Aperion Care Lincoln
Inspection history, citations, penalties and survey trends for this long-term care facility in Evansville, Indiana.
- Location
- 1236 Lincoln Ave, Evansville, Indiana 47714
- CMS Provider Number
- 155820
- Inspections on file
- 25
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Aperion Care Lincoln during CMS and state inspections, most recent first.
An LPN was hired and allowed to work independently on multiple units without verification of an active nursing license, contrary to facility policies and job requirements that mandate proof of current licensure and adherence to professional standards and state regulations. Review of the personnel file showed no documentation of a valid license, and the Administrator acknowledged that licensure had not been confirmed before the LPN provided nursing care to residents.
Surveyors found that pharmaceutical services did not ensure timely availability of routine medications, resulting in multiple missed doses for two residents. One resident with depression and anxiety missed scheduled doses of Ativan when the facility ran out and the pharmacy was awaiting a new prescription. Another resident with vitamin deficiency, cerebral palsy, and reduced mobility missed several doses of a multivitamin, a vaginal lubricant, and Chlorzoxazone over multiple days, with nursing notes repeatedly citing medications as on order, pending pharmacy arrival, or not available. An RN reported that nurses are responsible for reordering medications before they run out, and facility policy requires pharmacies to refill prescriptions in time to prevent interruption of drug regimens.
A facility did not report an alleged sexual abuse incident between two residents, one of whom was unable to give consent, to the State Survey Agency. The DON and Administrator were aware of the incident but did not report it, citing lack of awareness of the requirement and absence of a specific reporting policy.
A facility failed to thoroughly investigate and document an alleged incident of sexual abuse between two residents. Although staff were made aware of inappropriate sexual requests and possible exposure, there was no formal documentation or comprehensive investigation as required by facility policy. Interviews confirmed that while the event was discussed and capacity assessments were performed, the necessary investigative steps and documentation were not completed.
A resident with a surgical wound and diabetes had physician orders for a wound vac to be changed every three days, but the wound vac was not changed on two scheduled dates. The DON confirmed the missed treatments, and facility policy required documentation of such treatments, which was not completed.
A resident requiring moderate staff assistance with bathing did not receive scheduled baths or hair shampooing for several weeks, as confirmed by both observation and record review. The resident was noted to have poor hygiene and reported not having had a bath or bed linen change in weeks, despite facility policy requiring bathing to be offered at least twice weekly.
A resident with a history of mental health and behavioral issues made inappropriate sexual advances toward another resident with cognitive impairment. The incident was not documented, care plans were not updated, and there was no evidence of monitoring or follow-up, despite facility policies requiring these actions. Staff interviews revealed a lack of awareness and documentation regarding the event and the residents' behavioral health needs.
Surveyors found that the medication room, treatment cart, and medication refrigerator containing insulin and other medications were left unlocked. A QMA confirmed these areas were supposed to be locked, and facility policy required all medications and biologicals to be securely stored.
Staff did not knock or announce themselves before entering rooms to deliver meal trays, as observed and confirmed by staff and resident council complaints. Facility policy requires staff to protect residents' privacy by knocking and requesting permission before entering.
A resident reported that meals were sometimes served cold, and food temperature checks during a meal revealed that hot foods were below the facility's preferred standard of 120°F. Facility guidelines require monitoring and investigation of food temperature complaints, but observations showed these were not consistently met.
Surveyors found that food items in the kitchen were not consistently labeled or properly sealed after opening, and kitchen floors behind equipment remained soiled despite facility policies requiring daily cleaning. The Dietary Manager and staff described practices that did not align with written procedures, resulting in unsanitary food storage and preparation areas.
A resident with dementia and severe cognitive impairment exhibited wandering and elopement behaviors, but the facility failed to complete and document required elopement risk assessments in the clinical record as per policy. The lack of documentation persisted even after incidents of wandering and an actual elopement, resulting in incomplete and inaccurate records.
A resident with a history of hypertension and hypertensive encephalopathy did not receive prescribed antihypertensive medications on multiple occasions, as documented in the MAR. These medication omissions led to two separate hospitalizations for hypertensive emergencies. Staff interviews revealed a lack of clear policy on blood pressure parameters and adherence to physician orders.
Surveyors found that food items in both dry storage and the reach-in refrigerator were not labeled with open, preparation, or use-by dates. The Dietary Manager confirmed that labeling is required, and facility policy mandates all food items be labeled with the name and consumption date.
The facility did not ensure a certified Infection Preventionist was designated and assigned at least part-time hours to oversee the infection prevention and control program. The DON was responsible for the program in addition to her full-time DON duties, and there was no signed job description confirming assignment of the IP role.
The facility did not complete required quarterly care plan conferences for several residents, including those with cognitive impairment and complex medical conditions. Documentation was missing for recent conferences, and some residents had not had a care plan conference since admission, despite facility policy requiring quarterly participation by residents or their representatives.
Surveyors observed persistent offensive odors, including urine and feces, in hallways, alcoves, and stairwells, as well as unsanitary conditions in two residents' rooms, such as dirty floors and showers and food crumbs. Staff interviews revealed inconsistent cleaning practices and the absence of a daily cleaning list, despite facility policy requiring a clean and odor-free environment.
Multiple residents dependent on staff for ADLs did not receive scheduled showers or hair care as outlined in their care plans, with observations and interviews revealing missed showers, unwashed hair, and inadequate hygiene. Residents with significant medical needs reported infrequent bathing and lack of haircuts, and staff cited ongoing staffing shortages as a contributing factor. The DON confirmed the facility was aware of these ongoing issues, and documentation showed repeated failures to meet residents' bathing preferences.
A meal tray served to a resident included carrots at 115°F, which was below the facility's required holding temperature of 140°F as stated in policy. The Dietary Manager confirmed the expected standard, and the deficiency was identified during a survey in response to a complaint.
A resident who was cognitively intact and dependent on staff for transfers was not consistently able to attend mass as desired due to delays in morning care and insufficient staffing. The resident's care plan documented her preference to get up by a certain time, but staff were unable to consistently meet this preference, resulting in missed opportunities to participate in religious activities.
A resident was not properly informed of her rights and did not receive or sign her admission paperwork, despite documentation indicating otherwise. The resident reported being unaware of her rights and stated the signature on the admission packet was not hers. The Social Services Director confirmed that copies of admission packets are only provided upon request.
A resident with severe cognitive impairment and multiple diagnoses experienced a significant weight loss over a short period, but this was not accurately coded on the MDS assessment as required. Clinical records and staff interviews confirmed the weight loss, yet the MDS continued to indicate no weight loss, contrary to facility policy and assessment guidelines.
QMAs administered PRN pain medications and insulin to two residents without obtaining required nurse authorization or following documentation protocols. One resident with diabetes received hydrocodone-acetaminophen from a QMA without nurse approval, while another resident with cerebral palsy and diabetes received insulin and multiple PRN pain medications from QMAs, contrary to facility policy and QMA scope of practice.
Two residents developed facility-acquired heel pressure ulcers due to the facility's failure to identify risk, perform routine skin checks, and consistently follow wound care plans. Both residents were assessed as at risk for pressure ulcers, but comprehensive care planning and monitoring were lacking prior to ulcer development. Multiple wound treatments were missed without documentation of refusal, and physician orders for wound care were not consistently followed, as confirmed by interviews and record review.
Two residents with severe cognitive impairment and repeated falls were not consistently provided with required fall prevention interventions, supervision, or prompt assistance. Numerous falls were not followed by timely care plan updates, IDT reviews, or fall risk assessments, and essential safety measures such as call lights within reach and non-skid footwear were often missing. Documentation and communication lapses further contributed to ongoing fall incidents and injuries.
A resident with dementia, diabetes, and dysphagia experienced a significant, unaddressed weight loss, with no documentation of physician notification, dietitian referral, or nutritional assessment. Despite repeated notes from a mental health NP and the resident's own report of weight loss, the facility failed to re-weigh the resident, update the care plan, or involve the IDT, contrary to facility policy.
A resident with a feeding tube did not consistently receive enteral nutrition as ordered by the physician, with frequent undocumented interruptions in feeding, incomplete documentation of intake, and failure to change feeding equipment daily. Facility staff did not consistently document refusals or notify the physician when the resident did not receive the prescribed amount of nutrition, contrary to facility policy.
Staff failed to follow infection control protocols during care for two residents, including not changing gloves or performing hand hygiene between dirty and clean tasks during incontinence and wound care. Facility policy requires glove changes and hand hygiene, but these steps were not consistently followed by the CNA and RN involved.
A resident with cerebral palsy and other conditions was injured during a transfer using a Hoyer lift due to improper use and inadequate staffing. The lift tipped over because the resident's weight was not centered, and the procedure for safe transfers was not followed, resulting in the resident sustaining knee and back injuries.
Unverified LPN Licensure Resulting in Unqualified Nursing Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing care was provided by qualified personnel in accordance with each resident’s written plan of care. During review of an employee file for an LPN hired in late September and terminated in early November, surveyors found no documentation of an active LPN license. The Administrator reported that the LPN had been hired without verification of licensure and that the facility was unable to confirm that this individual ever held an active nursing license. The Administrator further indicated that the LPN worked on all units in the facility and provided dates on which the LPN worked independently after an initial orientation period. The facility’s own documents required proof of current licensure upon application for employment and at least annually thereafter, and the LPN job description specified that the position required a current, unencumbered state LPN license. Additional policies and role descriptions referenced that an LPN must accept assignments consistent with education, training, and competency, and adhere to professional standards, facility policies, and applicable state laws and regulations. Despite these written requirements, the LPN’s personnel file lacked evidence of a valid license, and the Administrator acknowledged that licensure had not been verified before the LPN was allowed to work and provide nursing care to residents on multiple units.
Failure to Ensure Timely Availability of Routine Medications
Penalty
Summary
The facility failed to ensure that pharmaceutical services provided physician-prescribed routine medications as ordered, resulting in missed doses for two residents. One resident with diagnoses including depression and anxiety had a physician order for Ativan 1 mg three times daily starting in December. Review of the January Medication Administration Record (MAR) showed that the 2:00 p.m. and 8:00 p.m. doses on one day were not documented as administered. Nursing progress notes for that day documented that the pharmacy was waiting on a new prescription and that the pharmacy was aware of the need for the medication, and the resident reported she had recently not received her routine antianxiety medication because the facility had run out. Another resident, with diagnoses including vitamin deficiency, cerebral palsy, and reduced mobility, had physician orders for a daily multivitamin, daily vaginal lubricant (Replens gel), and Chlorzoxazone 500 mg four times daily. The January MAR showed multiple days when these medications were not administered. The multivitamin was not given on one day; Replens gel was not given on four separate days; and Chlorzoxazone was not given on multiple consecutive and nonconsecutive days. Nursing notes repeatedly documented that these medications were pending pharmacy arrival, on order, not available, or waiting on pharmacy delivery, and that the facility was out of Replens and had reordered it. An RN stated it was the nurse’s responsibility to reorder medications before they ran out. The facility’s pharmaceutical services policy stated that residents may use a pharmacy of their choice as long as the pharmacy refills prescription drugs when needed to prevent interruption of drug regimens.
Failure to Report Alleged Sexual Abuse to State Survey Agency
Penalty
Summary
The facility failed to report an alleged incident of sexual abuse involving two residents to the State Survey Agency. According to interviews, a CNA informed the DON that one resident entered another resident's room, asked inappropriate sexual questions, and requested to be her boyfriend. The resident who was approached was not capable of giving consent. The DON also learned that the resident exposed her breasts to the other resident. Both the DON and the Administrator were aware of the incident but did not report it to the State Survey Agency, as they were unaware of the reporting requirement. The Administrator also stated that the facility did not have a policy related to reporting alleged violations and instead followed state regulations.
Failure to Investigate and Document Alleged Sexual Abuse Incident
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of abuse involving two residents. According to interviews and record review, a CNA reported to the DON that one resident entered another resident's room and made inappropriate sexual requests. The DON completed a capacity for sexual consent assessment for both residents and instructed the resident not to ask such questions again. However, there was no documentation of the incident or the investigation, despite the facility's policy requiring such documentation. Further, it was reported that the resident who was approached may have exposed herself, but this was also not documented or investigated thoroughly. Interviews with the DON, Administrator, and Regional President of Operations revealed that while the incident was discussed among staff and both residents were interviewed, there was no formal documentation or evidence of a comprehensive investigation. The facility's policy mandates that any suspicion of non-consensual sexual relations or questions about a resident's capacity to consent should trigger an investigation, with findings documented in the resident's record. In this case, the required documentation and investigative steps were not completed.
Missed Wound Vac Changes for Resident with Surgical Wound
Penalty
Summary
The facility failed to ensure that wound treatments were completed as ordered for a resident with a surgical wound and a diagnosis of type 2 diabetes mellitus. The resident had a physician's order for a wound vac to be changed every three days, starting from a specified date. Review of the electronic treatment administration record showed that the wound vac was not changed on two scheduled dates in September, as required by the physician's order. During interviews, the DON confirmed that the wound vac changes were missed on those dates. Facility policy required that physician-ordered treatments be documented by staff after each administration, but this was not done for the missed treatments.
Failure to Provide Required Bathing Assistance
Penalty
Summary
The facility failed to provide necessary assistance with bathing and personal hygiene for a resident who required moderate staff help. The resident, who was cognitively intact and diagnosed with type 2 diabetes mellitus, reported not having received a bath or had bed linens changed in weeks. During observation, the resident exhibited a strong sour odor, greasy hair, and long, soiled fingernails. Review of both paper and electronic records confirmed that the resident had not received or refused a bath or shower on multiple documented dates over the past month, and had not had their hair shampooed during that period. Facility policy required that showers, tub baths, or bed/sponge baths be offered according to resident preference at least twice weekly, but this was not followed for the resident in question.
Failure to Document and Address Sexual Behaviors and Behavioral Health Needs
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for a resident with a history of mental health disorders, substance use, and behavioral issues. An incident occurred in which the resident made inappropriate sexual advances toward another resident who had moderate cognitive impairment. The incident was not documented in the clinical record, and there was no evidence that the care plan was updated to address sexual behaviors or that the resident was monitored for such behaviors following the event. Interviews revealed that staff, including the Social Services Director and Certified Nurse Aides, were either unaware of the incident or did not document the behaviors and follow-up actions. The Director of Nursing acknowledged that a report was made about the incident and that capacity for sexual consent assessments were completed for both residents, but there was no documentation of the incident, investigation, or subsequent monitoring in the clinical records. Additionally, the family of the resident with cognitive impairment was not notified of the incident, despite claims to the contrary. The facility's documentation systems, including progress notes and care plans, lacked information about the sexual incident, the behaviors exhibited, and the interventions or monitoring implemented. The facility's policies required investigation, documentation, and care plan updates in response to such incidents, but these procedures were not followed. As a result, the necessary behavioral health services and protections were not provided to the residents involved.
Failure to Secure Medication Storage Areas
Penalty
Summary
Surveyors observed that the facility failed to ensure proper storage of medications in the first floor medication room. On observation, the medication room containing the Emergency Drug Kit (EDK) was found unlocked, and within the room, both the treatment cart and the medication refrigerator, which contained insulin, suppositories, and other cold medications, were also unlocked. During the observation, a Qualified Medication Aide (QMA) confirmed that the medication room, treatment cart, and medication refrigerator were all supposed to be locked. Review of the facility's current Medication Storage policy indicated that all medications and biologicals, including treatment items, should be securely stored in locked compartments or rooms inaccessible to residents and visitors.
Failure to Knock or Announce Before Entering Resident Rooms During Meal Delivery
Penalty
Summary
Staff failed to honor residents' rights to dignity and respect by not knocking or announcing themselves before entering resident rooms during meal tray delivery. This was observed when a CNA delivered lunch trays to multiple rooms without knocking or introducing herself. Resident council minutes also documented a complaint regarding staff not knocking or introducing themselves prior to entering rooms. Another CNA confirmed that the expected practice is to knock and inform residents before entering with food. The facility's policy requires staff to protect and value residents' private space, including knocking and requesting permission before entering rooms.
Failure to Serve Food at Appetizing and Safe Temperatures
Penalty
Summary
The facility failed to provide food at an appetizing and safe temperature for residents, as evidenced by observations and interviews on unit 200. One resident reported that food was not always served hot and was sometimes ice cold depending on delivery time. During a meal service, food temperatures were measured and found to be below the facility's preferred standard, with the pork loin at 115°F, stuffing at 85°F, and peas at 79°F. The facility's guidelines require hot foods on room trays to be at 120°F or greater to promote palatability, and complaints about food temperature are to be documented and investigated. However, the observed temperatures and resident complaint indicate that these procedures were not consistently followed.
Failure to Maintain Sanitary Food Storage and Kitchen Cleanliness
Penalty
Summary
Surveyors observed that the facility failed to serve food in a sanitary manner according to professional standards during two separate kitchen inspections. In the walk-in freezer, partially used bags of breaded chicken, mixed vegetables, and garlic bread were found unlabeled, and later, an open box of fish squares was left unsealed and exposed to air. The kitchen floor behind the stove, deep fryer, and under a stainless steel table with a sink had visible soil buildup and debris, and these areas remained soiled several days later. The Dietary Manager stated that floors under equipment are typically cleaned once a week, while facility policy requires daily cleaning. Additionally, although the facility's policy mandates labeling and dating opened food items, this was not consistently followed, as evidenced by the unlabeled and improperly stored food items.
Failure to Maintain Accurate Elopement Risk Assessments and Documentation
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident with a history of dementia and cognitive impairment. Although the care plan identified the resident as being at risk for elopement and required quarterly reassessment, there was no documentation of elopement risk assessments in the clinical record except for one completed after an actual elopement event. The facility's policy required new assessments after any actual or attempted elopement or when exit-seeking behaviors were identified, but these were not documented as required. The resident exhibited wandering behaviors, including an incident where the resident left the floor, exited the building, and was found outside by a staff member. Despite these behaviors and the facility's policy, the required elopement risk assessments were not completed or documented in the clinical record prior to the elopement event. The administrator confirmed that paper assessments could not be located and that the assessments were not transcribed into the clinical record, resulting in incomplete and inaccurate documentation.
Failure to Administer Antihypertensive Medications Leads to Hospitalizations
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, resulting in the resident not receiving prescribed blood pressure medications on multiple occasions. The resident, who had a diagnosis of hypertensive encephalopathy and was moderately cognitively intact, had physician orders for several antihypertensive medications, including Carvedilol, Isosorbide Mononitrate, Lisinopril, and later Hydralazine. On at least two documented occasions, the resident did not receive these medications as ordered, with the electronic medication administration record (MAR) showing missed doses and a lack of blood pressure recordings. Following these missed doses, the resident experienced hypertensive emergencies that required hospitalization. On one occasion, the resident was found on the floor complaining of pain, and his blood pressure was significantly elevated upon hospital admission. On another occasion, after missed medication doses and absent blood pressure documentation, the resident developed chest pain and was again hospitalized for a hypertensive emergency. Interviews with facility staff revealed that there was no policy provided regarding blood pressure parameters and following physician orders, and the DON stated that staff should use nursing judgment and follow physician orders.
Failure to Label and Date Food Containers in Storage and Refrigeration
Penalty
Summary
Surveyors observed that the facility failed to store food in a sanitary manner during kitchen inspections. In the dry storage area, a bag of noodles and a bag of marshmallows were found without open dates. In the reach-in refrigerator, multiple containers of juices and fluids were present without labels, preparation dates, or use-by dates. The Dietary Manager confirmed during an interview that containers should be labeled with preparation and use-by dates. The facility's food storage policy, provided by the Director of Nursing, also requires all food items to be labeled with the name of the food and the date it should be consumed by.
Failure to Designate a Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified and certified Infection Preventionist (IP) responsible for the infection prevention and control program. Review of the Director of Nursing's (DON) employee file revealed the absence of a signed job description for the IP role. The DON confirmed she was currently responsible for the infection prevention and control program while also working full time as the DON. Although a current IP job description was available, it was not signed or assigned, and the DON's job description did not reflect the IP responsibilities. This resulted in the lack of a dedicated staff member with at least part-time hours assigned specifically to the IP role, as required.
Failure to Hold Quarterly Care Plan Conferences for Multiple Residents
Penalty
Summary
The facility failed to ensure that care plan conferences were completed quarterly for six out of seven residents reviewed. For several residents, including those with diagnoses such as cerebral palsy, diabetes mellitus, major depressive disorder, dementia, repeated falls, wedge compression fracture, hypertensive encephalopathy, and hypertension, the most recent care plan conferences were either not held within the required quarterly timeframe or had not been conducted since admission. Clinical records showed that some residents had not had a care plan conference for several months, and in two cases, no care plan conference had been held since the residents were admitted. Interviews and record reviews confirmed that the facility's policy required residents and/or their representatives to be invited to participate in care plan conferences at least quarterly, either in person, by phone, or via video conference. However, documentation for recent care plan conferences was missing for multiple residents, and the Director of Nursing acknowledged that these conferences were supposed to be held quarterly. Requests for records of care plan conferences for certain residents could not be fulfilled, further confirming the deficiency.
Failure to Maintain a Safe, Clean, and Odor-Free Environment
Penalty
Summary
The facility failed to provide a safe, clean, and odor-free environment for residents, staff, and the public, as evidenced by multiple observations of offensive odors and unsanitary conditions over a five-day period. Strong smells of urine were repeatedly detected in public hallways, alcoves, stairwells, and near the chapel, as well as outside specific resident rooms and the Holy Family Nurses Station. Additionally, the smell of feces was noted in alcoves on the second floor. These conditions were observed on several occasions, indicating a persistent issue rather than isolated incidents. Further, interviews and direct observations revealed that resident rooms and bathrooms were not being cleaned adequately. One resident reported that her room was not cleaned daily, and brown dried mud and dirty shower floors were observed in her room on separate days. Another resident's family member reported finding food crumbs behind drawers, and subsequent inspection confirmed the presence of food crumbs, a sticky bathroom floor, and a dirty shower floor. A housekeeper stated there was no daily cleaning list and described inconsistent cleaning practices. The DON confirmed that there should be no offensive smells in the building and provided a policy stating the facility's intent to maintain a clean, odor-free environment, which was not being met.
Failure to Provide Scheduled Showers and Hair Care for Dependent Residents
Penalty
Summary
The facility failed to provide adequate care and assistance with activities of daily living (ADLs), specifically bathing and hair care, for 9 out of 10 residents reviewed. Multiple residents who were dependent on staff for bathing and personal hygiene did not receive showers or hair shampooing according to their care plans and preferences. Observations and interviews revealed that residents often received bed baths without hair washing, and some residents' hair appeared oily, unkempt, or unwashed. Several residents and family members reported infrequent showers, lack of haircuts, and inadequate hygiene, with some residents expressing dissatisfaction with the timing and quality of care provided. Clinical record reviews indicated that these residents had significant medical conditions such as cerebral palsy, diabetes mellitus, dementia, depression, hypertensive encephalopathy, and malignant neoplasm, and required varying levels of staff assistance for ADLs. Documentation showed missed showers on multiple scheduled days for each resident, and in some cases, no documentation of hair washing since admission. Care plans consistently indicated a preference for showers two times per week, but these preferences were not met. Staff interviews confirmed ongoing issues with staffing shortages, which contributed to the inability to complete all required ADL care. The Director of Nursing acknowledged that the facility was aware of the ongoing problem with missed ADL care, including showers, and that there was no designated staff member responsible for ensuring showers were given. Facility policy required that residents be offered showers or baths according to their preferences at least twice weekly, but this was not consistently implemented. The deficiency was cited under 3.1-38(a)(3) and related to specific complaints.
Failure to Serve Food at Palatable Temperature
Penalty
Summary
The facility failed to ensure that food was served at a palatable temperature, as evidenced by an observation of a meal tray on the 200 Unit where the carrots measured 115 degrees F. According to the Dietary Manager, the expected holding temperature on the steam table should be 145 degrees F or higher. The facility's policy on Monitoring Food Temperatures for Meal Service requires serving/holding temperatures to be at least 140 degrees F prior to meal service, and hot foods on room trays should be at 120 degrees F or greater for palatability. The deficiency was identified during a survey and relates to a specific complaint.
Failure to Accommodate Resident's Choice to Attend Religious Activity
Penalty
Summary
A resident with diagnoses including cerebral palsy and major depressive disorder, who was cognitively intact and dependent on staff for toileting and bathing, was not accommodated in her choice to attend mass due to delays in morning care. The resident expressed that staff did not always get her up in time for mass, which was scheduled daily at 11:00 A.M. Observations confirmed that on one occasion, the resident was still in bed waiting for staff to use a mechanical lift to transfer her, despite her care having just been completed. The resident's care plan indicated a preference to get up for the day at 10:00 A.M. or as desired, and that she required assistance from two staff members and a mechanical lift for transfers. Staff interviews revealed that there was insufficient staffing to complete all required tasks in a timely manner. The facility's Resident Rights policy stated that residents have the right to self-determination, including the right to choose activities and schedules consistent with their interests, such as participating in religious activities. The failure to accommodate the resident's choice to attend mass was attributed to staffing limitations and delays in providing necessary morning care and transfers.
Failure to Provide and Verify Resident Rights and Admission Paperwork
Penalty
Summary
The facility failed to ensure that a resident was properly informed of her rights and provided with the required admission paperwork. During interviews, the resident stated she was unaware of her rights and had not received or signed an admission packet. Review of the clinical record showed an admission packet was signed electronically by both the Social Services Director and the resident, but the resident later stated the signature was not hers. The Social Services Director confirmed that residents sign admission packets electronically and are only given a copy if they request it. The facility's policy requires healthcare professionals to make prompt, factual, and complete documentation entries.
Failure to Accurately Code Significant Weight Loss on MDS Assessment
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) Assessment was completed accurately for a resident with significant weight loss. The resident, who had diagnoses including dementia, diabetes mellitus, and dysphagia, was documented as having severe cognitive impairment and requiring setup assistance for eating. The Annual MDS Assessment recorded the resident's weight as 179 pounds with no weight loss, while the subsequent Quarterly MDS Assessment listed the weight as 132 pounds, also indicating no weight loss. However, clinical records showed the resident's weight dropped from 179.3 pounds to 131.7 pounds between assessments, representing a 26.55% loss, and further decreased to 123.3 pounds, totaling a 31.23% loss since the initial weight. Staff interviews confirmed the weight loss should have been coded on the MDS, but it was not, despite facility policy to follow the Resident Assessment Instrument (RAI) Manual for MDS coding.
QMAs Administered PRN Medications and Insulin Outside Scope of Practice
Penalty
Summary
The facility failed to ensure that Qualified Medication Aides (QMAs) practiced within their defined scope of practice for two residents who were reviewed for unnecessary medications. For one resident with type 2 diabetes mellitus, a QMA administered hydrocodone-acetaminophen, a pain medication, on multiple occasions without prior authorization from a nurse, as required by policy and the QMA scope of practice. The resident was noted to be moderately cognitively intact, and the medication was ordered to be given as needed for pain. For another resident with cerebral palsy, diabetes mellitus, and pain, QMAs administered both insulin and various PRN pain medications, including hydrocodone-acetaminophen, Tylenol, and Excedrin, without obtaining prior authorization from a nurse. The facility's policy did not permit QMAs to administer insulin, even if they were insulin certified. The QMA scope of practice and job description both required that PRN medications only be administered with nurse authorization, and that such administration be properly documented and cosigned by a licensed nurse. These requirements were not followed, as evidenced by the medication administration records and interviews with facility staff.
Failure to Prevent and Properly Manage Pressure Ulcers
Penalty
Summary
The facility failed to identify and address the risk of pressure ulcer development, perform routine skin checks, and follow care plans to promote wound healing for two residents who developed facility-acquired heel wounds. In the first case, a resident admitted for therapy after fracture surgery, with diagnoses including diabetes mellitus with polyneuropathy, was assessed as at risk for pressure ulcers but had no comprehensive care plan addressing this risk. The clinical record lacked weekly skin observations for over a month, and a new pressure injury to the right heel was only documented after this period, by which time the wound had progressed and required advanced interventions, including a wound vac and surgical procedures. In the second case, another resident admitted for therapy after an accident was also assessed as at risk for pressure ulcers but did not have monitoring for skin breakdown prior to the development of a pressure injury. The resident developed a deep tissue injury to the left heel, and although a care plan was created after the ulcer appeared, there were multiple documented instances where prescribed wound treatments were not administered as ordered and not refused by the resident. This included several missed dressing changes over multiple months, as evidenced by gaps in the treatment administration record. Observations and interviews confirmed that wound care orders were not consistently followed, and dressings were not changed as scheduled. The facility's policy required regular skin inspections and adherence to physician orders for wound care, but these were not implemented as documented. The Director of Nursing acknowledged that staff should be following physician's orders as written, but the records and observations indicated otherwise.
Failure to Implement and Document Fall Prevention Protocols for High-Risk Residents
Penalty
Summary
The facility failed to ensure that two residents at high risk for falls were adequately supervised and protected from accident hazards, as evidenced by repeated failures to follow fall protocols, update care plans, and implement or maintain fall prevention interventions. Both residents had extensive histories of falls, with one resident experiencing 23 falls and the other 34 falls within a year. Despite documented high fall risk and multiple interventions listed in their care plans, there were numerous instances where interventions were not in place, such as call lights not being within reach, lack of non-skid footwear, and absence of required safety equipment like dycem or non-skid strips. Observations also revealed that residents were left unattended in their rooms, contrary to care plan instructions. The clinical records for both residents showed significant gaps in documentation and follow-through after falls. Many falls lacked Interdisciplinary Team (IDT) notes, timely updates to care plans with new interventions, and completion of fall risk assessments. In several cases, there was no evidence that the physician or responsible party was notified after a fall, and some falls were only referenced in 72-hour charting notes without details on the circumstances or follow-up. Additionally, some interventions added to care plans after IDT reviews were not observed to be implemented during surveyor observations. Both residents had complex medical histories, including dementia, muscle weakness, repeated falls, and other comorbidities that increased their vulnerability. Despite these risks, the facility did not consistently anticipate or meet their needs, failed to ensure prompt response to call lights, and did not always provide appropriate supervision or assistance with toileting and transfers. The lack of consistent documentation, communication, and implementation of fall prevention strategies contributed to ongoing falls and injuries for these residents.
Failure to Identify and Address Significant Weight Loss
Penalty
Summary
The facility failed to provide adequate nutritional care and services for a resident with multiple diagnoses, including dementia, diabetes mellitus, and dysphagia. The resident experienced a significant and unaddressed weight loss, dropping from 179 pounds to 131.7 pounds within a short period, representing a 26.55% decrease. Despite this substantial weight loss, there was no documentation of physician notification, referral to the dietitian, or a nutritional assessment by the dietitian. The care plan identified the resident as being at risk for altered nutritional status, but no updated interventions or reviews were documented in response to the weight loss. The clinical record lacked evidence that the resident was re-weighed after the initial significant weight loss was identified, despite repeated notes from the mental health nurse practitioner highlighting the issue and requesting re-weighs. There was also no documentation of review by the Interdisciplinary Team (IDT) regarding the weight loss. The resident herself reported noticeable weight loss and ill-fitting clothes, yet no action was documented to address her nutritional needs or investigate the cause of the weight loss. Interviews with facility staff, including the DON and MDS Coordinator, confirmed that the weight loss was not properly identified or coded, and that the dietitian did not follow up as required. The facility's own policy required reporting significant weight changes to the physician and dietitian, as well as obtaining re-weights for discrepancies, but these steps were not taken for this resident. The deficiency was identified during a complaint investigation.
Failure to Follow Physician Orders and Document Enteral Nutrition Administration
Penalty
Summary
The facility failed to ensure that physician orders for enteral nutrition were followed and that appropriate documentation and care were provided for a resident receiving tube feedings. Observations over several days revealed that the resident's enteral nutrition was frequently turned off outside of the physician-ordered two-hour break, and feeding equipment, such as syringes, was not changed daily as required. The feeding formula and equipment were observed to be dated from previous days, and the feeding tube was found uncapped and wrapped around the pole when not in use. The resident in question had diagnoses including pneumonitis due to inhalation of food and vomit, dysphagia, and dementia, and was dependent on staff for transfers. The care plan required monitoring of caloric intake, and physician orders specified a continuous enteral feeding regimen with specific amounts and times, as well as regular flushing and equipment changes. However, the Medication Administration Record (MAR) showed inconsistent documentation of the amounts of formula administered, with several days lacking complete records or showing significant deviations from the ordered volume. There was also a lack of documentation regarding when the enteral nutrition was turned off or when the resident refused nutrition, except for two documented refusals with physician notification. Facility policies required close monitoring of tube feeding tolerance, intake and output, and prompt documentation of changes in the resident's condition, including refusals and notifications to the physician. Despite these policies, the clinical record did not consistently reflect refusals, changes in feeding administration, or timely notifications to the physician when the resident did not receive the prescribed amount of nutrition. Interviews with the DON and Regional Nurse confirmed that documentation and adherence to physician orders were expected but not consistently followed in this case.
Failure to Follow Infection Control Practices During Resident Care
Penalty
Summary
The facility failed to implement proper infection control practices during care for two of three residents observed. In one instance, during incontinence care, a CNA sanitized hands and donned gloves, while an RN only donned gloves. The CNA then gathered supplies with gloved hands, provided care, and applied barrier cream without changing gloves or performing hand hygiene between tasks. The same gloves were used to place barrier cream and to put on a clean incontinence brief, with the CNA wiping the gloved hands inside the clean brief. The RN removed soiled gloves and washed hands after care, but the CNA did not change gloves or perform hand hygiene as required by facility policy. In another instance, during wound care, an RN applied hand sanitizer, donned a gown and gloves, and performed wound care procedures. After removing the gown and gloves, the RN put on a new pair of gloves to apply a heel boot but did not perform hand hygiene during or after the procedure. The facility's policy requires gloves to be changed and hand hygiene to be performed when moving from dirty to clean tasks and after glove removal, which was not followed in these observed cases.
Improper Use of Hoyer Lift Leads to Resident Injury
Penalty
Summary
The facility failed to ensure adequate safety measures during the transfer of a resident, resulting in an accident. Resident B, who has a history of cerebral palsy, knee pain, osteoarthritis, and asthma, was being transferred from her bed to a shower chair using a Hoyer lift. During the transfer, the lift tipped over due to uneven weight distribution, causing the resident to sustain injuries, including a bruised knee and back pain. The incident occurred with only one staff member initially assisting, despite the resident's care plan indicating the need for two staff members for transfers. The incident was further complicated by the improper use of the Hoyer lift. The CNAs involved in the transfer did not follow the correct procedure, which requires the resident's weight to be centered over the base of the lift's legs and the resident to face the attendant operating the lift. Instead, the lift was brought in sideways, and the shower chair was tilted, leading to the lift tipping over. The CNAs attempted to stabilize the situation, but the resident still ended up on the floor, although she did not hit her head. The facility's Director of Nursing confirmed that staff receive training on Hoyer lift use during orientation and at quarterly skills fairs. However, the incident revealed a lapse in following the established procedures for safe transfers. The facility's procedure guide emphasizes the importance of keeping the lift's base spread to its widest position for stability and ensuring the resident faces the attendant, which was not adhered to in this case.
Latest citations in Indiana
Surveyors observed that dietary staff repeatedly worked in kitchen and meal service areas with uncovered facial hair, despite facility policy and state sanitation requirements mandating effective hair restraints. Two dietary aides with short beards or mustaches were seen walking through food preparation areas, taking food temperatures, handling food, and plating meals at steamtables in dining rooms without any facial hair coverings, while the current policy required all hair, including facial hair, to be restrained to prevent contamination.
The facility failed to consistently provide and document required bed-hold policy notices when several residents were transferred to the hospital. In multiple cases, residents with dementia, psychotic disorders, COPD, chronic respiratory failure, altered mental status, and cerebral infarction were sent out for acute changes in condition, and while transfer notes reflected physician and family notifications, they lacked documentation that the bed-hold policy was discussed with the resident or responsible party. Notices of Transfer or Discharge often indicated a copy of the bed-hold policy was sent with the resident, but the records did not show signed and dated acknowledgment by the resident or appropriate representative, including in situations where a resident had moderate cognitive impairment, short-term memory issues, or a documented need for a proxy and a financial POA authorizing an agent for health care decisions.
Surveyors found that the facility failed to provide trauma‑informed and culturally competent care by not incorporating two residents’ extensive trauma histories and specific behavioral triggers into their care plans. One resident with documented homelessness, polysubstance abuse, severe accidents with multiple fractures, viral encephalitis with coma, physical and sexual abuse, loss of family contact, and a past suicide attempt had multiple behavior‑focused care plans that referenced identifying triggers but listed none and did not mention their physical, sexual, medical, or psychosocial trauma. Another resident with TBI from being struck by a truck, an 11‑month coma, long‑term state hospital residence, alleged shooting of a parent, and diagnoses including intermittent explosive disorder and borderline personality disorder had a PASRR identifying a specific trigger and notes of inappropriate sexual behavior, yet their care plans omitted these traumatic events, the identified trigger, and the sexual behavior. Staff interviews confirmed that residents were screened for trauma, but the trauma histories and triggers were not reflected in the individualized plans of care.
A resident with schizophrenia, post‑stroke hemiparesis, and mild cognitive impairment expressed feeling down and wanting to kill himself, but staff did not document asking about a specific plan, did not notify the physician or psychiatric NP as expected, and did not develop or update a care plan addressing depression or suicidal ideation. The SSD documented offering support and initiating 15‑minute checks once, but there was no further follow‑up or documentation of interventions after subsequent suicidal statements made in a care plan meeting with the resident’s father. The DON and Administrator reported that facility policy requires immediate notification of key staff, assessment for a plan and means of self‑harm, and thorough documentation, which were not carried out or reflected in the medical record for this resident.
A resident with schizophrenia, post-stroke hemiparesis, and mild cognitive impairment verbalized suicidal ideation, but the care plan did not address depression or suicidal thoughts, and required assessments and services were not accurately or timely documented. An SSD note recorded the resident saying he wanted to kill himself and referenced 15‑minute checks and a care plan update, yet the active care plan lacked depression/suicidal ideation interventions. Multiple late-entry Social Services notes were later added, describing follow-up visits and the resident denying suicidal ideation, but the SSD later reported she did not typically ask about a suicide plan and did not personally provide individual follow-up visits as described. These practices conflicted with the facility’s policy requiring factual, first-hand, and timely documentation of assessments and services.
A resident was observed with an Albuterol inhaler on an overbed table and later reported keeping the inhaler in a nightstand drawer, with no staff present during these observations. Record review showed the resident had no cognitive impairment on the admission MDS but lacked any documented self-medication administration assessment. The DON acknowledged that the required assessment had not been completed, despite facility policy requiring staff and the practitioner to evaluate each resident’s mental and physical abilities before allowing self-administration of medications.
Surveyors found that the facility submitted inaccurate direct care staffing data to CMS through the PBJ system over multiple days in a quarter. CASPER reports showed apparent gaps in 24-hour licensed nurse coverage, low weekend staffing, and a 1-star staffing rating, while internal staffing sheets documented that licensed nurses were present and the facility was fully staffed on those days. The Administrator reported that the discrepancies were due to PBJ data entry errors, despite a facility policy requiring all PBJ entries to be accurate, auditable, and verifiable against payroll, invoices, or contracts.
Surveyors found that the facility did not provide or document required written transfer/discharge notices and bed-hold policy information for four residents who were sent to the hospital, including individuals with conditions such as dementia, CHF, chronic respiratory failure, and CKD. In each case, progress notes showed that the resident was transferred for acute issues, but the clinical records lacked evidence that written notices were given to the residents or their representatives, and in one case lacked documentation that required information was sent to the receiving provider. Facility leadership, including the ADON, DON, and Administrator, acknowledged that the records did not contain the required documentation, despite a written policy requiring such notices and information exchange.
A resident with Alzheimer’s disease and depression, previously on an antidepressant, exhibited intermittent refusals of medications and care, occasional yelling at staff, and reports of unusual perceptions, such as believing men were in or near her room. Nursing notes over several months documented these refusals and complaints but did not show that the behaviors were evaluated or recorded as dangerous, non-redirectable, or causing significant distress, nor did they document specific non-pharmacological interventions attempted or their outcomes. Despite this, a psychiatric NP later added new diagnoses of schizoaffective disorder, borderline personality disorder, and delusional disorder and ordered an antipsychotic (Seroquel) without a comprehensive evaluation in the record to support these diagnoses. The facility’s psychotropic medication policy, which requires identification and documentation of target behaviors, use of nonpharmacological interventions, and ongoing behavior monitoring, was not followed for this resident.
The facility failed to keep PASARR Level I screenings accurate and current for three residents when new mental health diagnoses and psychoactive medications were initiated. One resident’s PASARR omitted a PTSD diagnosis and an added antidepressant, despite documentation of PTSD on the MDS and care plan and a physician order for Pristiq. Another resident’s PASARR listed only depression and dementia, even after additional diagnoses such as borderline personality disorder, delusional disorder, and schizoaffective disorder were added and an antipsychotic (quetiapine) was ordered, with the MDS later reflecting psychotic disorder, schizophrenia, and depression with antipsychotic and antidepressant use. A third resident’s PASARR did not include a depression diagnosis or newly ordered escitalopram and lorazepam, although the admission MDS documented depression with antianxiety and antidepressant use. These omissions occurred despite facility policy requiring a new Level I review after significant mental status changes, including new mental health diagnoses or new psychotropic medications.
Uncovered Facial Hair During Food Preparation and Meal Service
Penalty
Summary
The deficiency involves the facility’s failure to ensure that food was served in a sanitary and safe manner in accordance with professional standards and facility policy during multiple kitchen and meal service observations. During an initial kitchen observation, two dietary aides were seen walking through the kitchen food preparation area with uncovered facial hair. One aide had facial hair above and below the lip and along the jaw line, approximately one-fourth inch in length, and the other had a mustache of similar length; neither used any facial hair covering. These observations occurred while staff were present in the kitchen area where food was stored and prepared. During subsequent observations on the same day, the same two dietary aides were again observed with uncovered facial hair while directly involved in meal preparation and service. One aide walked through the kitchen while the noon meal was being prepared and placed into a transport cart for service in the south dining room, and later was observed plating the noon meal at the steamtable in that dining room, still without a facial hair covering. The other aide walked through the kitchen while the noon meal was being prepared and placed into the steamtable for the north dining room, took food temperatures, assisted with plating meals at the steamtable, and retrieved food items and supplies from the kitchen, all while having an uncovered mustache approximately one-fourth inch in length. The Dietary Manager stated that staff hair was to be covered when in the kitchen and during meal service, and the facility’s written policy and the cited Indiana Food Establishment Sanitation Requirements both required effective hair restraints, including for facial hair, to prevent contamination of food, equipment, and utensils.
Failure to Provide and Document Bed-Hold Policy at Time of Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure that required bed-hold policy information was provided and documented for four residents transferred to the hospital. For a resident with dementia, psychotic disorder, and autistic disorder who had a BIMS score of 0 indicating severe cognitive impairment, progress notes documented physician notification and guardian notification when the resident was sent to the hospital, but there was no documentation that the bed-hold policy was provided to the responsible party. A Notice of Transfer or Discharge later indicated a copy of the bed-hold policy was sent with the resident. Another resident with COPD and chronic respiratory failure, cognitively intact with a BIMS score of 13, experienced a decline in condition and was transferred to the hospital by ambulance; progress notes documented family notification but did not document any discussion of the bed-hold policy, although a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident. A third resident with altered mental status and cerebral infarction, with a BIMS score of 10 indicating moderate cognitive impairment and documented short-term memory impairment, experienced changes in condition and was transferred to the hospital. Progress notes stated the resident was their own responsible party and that no other notification was completed, and transfer documentation did not include the bed-hold policy, although an untimed Notice of Transfer or Discharge indicated a copy of the bed-hold policy was signed by the resident. A financial power of attorney document in the record showed the resident had designated an agent to act in consent or refusal of health care. For a fourth resident with dementia and osteomyelitis, transfer documentation and a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident, and the transfer form noted the resident required a proxy for decision making. The facility’s policy required that at the time of transfer to a hospital, written notice specifying the duration of the bed-hold policy and information on return to the next available bed be provided, and that a signed and dated copy of the bed-hold notice given to the resident or representative be kept in the resident file, which was not consistently documented for these residents.
Failure to Integrate Trauma Histories and Behavioral Triggers Into Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to identify and incorporate residents’ trauma histories and specific behavioral triggers into their care plans, despite documented histories of significant trauma and behavioral health issues. For one resident, extensive social service and progress notes documented homelessness, polysubstance abuse, major depressive and anxiety disorders, chronic pain, a history of severe car accidents with multiple fractures, viral encephalitis resulting in a three‑month coma, loss of child custody, multiple divorces, physical abuse by a spouse, the death of a fiancé who was struck by a car while in a wheelchair, lack of family contact, and a past suicide attempt by Valium overdose. Additional documentation noted a history of rape by a brother at age eight and prior placement under direct supervision and 15‑minute checks related to suicidal ideation. Despite these documented traumatic events and behavioral health concerns, the resident’s care plans did not identify a history of physical trauma, sexual trauma, homelessness, substance abuse, medical trauma, or attempted suicide. For this same resident, the MDS showed no cognitive deficit and identified behaviors such as verbal aggression and rejection of care, along with diagnoses including seizure disorder, depression, chronic pain syndrome, homelessness, and anxiety disorder. Multiple care plans addressed behaviors such as drug‑seeking, pretending to have seizures for attention or medication, making false allegations, verbal aggression when unable to smoke, and a desire for intimate relationships with consenting male residents. These care plans referenced goals such as effective coping skills, seeking staff support, and compliance with the smoking policy, and they called for identification and reduction of behavioral triggers. However, none of these care plans actually listed any specific triggers. The care plan addressing the resident’s right to consensual intimate relationships focused on assessment and education regarding consent but did not integrate the resident’s extensive trauma history. Staff interviews indicated the resident had displayed sexual behaviors since admission, including an incident where the resident expressed anger at another resident for not buying a soda after engaging in sexual acts. A second resident with a documented history of traumatic brain injury (TBI), dementia, seizure disorder, borderline personality disorder, anxiety, intermittent explosive disorder, tobacco use, and other behavioral/emotional disorders was also affected by the same deficiency. Social history and progress notes documented that this resident sustained a TBI after being hit by a semi‑truck while riding a bicycle at age 18, resulting in an 11‑month coma, followed by 13 years in a state hospital and subsequent residence in a group home. Additional documentation indicated the resident allegedly shot their father at age 26 after being sworn at and had a PASRR identifying TBI, intermittent explosive disorder, and borderline personality disorder, with a specific trigger of hearing the name of the current U.S. President. Progress notes also described inappropriate sexual behavior toward staff, including touching themselves intimately during personal care and refusing to stop when redirected. Despite this, the resident’s care plans, which addressed explosive disorder and history of altercations, risk for decreased psychosocial well‑being, and refusal to bathe or shower, did not list any specific behavioral triggers, did not reference the traumatic events such as being hit by a truck or shooting their father, and did not document the inappropriate sexual behavior. The Administrator and Social Service Director acknowledged that residents were to be screened for trauma and that trauma responses and PTSD should be added to care plans, but the specific trauma histories and triggers for these two residents were not incorporated into their plans of care.
Failure to Assess and Care Plan for Resident Suicidal Ideation
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess, investigate, and care plan for a resident’s suicidal ideation in accordance with its own policy and staff expectations. The resident had diagnoses including schizophrenia, cerebral edema, and hemiparesis/hemiplegia following a cerebral infarction, and a current MDS showed mild cognitive impairment (BIMS score 12). A progress note documented that the resident told the Social Services Director (SSD) he was feeling down and wanted to kill himself; the SSD offered assistance, activities, and initiated 15‑minute checks, and the note stated the care plan was updated. However, the note did not indicate that the SSD asked whether the resident had a plan to kill himself, and there were no additional notes regarding suicidal ideation or follow‑up. Review of the current care plan showed no problem, goal, or interventions addressing depression or suicidal ideation, and progress notes over the following month contained no documentation of physician notification related to the suicidal statement. Further record and interview evidence showed that the care plan conference summary did not document interventions for suicidal ideation, and the SSD acknowledged she did not normally ask residents expressing suicidal ideation if they had a plan. The SSD reported that the resident had admission paperwork mentioning suicidal ideation related to depression after a stroke and that the resident again vocalized suicidal ideation during a care plan meeting with his father, after which emotional support was offered and the father took the resident out on a leave of absence; no further visits or follow‑up were done. The DON stated that, upon notification of suicidal verbalization, staff should assess the resident, ask if there is a plan, remove potential means of self‑harm, immediately notify the psychiatric NP, and document the occurrence, and that a detailed progress note and updated care plan were expected but not present for this resident. The Administrator similarly stated that staff should ask about a plan, document interventions, notify the physician and family, and update the care plan, and indicated the resident should have had a care plan addressing depression with suicidal ideation. The facility’s written policy required immediate notification of the DON, SSD, and physician, an interview including asking about a plan and assessing mood and means for self‑harm, and thorough documentation of mood, behavior, and all actions taken, which were not reflected in the resident’s record.
Incomplete and Inaccurate Documentation of Suicidal Ideation and Follow-Up
Penalty
Summary
The facility failed to ensure accurate, complete, and timely documentation of assessments and services for a resident who verbalized suicidal ideation. Resident 6, who had schizophrenia, cerebral edema, and right-sided hemiparesis/hemiplegia following a cerebral infarction, had a BIMS score of 12 indicating mild cognitive impairment. The resident’s admission paperwork mentioned suicidal ideation related to depression after a stroke, and a Social Services note on 3/11/2026 documented that the resident was feeling down and said he wanted to kill himself. The Social Services Director (SSD) documented that she talked with the resident, coordinated with Activities, advised the resident to contact SSD or nursing if he wanted to talk, and that the resident was scheduled for 15-minute checks and the care plan was updated. However, the current care plan initiated on 2/26/2026 did not address depression or suicidal ideation. Multiple Social Services progress notes were later entered as late entries in April, with effective dates in March, stating that the resident had no plan and no longer had suicidal ideation, that he felt much better after 1:1 time, and that he continued his daily routine and therapy. These late entries described follow-up visits and reassessments of suicidal ideation on several consecutive days, but in interviews the SSD stated she did not normally ask residents about having a plan when they verbalized suicidal ideation and did not recall any other occurrences beyond the initial event. She further indicated she did not personally provide individual follow-up visits with this resident regarding suicidal ideation, despite the late-entry notes describing such visits. The DON acknowledged that late entries had been added to address concern about suicidal verbalization, and the Administrator stated that upon suicidal statements staff should ask about a plan, notify the physician and family, and update the care plan, and that this resident should have had a care plan addressing depression with suicidal ideation. The facility’s documentation policy required factual, first-hand, timely documentation, which was not followed in this case.
Failure to Complete Required Self-Administration Assessment for Inhaler Kept at Bedside
Penalty
Summary
Surveyors identified that a resident was allowed to keep and access an Albuterol inhaler without the facility completing the required self-administration medication assessment. During an initial tour, the resident was observed sitting in a wheelchair with a handheld Albuterol inhaler on the overbed table and no staff present in the room or hallway. On a subsequent observation, the resident again was in a wheelchair and reported that the Albuterol inhaler was stored in the top drawer of the nightstand, where it was found. Review of the clinical record showed an admission MDS indicating no cognitive impairment, but there was no documentation of a self-medication administration assessment. In an interview, the DON confirmed that the resident did not have the required self-medication assessment, despite the facility’s policy stating that staff and the practitioner must assess each resident’s mental and physical abilities to determine whether self-administering medications is clinically appropriate. This failure to complete and document a self-administration medication assessment for a resident who had an Albuterol inhaler kept at bedside constituted noncompliance with the facility’s own policy and with 410 IAC 16.2-3.1-11(a).
Inaccurate PBJ Staffing Data Submission to CMS
Penalty
Summary
The deficiency involves the facility’s failure to electronically submit complete and accurate direct care staffing information to CMS through the Payroll-Based Journal (PBJ) system for 22 days in a fiscal quarter. A CASPER report review on 4/6/26 showed that, according to PBJ data, the facility did not have licensed nursing coverage 24 hours per day on multiple specific dates across three months, had low weekend staffing, and held a 1-star staffing rating. However, review of the facility’s internal staffing sheets for that quarter indicated the facility was fully staffed and had licensed nurse coverage on all of the dates in question. During an interview, the Administrator stated that the PBJ information must have contained data entry errors, as she had verified licensed staff coverage on the timesheets. The facility’s PBJ policy in effect stated that all staffing data entered into the PBJ system would be auditable and verifiable through payroll, invoices, or contracts, but the submitted PBJ data did not accurately reflect the facility’s actual licensed nurse staffing as documented on internal records. No specific residents or clinical conditions were mentioned in the report, and the deficiency centers solely on inaccurate staffing data submission rather than direct resident care events.
Failure to Provide and Document Required Transfer/Discharge and Bed-Hold Notices
Penalty
Summary
The deficiency involves the facility’s failure to provide and document required written notices of transfer/discharge and bed-hold policies, as well as required information to receiving providers, for four residents who were transferred or discharged to the hospital. For a resident with generalized anxiety disorder, major depressive disorder, and dementia, progress notes showed that the resident was sent to the hospital via 911 for chest pain, lower back pain, and shortness of breath and later returned to the facility, but the clinical record lacked documentation that a written Notice of Transfer/Discharge and the bed-hold policy were provided to the resident or representative, and lacked documentation that required information was conveyed to the receiving facility. The ADON and the Administrator both confirmed there was no documentation that these written notices were provided. For a resident with congestive heart failure and muscle weakness who was sent to the emergency room for painful urination and bloody urine, the clinical record lacked documentation that a Notice of Transfer/Discharge or bed-hold policy was given to the resident or representative, which the DON confirmed. Another resident with chronic respiratory failure and diabetes was discharged to the hospital for respiratory failure, and a resident with chronic kidney disease and dementia was discharged to the hospital, but in both cases there was no documentation that a written notice of transfer/discharge or bed-hold policy was provided to the residents or their representatives. Review of the facility’s Transfer and Discharge policy, dated 1/15/26, showed that the policy required the facility to provide written transfer/discharge notices and bed-hold information to residents and representatives and to provide specified information to receiving providers, but the records for these four residents did not contain the required documentation.
Failure to Document Target Behaviors and Non-Pharmacological Interventions Before Initiating Antipsychotic
Penalty
Summary
The deficiency involves the facility’s failure to document how a resident’s behaviors presented danger or distress to self or others, and failure to document non-pharmacological interventions attempted prior to initiating an antipsychotic medication. Resident 6 had documented diagnoses of Alzheimer’s disease, depression, and severe cognitive impairment, and was receiving sertraline for depression. A PASSAR identified only depression and dementia, and the admission MDS listed Alzheimer’s disease and depression as active diagnoses. Over several months, nursing progress notes documented that the resident intermittently reported unusual perceptions, such as believing there were men causing trouble, a man in her room, or a man wanting to marry her and yelling through the walls, but there was no documentation that these episodes caused danger to the resident or others or that they resulted in unmanageable distress. From late April through mid-July, nursing notes primarily described the resident’s frequent refusals of evening and morning medications, blood sugar checks, blood pressure checks, insulin administration, hygiene care, and showers. Staff documented that the resident sometimes yelled at staff, said “Get out!”, was visibly upset by a room move, was leery of staff and asked to see name badges, and became upset about a pillow under her head until it was removed, after which she calmed down. The notes also recorded instances where the resident believed housekeeping had not cleaned her room or that she had not received medications when she had. However, there were no progress notes or assessments indicating that these behaviors were evaluated as dangerous, non-redirectable, or causing significant distress or functional impairment, and no detailed behavior monitoring logs were present as required by facility policy. On a psychiatric NP visit for initial psychotropic medication management, new mental health diagnoses of schizoaffective disorder, borderline personality disorder, and delusional disorder were added, and Seroquel 25 mg, an antipsychotic, was ordered. The clinical record did not contain a comprehensive evaluation to support these new diagnoses, and there was no documentation of target behaviors meeting the facility’s policy criteria for psychotropic use, such as behaviors representing danger to self or others, causing distress and impairment in functional abilities, or clearly attributable to psychosis or mania. The resident’s representative reported that the resident had no prior history of mental health disorders or psychiatric hospitalization and was unaware of the new diagnoses. The facility’s own psychotropic medication policy required identification and documentation of specific target behaviors, use and documentation of nonpharmacological interventions, and ongoing monitoring of behaviors and interventions, which were not reflected in the record for this resident.
Failure to Update PASARR Screens for New Mental Health Diagnoses and Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that Preadmission Screening and Resident Review (PASARR) Level I screenings were accurate and updated when new mental health diagnoses and psychoactive medications were initiated for multiple residents. For one resident with dementia, anxiety, depression, and post-traumatic stress disorder (PTSD), the PASARR completed on admission listed anxiety, depression, and dementia with sertraline and quetiapine, but did not include the PTSD diagnosis or the antidepressant Pristiq, despite the admission MDS and care plan documenting PTSD and a subsequent physician’s order for Pristiq. For another resident with Alzheimer’s disease, borderline personality disorder, delusional disorder, schizoaffective disorder, and depression, the PASARR only reflected depression and dementia with sertraline, even though additional mental health diagnoses were added later and an antipsychotic (quetiapine) was ordered for borderline personality disorder, and the quarterly MDS documented psychotic disorder, schizophrenia, and depression with antipsychotic and antidepressant use. A third resident had diagnoses including Alzheimer’s disease, depression, anxiety disorder, irritability and anger, and nonrheumatic aortic valve stenosis. The PASARR for this resident listed dementia and anxiety with Risperdal but omitted the diagnosis of depression and the medications escitalopram and lorazepam, although physician’s orders were in place for escitalopram for depression and lorazepam for anxiety, and the admission MDS documented depression with antianxiety and antidepressant use. Interviews with the Assistant Director of Nursing confirmed that new Level I PASARR screens should have been completed when new mental health diagnoses and psychoactive medications were added, and that the PASARR for one resident, completed prior to arrival, should have included all mental health diagnoses and medications. The facility’s own policy required notification of the state mental health authority within 14 days after a significant change in mental condition and specified that a new Level I screen is required for new mental health diagnoses or newly prescribed psychotropic medications, which was not followed in these cases.
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