Aperion Care Marion Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Marion, Indiana.
- Location
- 614 West 14th Street, Marion, Indiana 46953
- CMS Provider Number
- 155799
- Inspections on file
- 44
- Latest survey
- February 26, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Aperion Care Marion Llc during CMS and state inspections, most recent first.
A resident with diabetes, neuropathy, prior toe amputations, and multiple comorbidities developed severe necrotic wounds on the left foot after staff failed to consistently assess and monitor his feet and to implement targeted preventive interventions despite existing skin-impairment and non-compliance care plans. Documentation showed a recent Braden assessment rated him not at risk, weekly skin checks and shower-related assessments either reported no concerns or were incomplete due to refusals, and calloused feet were noted without further action. The resident, who often propelled his wheelchair with his feet and sometimes managed his own footwear, was ultimately found—only after a family member demanded an exam—to have a large necrotic plantar wound and additional darkened areas on the heel and toe, described as facility-acquired abrasions, with the plantar wound appearing trimmed or picked. This failure to recognize risk factors, perform thorough foot assessments per policy, and implement timely preventive measures led to a severely infected diabetic ulcer requiring hospital surgical incision and drainage of a deep tissue abscess and septic arthritis.
A resident with a right hip fracture, decreased mobility, ESRD on dialysis, heart failure, muscle wasting, and gait abnormalities was identified as at risk for pressure injuries and had a care plan for potential skin impairment, but the plan contained only a general directive to minimize pressure over bony prominences and lacked individualized interventions. Although orders included nutritional supplements and skin protectant and policies required frequent skin inspections and use of positioning devices to offload heels, documentation showed inconsistent skin checks during showers and routine care. A Braden assessment confirmed pressure injury risk, and a weekly skin note later described an open area on the right heel. A subsequent wound assessment documented a facility-acquired DTI on the right heel, 100% necrotic and 6 cm by 6 cm, which the ADON stated was first reported by therapy; at that time, pressure relief boots had not been implemented despite facility standards for turning, repositioning, and floating heels.
A resident with multiple chronic conditions and depression was verbally abused and threatened by a dietary aide after attempting to get a drink in the dining room. The aide used profane and intimidating language, escalating the situation and continuing to threaten the resident even after he walked away. The incident was confirmed through staff interviews and documentation, and the aide admitted to the unprofessional conduct, which violated the facility's abuse prevention policy.
The facility failed to follow physician orders for BP and HR parameters when administering antihypertensive medications for two residents. Medications were given outside of ordered parameters or not given when indicated, as shown in medication records and confirmed by staff interviews. Care plans directed staff to administer medications as ordered and monitor for side effects, but these instructions were not consistently followed.
Two residents with histories of smoking and vaping were found with smoking materials in their possession outside the designated area, despite facility policy requiring all smoking items to be turned in to staff. One resident, cognitively intact with multiple diagnoses, was observed carrying cigarettes and a lighter to her room without a smoking care plan or completed risk assessment. Another resident, with significant physical and cognitive impairments, had a vape device in her room and an incomplete smoking assessment, and was not listed among smokers requiring supervision. Facility records and interviews confirmed that required supervision and documentation were not in place.
The facility's Dietary Manager did not possess the required certification for the position, despite being employed in the role and responsible for food service to all residents. Interviews and record review confirmed the manager was not certified and was only preparing to take the certification exam, contrary to the job description's requirements.
Dietary staff failed to perform proper hand hygiene and used bare hands to handle food items during meal service. One employee handled a resident's wheelchair and then food without washing hands, while another touched his face and clothing before handling buns and plates, with his thumb contacting the food portion. The dietary manager confirmed these actions were not in line with expected food safety practices.
The facility did not distribute mail to residents on Saturdays because the BOM, responsible for sorting mail, only worked weekdays. Multiple residents reported not receiving mail on Saturdays, and staff interviews confirmed that mail delivery was limited to days when the BOM was present, despite facility policy requiring delivery Monday through Saturday.
The facility did not provide baseline care plans to residents or their representatives upon admission, as required before the comprehensive care plan was completed. Multiple residents with complex medical conditions were admitted without documentation that they or their representatives received or discussed the baseline care plan, a fact confirmed by staff interviews and record review.
Staff failed to consistently change, label, and date oxygen and nebulizer supplies for several residents, and did not ensure that the correct oxygen flow rates were administered. Observations showed that respiratory equipment was not always changed weekly or properly documented, and some residents received oxygen at rates different from physician orders, with staff unable to verify the correct settings.
Multiple residents reported receiving cold meals, including scrambled eggs, chili dogs, burgers, and French fries, due to delays in meal tray delivery and inadequate temperature monitoring. Staff confirmed that food was often not hot upon arrival and required reheating, and resident council feedback indicated this was a recurring issue, especially with room tray service in the evenings.
A resident who was dependent on staff for all ADLs and had moderate cognitive impairment was required by facility administration to disconnect phone calls with a family member during care, despite the resident and family member's wishes to remain connected for communication support. Staff enforced this practice citing privacy and dignity, but there was no facility policy addressing phone usage during care.
A resident with hypertension and dementia had conflicting code status documentation, with the electronic health record, physician's order, and care plan indicating DNR, while a signed POST form indicated full code status based on the POA's verbal consent. The administrator was unaware of the discrepancy, and the facility failed to ensure accurate and consistent documentation of the resident's advance directives.
A resident with multiple chronic conditions experienced weight gains that exceeded the physician-ordered thresholds for notification, but there was no documentation that the physician or nurse practitioner was informed as required. Nursing staff and the DON confirmed that the necessary notifications were not made or documented.
A resident with severe cognitive impairment and multiple medical conditions was found to be living in a room that was not kept clean or sanitary over several days. Observations revealed overflowing trash, debris and masks on the floor, a dirty bedside table with dried residue, and clothing left on the bathroom floor. Despite facility policies requiring daily cleaning, these tasks were not consistently performed, and the resident's care plan did not indicate any refusal of housekeeping services.
A resident with significant medical conditions and moderate cognitive impairment was not accurately assessed or documented for dental status during the MDS process. Despite having no upper teeth and only three lower teeth, the MDS did not reflect edentulism, and the care plan lacked dental information.
Two residents did not receive care according to physician orders: one was not weighed daily as ordered, and another received antihypertensive medication despite blood pressure readings below the prescribed threshold. Staff interviews confirmed missing documentation and administration outside of parameters, with no facility policy in place for such medication orders.
A facility failed to protect a resident from sexual abuse by an employee, CNA 3, who sent sexually explicit photos to the resident. The resident, who was cognitively intact but had a history of stroke and other conditions, confirmed receiving the photos and had given the CNA $50.00. The facility's DON and Administrator were informed, and CNA 3 was suspended. An investigation revealed attempts by CNA 3 and her husband to take the resident off the premises, which was prevented by staff.
A facility failed to ensure an LPN's active licensure, allowing her to provide resident care with an expired license over several months. The DON indicated that human resources was responsible for tracking licensure, but the oversight led to the LPN working without a valid license, contrary to facility policy.
The facility failed to maintain sanitary conditions in the kitchen and dining areas, affecting all residents who received meals. Observations included improperly stored and soiled dishes, undated food items, and a lack of structured cleaning protocols. Staff interviews revealed uncertainty about cleaning schedules, and the Corporate Regional Dietary Consultant noted the need for more education on food handling and cleaning.
A facility failed to report a resident-to-resident altercation to the State Agency. A resident was hit by another resident with a history of aggressive behavior, resulting in a bruise. The incident, witnessed by staff, was not documented in clinical records or reported as required by facility policy.
A resident with multiple health issues received both hydrocodone-acetaminophen and hydromorphone concurrently on several occasions, despite orders indicating they should not be given together. The MAR showed these medications were administered by an RN, with pain ratings documented as high. The DON confirmed the error, and the deficiency was noted during a complaint investigation.
A facility failed to ensure nursing staff competency in administering controlled medications, as a nurse administered two opioid analgesics together to a resident with multiple diagnoses, including spinal stenosis and diabetes. The resident had physician orders for hydrocodone-acetaminophen and hydromorphone, which were administered together on several occasions despite the DON's indication that they should not be combined. The report referenced increased health risks associated with taking opioids with other drugs.
The facility failed to have a qualified dietary manager supervising kitchen operations for several months, affecting 54 residents who received meals from the kitchen. The Administrator temporarily filled the role, and a new dietary manager was hired with a ServSafe certification. The deficiency was identified due to non-compliance with required qualifications for food and nutrition services management.
Two residents were found with medications in their rooms without proper physician orders or self-administration assessments. One resident had a nasal spray without a physician's order, while another had an ointment and inhaler, with only the inhaler having a proper order. Facility policy requires a 'may keep at bedside' order and assessment, which were missing.
A facility failed to ensure that advance directives were properly signed by a cognitively intact resident, who was their own representative. Despite being the responsible party, the resident's POST form was signed by a representative. Interviews revealed confusion among staff about who was responsible for completing advance directives, and the facility's policy on providing information to capable residents was not followed.
A facility failed to accurately code medications on MDS assessments for a resident with multiple diagnoses, including depression and vascular dementia. The resident was prescribed several medications, but the MDS assessments did not reflect the actual medications received. The MDS coordinator misinterpreted the MAR, believing the resident had refused medications, leading to inaccurate coding. The facility's use of the RAI manual for MDS policy was confirmed, but the failure to follow it resulted in a deficiency.
A resident with multiple health conditions, including diabetes and peripheral vascular disease, developed a pressure injury due to the facility's failure to implement individualized interventions. Despite having a care plan that included turning and repositioning every two hours, the plan lacked specific measures to prevent shearing or skin-to-skin contact. The resident, who preferred to stay in bed, was observed lying on his back with heel boots on multiple occasions, and the facility did not document refusals of care prior to the injury's development.
A facility failed to meet the dietary needs of a dialysis resident, who struggled with eating due to denture issues and inconsistent meal provision. The resident often missed meals before or during dialysis and received cold food upon return. Staff acknowledged inconsistent communication and meal provision, despite the resident's medical history indicating a need for careful nutritional management.
The facility failed to provide prescribed pain medications for two residents, leading to significant deficiencies in pain management. One resident experienced severe pain due to the unavailability of a fentanyl patch, while another resident did not receive hydrocodone-acetaminophen for several days. The facility's staff did not adequately communicate or document the medication shortages, and pain assessments were inconsistent, contributing to the deficiencies observed.
A facility failed to conduct a required AIMS assessment for a resident on Risperdal, despite two requests from a pharmacist. The resident, with multiple psychiatric diagnoses, had not received an AIMS assessment since 5/22/23. The DON was aware of the oversight but could not provide a reason for the missed assessments, leading to non-compliance with the care plan aimed at preventing psychotropic drug-related complications.
A resident with medical conditions including dementia and malnutrition experienced ill-fitting dentures for over three months without timely intervention from the facility. Despite requests from the resident's daughter and multiple notes indicating the need for dental adjustments, the resident was not seen by a dentist until several months later. Observations showed the resident struggled with eating and expressed frustration with the dentures. The facility's policy required prompt referral for dental services, which was not followed, and the MDS Coordinator was unaware of the issue.
The facility failed to implement enhanced barrier precautions (EBP) for two residents with chronic wounds. A resident with a methicillin susceptible staphylococcus aureus infection and chronic wounds was not placed on EBP, lacking signage and PPE at the door, and staff did not wear a gown during wound care. Another resident with a pressure wound had an EBP sign, but the ADON did not wear a gown during care, contrary to facility policy. These actions indicate a deficiency in the infection prevention and control program.
Two residents in the facility did not receive adequate grooming assistance and scheduled showers as required. One resident was observed with dirty fingernails and inconsistent shower documentation, while another was unshaven with overgrown nails despite needing assistance due to limited mobility. Staff interviews revealed inconsistencies in care provision and documentation, contrary to facility policies.
A resident's preference to use a foot pedal for her wheelchair was not honored by the facility, despite her medical condition requiring leg elevation due to swelling and foot drop. The Administrator removed the foot pedal to encourage leg use, disregarding the resident's expressed discomfort and need for elevation.
A resident with an unstageable pressure ulcer on his right heel did not receive the prescribed Santyl ointment for treatment. Instead, an LPN applied medical grade honey, later admitting the error despite having reviewed the physician's order.
The facility failed to ensure that the Administrator completed the required annual resident rights training. During an interview, it was revealed that many inservices had not been opened yet, and employees should have completed the previous year's inservices. The facility's policy mandates annual education for all employees, including training on resident rights, which was not adhered to in this instance.
The facility failed to ensure that required annual abuse training was completed for two employees, specifically the Administrator and an LPN. Employee records indicated that neither had completed their annual abuse training. The Administrator acknowledged that many inservices had not been opened yet and that employees should have completed the previous year's inservices. The facility's policy mandates annual education for all employees, including training on abuse.
Failure to Identify Skin Risk and Prevent Severe Diabetic Foot Wound
Penalty
Summary
The deficiency involves the facility’s failure to identify a resident’s risk for skin breakdown and to develop and implement interventions to prevent the development of significant foot wounds. The resident had multiple diagnoses including vascular dementia, hemiplegia and hemiparesis, type 2 diabetes mellitus, morbid obesity, chronic respiratory failure, chronic heart failure, COPD, peripheral autonomic neuropathy, and prior toe amputations. A quarterly MDS indicated the resident was cognitively intact and at risk for pressure ulcers, with pressure-reducing devices in use. Existing care plans addressed potential for skin impairment and non-compliance with care, but the clinical record did not document that the resident picked at his skin or used implements to cut his skin or wounds. A Braden Scale assessment in January indicated he was not at risk for pressure injuries, and a weekly skin observation on 2/7/26 documented intact skin with no foot concerns. In the days leading up to the discovery of the wound, documentation showed incomplete or limited skin assessments. On 2/13/26, the resident refused a shower, and a nurse’s note indicated he did not feel well enough to shower and signed a refusal form. A shower sheet for that date indicated a full body check was completed with no concerns noted, and a CNA later reported that on that date there were no foot concerns other than a scab where a toe had been amputated, and nothing on the ball of the foot. A late-entry weekly skin observation note for 2/14/26, written on 2/19/26, indicated the resident’s skin was within normal limits but also stated he refused his shower and the skin assessment with the shower, so his feet were not assessed; it also noted he had calloused areas to his feet prior to that date. The facility’s policy required that each resident be observed for skin breakdown daily during care and on the assigned bath day by the CNA, with changes promptly reported to the charge nurse for detailed assessment. On 2/16/26, the resident’s family member approached the nurse’s station demanding that someone examine the resident’s left foot, prompting discovery of multiple wounds. The nurse practitioner and facility nurse found a circular necrotic wound on the plantar surface of the left forefoot measuring 5 cm by 4.5 cm with no depth, with pink granular tissue and peeling skin, a darkened area along the heel, a darkened area along the left third toe nail, and another darkened area with erythema and coolness along the lateral nail and dorsal foot. The plantar wound assessment described a facility-acquired abrasion with 40% pink/red non-granulating tissue and 60% hard, adherent necrotic tissue, and noted it appeared the resident had been picking at the wound and cutting surrounding tissue. A left heel wound assessment documented a facility-acquired abrasion with 100% necrotic tissue. Interviews with staff indicated they had not previously seen the resident with scissors or nail clippers, though the wound appeared trimmed or peeled back when first observed. The failure to identify the resident’s risk factors, consistently assess his feet in accordance with policy, and implement timely preventive interventions resulted in the development of a severely infected diabetic foot ulcer requiring hospitalization and surgical incision and drainage of a deep tissue abscess and septic arthritis in the left foot. Additional observations and interviews highlighted the resident’s mobility patterns and behaviors that were not fully addressed in preventive planning. The resident was very mobile in a wheelchair, often propelling himself with his feet rather than using his hands on the wheels, and he was sometimes able to put on his own socks and shoes. Staff reported he normally wore socks, shoes, non-skid socks, or slippers, and he had a history of picking at scabs, though this behavior was not reflected in the care plan. When the wound was discovered, the nurse practitioner noted the sock was off and the wound looked trimmed. Subsequent notes described the resident as non-compliant with wearing a protective heel boot and continuing to propel his wheelchair with the affected foot. These documented patterns, combined with incomplete foot assessments and lack of documented interventions specific to his known risk factors and behaviors, formed the basis of the cited deficiency for failing to provide appropriate treatment and care according to orders, resident preferences, and goals, and for failing to prevent the development of the wounds.
Failure to Implement Individualized Pressure Injury Prevention for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement individualized pressure injury prevention interventions for a resident recovering from a right intertrochanteric femur fracture with decreased mobility and multiple comorbidities, including chronic combined systolic and diastolic heart failure, end stage renal disease on dialysis, muscle wasting, and gait abnormalities. The resident’s admission MDS showed he was cognitively intact, at risk for pressure ulcers, had a surgical wound, used a manual wheelchair, and had pressure-reducing devices for bed and chair. A care plan for potential skin impairment was initiated and included a general intervention to minimize pressure over bony prominences, but the clinical record lacked specific, individualized interventions to prevent or mitigate pressure injuries. Physician orders included several nutritional supplements and a skin protectant every shift, and facility policies required daily skin observation by CNAs and frequent skin inspection during bathing, hygiene, and repositioning, with use of positioning devices to offload heels as indicated. Despite these orders and policies, documentation and staff interviews showed gaps in implementation. A shower sheet documented a full body check on one date, but a subsequent shower sheet lacked documentation of a skin check. A Braden Scale assessment identified the resident as at risk for pressure injuries. A weekly skin observation later noted a small open area on the back of the right heel with treatment in place, and a facility-acquired ulceration assessment documented a deep tissue injury (DTI) to the right heel, first identified earlier in the month, described as 100% necrotic, hard, and measuring 6 cm by 6 cm with no depth. The ADON stated that the DTI was initially reported by therapy, that the resident’s surgical incision was on the same side as the DTI, and that pressure relief boots were not in place when the DTI was noticed, even though facility standards included turning and repositioning every two hours, floating heels, and offloading prominent areas. A physical therapist reported noticing the heel area while applying socks and then reporting it to the nurse, further indicating that the pressure injury was identified through therapy rather than through routine nursing skin assessments and individualized preventive measures.
Resident Subjected to Verbal Abuse and Intimidation by Staff
Penalty
Summary
A resident with diagnoses including COPD, hypertension, depression, atrial fibrillation, and congestive heart failure, who was cognitively intact and required supervision for daily activities, was subjected to verbal abuse and intimidation by a dietary aide. The incident occurred when the resident attempted to get a drink in the dining room and was told by the dietary aide that he was not allowed to do so. An exchange of words escalated, culminating in the dietary aide threatening the resident by stating he would "knock his dumb f****ing a** out." The resident reported that the aide continued to threaten him even after he walked away, and that this was not the first instance of disrespectful behavior from the aide. The facility's records and staff interviews confirmed that the dietary aide admitted to responding in an unprofessional manner and acknowledged the use of threatening language. The dietary manager and administrator were informed of the incident, and the aide was suspended pending investigation. Other staff present did not directly witness the verbal exchange, but one staff member noted the aide appeared visibly upset after the incident. The resident did not have a history of dishonesty, and the aide admitted to previous confrontations with the resident, including yelling at him outside the facility. The facility's abuse prevention policy explicitly prohibits any form of abuse, including verbal abuse and intimidation, and requires immediate reporting of such incidents. The policy defines verbal abuse as the use of language that includes threats of harm or statements intended to frighten a resident. In this case, the dietary aide's actions constituted a violation of the facility's policy and resulted in the resident being subjected to verbal abuse and intimidation.
Failure to Follow Physician Orders for Blood Pressure and Heart Rate Parameters
Penalty
Summary
The facility failed to ensure that physician orders for blood pressure (BP) and heart rate (HR) parameters were followed when administering antihypertensive medications for two residents. For one resident with diagnoses including hypertension, heart failure, and coronary artery disease, physician orders specified holding certain medications if BP or HR fell below set thresholds. Despite these orders, the medication administration records showed that medications such as metoprolol, amlodipine, and losartan were administered on multiple occasions when the resident's BP or HR were below the ordered parameters. The resident's care plans also directed staff to give medications as ordered and monitor for side effects, but these instructions were not consistently followed as evidenced by the documented administration outside of parameters. For another resident with a history of heart disease and hypertension, physician orders required administration of midodrine for systolic BP less than 90. However, the medication administration records indicated that on several occasions when the resident's BP was below this threshold, there was no documentation that midodrine was administered as ordered. The care plan for this resident also included monitoring BP and administering medications for hypertension as ordered, but the records did not reflect compliance with these directives. Interviews with nursing staff and the Director of Nursing confirmed that staff were expected to follow medication parameters and contact providers if there were questions or discrepancies. Despite this, the records demonstrated that medications were either administered when parameters were not met or not administered when indicated, contrary to physician orders. The facility did not have a specific policy on following physician orders, relying instead on federal and state guidelines.
Failure to Prevent Smoking Hazards and Incomplete Supervision
Penalty
Summary
The facility failed to ensure that the environment was free from accident hazards and did not provide adequate supervision to prevent accidents for two residents who smoked or vaped. One resident, who was cognitively intact and had diagnoses including hypertension, COPD, depression, and anxiety, was observed carrying cigarettes and a lighter away from the designated smoking area to her room. Her clinical record did not contain a physician's order for smoking, a completed smoking safety risk assessment, or a smoking care plan, despite documentation that she smoked daily and used smoking materials. The assessment section regarding the storage of smoking materials was incomplete, and there was no evidence that all smoking materials were being locked in the designated area as required by policy. Another resident, with a history of stroke, COPD, and requiring significant assistance with personal care, was found to have a vaping device in her possession in her room. Her clinical record included an order permitting smoking for psychosocial and medical necessity, but lacked a smoking care plan. The smoking safety risk assessment for this resident was incomplete and incorrectly indicated she did not use electronic smoking devices. Interviews revealed that she had not attended supervised smoking breaks for two months, was not listed as a dependent or independent smoker, and that all smoking materials for skilled nursing residents were supposed to be kept at the front desk. Facility policy required all residents to turn in smoking materials to staff, but this was not followed for these two residents.
Dietary Manager Lacked Required Certification
Penalty
Summary
The facility failed to ensure that the Dietary Manager met the required qualifications for the position, specifically lacking the necessary dietary manager certification. The employee record indicated that the Dietary Manager had been employed since February 2025 without obtaining the required certification. Interviews with the Dietary Manager and the Nurse Consultant confirmed that the manager was not certified and was only in the process of preparing for the certification exam. The Dietary Manager reported having twenty years of food service experience but had not previously held the title of dietary manager before this employment. The job description for the position, signed by the Dietary Manager, explicitly required a Food Service Sanitation Manager Certification, which was not possessed at the time of the survey. This deficiency had the potential to impact all 58 residents receiving meals from the facility kitchen.
Failure to Maintain Sanitary Food Handling and Hand Hygiene
Penalty
Summary
During a lunch service observation, dietary staff failed to follow safe and sanitary food handling practices. One dietary employee locked a resident's wheelchair brake and then, without performing hand hygiene, handled tongs to place a lemon slice into a drink and touched the inside of a lemon slice container. This employee also touched the back of another staff member before handling food items, again without hand hygiene. Another dietary employee was observed grabbing hot dog and hamburger buns with bare hands, opening them, and plating them without performing hand hygiene. This employee also touched his waist, lower back, and face, then continued to handle food and plates, with his thumb repeatedly touching the food portion of the plates. Interviews with the employees confirmed these actions, and the dietary manager acknowledged that staff should not touch food or their clothing, glasses, or face without performing hand hygiene.
Failure to Deliver Resident Mail on Saturdays
Penalty
Summary
The facility failed to ensure that residents received their mail on Saturdays, as required by facility policy. During a Resident Council meeting, multiple residents reported not receiving mail on Saturdays. The process for mail distribution involved the Business Office Manager (BOM) sorting the mail and then the activity department delivering it to residents. However, the BOM only worked Monday through Friday, resulting in no mail being sorted or distributed on Saturdays. Interviews with the Activity Director and BOM confirmed that mail was only distributed on days when the BOM was present, and the current mail policy stated that mail should be delivered Monday through Saturday.
Failure to Provide Baseline Care Plans to Residents and Representatives Upon Admission
Penalty
Summary
The facility failed to ensure that residents and/or their representatives received a copy of the baseline care plan upon admission, as required prior to the completion of the comprehensive care plan. This deficiency was identified for five residents, each with complex medical histories, whose records lacked documentation that the baseline care plan was provided or discussed at the time of admission. The absence of this documentation was confirmed through both record review and staff interviews. For example, one resident with diagnoses including alcoholic hepatic failure, hepatic encephalopathy, diabetes, anemia, and thrombocytopenia was admitted without evidence that a baseline care plan was given to the resident or their representative. The Social Services Director (SSD) acknowledged that she had not provided the baseline care plan at admission and only met with the representative months later. Similarly, another resident with hypertension, gastroesophageal reflux disease, Charcot's joint, repeated falls, and cellulitis was admitted without documentation of receiving a baseline care plan, which the SSD confirmed had not been provided or discussed. Additional residents with significant health issues such as repeated falls, chronic viral hepatitis C, fractures, stroke sequelae, dysphagia, malnutrition, respiratory failure, heart failure, kidney failure, and cancer were also admitted without documented provision of the baseline care plan. The SSD indicated that she had only recently been educated on the requirement to provide baseline care plans at admission, and prior to this, baseline care plans were not consistently completed or distributed. Facility policy required that residents and/or their representatives receive a summary of the baseline care plan prior to the comprehensive care plan, but this was not followed for the residents reviewed.
Failure to Change, Label, and Date Respiratory Supplies and Ensure Correct Oxygen Flow Rates
Penalty
Summary
The facility failed to properly change, label, and date oxygen and nebulizer supplies for four residents who required respiratory care. Observations revealed that oxygen tubing bags, humidifier bottles, and nebulizer masks were either not changed according to facility policy, not labeled, or not dated as required. For example, one resident's oxygen tubing bag was dated nearly three months prior to the observation, and another resident's oxygen tubing had a date that was altered. Additionally, some residents' respiratory equipment lacked any labeling or dating, and staff interviews confirmed that the required weekly changes and documentation were not consistently performed. Furthermore, the facility did not ensure that residents received the correct oxygen flow rates as ordered by their physicians. In one instance, a resident was observed receiving a higher flow rate of oxygen than prescribed, and staff were unsure of the correct flow rate for that resident. The facility's policy required weekly changes and proper labeling of all respiratory equipment to minimize infection risk and ensure resident safety, but these procedures were not followed for the residents reviewed.
Failure to Serve Meals at Palatable Temperatures
Penalty
Summary
The facility failed to ensure that meals were served at an appetizing and safe temperature for 12 of 15 residents reviewed. Multiple residents reported that their food, including items such as scrambled eggs, chili dogs, burgers, and French fries, was consistently served cold or not hot enough. Observations confirmed that meal trays were delivered to units with significant delays, and residents received their food well after the meal carts arrived. Staff interviews corroborated that food was often not hot upon arrival, and CNAs frequently had to reheat meals in microwaves before serving them to residents. Resident council feedback and individual interviews highlighted that the issue was particularly prevalent with room tray meals, especially during the evening meal service. Facility documentation indicated scheduled meal times, but observations showed that the actual delivery and serving of meals did not align with these times, resulting in cold food. The facility's policy required monitoring of food temperatures to ensure palatability and prevent foodborne illness, but this was not consistently followed, as evidenced by the repeated resident complaints and staff admissions.
Failure to Honor Resident's Right to Communication and Self-Determination
Penalty
Summary
The facility failed to honor a resident's right to self-determination and communication. A resident with cerebral palsy, obsessive-compulsive disorder, mild intellectual disabilities, fibromyalgia, and mobility impairments was dependent on staff for all activities of daily living and was cognitively moderately impaired. The resident was unable to reposition herself or independently contact her family and relied on staff for assistance. The Administrator and Social Services spoke with the resident about her frequent phone calls to her family member, instructing her that she could not be on the phone during care and that all electronic devices would be shut off while care was provided. The stated reason was to protect the resident's privacy and dignity, and staff would assist the resident in resuming the call after care was completed. Despite the resident and her family member expressing a desire to remain connected by phone, even during care, the facility enforced the policy of disconnecting calls during care. The resident's family member indicated that being on the phone was necessary to help the resident communicate, as she was sometimes difficult to understand. Staff interviews confirmed that the family member was frequently on speaker phone during care, and some staff were not bothered by this, suggesting alternatives such as muting the call or lowering the volume. The facility did not have a policy addressing resident phone usage during care, and the local Ombudsman had suggested hanging up the phone during care for privacy reasons.
Failure to Maintain Accurate Code Status Documentation
Penalty
Summary
The facility failed to maintain an accurate and consistent code status for a resident with a history of hypertension and dementia, who was assessed as moderately cognitively impaired. The resident's electronic health record, current physician's order, and care plan all indicated a Do Not Resuscitate (DNR) status, with documentation that a valid DNR was in place and interventions were aligned with this directive. However, a Physician Orders for Scope of Treatment (POST) form, signed and provided by the administrator, indicated that the resident was actually designated as full code, with instructions for CPR and full interventions, based on verbal consent from the resident's power of attorney (POA). The administrator was unaware of the conflicting information regarding the resident's advance directives, and the POST form was the only signed code status document available for the resident. The facility's policy required that advance directives be documented, maintained in the clinical record, and reviewed during care plan meetings, but this process was not followed, resulting in inconsistent documentation and a failure to honor the resident's or POA's most current wishes regarding code status.
Failure to Notify Physician of Significant Weight Gain
Penalty
Summary
The facility failed to follow physician orders regarding the notification of a physician or nurse practitioner when a resident experienced significant weight gain. The resident, who had multiple diagnoses including hypertension, type 2 diabetes with neuropathy, chronic kidney disease, and cardiac pacemaker, had a physician order in place to weigh daily and notify the physician if there was a weight gain of three pounds in a day or five pounds in a week. Despite documented weight increases exceeding these thresholds on two occasions, there was no evidence that the physician was notified as required. Interviews with nursing staff and the Director of Nursing confirmed that the expected notifications did not occur and could not be found in the resident's records.
Failure to Maintain Clean and Sanitary Resident Room
Penalty
Summary
Surveyors observed that a resident's room was not maintained in a clean and sanitary condition over several days. The room had an overflowing trash can, trash and masks on the floor, a visibly dirty bedside table with a large area of dried, sticky residue, and a pile of clothing on the bathroom floor. These conditions persisted despite multiple observations on different days, with the same trash, masks, and residue remaining in place. The resident reported that housekeeping only occasionally emptied the trash and swept the floor, and could not recall when the bedside table was last cleaned. Interviews with housekeeping staff confirmed that daily cleaning was required, including vacuuming, mopping, sweeping visible debris, cleaning surfaces, and emptying trash, but these tasks were not consistently performed in this resident's room. The resident involved had significant medical conditions, including Guillain-Barre syndrome, difficulty walking, abnormal gait, COPD, and osteoarthritis, and was assessed as severely cognitively impaired, requiring varying levels of assistance with daily activities. The care plan did not indicate any refusal of housekeeping services. Facility policies required daily cleaning of resident rooms, including work surfaces, furniture, and floors, but these standards were not met in this case, resulting in a failure to provide a safe, clean, and homelike environment for the resident.
Failure to Accurately Assess and Document Resident's Dental Status
Penalty
Summary
The facility failed to accurately assess and document the dental status of a resident during the Minimum Data Set (MDS) assessment process. Observations and interviews revealed that the resident had no upper teeth and only three lower teeth, yet the admission MDS assessment did not indicate that the resident was edentulous or had any tooth fragments. Additionally, the resident's current care plan did not include information regarding their dental status. The resident also reported not having dentures, and direct observation confirmed the absence of upper teeth and the presence of only three lower teeth. The resident's clinical record showed diagnoses including malignant neoplasm of the stomach, gastric ulcer, unspecified cirrhosis of the liver, and major depressive disorder. The MDS assessment noted moderate cognitive impairment and a need for partial to moderate assistance with eating. Despite these findings and the resident's self-reported dental condition, the facility did not accurately document or assess the resident's oral health status as required by the Resident Assessment Instrument (RAI) guidelines.
Failure to Follow Physician Orders for Weight Monitoring and Medication Parameters
Penalty
Summary
The facility failed to follow physician orders for two residents regarding daily weight monitoring and administration of blood pressure medication according to specified parameters. For one resident with multiple diagnoses including hypertension, diabetes, chronic kidney disease, and cardiac issues, there was a physician order to obtain daily weights and notify the physician if certain weight gains occurred. However, the medication administration record showed that weights were not recorded for 11 out of 28 days, and staff interviews confirmed the missing documentation and inability to locate the required weights. For another resident with heart failure, COPD, chronic respiratory failure, hypertension, and dementia, there was an order for carvedilol to be held if the systolic blood pressure was below 120 mmHg. Despite this, the medication administration record indicated that the resident received carvedilol on multiple occasions when her systolic blood pressure was below the ordered threshold. Staff interviews confirmed that the medication was administered outside the prescribed parameters, and the facility did not have a specific policy regarding medication administration by parameters, relying instead on state guidelines.
Failure to Protect Resident from Sexual Abuse by Employee
Penalty
Summary
The facility failed to protect a resident from sexual abuse by an employee, CNA 3, who engaged in inappropriate behavior with Resident B. The incident involved CNA 3 sending sexually explicit photos to Resident B, who was cognitively intact but had a history of stroke, seizures, mild vascular dementia, and major depression. The inappropriate photos were discovered when another CNA assisted Resident B with his phone, leading to the discovery of the images. Resident B confirmed receiving the photos and expressed no concerns about the relationship, although he had given CNA 3 $50.00, which he claimed was not for the photos. The facility's Director of Nursing (DON) and Administrator were informed of the situation, and CNA 3 was suspended pending an investigation. The investigation revealed that CNA 3 and her husband attempted to take Resident B off the premises, but facility staff intervened. The facility's policy on abuse prevention and reporting was reviewed, which defines abuse as the willful infliction of harm, including through technology. The investigation file included staff statements, copies of the photos, and interviews with other residents. CNA 3's employee file showed she had completed training on abuse, neglect, and exploitation prior to the incident.
Expired Nursing License Overlooked
Penalty
Summary
The facility failed to ensure the active licensure of a Practical Nurse (PN) who provided care to residents. During a review of employee records, it was discovered that the PN's nursing license had expired, as indicated on the MyLicense.IN.gov website. Despite the expiration, the PN continued to work and provide resident care on multiple dates across three months. During an interview, the Director of Nursing (DON) stated that human resources was responsible for tracking staff licensure, and the facility was unaware of the expired license, allowing the PN to continue working. The facility's policy required staff to have valid licensure to provide resident care, which was not adhered to in this instance.
Facility Fails to Maintain Sanitary Kitchen and Dining Conditions
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen and dining areas, affecting all 59 residents who received meals from the facility kitchen. During a kitchen tour, numerous issues were observed, including an open bag of sugar with unknown particles, clean dishes stored improperly, and visibly soiled carts and utensils. Additionally, there were issues with food storage, such as undated and open food items, and the presence of trash and dried spillage on floors and equipment. The facility lacked a cleaning schedule, and staff were unsure of the last time the kitchen was thoroughly cleaned. Interviews with staff revealed a lack of structured cleaning protocols, with employees attempting to clean as needed without a formal schedule. The Corporate Regional Dietary Consultant acknowledged the need for more education on food handling and cleaning. The facility's policies on handling leftover food, cleaning rotation, and food storage were not being followed, contributing to the unsanitary conditions. This deficiency was related to complaints IN00448904 and IN00448992.
Failure to Report Resident Altercation
Penalty
Summary
The facility failed to report a resident-to-resident altercation to the State Agency, as required by their policy. During an interview, a resident, identified as Resident F, reported being hit in the chest by another resident, identified as Resident G, while attempting to enter the dining room. Resident G, who has a history of verbally aggressive behaviors and diagnoses including depression, dementia, anxiety, schizoaffective disorder, and hypertension, was blocking the entryway and became aggressive when asked to move. Resident F responded by hitting Resident G, and there were staff witnesses to the incident. However, the clinical records for both residents lacked documentation of behavioral concerns related to this incident. The Corporate Regional President of Operations acknowledged during an interview that the incident was not reported to the State Agency, although it should have been. The facility's current policy on Abuse Prevention and Reporting requires that any allegations of abuse, exploitation, neglect, mistreatment, or misappropriation of resident property be reported to the Department of Public Health and local law enforcement, especially in cases of physical abuse involving injury inflicted by one resident on another. This incident was related to a complaint identified as IN00449266.
Significant Medication Error: Concurrent Opioid Administration
Penalty
Summary
The facility failed to prevent a significant medication administration error involving a resident with multiple diagnoses, including cervical region spinal stenosis, type 2 diabetes, muscle wasting and atrophy, abnormalities of gait and mobility, and depression. The resident had physician orders for hydrocodone-acetaminophen and hydromorphone, both opioid analgesics, to be administered as needed for pain. However, the Medication Administration Record (MAR) for October 2024 showed that these medications were administered together on multiple occasions by RN 1, despite the Director of Nursing (DON) indicating that they should not be given concurrently. The MAR indicated that on four separate occasions, RN 1 administered both hydrocodone-acetaminophen and hydromorphone to the resident, with documented pain ratings ranging from 8 to 10 out of 10. The administration of these medications together raised the likelihood of harm, as noted in a National Institute on Drug Abuse article, which highlighted the increased health risks and potential for overdose when opioids are taken with other drugs. RN 1 was unavailable for interview during the survey, and the deficiency was related to a complaint investigation.
Incompetent Administration of Opioid Analgesics
Penalty
Summary
The facility failed to ensure that nursing staff were competent in the administration of controlled medications, as evidenced by a registered nurse (RN 1) administering two opioid analgesics together to a resident (Resident B). The clinical record for Resident B, who had diagnoses including cervical region spinal stenosis, type 2 diabetes, muscle wasting and atrophy, abnormalities of gait and mobility, and depression, was reviewed. Physician orders for October 2024 indicated that Resident B had an order for hydrocodone-acetaminophen 10-325 mg every 6 hours as needed for pain, and an order for hydromorphone 4 mg every 4 hours as needed for severe pain. Both orders were active from 10/10/24 to 10/18/24. The Medication Administration Record (MAR) for October 2024 showed that RN 1 administered both hydrocodone-acetaminophen and hydromorphone to Resident B on multiple occasions, despite the Director of Nursing (DON) indicating that these medications should not be given together. Specifically, RN 1 administered both medications on 10/12/24, 10/13/24, and 10/17/24, with documented pain ratings ranging from 8 to 10 out of 10. The report also referenced a National Institute on Drug Abuse article highlighting the increased health risks associated with taking opioids with other drugs, including the risk of overdose. RN 1 was unavailable for interview during the survey.
Deficiency in Dietary Management Staffing
Penalty
Summary
The facility failed to ensure a qualified dietary manager was supervising the kitchen staff and operations, which had the potential to affect 54 of 55 residents who received meals from the facility kitchen. Interviews revealed that the kitchen had been without a manager for six to seven months, and the Administrator was temporarily filling in as the dietary manager. Employee records confirmed the absence of a dietary manager, and the Head of the kitchen was not certified as a dietary manager, although discussions about certification were ongoing. The dietician visited the facility about three times a month, and one resident received nutrition through a feeding tube, while the remaining 54 residents received meals and snacks from the kitchen. A new dietary manager was hired and started on June 24, 2024, but the facility had been without a dietary manager for several months prior. The newly hired dietary manager had a ServSafe food production manager certification, which would expire in August 2025. The Indiana Department of Health Long-term Care Newsletter outlined the qualifications required for a director of food and nutrition services, which the facility had not met during the period without a dietary manager. The deficiency was identified as a failure to employ sufficient staff with the appropriate competencies and skills to carry out the functions of the food and nutrition service.
Failure to Obtain Physician Orders and Assessments for Self-Administration of Medications
Penalty
Summary
The facility failed to obtain physician orders and conduct assessments for self-administration of medications for two residents who had medications stored in their rooms. Resident 52 was observed with a mometasone furoate nasal spray on her bedside table, which she self-administered without a physician's order or a self-administration assessment. Interviews with LPNs and the DON confirmed that residents should not have medications in their rooms without a 'may keep at bedside' (MKABS) order and a completed assessment, which were missing in this case. Similarly, Resident 35 had a tube of nystatin triamcinolone ointment and an albuterol sulfate inhaler in her room. While there was a physician's order for the inhaler, there was no order for the ointment, and the clinical record lacked a self-administration assessment for both medications. The facility's policy requires a written order from the attending physician and a self-administration assessment before residents can retain medications in their rooms, which was not adhered to in these instances.
Failure to Ensure Proper Signing of Advance Directives
Penalty
Summary
The facility failed to ensure that advance directives were properly developed and signed by a cognitively intact resident, identified as Resident 35, who was their own representative. The resident's clinical record indicated diagnoses of unspecified adrenocortical insufficiency, epilepsy, and cirrhosis of the liver. Despite being cognitively intact, as noted in the Minimum Data Set assessment, the Indiana Physician Orders for Scope of Treatment (POST) form was signed by the resident's representative instead of the resident themselves. The resident's profile confirmed that they were the responsible party and health care decision maker, with no documentation of a guardian, healthcare representative, or power of attorney. Interviews with facility staff revealed a lack of clarity and responsibility regarding the completion of advance directives. The Director of Nursing (DON) was uncertain why the POST form was signed by the representative, and the Social Services Director indicated that the nursing department was responsible for ensuring the completion of advance directives. The Administrator and Business Office Manager (BOM) also expressed uncertainty about who completed the advance directives, with the BOM confirming the absence of documentation for a guardian or healthcare representative. The Assistant Director of Nursing (ADON) mentioned that the resident was emotional upon admission, which might have led to the representative signing on their behalf. The facility's policy stated that advance directive information should be provided to the resident once they are capable of understanding and making decisions, but this was not adhered to in this case.
Inaccurate Medication Coding on MDS Assessments
Penalty
Summary
The facility failed to accurately code medications on the Minimum Data Set (MDS) assessments for a resident reviewed for medication use. The resident, who had diagnoses including depression, delusional disorders, hallucinations, vascular dementia with agitation, and atherosclerotic heart disease, was prescribed several medications, including clopidogrel bisulfate (an antiplatelet), mirtazapine and sertraline (antidepressants), and risperidone (an antipsychotic). However, the MDS assessments for February and May did not accurately reflect the medications the resident received. The February assessment incorrectly indicated the resident received insulin but did not note the antidepressants or antiplatelet, while the May assessment failed to indicate the resident received an antipsychotic, antidepressants, or an antiplatelet. The MDS coordinator, during an interview, acknowledged reviewing the Medication Administration Record (MAR) but mistakenly believed the resident had refused medications during the assessment windows. The MAR showed that the resident had indeed received the medications during the specified periods. The facility's President of Operations confirmed the use of the Resident Assessment Instrument (RAI) manual for MDS policy, which requires coding all high-risk drug class medications according to their pharmacological classification. The failure to accurately code the medications on the MDS assessments led to the deficiency identified by the surveyors.
Failure to Prevent Pressure Injury Due to Inadequate Individualized Care Plan
Penalty
Summary
The facility failed to implement interventions to prevent the development of a pressure injury for a resident who was reviewed for pressure injuries. The resident, who was cognitively intact, had multiple diagnoses including methicillin susceptible staphylococcus aureus infection, peripheral vascular disease, and diabetes mellitus with neuropathy. The resident required substantial assistance for activities of daily living and was observed lying on his back in bed with heel boots on multiple occasions. Despite having a care plan that included interventions such as turning and repositioning every two hours, the plan lacked individualized interventions specific to avoiding shearing or skin-to-skin contact. The resident's clinical record indicated a history of an unstageable wound to the right heel, which was related to the disease process and immobility. The care plan included interventions like administering treatments as ordered, floating heels, and using pressure relief boots. However, the facility's documentation lacked evidence of resident refusals of care prior to the development of the pressure injury. Interviews with staff revealed that the resident preferred to stay in bed and was resistant to getting up, which was not adequately addressed in the care plan. The facility's policy on pressure ulcer prevention required turning dependent residents approximately every two hours and encouraging residents to change positions to promote circulation. However, the facility failed to document and implement individualized interventions for the resident's condition and preference to stay in bed, leading to the development of a pressure injury. The deficiency was identified through observations, interviews, and record reviews conducted by surveyors.
Failure to Address Dietary Needs for Dialysis Resident
Penalty
Summary
The facility failed to adequately address the dietary needs of a dialysis resident, identified as Resident 28, who was observed to have impaired nutrition. During multiple observations, it was noted that the resident struggled with eating due to issues with his dentures and the lack of condiments on his meal trays. On one occasion, the resident ate less than 25% of his meal and expressed difficulty eating with his dentures. Additionally, the resident reported not receiving lunch before or during dialysis sessions, which occurred three times a week, and often received cold food upon returning to the facility. The facility staff, including CNAs and the DON, acknowledged that the resident was sometimes offered an early lunch tray before dialysis or food upon return, but this was not consistently done. The resident was observed to return from dialysis without being checked on or offered food until dinner, which could be delayed. Interviews with staff revealed that there was no consistent communication between ambulance staff and facility staff regarding the resident's return from dialysis, leading to delays in providing meals or snacks. The resident's clinical record indicated a history of chronic kidney disease, dependence on dialysis, and protein-calorie malnutrition, with a care plan in place to monitor and maintain his nutritional intake. Despite this, there were inconsistencies in meal documentation, particularly on dialysis days, and a significant weight fluctuation was noted in the resident's weight history. The facility's agreement with the dialysis center required ensuring residents received proper nourishment before dialysis, which was not consistently met for Resident 28.
Deficiencies in Pain Management for Two Residents
Penalty
Summary
The facility failed to provide pain medications as ordered for two residents, Resident 22 and Resident 108, leading to significant deficiencies in pain management. Resident 22, who had a history of chronic pain syndrome and opioid dependence, was observed in distress due to the unavailability of his prescribed fentanyl patch. Despite the resident's complaints of severe pain, rated as high as 10 on a 0-10 scale, the facility did not apply the fentanyl patch on multiple occasions due to supply issues. The facility's staff failed to notify the medical provider of the unavailability of the medication in a timely manner, and there was a lack of documentation regarding attempts to address the issue or provide alternative pain management solutions. Resident 108, who was admitted with a prescription for hydrocodone-acetaminophen for moderate pain, also experienced a lapse in pain management. The resident reported not receiving pain medication for several days, despite experiencing significant pain levels. The facility's records showed inconsistencies in pain assessments, and the resident indicated that pain levels were only addressed when he requested medication. The facility failed to maintain an adequate supply of the prescribed medication and did not ensure consistent pain assessments as ordered by the physician. Interviews with facility staff revealed a lack of communication and documentation regarding the unavailability of medications and the steps taken to address these issues. The Director of Nursing (DON) and other staff members were aware of the medication shortages but did not document their communications with the medical provider or take sufficient action to ensure the residents received appropriate pain management. The facility's policies on pain management and medication orders were not effectively implemented, contributing to the deficiencies observed.
Failure to Conduct Required AIMS Assessment for Resident on Antipsychotic Medication
Penalty
Summary
The facility failed to follow pharmacy recommendations for a resident who was receiving the antipsychotic medication Risperdal. The resident, diagnosed with schizophrenia, major depressive disorder, unspecified intellectual abilities, and anxiety disorder, was noted to be cognitively intact and required substantial to maximal assistance for activities of daily living. A pharmacist recommended a gradual dose reduction and highlighted the need for an AIMS (abnormal involuntary movement scale) assessment, which was overdue. The last AIMS assessment was conducted on 5/22/23, and despite two requests from the pharmacist, no subsequent assessment was completed. The Director of Nursing (DON) acknowledged awareness of the pharmacist's requests and confirmed that the last AIMS assessment was indeed performed on 5/22/23. However, the clinical record lacked documentation of any AIMS assessment after this date. The DON was unable to provide a reason for the missed assessments, indicating a lapse in following the established guidelines for monitoring residents on psychotropic medications. This oversight resulted in the facility's failure to ensure the resident remained free of psychotropic drug-related complications as outlined in the care plan.
Failure to Provide Prompt Dental Services for Ill-Fitting Dentures
Penalty
Summary
The facility failed to provide prompt dental services for a resident with ill-fitting dentures, leading to a deficiency. The resident, who had medical diagnoses including unspecified protein-calorie malnutrition, anemia in chronic kidney disease, and unspecified dementia, was noted to have no natural teeth and was on a regular diet with specific restrictions. Despite a care plan initiated in 2021 to prevent oral/dental complications, the resident's ill-fitting dentures were not addressed in a timely manner. The resident's daughter had requested dental services as early as November 2023, but the resident was not seen by a dentist until June 2024, despite multiple notes indicating the need for dental adjustments. Observations and interviews revealed that the resident struggled with eating due to the ill-fitting dentures and expressed frustration by throwing them away. A nurse noted the resident's refusal to wear the dentures because they had not fit for over three months. The facility's policy required prompt referral for dental services within three business days of identifying damaged dentures, but this was not adhered to. The MDS Coordinator was unaware of the issue, indicating a lack of communication within the facility's interdisciplinary team. The resident's representative confirmed that the facility had been aware of the issue since October 2023, yet no adjustments were made until June 2024.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement infection prevention strategies related to enhanced barrier precautions (EBP) for two residents. Resident 53, who had a methicillin susceptible staphylococcus aureus infection and chronic wounds, was not placed on EBP despite having a surgical wound and an unstageable pressure injury. Observations revealed that there was no signage or personal protective equipment (PPE) available at the resident's door, and staff did not apply a gown during wound care. Interviews with staff indicated a lack of awareness regarding the need for EBP for Resident 53, and the Director of Nursing (DON) confirmed that the resident should have been on EBP due to the chronic nature of the wounds. Resident 44, who had a pressure wound to the coccyx, was observed with an EBP sign on the door and a PPE cart outside the room. However, during wound care, the Assistant Director of Nursing (ADON) did not wear a gown, which was required as per the facility's policy for residents on EBP. The facility's policy indicated that EBP should be employed for residents with chronic wounds during high-contact activities, including wound care. The failure to adhere to these precautions for both residents highlights a deficiency in the facility's infection prevention and control program.
Failure to Provide Adequate Grooming and Shower Assistance
Penalty
Summary
The facility failed to provide adequate grooming assistance and scheduled showers for two residents, identified as Resident C and Resident D, who were reviewed for activities of daily living (ADLs). Resident D was observed with dirty fingernails on multiple occasions, and her clinical records indicated a need for substantial assistance with personal hygiene. Despite the care plan interventions, there was a lack of documentation for refusals of care, and the resident's showers were not consistently documented. Interviews with staff revealed inconsistencies in the provision of care and documentation practices. Resident C was observed to be unshaven and with overgrown fingernails on several occasions. His clinical records showed a need for maximal assistance with personal hygiene due to limited mobility from a stroke. Despite this, there were no documented refusals of care, and the resident expressed a need for help with shaving and nail care. Staff interviews indicated that shaving was typically done on shower days, but there were inconsistencies in the frequency and documentation of these activities. The facility's policies required showers to be offered twice a week and nail care to be provided with showers and as needed. However, the observations and interviews highlighted a failure to adhere to these policies, resulting in unmet personal hygiene needs for the residents. The documentation did not reflect any refusals of care, suggesting a gap in communication and record-keeping among the staff.
Failure to Honor Resident's Preference for Wheelchair Foot Pedal
Penalty
Summary
The facility failed to honor a resident's preference to utilize a foot pedal for her wheelchair, which was necessary due to her medical condition. Resident C had a history of a broken right leg, swelling, and foot drop, which made it difficult for her to flex her foot toward her knee. Despite her need to elevate her leg to reduce swelling, the Administrator removed the right foot pedal from her wheelchair, stating it was a therapy intervention to encourage the resident to use her leg more. This action was taken without considering the resident's expressed discomfort and need for elevation due to swelling. Interviews with Resident C and the Physical Therapist revealed that while Resident C was full weight-bearing, she experienced pain and swelling in her leg, which limited her mobility. The Physical Therapist acknowledged that Resident C had good potential for improvement but was self-limiting due to her pain and swelling. The facility's policy on Resident Rights emphasized the importance of autonomy and choice for residents, which was not upheld in this case. The deficiency was related to a complaint investigation, indicating a failure to respect the resident's rights and preferences regarding her care and mobility needs.
Failure to Follow Physician's Orders for Wound Care
Penalty
Summary
The facility failed to ensure competent treatment for a pressure injury was completed according to physician's orders for one resident. Resident D, who had a diagnosis of methicillin susceptible staphylococcus aureus infection, type 2 diabetes mellitus with diabetic neuropathy, and peripheral vascular disease, had an unstageable pressure ulcer on his right heel. The physician's orders specified the use of Santyl ointment for enzymatic debridement. However, during a wound care observation, an LPN applied medical grade honey instead of Santyl. The LPN later acknowledged the mistake, stating he had no idea why he used the wrong treatment despite reviewing the order beforehand.
Failure to Complete Annual Resident Rights Training
Penalty
Summary
The facility failed to ensure that annual resident rights training was completed for the Administrator, as required by their policy. Employee records reviewed indicated that the Administrator had not completed the necessary training. During an interview, the Administrator, with the Nurse Consultant present, acknowledged that many inservices had not been opened yet and that employees should have completed the previous year's inservices. The facility's policy mandates annual education for all employees, including training on resident rights, which was not adhered to in this instance. This deficiency was identified during a complaint investigation.
Failure to Complete Annual Abuse Training
Penalty
Summary
The facility failed to ensure that required annual abuse training was completed for two employees, specifically the Administrator and an LPN. Employee records reviewed indicated that neither the Administrator nor the LPN had completed their annual abuse training. During an interview, the Administrator acknowledged that many inservices had not been opened yet and that employees should have completed the previous year's inservices. The facility's policy, dated 10/1/22, mandates annual education for all employees, including training on abuse. This deficiency was identified during a complaint investigation.
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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