was not completed by the staff. Residents C, D, and F also experienced deficiencies in personal hygiene care. Resident C had long, dirty fingernails despite needing assistance for personal hygiene due to hemiplegia. Resident D, who was totally dependent on staff for personal hygiene, did not receive oral care consistently, with documentation showing infrequent entries. Resident F was observed wearing a hospital gown with dirty fingernails and food debris, despite having a care plan that included preferences for choosing clothing and personal hygiene. The Director of Nursing confirmed that these residents should have received appropriate care as per their care plans.
Failure to Ensure Physician's Orders for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident had the necessary Physician's Orders and an assessment to self-administer medications. During multiple observations, a resident was found with a bottle of Tums, a package of Tagamet, and a tube of Bacitracin in his room. The resident, who was cognitively intact according to the latest MDS assessment, indicated he used Tums for heartburn. However, there was no Care Plan or self-administration assessment completed for this resident, and no Physician's Orders for the medications were present. The facility's policy requires written orders from the attending physician for a resident to self-administer or retain medications in their room, which was not adhered to in this case.
Failure to Follow Wound Care Orders for Pressure Ulcers
Penalty
Summary
The facility failed to ensure that wound care treatments were completed as ordered and initiated in a timely manner for two residents with pressure ulcers. For Resident 123, an LPN was observed applying a dry dressing to a sacral wound, contrary to the physician's order which required cleansing with normal saline, application of Calcium Alginate, and covering with a dry dressing. The resident had a history of stroke, acute kidney failure, and alcohol withdrawal delirium, and was admitted with a Stage 2 pressure ulcer that progressed to Stage 4. The Regional Nurse Consultant confirmed that the treatment should have been completed as ordered. For Resident 45, the facility did not initiate the recommended treatment for a pressure ulcer in a timely manner. The resident, who had vascular dementia and received nutrition through a peg tube, developed a pressure ulcer on the coccyx. The Wound Physician recommended a new treatment involving Calcium Alginate, but this was not initiated at the time of the recommendation. The resident's pressure sore worsened, as noted in subsequent assessments. The Corporate Wound Nurse acknowledged the delay in initiating the treatment.
Failure to Document Meal Consumption for Resident with Weight Loss
Penalty
Summary
The facility failed to ensure meal consumption logs were completed for a resident with a history of significant weight loss. Resident 83, who has diagnoses including dementia, stroke, anemia, and major depressive disorder, was observed eating breakfast in the dining room. The resident's record indicated a significant weight loss from 152 pounds on April 8, 2024, to 143 pounds on May 7, 2024, a 5.92% decrease in one month. Despite this, there was a lack of documentation in the meal consumption logs for several dates in May and June 2024, covering breakfast, lunch, and dinner meals. The Director of Nursing confirmed that food consumption documentation was expected to be completed after every meal.
Improper Positioning During Enteral Feeding
Penalty
Summary
The facility failed to ensure that a resident was positioned correctly while receiving enteral feeding through a PEG tube. During an observation, Resident 45 was found lying in bed with the head of the bed elevated while the enteral feeding was infusing at 52 ml per hour. However, a CNA was observed lowering the head of the bed to a flat position while the feeding was still infusing, which is against the facility's policy and the resident's care plan. The CNA acknowledged the mistake and indicated she would get a nurse to pause the feeding. Resident 45's medical record indicated diagnoses including vascular dementia, PEG tube, anxiety, anemia, abnormal weight loss, major depressive disorder, and dysphagia. The resident was not cognitively intact for daily decision-making and received at least 50% of her nutrition through a PEG tube. The care plan required the head of the bed to be elevated at least 30 degrees during feeding. The Director of Nursing confirmed that the resident's head of the bed should not have been lowered while the feeding was infusing, and the facility's policy also required the head of the bed to be elevated at least 30 degrees during feeding.
Failure to Monitor Fluid Restriction for Dialysis Resident
Penalty
Summary
The facility failed to adequately monitor a fluid restriction for a resident receiving hemodialysis, identified as Resident 230. The resident's medical history included renal dialysis, type 2 diabetes, high blood pressure, vascular dementia, anemia, and stroke. The resident was cognitively intact and received hemodialysis three times a week, with a care plan that included a 1200 cc fluid restriction as per nephrology orders. The physician's orders specified a fluid restriction of 1200 ml per 24 hours, divided between dietary and nursing allocations, with instructions to document compliance or non-compliance in the progress notes every shift. However, the Medication Administration Record (MAR) for May and June 2024 showed multiple instances where the resident did not stay within the fluid restriction, marked with an 'N', but there was no documentation in the progress notes explaining the reasons or notifications for these occurrences. The Director of Nursing confirmed that the physician's orders regarding the fluid restriction were to be followed as ordered, indicating a lapse in adherence to the prescribed care plan and documentation requirements.
Failure to Administer Sliding Scale Insulin and Monitor Blood Sugars
Penalty
Summary
The facility failed to ensure that sliding scale insulin was administered as ordered and that blood sugar levels were monitored for a resident with type 2 diabetes. The resident, who was cognitively intact, had a care plan indicating insulin dependency and required administration of diabetes medication as ordered. A physician's order specified a sliding scale for insulin administration based on blood sugar levels, with instructions to call the physician if levels were below 60 or above 400. However, the Medication Administration Record (MAR) for April 2024 showed that the resident's sliding scale insulin administration and glucometer results were not documented on several occasions, including specific dates and times. During an interview, the Director of Nursing acknowledged that the resident's blood sugars and insulin administration should have been monitored as ordered.
Incomplete Records and Conflicting Advance Directives
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for two residents, leading to deficiencies in monitoring food consumption and managing advance directives. For one resident with diagnoses including Parkinson's, anxiety, dementia, depression, and hyperlipidemia, the facility did not document meal consumption consistently. The resident required a mechanically altered diet and had interventions in place to monitor intake and alert the dietician if consumption was poor. However, meal logs for several days were incomplete, with missing documentation for breakfast and dinner meals. The Director of Nursing acknowledged the concern but did not provide additional information. In another case, a resident with multiple diagnoses, including pneumonia, diabetes, and heart failure, had conflicting orders regarding their code status. The resident, who was cognitively intact, had a POST form indicating a Do Not Attempt Resuscitation (DNR) status. However, a full code order was mistakenly entered after the resident returned from the hospital. The Assistant Director of Nursing confirmed the error, and the Director of Nursing noted that the advance directive order should have been clearer.
Infection Control Breach During Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure proper infection control practices were followed during a random infection control observation involving a resident under enhanced barrier precautions. A CNA was observed performing incontinence care for the resident, while an LPN entered the room, donned a gown and gloves, and placed the resident's tube feeding pump on hold. During this care, the resident's sacrum dressing was noted to be soiled. The LPN left the resident's room to retrieve wound care supplies without removing her gown and gloves, and was observed at the treatment cart near the nurses' station still wearing the same PPE. Upon returning to the resident's room, the LPN changed her gloves but not her gown before completing the treatment. The Regional Nurse Consultant later confirmed that the LPN should have removed her gown and gloves before leaving the resident's room, as PPE is not to be worn in the hallway.
Failure to Administer Pain Medication as Ordered
Penalty
Summary
The facility failed to ensure pain medication was administered as ordered by the Physician for two residents receiving hospice care. Resident D, who had multiple diagnoses including breast cancer and Alzheimer's dementia, was prescribed Tramadol and later Norco for pain management. However, the Medication Administration Record (MAR) indicated that these medications were frequently not administered as ordered, with nurses documenting that the resident was asleep as the reason for not administering the medication. The Nurse Consultant confirmed that nurses were instructed not to hold pain medication when residents were sleeping, yet this instruction was not followed consistently. Resident E, who had diagnoses including heart failure and end-stage renal disease, was also not administered pain medication as ordered. The resident's Physician's Orders included various dosages of morphine sulfate for pain management. However, the MAR and narcotic count accountability sheet showed discrepancies in the administration of the medication, with incorrect dosages being given and improper documentation. The Regional Nurse Consultant acknowledged that the staff failed to document the correct amount of medication administered on both the MAR and the narcotic count accountability sheet. These deficiencies highlight a failure in the facility's pain management protocols, particularly in ensuring that pain medications are administered as prescribed and properly documented. Both residents experienced lapses in their pain management due to these failures, which were identified through record reviews and staff interviews conducted by the surveyors.
Failure to Accurately Document and Reconcile Controlled Drugs
Penalty
Summary
The facility failed to establish and maintain a system that accurately accounted for, periodically reconciled, and ensured the disposition of all controlled drugs. This deficiency was identified through record review and interview, specifically related to the incomplete and inaccurate documentation of narcotic medications for a resident receiving hospice care. The resident had multiple diagnoses, including heart failure, hypertension, diabetes mellitus, end-stage renal disease, and anxiety. The resident's Minimum Data Set (MDS) assessment indicated death in the facility, and a nurse's note detailed the resident's unresponsive state and subsequent hospice care intervention. However, discrepancies were found in the documentation of morphine sulfate administration, with missing entries on the narcotic count accountability sheet and inconsistencies between the Medication Administration Record (MAR) and the accountability records. The March 2024 Physician's Order Summary and MAR indicated various orders and administrations of morphine sulfate for pain management, but the narcotic count accountability sheet was either blank or incomplete. The Regional Nurse Consultant confirmed that staff should have documented the correct amount and times of medications administered on both the MAR and the accountability sheet. The facility's policy on controlled substances emphasized the need for accurate accountability of all controlled drugs, including immediate documentation of administration details. This deficiency was related to a specific complaint and highlighted the facility's failure to adhere to its own policies and procedures for controlled substance management.
Incomplete Documentation of Resident Death
Penalty
Summary
The facility failed to ensure a complete and accurate medical record for a resident who passed away while under hospice care. The resident, who had diagnoses including heart failure, hypertension, diabetes mellitus, end-stage renal disease, and anxiety, was found unresponsive by a nurse. Despite attempts to wake the resident and measures taken to stabilize their condition, the resident's status continued to decline. The nurse contacted hospice care and the resident's family, and hospice provided a verbal order to discontinue all medications except for comfort medications. However, there was no further documentation in the resident's medical record regarding their status or death. The hospice documentation indicated that the resident passed away the following morning, attended by a facility LPN, with the hospice nurse informed and en route. The facility's Regional Nurse Consultant and Administrator both acknowledged that the facility nurse should have completed the necessary documentation related to the resident's death and pertinent notifications. The Administrator also noted that the hospice notes should have been uploaded into the resident's record. This deficiency was identified during a complaint investigation.
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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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