Aperion Care Vincennes
Inspection history, citations, penalties and survey trends for this long-term care facility in Vincennes, Indiana.
- Location
- 3801 Old Bruceville Road, Box 136, Vincennes, Indiana 47591
- CMS Provider Number
- 155042
- Inspections on file
- 48
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 22
Citation history
Health deficiencies cited at Aperion Care Vincennes during CMS and state inspections, most recent first.
Two residents receiving hospice care did not have collaborative care plans established, and required routine assessments and physician orders were not completed or documented. Pain and oxygen assessments were missed, and the effectiveness of PRN medications was not consistently monitored or recorded, contrary to facility policy.
A resident with significant mobility impairments was given a cup of hot water by a CNA who did not check the temperature or monitor the resident. The resident accidentally spilled the hot water while adjusting her bed, resulting in second-degree burns to her abdomen, back, and hip. The incident occurred due to staff not following facility procedures for serving hot beverages.
The facility did not ensure a safe, clean, and homelike environment in certain resident units and a dining room, as evidenced by missing paint, missing cove base, a window covered with plywood, peeling door coverings, and black discoloration on a ceiling. Maintenance issues were observed in multiple areas, and repairs were delayed due to reliance on outside contractors.
Surveyors found that food was stored directly on the floor in both dry storage and the walk-in freezer, and there was a buildup of dust and debris in multiple kitchen areas. Staff interviews revealed daily cleaning checklists were not being completed or were unknown to some, and the kitchen was short-staffed. The Dietary Manager confirmed that cleaning and proper food storage practices were not being followed, in violation of facility policy.
A facility failed to provide necessary treatment and services for pressure injuries in three residents. One resident with heart failure and diabetes had unstageable pressure ulcers on the heel and coccyx, with incomplete care plans and inconsistent treatment. Another resident with hemiplegia had an unstageable ulcer on the buttock, with delayed care planning and treatment inconsistencies. A third resident with paraplegia had a Stage 4 ulcer, with treatment delays and discrepancies in assessments. These deficiencies highlight inadequate pressure ulcer care.
The facility failed to employ a certified Dietary Manager, as the current manager's certification had expired and she had not completed the necessary training. Despite being on a 30-day Performance Improvement Plan, the Dietary Manager had not yet passed her certification test, and the Administrator was aware of the situation.
The facility failed to provide timely transfer or discharge notices to residents or their representatives for five hospitalizations. Clinical records lacked documentation of notices, and staff interviews revealed gaps in the process. The Social Services Director could not verify sending reports to the ombudsman, and the facility's policy was not provided.
The facility failed to provide a bed hold policy to residents or their representatives during hospital transfers, affecting five residents. Clinical records lacked documentation of the policy being given, and staff interviews confirmed the oversight. The facility's bed hold policy requires notification upon admission and transfer, but this was not followed.
The facility failed to update comprehensive care plans for several residents, including one with an outdated catheter care plan, another with unaddressed declines in eating and mobility, a resident on an NPO diet without corresponding care plan interventions, and a resident with bed and chair alarms not reflected in their care plan. The facility's policy required care plans to be reviewed and revised by the IDT after each assessment, which was not followed.
A facility failed to provide appropriate care for a resident with dementia, as a CNA was reported to provide substandard care and exhibit intimidating behavior. The resident, who required assistance with ADLs, was observed with unkempt hair and left unattended. Staff reported the CNA's conduct, including denying residents' requests and neglecting duties, but no corrective action was taken.
The facility failed to ensure safe medication storage and administration for five residents. Medications were pre-prepared and stored in medication carts against facility policy. A QMA admitted to pre-preparing medications for four residents, while an LPN stored refused medications for another resident in the cart. The DON was unaware of the policy, which states medications should be administered when prepared.
The facility failed to ensure dietary staff followed menus, as identified during a kitchen review. The Administrator, who took over in December 2024, found significant issues with kitchen operations, leading to a Performance Improvement Plan (PIP) for the Dietary Manager. The PIP highlighted the need for staff to follow menus, order correctly, and complete inventory checks. The majority of resident grievances were related to dietary services, indicating a widespread issue.
The facility failed to maintain infection control standards, as observed in the care of several residents. CNAs did not sanitize hands between glove changes during incontinence care for a resident, and a glucometer was used without cleaning between residents. Additionally, Enhanced Barrier Precautions were not consistently implemented for residents with open wounds or indwelling devices, as staff did not wear gowns or follow proper protocols.
The facility failed to treat residents with dignity and respect, as evidenced by incidents involving three residents. A resident reported rude and unresponsive night staff, another faced a degrading confrontation for calling his sister for help, and a third was subjected to inappropriate comments by the ADON during medication administration. These incidents highlight a lack of adherence to the facility's Resident Rights policy.
The facility failed to conduct timely care plan conferences for three residents, including one with chronic conditions and dementia, another with severe cognitive impairment, and a third with chronic kidney disease. The Social Services Director confirmed that care plan conferences were not held quarterly as required, despite the facility's policy.
A facility failed to clarify a resident's code status, leading to a discrepancy between the physician's order and the POST form. The resident, with severe cognitive impairment and multiple diagnoses, was listed as Full Code in the physician's orders but as DNR on the POST form. A nurse indicated she would follow the Full Code status despite the inconsistency, contrary to the facility's policy requiring matching documentation.
A facility failed to provide a detailed incident report for an alleged abuse involving a CNA and a resident with severe cognitive impairment. The report lacked specifics about the incident where the CNA was accused of inappropriate conduct during care. An investigation found no signs of abuse, but the initial report did not meet the facility's policy requirements for detailed documentation.
The facility failed to develop care plans for residents receiving specific treatments. A resident on hospice lacked a hospice care plan, while another with severe cognitive impairment had no care plans for bed and chair alarms or antiplatelet medication. Additionally, a resident on anticoagulants did not have a corresponding care plan, contrary to facility policy.
The facility failed to ensure proper catheter care and documentation for two residents, leading to deficiencies in preventing UTIs. One resident had a catheter bag incorrectly placed under his leg, while another had a Foley catheter without a physician's order or care plan. Staff interviews confirmed these lapses in compliance with facility policies.
A facility failed to timely administer antibiotics to a resident post-hospital discharge, leading to missed doses. The resident, with multiple health conditions, was discharged with orders for cefdinir and doxycycline, but the facility did not continue these antibiotics promptly. The cefdinir dose was missed, and the doxycycline was not transcribed, causing a delay. The issue was identified during a pharmacy review, and the facility's administrator noted it was the receiving nurse's responsibility to input medication orders. The Infection Preventionist stated that medications are usually available from the emergency drug kit or delivered promptly.
The facility exceeded the acceptable medication error rate of 5%, reaching 6.45%, due to two incidents involving insulin administration. An ADON failed to prime an insulin pen before administering Lyumjev to a resident, and another resident missed a Novolog insulin dose because the insulin was misplaced. The facility's policy requires insulin pens to be primed, which was not followed.
A resident missed a scheduled insulin dose due to the medication being misplaced in another cart, leading to a significant increase in blood sugar levels. The ADON was unable to locate the insulin initially and planned to request it from the pharmacy. The resident's blood sugar rose significantly by noon, requiring a higher insulin dose. The facility failed to document notification to the physician about the missed dose, as required by policy.
The facility failed to enforce smoking safety policies, leading to residents smoking in non-designated areas without protective devices. A housekeeper took residents to smoke after a delay, and they smoked under a covered patio near the facility without an ashtray. Used cigarette butts were improperly disposed of, and the smoking schedule was not updated, causing confusion about departmental responsibilities.
The facility failed to maintain a sanitary kitchen environment, with staff not fully containing hair within hairnets and not adhering to proper hand hygiene practices. The Dietary Manager and another staff member were observed with exposed hair during food preparation, and handwashing times were significantly shorter than the facility's policy requirements.
The facility failed to ensure a safe, sanitary, and homelike environment in two resident halls, with issues such as dirty floors, uncovered bedpans, and uncleaned wheelchairs. Residents and family members reported inadequate housekeeping services, and observations confirmed non-functioning restroom lights and holes in walls. The maintenance director acknowledged being behind on work, and the facility administrator noted the absence of a cleaning schedule for wheelchairs.
A facility failed to ensure accurate and complete documentation for a resident's pressure wound and diabetic care. The resident's TAR lacked documentation for wound treatment on several dates, and the MAR did not record insulin administration or blood sugar levels on specific occasions. An LPN confirmed the requirement for complete documentation, which was not followed according to the facility's policy.
The facility failed to ensure a safe, sanitary, and homelike environment, with deficiencies observed in resident halls and shared restrooms, including stained toilet bowls, missing window trim, and cracked tiles. Maintenance staff shortages and reliance on staff to report issues contributed to the problem, despite a policy requiring daily inspections.
The facility failed to provide routine catheter and ostomy care for three residents, as observed during a survey. A resident with paraplegia and a stage 4 pressure ulcer reported waiting through multiple shifts for colostomy bag changes, while another resident with benign prostatic hyperplasia indicated staff did not routinely empty his catheter drainage bag. A third resident with hemiplegia and chronic kidney disease reported providing her own catheter care despite needing assistance. Documentation showed missed care on several dates, contrary to the residents' care plans.
A facility failed to ensure a resident was clinically appropriate to self-administer medications without supervision. The resident was found alone with a cup of medications, had no physician order or self-administration assessment, and staff confirmed the need for supervision. The facility's policy required a written order for self-administration, which was not present.
A resident with a history of dysphagia and cognitive impairment was hospitalized after staff failed to follow his care plan, administering medications while he was lying flat. The care plan required two staff members to be present due to the resident's behaviors and risk of aspiration, which was not adhered to, resulting in a medication getting stuck in his throat and causing a burn.
The facility failed to provide assistance with bathing for two residents according to their care plans and schedules. One resident, with multiple health issues, received only two showers and two bed baths over a month, while another resident, requiring substantial assistance, had only one bed bath and three showers documented, with one refusal noted.
Failure to Provide and Document Hospice Services and Assessments
Penalty
Summary
The facility failed to ensure that two out of three residents reviewed for hospice care received appropriate end-of-life care. For one resident with chronic kidney disease and malignant cancer, the facility did not establish a collaborative plan of care for hospice services, and routine assessments and physician orders were not completed. Although hospice was notified and assessed the resident upon readmission from the hospital, the facility did not document further assessments of pain, discomfort, restlessness, or oxygen saturation after the initial hospice visit. No as-needed medications were administered between readmission and the resident's death, and required routine observations were not documented. For another resident with large B-cell lymphoma, the facility also failed to include a hospice care plan in the resident's care plan. Physician orders for pain assessments and supplemental oxygen were not consistently followed, as oxygen levels were not assessed every shift as ordered. After administration of PRN pain medication, there was no documented reassessment to monitor the effectiveness of the medication. Facility policy required documentation of all treatments and services, but this was not consistently done for these residents receiving hospice care.
Failure to Monitor Hot Beverage Temperature Results in Resident Burns
Penalty
Summary
A resident with diagnoses including spastic paraplegia, demyelinating disease of the central nervous system, hypertrophic osteoarthropathy, cerebellar ataxia, lack of coordination, and muscle spasm, who required setup assistance for eating due to limited mobility, requested a CNA to heat a cup of water. The CNA heated the water in a microwave and placed it on the resident's bedside table without monitoring or checking the temperature of the water. When the resident raised the head of her bed, the cup of hot water was knocked over, spilling onto her abdomen, back, and hip. As a result of the spill, the resident sustained second-degree burns to her abdomen, lower back, and left hip. The burns were described as partial thickness with large blisters, reddened areas, and peeling of the outer skin layer. Wound assessments documented significant areas of injury, with pain rated at 4 to 5 on a scale of 0 to 10. The resident required topical treatments and dressings for the burns, and the incident was reported to the physician, who ordered further care and assessment. The facility's policy required staff to monitor, serve, and hold hot beverages in a safe manner, including checking temperatures and monitoring high-risk residents. However, there was no documentation or indication that the temperature of the water served to the resident was checked, and the staff did not monitor the resident while serving the hot beverage. This failure to follow established procedures for serving hot beverages directly contributed to the resident's injuries.
Failure to Maintain Safe and Sanitary Resident and Dining Areas
Penalty
Summary
The facility failed to maintain a safe, sanitary, and homelike environment in one of three resident units and one of two dining rooms observed. Observations revealed missing paint on the walls under windows, around air conditioning units, and behind beds in multiple resident rooms. Additionally, cove base was missing from the wall behind beds, and one resident room had a window completely covered with plywood due to a previous breakage. A shared restroom door near the nurse's station had a protective covering that was peeling away, and the dining room's activity area had approximately 80% of its paint peeled off the wall, with a black discoloration noted on the vaulted ceiling. Interviews with the maintenance director indicated that repairs and renovations are typically performed after residents move out of their rooms, and that larger projects require outside contractors. The maintenance director had only been at the facility for four weeks and noted that an assistant maintenance staff member was soon to be hired. The facility was awaiting a replacement window and had scheduled an outside source to bid on the dining room repairs. Facility policy requires the environment to be maintained in accordance with all governing rules and regulations to protect the health and safety of residents, personnel, and the public.
Failure to Maintain Sanitary Food Storage and Kitchen Environment
Penalty
Summary
The facility failed to maintain a sanitary environment in the kitchen and food storage areas, as observed during a survey. Inspectors noted that containers of food were stored directly on the floors of both the dry food storage room and the walk-in freezer, contrary to facility policy requiring food to be stored at least six inches off the floor. Additionally, there was a significant buildup of dust and debris over the cookstove hood, on the ceiling and vents above the dishwashing area, on top of the dishwasher, and along the base of the walls and floor in the dishwashing area. These conditions were confirmed through direct observation. Interviews with kitchen staff revealed that daily cleaning task checklists were not being completed, and some staff were unaware of the existence or location of such checklists. The kitchen was reported to be short-staffed, and recent food deliveries had not been properly stored according to policy. The Dietary Manager acknowledged that certain areas of the kitchen required cleaning and that food should not be stored on the floor. Facility policies reviewed by surveyors confirmed the requirements for proper food storage and sanitation, which were not being followed at the time of the survey.
Inadequate Pressure Ulcer Care in LTC Facility
Penalty
Summary
The facility failed to provide necessary treatment and services to prevent and promote healing of pressure injuries for three residents. Resident 20, who had diagnoses including heart failure, diabetes mellitus, and dementia, was observed with unstageable pressure ulcers on the left heel and coccyx. The facility did not develop specific care plans for these ulcers, and physician orders were not consistently followed. Assessments were incomplete, and there were gaps in documentation and treatment administration, leading to the worsening of the pressure ulcers. Resident 7, with severe cognitive impairment and a history of hemiplegia, had an unstageable pressure ulcer on the left buttock. The care plan for this ulcer was delayed by 15 days, and there were inconsistencies in following physician orders. The wound nurse and physician assessments differed, and there were multiple instances where treatments were not documented or completed as ordered. The facility's failure to adhere to treatment protocols and documentation requirements contributed to the persistence of the pressure ulcer. Resident 25, diagnosed with paraplegia, had a Stage 4 pressure ulcer on the left buttock. The facility did not update treatment orders in a timely manner, and there were discrepancies between the wound nurse and physician assessments. The resident's treatment was not consistently administered, and the wound nurse was unable to perform dressing changes due to the resident's positioning. These lapses in care and documentation resulted in inadequate management of the pressure ulcer, highlighting the facility's failure to provide appropriate pressure ulcer care.
Deficiency in Dietary Manager Certification
Penalty
Summary
The facility failed to employ sufficient staff with the appropriate competencies and skills set to carry out the functions of the food and nutrition service. The Dietary Manager, who was responsible for overseeing the kitchen, was not certified at the time of the survey. She had started working at the facility in August 2024, and her previous certification had expired. Despite being aware of the need for certification, the Dietary Manager had not completed her training and was on a 30-day Performance Improvement Plan (PIP) due to failing her certification test. The Administrator acknowledged the requirement for a certified Dietary Manager and indicated that the Dietary Manager was working on completing her training, which had been addressed multiple times but remained incomplete.
Failure to Provide Transfer/Discharge Notices
Penalty
Summary
The facility failed to provide timely notification of transfer or discharge to residents or their representatives, as well as the ombudsman, for five residents who were hospitalized. The clinical records of these residents lacked documentation of a notice of transfer or discharge at the time of hospitalization. Specifically, Resident 30 was transferred to the hospital and returned without any record of a notice being given. The Administrator confirmed the absence of such documentation. Similarly, Resident B, Resident 48, and Resident 79 were hospitalized, and their records also lacked hospital transfer notices. Resident D's clinical record indicated a transfer to the hospital without a completed transfer/discharge notice, and the transfer assessment lacked information about the appeals process and ombudsman contact details. Interviews with staff revealed that the floor nurse was responsible for filling out transfer forms electronically, but no additional documentation was provided. The Social Services Director mentioned sending monthly transfer reports to the ombudsman's portal but could not verify this due to email issues. The State Long-Term Care Ombudsman Program Deputy Director confirmed only receiving reports for October and an unspecified date, with no records after that. The facility's current Transfer/Discharge Notice Policy was requested but not provided.
Failure to Provide Bed Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to provide a bed hold policy to residents or their representatives during hospital transfers, as required. This deficiency was identified for five residents who were hospitalized and subsequently returned to the facility. The clinical records of these residents, including those of Resident D, Resident B, Resident 79, Resident 48, and Resident 30, lacked documentation of a bed hold policy being given at the time of their transfer to the hospital. Interviews with facility staff, including the Administrator and an LPN, confirmed the absence of such documentation and revealed that the responsibility for issuing bed hold notices had been neglected. Resident 30 was admitted to the hospital on November 8, 2024, and returned on November 15, 2024, without receiving a bed hold policy. Similarly, Resident D was transferred to the hospital on January 18, 2025, and returned on January 22, 2025, without documentation of a bed hold notice. The facility's current bed hold policy, revised in 2017, mandates that residents and their representatives be notified of the bed hold policy upon admission and at the time of transfer. However, the facility's practice did not align with this policy, as evidenced by the lack of documentation and staff interviews indicating that bed hold notices were no longer being issued.
Failure to Update Comprehensive Care Plans
Penalty
Summary
The facility failed to ensure that comprehensive care plans were reviewed and revised by the interdisciplinary team (IDT) after each assessment, including both comprehensive and quarterly review assessments. This deficiency was observed in several residents, including Resident C, who was noted to have an outdated care plan indicating the presence of an indwelling catheter, despite the absence of such a catheter during an incontinence care observation. Similarly, Resident 4 experienced a decline in eating and mobility, which was not reflected in the care plan, even though staff were aware of the changes and therapy was involved. Additionally, Resident 73, who was on an NPO diet with a feeding tube, lacked care plan interventions related to the NPO status. Resident 79, who had orders for bed and chair alarms following a fall, did not have these interventions included in the care plan. The facility's policy required that care plans be reviewed and revised by the IDT after each assessment, but this was not adhered to, leading to discrepancies between the residents' current needs and their documented care plans.
Inadequate Care for Dementia Resident Due to CNA Conduct
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident diagnosed with dementia, identified as Resident B, to maintain his highest practicable physical, mental, and psychosocial well-being. Observations revealed that Resident B, who had severe cognitive impairment and required assistance with activities of daily living (ADLs), was not receiving adequate care. On multiple occasions, Resident B was observed in a wheelchair with unkempt hair and was left unattended in common areas. The resident's clinical record indicated diagnoses of heart failure, diabetes, dementia, anxiety, depression, and a psychotic disorder, highlighting the need for comprehensive care. The deficiency was further compounded by the conduct of CNA 31, who was reported to provide care that did not meet company standards. Interviews with staff revealed that CNA 31 was perceived as gruff, loud, and intimidating, often failing to communicate with residents before providing care. Additionally, CNA 31 was reported to deny residents' requests for coffee and was observed neglecting duties by disappearing for extended periods and using a resident's bed for personal phone calls. Despite these issues being reported to the Assistant Director of Nursing (ADON), no corrective action was taken, contributing to a negative atmosphere on the dementia unit.
Medication Storage and Administration Deficiency
Penalty
Summary
The facility failed to ensure the safe and secure storage of medications for five residents during two random observations of the medication carts. During the first observation, a Qualified Medication Aide (QMA) was found to have pre-prepared medication cups for four residents, with pills placed in the cups and stored in the medication cart. The QMA acknowledged that the medication cups were prepared for the upcoming medication pass and admitted awareness that pre-preparing medications was against facility policy. In a separate observation, an LPN was found with a medication cup containing eight pills for a resident who had refused their morning medications. The LPN indicated that the medications were locked in the cart after the refusal, awaiting another nurse to attempt administration. The Director of Nursing was unaware of the facility's policy regarding pre-preparing medications, while the Vice President of Operations provided a policy stating that medications should be administered at the time they are prepared and not pre-poured in advance.
Failure to Follow Menus in Dietary Services
Penalty
Summary
The facility failed to ensure that menus were being followed by the dietary staff, as observed during a review of the kitchen. The Administrator, who took over on December 9, 2024, identified significant concerns with the kitchen operations within two days of her tenure. The Dietary Manager was already on a 30-day Performance Improvement Plan (PIP) for not adhering to the menus as required. The Administrator noted that the lack of accountability among staff and turnover in administration contributed to the issues, as staff were left to manage on their own. The majority of resident grievances were related to dietary services, indicating a widespread issue. The PIP for the Dietary Manager, dated December 2, 2024, and January 15, 2025, highlighted several areas needing improvement. These included ensuring staff followed menus, ordering the correct items, completing inventory before placing orders, and monitoring and educating cooks. The Administrator emphasized that it was policy to adhere to regulations and follow the assigned menus. This deficiency was related to a specific complaint, IN00449788, and was documented under citation 3.1-20(i).
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to maintain a safe and sanitary environment, leading to the potential transmission of infections among residents. During an observation of incontinence care for Resident C, it was noted that the Certified Nurse Aides (CNAs) did not follow proper hand hygiene protocols. The CNAs changed gloves multiple times without sanitizing their hands in between, and they did not follow the expected procedure of wiping from clean to dirty areas. This lack of adherence to infection control practices was confirmed by the Infection Preventionist, who stated that staff should sanitize hands between glove changes and follow specific wiping techniques during incontinence care. In another instance, the Assistant Director of Nursing (ADON) was observed using a glucometer machine for Resident D without cleaning it between uses. The ADON admitted that she could not confirm if the glucometer had been cleaned after its last use, as she had just taken over the medication cart. The Director of Nursing (DON) later confirmed that the expectation was for the glucometer to be cleaned at the beginning of each shift and between each resident use, which was not adhered to in this case. Additionally, the facility did not implement Enhanced Barrier Precautions (EBP) for residents with specific needs. Resident H, who had an open elbow wound, did not have the required EBP signage, and staff did not wear gowns during dressing changes. Similarly, Resident G, who had an indwelling catheter, did not receive care with the necessary EBP measures, as the CNA did not wear a gown despite the presence of an EBP sign. The Infection Preventionist confirmed that residents with indwelling devices or open wounds should have EBP in place, which was not consistently practiced in the facility.
Failure to Ensure Resident Dignity and Respect
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity, as evidenced by multiple incidents involving three residents. Resident C, who had a history of stroke, hemiplegia, and dementia, reported that night shift staff were rude and unresponsive to her requests for ice and assistance getting out of bed. This led to her becoming upset and throwing her call light onto the floor. The facility's administrator acknowledged the incident but was uncertain of its occurrence, attributing it to agency staff who were being phased out. Resident E, who had a history of stroke, dementia, and diabetes, experienced a delay in response to his call light, prompting him to call his sister for assistance. A staff member reportedly confronted him in a degrading tone for contacting his sister instead of using the call light. The resident's sister had previously reported similar concerns to the Social Services Director, but no changes were made. The SSD was aware of the incident and had planned a care plan conference, but the grievance was not documented in the resident's chart. Resident F was subjected to disrespectful comments by the Assistant Director of Nursing (ADON) during medication administration. The ADON made remarks about the resident's behavior within earshot, which were deemed inappropriate. The facility's Resident Rights policy emphasizes the importance of treating residents with dignity and respect, which was not upheld in these instances.
Failure to Conduct Timely Care Plan Conferences
Penalty
Summary
The facility failed to ensure timely care plan conferences with residents and/or their representatives for three of the seven residents reviewed. Resident D, who has diagnoses including chronic obstructive pulmonary disease, diabetes mellitus type II, and dementia with behaviors, did not have quarterly care plan conferences as required. The clinical record showed that Resident D had care plan conferences on 1/26/24, 4/26/24, and 10/4/24, but no other conferences were held in the last year, as confirmed by the Social Services Director (SSD). Similarly, Resident 4, with severe cognitive impairment and dementia with behaviors, had care plan conferences on 2/12/24, 6/14/24, and 9/27/24. The SSD was unable to contact Resident 4's guardian to set up a conference, but acknowledged that a conference should have been held regardless. Resident 35, who is cognitively intact and has diagnoses including stage 5 chronic kidney disease and hypertension, did not receive a care plan conference between 7/23/24 and 12/17/24. The SSD confirmed that care plan conferences should be completed quarterly, as per the facility's Comprehensive Care Plan policy.
Discrepancy in Resident's Code Status Documentation
Penalty
Summary
The facility failed to clarify a resident's code status, resulting in a discrepancy between the resident's current facesheet, physician's order, and the Indiana Physician Orders for Scope of Treatment (POST) form. The resident, who had severe cognitive impairment and multiple diagnoses including heart failure and dementia, was documented as having a Full Code status in the physician's orders and care plans. However, the POST form indicated a Do Not Attempt Resuscitation (DNR) status. This inconsistency was identified during a review of the resident's clinical record. During an interview, a registered nurse (RN) indicated that she would refer to the computer to determine the resident's code status and believed the resident was a DNR. However, upon checking the computer, it showed a Full Code status, conflicting with the POST form's DNR indication. The RN stated that if the resident coded, she would follow the Full Code status, acknowledging that the order and POST form should match. The facility's Advance Directives policy requires that a written physician's order be specific and address each advanced directive, which was not adhered to in this case.
Incident Report Lacks Detailed Explanation of Alleged Abuse
Penalty
Summary
The facility failed to ensure that an incident report contained a detailed explanation of the circumstances surrounding an alleged incident involving a Certified Nurse Aide (CNA) and a resident. The incident report, dated 1/22/25, lacked specific details about the alleged incident where a staff member reported that CNA 31 was providing care that did not meet company standards for Resident B. Resident B, who had severe cognitive impairment and multiple diagnoses including heart failure, diabetes, and dementia, was reportedly involved in an incident where CNA 31 allegedly grabbed the resident's testicles and pressed her arm against his neck during care. However, upon investigation, no signs or symptoms of abuse were found, and the resident did not express any pain. The report indicates that the initial complaint was made by CNA 29, who observed the alleged incident and reported it to the Administrator. The Administrator conducted an immediate investigation, which included a full body assessment of the resident and a demonstration by CNA 31 of how she provided care. The investigation did not find any physical evidence of abuse, and the resident's family was notified. Despite the investigation, the initial incident report failed to include a comprehensive account of the circumstances, which is a requirement according to the facility's Abuse Prevention and Reporting policy.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for residents receiving specific medical treatments and services. Resident 67, who had diagnoses including non-traumatic brain dysfunction, anxiety, and depression, was admitted to hospice care but did not have a corresponding care plan. The facility's President of Operations confirmed that a hospice care plan should have been initiated for residents on hospice services. Resident 79, with severe cognitive impairment and multiple diagnoses such as hypertension, hip fracture, diabetes, and dementia, was on medications including antianxiety, antidepressant, and antiplatelet. However, the resident's clinical record lacked care plans for the use of bed and chair alarms, as well as for the antiplatelet medication. Similarly, Resident D, who had conditions like chronic obstructive pulmonary disease, diabetes, and deep vein thrombosis, was receiving an anticoagulant but did not have a care plan for this medication. The facility's policy required comprehensive care plans to be developed within seven days after a comprehensive assessment, but this was not adhered to in these cases.
Deficiencies in Catheter Care and Documentation
Penalty
Summary
The facility failed to provide appropriate care for residents with indwelling urinary catheters, leading to deficiencies in preventing urinary tract infections (UTIs). Resident D was observed with a catheter bag placed incorrectly under his leg, contrary to the care plan that required the bag to be positioned below the bladder. The resident's clinical record indicated multiple diagnoses, including chronic obstructive pulmonary disease, diabetes, sepsis, UTI, flaccid bladder, and dementia. Despite having a physician's order for catheter care, the catheter bag was not managed according to the specified guidelines, as confirmed by a Certified Nurse Aide (CNA) who stated that the bag should not be on the resident's leg. Another resident, Resident 48, was found to have a Foley catheter without a corresponding physician's order or care plan. The resident's clinical record showed severe cognitive impairment and occasional urinary incontinence, but no documentation of catheter use. The catheter was inserted during a hospital stay for pneumonia and UTI, and hospital staff were unable to remove it before discharge. Interviews with facility staff, including a Registered Nurse (RN) and the President of Operations, confirmed the absence of a necessary order and care plan for the catheter. The facility's policy required catheters to be positioned to prevent backflow, but there was no specific policy for catheter orders, highlighting a gap in compliance with established procedures.
Failure to Timely Administer Antibiotics Post-Hospital Discharge
Penalty
Summary
The facility failed to ensure that pharmaceutical services met the needs of a resident, specifically in the accurate acquiring, receiving, dispensing, and administering of antibiotics. Resident D, who had multiple diagnoses including COPD, diabetes mellitus type II, DVT, sepsis, UTI, flaccid bladder, and dementia, was discharged from the hospital with orders to continue antibiotics cefdinir and doxycycline. However, the facility did not continue these antibiotics in a timely manner. The cefdinir dose was missed, and the doxycycline was not transcribed from the discharge orders, leading to a delay in administration. The issue was identified during a pharmacy review, which noted the missed doses and the lack of transcription for doxycycline. The facility's administrator indicated that it was the responsibility of the receiving nurse to review and input medication orders upon a resident's readmission from the hospital. Despite the cefdinir being available, the doxycycline was not received from the pharmacy for an unknown reason. The nurse notified the MD about the missed doses, and once the doxycycline was received, the resident was administered all doses. The facility's Infection Preventionist mentioned that they follow an antibiotic stewardship program and that medications are usually available from the emergency drug kit or delivered promptly by the pharmacy.
Medication Error Rate Exceeds 5% Due to Insulin Administration Issues
Penalty
Summary
The facility failed to maintain a medication error rate below 5 percent, resulting in a rate of 6.45 percent. This deficiency was observed during a medication pass involving two residents. The first incident involved the Assistant Director of Nursing (ADON) administering 16 units of Lyumjev insulin to a resident without priming the insulin pen, contrary to the facility's policy. The ADON expressed uncertainty about the need to prime the pen, indicating a lack of adherence to proper medication administration procedures. The second incident involved another resident who missed an 8:00 A.M. dose of Novolog insulin due to the ADON's inability to locate the insulin. The insulin was later found in a different medication cart, but the resident did not receive the required 4 units of insulin based on their blood sugar level of 223. The Director of Nursing confirmed that the facility's policy required insulin pens to be primed before use, highlighting a deviation from established protocols.
Significant Medication Error Due to Missed Insulin Dose
Penalty
Summary
The facility failed to prevent a significant medication error involving a resident who missed a scheduled dose of insulin. On the morning of the incident, the Assistant Director of Nursing (ADON) was unable to locate the resident's insulin in the medication cart or storage room and planned to request it from the pharmacy for afternoon delivery. Later that day, it was discovered that the insulin had been misplaced in another medication cart, resulting in the resident missing their 8:00 A.M. dose. The resident's clinical records indicated a blood sugar level of 223 at 8:00 A.M., which required 4 units of insulin according to the sliding scale. By noon, the resident's blood sugar had increased to 362, necessitating 10 units of insulin. The clinical record did not show any notification to the physician about the missed dose. The Vice President of Operations confirmed that the ADON was advised to contact the physician, but no documentation of this communication or the physician's response was provided. The facility's policy requires notifying the attending physician or Medical Director in such cases, but this was not documented.
Failure to Enforce Smoking Safety Policies
Penalty
Summary
The facility failed to enforce its smoking policies related to smoking safety for two observed instances involving residents. During a random observation, three residents were seen waiting in wheelchairs in a common area for staff to take them outside to smoke. The scheduled smoke break was delayed because the dietary department, responsible for escorting the residents, did not have time. Eventually, a housekeeper agreed to take the residents outside. However, the residents were not offered protective devices such as smoking aprons, and they smoked in a non-designated area under a covered patio close to the facility, where no ashtray was available. Used cigarette butts were improperly disposed of in a stone plant pot containing dried plant material, posing a potential fire hazard. Further observations revealed that the facility's smoking schedule was not updated to reflect changes in departmental responsibilities, leading to confusion and non-compliance with the smoking policy. The dietary department had stopped taking residents to smoke, and the responsibility was shifted to the laundry staff, but this change was not communicated effectively. The Administrator was unaware of the outdated schedule posted in the facility, and the residents continued to smoke in non-designated areas without appropriate safety measures in place, contrary to the facility's Smoking Safety policy.
Sanitation and Hand Hygiene Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain a sanitary environment in the kitchen, as observed during two separate kitchen inspections. The Dietary Manager (DM) and another staff member were seen with hair not fully contained within their hairnets, with loose strands exposed during food preparation and service. Despite the Facility Administrator previously addressing this issue with the DM, the problem persisted. The facility's policy, dated 2020, requires all dining services staff to wear hair restraints in food production and serving areas, which was not adhered to during these observations. Additionally, the facility did not ensure proper hand hygiene practices were followed by kitchen staff. During observations, the DM and a cook were noted to wash their hands for significantly less time than the 20 seconds recommended by the facility's posted instructions and policy. The DM was observed washing hands with no scrubbing time after handling a bowl of ice, and the cook washed hands for only 9 seconds. The facility's policy outlines a detailed handwashing procedure, including scrubbing for 15 to 20 seconds, which was not followed. These deficiencies were related to complaints IN00448562, IN00447164, and IN00442047.
Facility Fails to Maintain Sanitary and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, sanitary, and homelike environment in two of the six resident halls observed. Observations revealed multiple issues, including holes in walls, dirty and unmopped floors, uncovered bedpans, missing cove base in a restroom, a vent fan without a cover, and used Styrofoam cups left in a resident's room. Additionally, resident wheelchairs were not cleaned, and there were complaints about the lack of housekeeping services. Specific incidents included a family member reporting that a resident's room had not received housekeeping services for days, resulting in a filthy environment and a lack of toilet paper. Resident council minutes also indicated concerns about inadequate restroom cleaning. Further observations noted that a resident's restroom had a non-functioning light, an uncovered bedpan with a brown substance, and a hole in the wall. Another resident's restroom lacked cove base, had an uncovered bedpan, and had toothpaste and splatter marks on the walls. Common areas were observed to be unmopped, with visible wheelchair markings and stains on the floor. Interviews with residents and staff confirmed that wheelchairs were not routinely cleaned, and the maintenance director acknowledged being behind on necessary maintenance work. The facility administrator admitted that there was no existing cleaning schedule for resident wheelchairs.
Incomplete Documentation of Resident Care
Penalty
Summary
The facility failed to ensure that resident records were accurate and complete for a resident reviewed for pressure wounds and diabetic care. Specifically, the Medication Administration Records (MAR) and Treatment Administration Records (TAR) for Resident D were not documented completely. Resident D, who had diagnoses including diabetes mellitus, morbid obesity, and chronic kidney disease, had a care plan that included treatment for a left toe infection and diabetes management. However, the TAR showed that the wound treatment to the left toe was not documented as completed on several specified dates, and there was no documentation explaining why the treatment was not completed. Additionally, the MAR for Resident D indicated that the sliding scale insulin was not documented as administered on certain dates, and there was no documentation of the required blood sugar levels for specific times in November. During an interview, an LPN confirmed that all ordered medications and treatments should be documented as completed in the resident's MAR and TAR, and any deviations should be documented with an explanation. The facility's policy on medication administration also required documentation of any withheld or refused doses, but this was not adhered to in Resident D's case.
Facility Fails to Maintain Safe and Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe, sanitary, and homelike environment in several areas, including three of four resident halls and two of three shared restrooms. Observations revealed multiple deficiencies such as stained toilet bowls, missing window trim, and thresholds in resident rooms. Shared shower rooms were found to have missing light covers, cove base, corner trim, cracked or broken tiles, a broken switch plate, and old screw holes in the walls. Additionally, hall floors were missing baseboards and had worn spots and paint splatters. During interviews, it was revealed that the facility was experiencing a shortage of maintenance personnel, with one staff member having recently left. Maintenance staff indicated that they conduct routine checks weekly but rely on other staff to report missing or broken items. The facility's policy on daily inspections was not adhered to, as evidenced by the undated policy provided by the Facility Administrator, which stated that buildings and grounds should be inspected daily and repairs should be addressed immediately. This deficiency was related to a specific complaint, IN00437748.
Failure to Provide Routine Catheter and Ostomy Care
Penalty
Summary
The facility failed to provide routine catheter and ostomy care for three residents, as observed during a survey. Resident C, who has paraplegia, neuromuscular dysfunction of the bladder, and a stage 4 pressure ulcer, reported waiting through multiple shifts for her colostomy bag to be changed. Her care plan required catheter and colostomy care every shift, but documentation showed these were not completed on several occasions in July 2024. Resident D, with benign prostatic hyperplasia and neuromuscular dysfunction of the bladder, indicated that staff did not routinely empty his catheter drainage bag or provide catheter care. His care plan also required catheter care every shift, yet records showed missed care on multiple dates in July and August 2024. Resident F, who has hemiplegia, chronic kidney disease, and a cystocele, reported providing her own catheter care despite requiring substantial assistance. Her care plan mandated catheter care every shift, but documentation indicated missed care on several dates in July 2024. An RN confirmed that staff should document reasons for any missed routine care. The facility's policies on colostomy and urinary catheter care were reviewed, but the care was not provided as ordered by the residents' physicians.
Failure to Ensure Resident Appropriateness for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident was clinically appropriate to self-administer their medications without supervision. During a random observation, a resident was found alone in their room with a cup of medications on their bedside table. The resident indicated that they did not know what the medications were and intended to take them after lunch. The resident's diagnoses included heart failure and anxiety, and their most recent MDS assessment indicated no cognitive impairment. However, there was no physician order or self-administration assessment in the resident's record to support self-administration of medications. Interviews with staff revealed that the resident should have been supervised during medication administration. The LPN confirmed that the resident should be observed when taking medications, and the DON stated that residents who do not self-administer should not be left alone with their medications. The facility's policy required a written order from the attending physician for a resident to self-administer medications, which was not present in this case. The resident was also not listed on the facility's self-administration list.
Failure to Follow Care Plan Leads to Resident Hospitalization
Penalty
Summary
The facility failed to ensure that a resident's care plan was followed, resulting in an allegation of staff negligence. Resident B, who had a history of cerebral infarction, dysphagia, cognitive communication deficit, and hemiplegia, was hospitalized after nursing staff administered medications orally while he was lying flat in bed. This caused a medication to get stuck in his throat, leading to a burn and subsequent hospitalization. The resident's care plan required that he receive care from at least two staff members due to his behaviors and risk of aspiration, but this was not followed during the incident on 2/16/24. During the investigation, it was revealed that the Qualified Medication Aide (QMA) elevated the resident's bed and administered the medications, but the resident reported difficulty swallowing and indicated that he was lying flat when the medications were given. The Speech Therapist and Licensed Practical Nurse (LPN) confirmed that two staff members should be present when providing care to Resident B. The facility's policy on comprehensive care plans was not adhered to, leading to the resident's hospitalization and subsequent changes in his care plan, including the initiation of a feeding tube and an NPO diet.
Failure to Provide Assistance with Bathing
Penalty
Summary
The facility failed to provide assistance with bathing for two residents, Resident B and Resident C, according to their care plans and bathing schedules. Resident B, who had diagnoses including cerebral infarction, cognitive communication deficit, and hemiplegia, was observed with multiple stains on his shirt and yeast growing in the palm of his left hand. His care plan indicated he was dependent on staff for bathing, with scheduled shower days on Mondays and Thursdays. However, from 3/19/24 to 4/19/24, Resident B only received two showers and two bed baths, which did not meet the scheduled frequency. Resident C, diagnosed with nontraumatic intracranial hemorrhage, difficulty in walking, nausea with vomiting, morbid obesity, and major depressive disorder, required substantial to maximum assistance with bathing. Despite this, Resident C's documented bathing records from 3/19/24 to 4/19/24 showed only one bed bath and three showers, with one refusal noted. The facility's policy required offering a shower, tub bath, or bed/sponge bath at least twice weekly according to the resident's preference, which was not adhered to in these cases.
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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