Brickyard Healthcare - Golden Rule Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Richmond, Indiana.
- Location
- 2330 Straight Line Pike, Richmond, Indiana 47374
- CMS Provider Number
- 155264
- Inspections on file
- 29
- Latest survey
- February 4, 2026
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Brickyard Healthcare - Golden Rule Care Center during CMS and state inspections, most recent first.
Two residents experienced mental and verbal abuse and threats of involuntary seclusion by an RN. One resident with psychiatric and cognitive diagnoses, who used a wheelchair, was reportedly subjected to an attempt by the RN to have CNAs push the resident into a locked supply closet, during which the resident fell from the wheelchair; CNAs reported being told not to assist or report the incident, and the closet contained medical equipment and chemicals rather than being a resident care area. Another cognitively intact resident with serious medical conditions reported that the same RN entered her room after she yelled for help when she could not find her call light, yelled at her for waking others, told her she should be moved off the floor, and made disparaging comments that left the resident crying; a CNA corroborated that the RN lectured the resident, initially refused to take her BP, and initially refused to help her back to bed. These events occurred despite a facility policy that defines and prohibits abuse, involuntary seclusion, mental abuse, and verbal abuse.
A resident with bipolar disorder, paranoid schizophrenia, dementia, insomnia, and Alzheimer’s disease had detailed care plans calling for calm, person-centered, non-pharmacological interventions during behavioral episodes, including leaving the resident alone to calm, speaking calmly, and allowing expression of feelings. During episodes of yelling, paranoia, and threats, an RN repeatedly followed the resident, pressed medication administration, told the resident to stop yelling and be respectful, and, according to staff interviews, antagonized the resident and attempted to have the resident placed in a supply closet to prevent disturbance of others. Other staff reported having to remove the resident from the RN and noted that residents appeared agitated with the RN. These actions conflicted with the resident’s care plan and the facility’s behavioral health and dementia policies, leading surveyors to find that the facility failed to provide appropriate, individualized behavioral health services and that the RN’s handling of interactions would likely cause psychological harm using the reasonable person concept.
A resident with chronic pain, hemiplegia, and aphonia who communicates via tablet repeatedly requested PRN opioid pain medication and attempted to speak with an RN at the nurse’s station, but the RN did not acknowledge the resident, made a dismissive remark to a CNA who tried to help, and only responded without making eye contact, leaving the resident very upset. CNAs and an LPN reported that this RN often delayed the resident’s PRN pain medications for hours despite the resident knowing her dosing schedule, while the resident’s care plans called for supportive communication and pain management and the facility’s policy guaranteed respect and dignity.
A resident with chronic pain, prior CVA, anxiety, and aphonia became upset at the nurse’s station when an RN stated it was not time for PRN pain medication and did not initially acknowledge the resident’s attempts to communicate, later responding without making eye contact. A CNA, who observed the incident and assisted the distressed resident back to her room, completed a written grievance and submitted it to leadership. Despite this, no one from the facility followed up with the CNA or the resident, and the DON confirmed no investigation or resident contact occurred, contrary to the facility’s grievance policy requiring prompt investigation, resident updates, and a written decision.
Staff failed to report an allegation of abuse and an associated fall involving a cognitively intact wheelchair-bound resident with multiple psychiatric and neurological diagnoses to the ED as required by facility policy. CNAs reported that an RN was emotionally abusive during the resident’s behavioral episode, attempted to have staff push the resident in her wheelchair into a supply closet, and then grabbed the wheelchair, causing the resident to fall. The CNAs reported the incident only up the nursing chain (to a unit manager and the DON), and the ED later confirmed that no one had informed him of the allegation, despite a policy requiring immediate reporting of abuse allegations to the ED.
Two residents at risk for falls did not receive required post-fall assessments after separate fall events. One resident with dementia, a history of repeated falls, and wheelchair use reportedly fell near the nursing station during a behavioral episode; CNAs stated an RN’s handling of the wheelchair contributed to the fall and that the RN did not assess or document the incident, while the RN denied a fall occurred. Another cognitively intact resident with generalized anxiety disorder, identified as a fall risk and dependent for transfers, was found on the floor yelling in pain, reported falling while trying to get out of bed, and was sent to the hospital where a hip fracture requiring surgical repair was diagnosed. The DON confirmed that no post-fall assessments were completed for either event, despite facility policy requiring assessment and documentation after any fall.
Several residents experienced significant delays in call light response, leading to episodes of incontinence, lack of assistance with ADLs such as bathing and toileting, and unaddressed requests for food reheating and transfers. These delays occurred despite residents being cognitively intact and having care plans requiring prompt assistance, with some residents expressing feelings of humiliation and others refraining from reporting due to concerns about staff workload.
The facility did not administer insulin as ordered or perform required blood sugar checks for two residents with diabetes, and failed to complete weekly skin assessments for one of them. Additionally, two residents who experienced falls did not receive the required neurological checks according to facility protocol. Staff interviews and record reviews confirmed these omissions, despite existing facility policies mandating these actions.
The facility did not notify a physician of a resident's MDRO-positive urinalysis, delayed implementing enhanced barrier precautions and moving the resident to a private room, and failed to provide required PPE for two residents on EBP. Additionally, an ice scoop was improperly stored inside a cooler, contrary to infection control practices.
Two residents with diabetes did not have complete documentation of their insulin administration on the MAR, with missing entries for both medication administration and blood glucose readings. The DON confirmed that undocumented administrations are considered not completed, and facility policy requires staff to sign the MAR after giving medications.
Several residents with chronic medical conditions and no elopement risk were unable to open their bedroom windows for fresh air due to the windows being screwed shut by facility maintenance at management's direction. Despite residents expressing their preference for fresh air and being cognitively able to communicate their needs, their requests were not accommodated.
A resident who was dependent on staff for bathing and incontinent care, and who was frequently incontinent, was not provided with sufficient showers or timely changes of their brief. Family members observed persistent body odor and urine smell, and confirmed through marking the brief that it was not changed for several days. The resident reported embarrassment due to this lack of care, which was not in accordance with the facility's policy on dignity and respect.
A resident with multiple chronic conditions was not notified in advance of several outside physician appointments. Instead, transportation staff would arrive unannounced to take the resident to these appointments, and there was no documentation of prior notification. The resident was moderately impaired in decision-making but able to communicate effectively, and facility policy required support of resident choice, which was not followed.
A resident with diabetes, neuropathy, and a foot infection was prescribed antibiotics and received dressing changes, but the facility failed to develop and implement a comprehensive care plan addressing the cellulitis. The Infection Preventionist confirmed that tracking and care planning for the infection was not completed, which did not meet facility policy requirements.
A resident with diabetes and neuropathy was treated twice with antibiotics for cellulitis, but the Infection Preventionist did not track the infection or antibiotic use as required by the facility's antibiotic stewardship policy. The lack of documentation and monitoring meant the facility did not follow its own protocols for infection control and antibiotic stewardship.
The facility failed to investigate allegations of sexual abuse involving three residents with dementia, who exhibited inappropriate behaviors. Despite interventions, the behaviors persisted, and there was no assessment of the residents' capacity to consent. Staff were unaware of the extent of the behaviors, and families were not adequately informed.
The facility failed to prevent sexual abuse among residents in the Alzheimer's Care Unit, involving inappropriate behaviors by three residents with dementia. Despite behavior care plans, there was no assessment of their capacity to consent, and interventions to separate and redirect them were ineffective. Staff lacked awareness and training, and families were not adequately informed, leading to repeated incidents without proper intervention or supervision.
The facility failed to immediately notify the Administrator of sexual abuse allegations involving three residents on the Alzheimer's Care Unit. Residents with severe cognitive impairments exhibited sexually inappropriate behaviors, and interventions to separate them were ineffective. The Administrator and DON were unaware of specific incidents, and the facility's policy on abuse reporting was not followed.
The facility failed to implement behavior care plans and provide adequate monitoring for residents with dementia, leading to inappropriate interactions and behaviors. Residents exhibited sexually inappropriate behaviors and aggression, but care plan interventions were not effectively implemented, and physicians were not informed. The facility's physical setup and staffing issues hindered effective monitoring, contributing to repeated incidents of inappropriate resident interactions.
The facility failed to maintain the dignity of two residents. One resident, who required assistance with eating, was found with dried oatmeal on her clothing, and her family member's grievance received no follow-up. Another resident, dependent on staff for toileting, waited 45 minutes for assistance, resulting in soiling themselves. The DON acknowledged the need for dignity and timely care.
The facility failed to maintain a clean environment for three residents, leading to deficiencies in providing a safe, clean, comfortable, and homelike environment. A resident with heart failure had dried oatmeal debris on her recliner, which remained uncleaned despite a formal grievance. Another resident with respiratory failure had a dusty box fan, and a resident with diabetes had food debris and dust on his motorized scooter. These issues persisted despite the facility's policy to provide a clean environment.
The facility inaccurately encoded MDS assessments for two residents regarding their hospice status and prognosis. One resident with respiratory failure was receiving hospice services, but the MDS assessment incorrectly indicated no terminal prognosis. Another resident with diabetes and neuropathy was ordered to receive hospice services, yet the MDS assessment inaccurately stated they were not receiving such services. The RN Assessment Coordinator acknowledged these errors.
The facility failed to assist a resident with eating and another with grooming. A cognitively impaired resident was left without assistance during meals, leading to food spills and cold meals. Another resident, who preferred to be clean-shaven but had physical impairments, was observed with facial hair, indicating a lack of grooming assistance. Staff assumptions and busy schedules contributed to these deficiencies.
A facility failed to change the humidification for a resident's oxygen concentrator as required. The resident, who was cognitively impaired and diagnosed with heart failure, had a physician's order for weekly changes of the humidification bottle. Observations revealed the bottle was empty and not changed since a specified date, contrary to the facility's policy. An LPN confirmed the oversight.
Failure to Prevent Verbal Abuse and Threatened Involuntary Seclusion of Residents
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from mental and verbal abuse and threats of involuntary seclusion, resulting in fear, intimidation, and mental anguish for two cognitively intact residents. Resident B had diagnoses including bipolar disorder, anxiety, paranoid schizophrenia, dementia, and a history of repeated falls, and used a wheelchair for mobility. On a night in early January, Resident B exhibited paranoid and accusatory behaviors, yelling and screaming in her room and the hallway, and threatening staff, leading to her transfer to the hospital. The nurse’s progress note documented these behaviors and the decision to send the resident out, but did not document any fall or attempt at seclusion. CNA witnesses later reported that during this same behavioral episode, RN 5 attempted to have Resident B placed in a supply closet behind the nursing station. CNA 6 stated that RN 5 asked CNA 5 to put Resident B in the supply closet, and when CNA 5 refused, RN 5 told both CNAs not to say anything about what happened. CNA 5 reported that RN 5 tried to get her to push the resident’s wheelchair into the supply closet while RN 5 held the door, and when she refused, RN 5 grabbed the wheelchair and the resident fell to the floor. CNA 5 and CNA 6 reported that RN 5 instructed them not to help the resident, but CNA 6 assisted Resident B back into her wheelchair and they kept the resident away from RN 5 until EMS arrived. LPN 8 reported that CNA 5 had informed her that RN 5 tried to have Resident B involuntarily secluded in the supply closet and that the resident had a fall that same night. The supply closet was later observed to be a locked room containing medical equipment, oxygen, supplies, and chemicals, and was not a resident care area. The deficiency also includes an incident of verbal and mental abuse toward Resident C, who was cognitively intact and had diagnoses including idiopathic pulmonary fibrosis, migraines, and cirrhosis of the liver. Resident C reported that one night she could not find her call light and yelled out for help because she needed repositioning, medications, and assistance back to bed. She stated that RN 5 entered the room and said she did not know what the resident was yelling about but that someone would take care of it, then yelled at her for waking other residents and told her that if she could not be quiet, she needed to be moved to a different floor. Resident C reported that RN 5 told her that the next time she saw her, it better not be on her floor, and that she needed to grow up and stop worrying only about herself, which made the resident cry and feel very small. CNA 4 corroborated that Resident C was yelling for help to have her blood pressure taken so she could receive medications and go to bed, and that RN 5 lectured the resident for being loud and disrupting others, initially refused to take her blood pressure, and initially refused to assist with getting her back to bed. These actions occurred despite the facility’s written policy defining abuse, involuntary seclusion, mental abuse, and verbal abuse, and prohibiting intimidation, unreasonable confinement, and threats of punishment or deprivation.
Failure to Provide Appropriate Behavioral Health Interventions for a Resident With Major Mental Illness
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate, individualized behavioral health treatment and services to a resident with major mental illness, resulting in an altercation between a nurse and the resident. Resident B had multiple documented psychiatric and neurologic diagnoses, including bipolar disorder, anxiety, paranoid schizophrenia, dementia, insomnia, and Alzheimer’s disease. The resident’s care plans, initiated and updated on multiple dates, identified depression, anger, negative statements, withdrawal, a history of comments about not wanting to live, behavioral symptoms such as rejection of care, cursing at staff, wandering, hallucinations, and physical aggression toward staff, as well as social isolation and disturbed sleep patterns. The care plans contained specific non-pharmacological interventions such as allowing the resident time to express feelings, encouraging discussion of thoughts when sad or upset, speaking in a calm and unhurried voice, offering diversions, allowing a specific staff member to hold the resident’s hand, and leaving the resident alone when she was having behaviors so she could calm down. On a documented change in condition, Resident B exhibited significant behavioral escalation, including paranoia, false accusations toward staff, disorientation to situation, yelling and screaming in her room and the hallway, waking other residents, threatening to beat up staff, cursing, and rolling around in her wheelchair staring at staff in an intimidating manner. The progress note, signed by RN 5, stated that staff and other residents did not provoke the resident and that staff only attempted to reorient her to reality and ask her to lower her voice. The resident was ultimately transferred to the hospital via EMS. However, interviews with multiple staff members later described that during a January night shift when the resident was yelling and screaming, RN 5 repeatedly tried to give the resident medication, told her to stop yelling and be respectful to other residents, and did not attempt other interventions consistent with the resident’s care plan. The Unit Manager reported that she was unsure if RN 5 knew how to deal with residents with psychiatric issues and gave an example that RN 5 wanted to follow Resident B around when the resident needed to be left alone, despite being told not to do that. CNAs reported that during an episode of yelling and screaming, RN 5 would not leave the resident alone, was antagonizing her, and seemed spiteful, and that other staff had to remove the resident from RN 5. Another nurse (LPN 8) reported being told that RN 5 had attempted to get a CNA to place Resident B in involuntary seclusion in a supply closet because the resident was yelling and might wake other residents, and also observed that several residents appeared agitated with RN 5, who seemed to be making residents angry. RN 5 stated she did not understand why Resident B was on a regular unit and did not realize there were so many psychiatric residents with behaviors mixed with other residents. These observations and interviews, contrasted with the facility’s dementia and behavioral health policies requiring person-centered, non-pharmacological interventions and an environment conducive to mental and psychosocial well-being, support the finding that the facility failed to ensure Resident B received appropriate, individualized behavioral health services and that RN 5’s handling of interactions with the resident would likely cause psychological harm using the reasonable person concept. The facility’s own policies on dementia and behavioral health services emphasized providing appropriate treatment and services to meet each resident’s highest practicable physical, mental, and psychosocial well-being, ensuring necessary behavioral health services, and implementing person-centered, non-pharmacological interventions. Despite these policies and the detailed care plans for Resident B, the documented and reported actions of RN 5—following the resident instead of leaving her alone, repeatedly pressing medication administration during an acute behavioral episode, verbally directing the resident to stop yelling and be respectful, allegedly attempting to have the resident placed in a supply closet, and generally antagonizing the resident—were inconsistent with the individualized interventions outlined in the care plan. Based on observation, interview, and record review, surveyors concluded that the facility failed to ensure that a resident with a major mental illness was treated appropriately and that individualized interventions were implemented, resulting in a physical/mental altercation between staff and the resident and likely psychological harm under the reasonable person concept.
Failure to Treat Resident Requesting PRN Pain Medication With Respect and Dignity
Penalty
Summary
The deficiency involves staff failure to treat a resident with respect and dignity when the resident attempted to request PRN pain medication. Certified Nursing Assistant (CNA) 2 reported witnessing a registered nurse (RN 5) not acknowledging Resident E, who is cognitively intact, has chronic pain syndrome, uses opioid pain medication, and communicates via a tablet due to aphonia. Resident E came to the nurse’s station with her communication tablet to speak with RN 5 about pain medication that was due, but RN 5 did not look up or acknowledge her. Resident E then began pounding her cane on the desk and kicking it to get attention. When CNA 2 informed RN 5 that the resident needed her attention, RN 5 responded, “I know, thanks captain obvious, I know how to do my job,” and continued to work without acknowledging the resident, later speaking to her without looking up. CNA 3 corroborated this sequence, stating that Resident E was very upset after being taken back to her room. Earlier that morning, CNA 3 had answered Resident E’s call light when the resident requested PRN pain medication around 6:00 a.m. CNA 3 relayed the request to RN 5, who stated the resident had received pain medication at 2:30 a.m. and was not due again until 8:30 a.m. When CNA 3 informed Resident E of this, the resident stated it was incorrect and that she had last received pain medication around midnight, which made her very upset because she knows when her PRN medications are due. In an interview, Resident E reported that a nurse gave her PRN pain medication at 11:00 p.m. and refused to give her PRN oxycodone at 5:00 a.m., and that she did not receive her medication until 8:00 a.m. She stated that RN 5 frequently withholds and prolongs giving her PRN pain medications, causing her to wait up to two hours and resulting in increased pain. LPN 8 indicated that during training with RN 5, they observed RN 5 specifically make Resident E wait hours for PRN pain medication without knowing why. The resident’s care plans included interventions to support communication and pain management, such as allowing a calm, unhurried environment, listening carefully, validating expressions, and using non-pharmacological pain interventions, and the facility’s Resident Rights policy affirmed the right to be treated with respect and dignity.
Failure to Investigate and Follow Up on Resident Grievance Regarding Pain Management Interaction
Penalty
Summary
The deficiency involves the facility’s failure to follow its grievance policy and promptly investigate and resolve a resident grievance. On the morning of 1/24/26, a cognitively intact resident with chronic pain syndrome, frequent pain, a history of cerebral infarction, anxiety, impaired neurological status, and aphonia was at the nurse’s station upset about her pain medication, believing it was due. The resident, who primarily communicated via tablet and used a cane, attempted to get the attention of an RN who stated it was not time for the PRN pain medication. According to a CNA, the RN did not initially acknowledge the resident despite the resident pounding her cane on the desk and kicking it, and when the RN eventually responded, the RN did so without looking up at the resident. The CNA reported that the resident was very upset and assisted her back to her room. The CNA completed a written grievance form that same morning and placed copies under the DON’s and ED’s doors. However, no one from the facility followed up with the CNA or the resident regarding the grievance. In interviews conducted days later, both the CNA and the resident confirmed that no follow-up had occurred. The DON also acknowledged that they had not followed up with the resident about the grievance. This inaction conflicted with the facility’s Resident and Family Grievance policy, which states that written complaints to staff or the Grievance Official are recognized forms of grievances, that the Grievance Official or designee will keep the resident apprised of progress toward resolution, and that a written decision including investigative steps and findings will be issued, with prompt efforts made to resolve grievances.
Failure to Report Alleged Abuse and Injury to Executive Director
Penalty
Summary
The facility failed to follow its abuse policy requiring that all allegations of abuse be reported immediately, and no later than two hours, to the Executive Director. Resident B, who had diagnoses including bipolar disorder, anxiety, paranoid schizophrenia, dementia, and a history of repeated falls, was cognitively intact for daily decision making per a quarterly MDS dated 12/5/25 and used a wheelchair for mobility. Certified nursing assistants (CNAs) reported that in early January 2026, during an episode when Resident B was yelling and screaming, RN 5 was emotionally abusive, antagonizing, and spiteful toward the resident instead of allowing her to calm down as staff typically did. RN 5 allegedly attempted to have CNAs push the resident, in her wheelchair, into a supply closet, and when the CNAs refused, RN 5 grabbed the wheelchair, resulting in the resident falling to the floor. CNA 6 reported that she informed the DON about RN 5 trying to get staff to put Resident B in the supply closet and causing the resident to fall, but she did not report the incident to the Executive Director. CNA 5 similarly reported that she informed the Unit Manager about RN 5’s emotionally abusive behavior, the attempt to place the resident in the supply closet, and the resulting fall, and the Unit Manager stated she would report it to the DON. During an interview, the Executive Director stated that no staff had reported that RN 5 requested staff to put Resident B in the supply closet or that RN 5 had caused Resident B to fall. The facility’s abuse policy, provided by the Executive Director, specified that allegations of abuse were to be reported to the Executive Director immediately, but not later than two hours after the allegation was made, which did not occur in this case.
Failure to Complete Post-Fall Assessments for Two Residents at Risk for Falls
Penalty
Summary
The deficiency involves the facility’s failure to complete required post-fall assessments for two residents identified as being at risk for falls. Resident B had diagnoses including dementia, repeated falls, Alzheimer’s disease, vitamin D deficiency, and bone density disorders, and used a wheelchair for mobility. The resident’s care plan identified multiple fall risk factors, and no new interventions had been implemented since 4/27/23. A change in condition note documented that Resident B was exhibiting paranoid and aggressive behaviors and was sent to the hospital via EMS, but there was no documentation of a fall or any post-fall assessment associated with that event. Resident B later reported having fallen near the nursing station about three weeks prior to the interview, stating she lost her balance and that 2 or 3 staff witnessed the fall. One CNA reported witnessing Resident B attempt to stand from her wheelchair when an RN pushed her down, causing the resident to fall to the floor, and stated that the RN instructed staff not to say anything about the incident. Another CNA reported that on the same date, during behavioral outbursts, the RN grabbed the resident’s wheelchair and the resident fell, and that the RN told staff not to help the resident; the CNA stated that another CNA assisted the resident back into the wheelchair. This CNA also reported the incident to the Unit Manager. The RN involved stated she did not think the resident had fallen and did not document or assess a fall. Another nurse reported that she only learned of the fall weeks later from a CNA and that there was nothing in report about a fall. Resident C had generalized anxiety disorder, was cognitively intact, used a wheelchair, and required assistance with bed mobility and transfers. A fall risk evaluation identified the resident as at risk for falls. A progress note documented that staff responded to the resident yelling out and found her lying on the floor against the wall, crying out in pain with her left leg, and that the physician was notified and the resident was sent to the ER. A facility-reported incident stated that the resident told staff she fell while attempting to get out of bed and that she was evaluated by a nurse and sent to the hospital. A hospital discharge summary documented that the resident sustained a mechanical fall resulting in a closed hip fracture and underwent surgery with nail and screw placement. The DON confirmed that although there was an IDT note about the fall, no post-fall assessment was completed for this resident, despite facility policy requiring assessment and completion of a post-fall assessment, including documentation of all assessments and actions, after any resident fall.
Failure to Uphold Resident Dignity and Timely Response to Call Lights
Penalty
Summary
The facility failed to uphold residents' rights to dignity and timely assistance, as evidenced by multiple incidents involving delayed responses to call lights and inadequate support with activities of daily living (ADLs). One resident, with a history of right lower leg fracture and muscle weakness, was left on a bedpan for over thirty minutes without assistance, despite using the call light and having a care plan that required prompt response to requests for help. The resident's family member had to seek staff assistance directly at the nurses' station, where a nurse indicated that aides were busy with meal trays and would assist after completing those duties. The same resident was also pressured to sign a refusal for a bath when she only wished to delay it due to fatigue from therapy, rather than refuse it entirely. Another resident, with a history of stroke and respiratory failure, reported waiting up to an hour for assistance to use the bathroom, resulting in urinary incontinence. This resident, who was cognitively aware and required standby assistance for toileting, described feeling humiliated by these delays. A third resident, dependent on staff for toileting due to weakness and age-related debility, reported that call lights were not answered in a timely manner, particularly during the third shift, leading to episodes of incontinence that left pajamas, sheets, and blankets soaked with urine. This resident also experienced staff refusal to assist with transferring to a recliner and to warm up cold food, despite repeated requests. A fourth resident, with diagnoses including spinal stenosis and chronic kidney disease, described waiting up to 45 minutes for call light responses, resulting in both urinary and bowel incontinence. This resident, who was cognitively intact and required substantial assistance with toileting, had not reported the issue due to sympathy for the understaffed facility. Facility policies reviewed indicated that all staff were responsible for responding to call lights and that residents had the right to be treated with respect and dignity. The DON confirmed that the expectation was for call lights to be answered within five minutes.
Failure to Administer Insulin, Complete Skin Assessments, and Perform Post-Fall Neurological Checks
Penalty
Summary
The facility failed to provide care and treatment according to physician orders and established protocols for multiple residents. For two residents with diabetes, insulin was not administered as ordered by the physician on specific dates, and blood sugar checks were omitted. One of these residents also did not receive a weekly skin assessment as required, with a gap of 13 days between assessments, despite being at moderate risk for skin breakdown. Staff interviews confirmed that weekly skin assessments and insulin administration were not consistently performed as ordered. Additionally, the facility did not complete required neurological checks after falls for two residents. One resident, who had a history of dementia and falls, experienced a fall with head injury and was sent to the emergency room. Upon return, the neurological check sheet showed multiple omissions in the required monitoring intervals. Another resident, who was at risk for falls and had an unwitnessed fall, did not have any neurological checks documented after the incident. Staff interviews confirmed that neurological checks were not consistently completed following falls. Facility policies required that insulin be administered according to physician orders and that full body skin assessments be performed weekly for residents at risk of pressure ulcers. The facility also had protocols for post-fall neurological monitoring, especially after unwitnessed falls or head injuries. Despite these policies, the clinical records and staff interviews revealed that these protocols were not followed for the affected residents.
Failure to Implement Infection Control Precautions and Proper PPE Availability
Penalty
Summary
The facility failed to notify a physician of a resident's urinalysis results that identified a multidrug-resistant organism (MDRO), providencia stuartii, and did not implement enhanced barrier precautions (EBP) or move the resident to a private room until several months after the diagnosis. The resident, who had diagnoses including cellulitis of the left lower limb and diabetes, remained in a semi-private room with another resident for over three months after the MDRO was identified. There was no documentation that the physician was notified of the urinalysis or that any orders for precautions were implemented until much later. The infection control map captured the urinalysis, but it was not included in the facility's infection control surveillance log. For another resident with cellulitis of the lower extremities, the facility failed to provide PPE or a container for PPE disposal despite orders for EBP. Observations confirmed that there was no PPE available inside or outside the resident's room, and staff interviews revealed a lack of awareness regarding responsibility for ensuring PPE availability. The resident's legs were red, swollen, and seeping fluid, and staff did not use gloves, gowns, or face shields when providing care, contrary to the care plan and physician orders. Additionally, the facility failed to properly store an ice scoop used for passing ice water, as it was found lying inside a portable cooler rather than in a designated holder. Staff interviews confirmed that this was not in accordance with infection control practices. The facility's policies required specific infection control measures for MDROs and EBP, including the availability of PPE and proper signage, but these were not consistently implemented or followed.
Incomplete Documentation of Medication Administration Records
Penalty
Summary
The facility failed to ensure complete and accurate documentation of medication administration for two residents. For one resident with diabetes mellitus, the physician ordered ten units of Lantus insulin to be administered at bedtime. The medication administration record (MAR) showed the medication was given on one evening, but the following evening's administration was left blank. The DON confirmed that if a medication is not signed off on the MAR, it either was not administered or not documented, and the nurse responsible was unavailable for interview. For another resident with emphysema and diabetes, the care plans required monitoring of blood glucose and administration of sliding scale insulin as ordered. The MAR for this resident was missing documentation for both the administration of sliding scale insulin and the associated blood glucose reading for a specific morning. The DON stated that undocumented administration on the MAR is considered not completed and was unsure why the documentation was missing. Facility policy requires staff to sign the MAR after medication administration, but this was not followed in these instances.
Failure to Accommodate Resident Preferences for Fresh Air
Penalty
Summary
The facility failed to accommodate the preferences of four residents who wished to open their bedroom windows for fresh air. Observations and interviews revealed that the windows in the residents' rooms were screwed or nailed shut, preventing them from being opened. Residents expressed their desire to have access to fresh air, especially when the weather was good, and noted their inability to open the windows. Family members and staff also confirmed that the windows could not be opened, and the Maintenance Director stated that he had installed the screws in the windows at the direction of management, though he was unsure of the reason for this action. The affected residents had various medical conditions, including respiratory failure, chronic kidney disease, heart disease, diabetes, and mobility issues. Assessments indicated that these residents were either cognitively intact or able to make their needs known, and none were at risk for elopement. Despite their stated preferences and lack of elopement risk, their requests to have their windows opened for fresh air were not accommodated, as the physical barriers remained in place.
Failure to Provide Timely Showers and Incontinent Care
Penalty
Summary
The facility failed to provide adequate showers and timely incontinent care to a resident who was dependent on staff for activities of daily living. The resident, who had diagnoses including respiratory failure, morbid obesity, diabetes, and age-related debility, was cognitively intact and required substantial to maximal assistance for bathing and dressing. According to the Minimum Data Set assessment, the resident was frequently incontinent of both bowel and bladder and did not exhibit behaviors of care rejection. Family members reported that the resident consistently had body odor and smelled of urine during their frequent visits. The resident also reported to family that staff were not providing showers or changing their incontinent brief, which caused embarrassment. To verify their concerns, a family member marked the resident's brief with a magic marker; upon returning three days later, the marked brief was still in place, indicating a lack of timely care. The issue was reported to nursing staff, who then changed the resident. The facility's own policy stated that residents have the right to respect and dignity.
Failure to Notify Resident of Outside Physician Appointments
Penalty
Summary
The facility failed to notify a resident about their scheduled outside physician appointments, as required to support resident self-determination and choice. According to interviews, the resident reported that on multiple occasions, the facility's transportation staff would arrive at their door and inform them of an appointment without prior notice. This occurred at least four times, and possibly more, with the resident expressing that while they were always prepared, they felt it would be courteous to be informed ahead of time. The resident did not wish to cause trouble but highlighted the lack of notification as an issue. Record review confirmed that the resident had five outside doctor appointments over a three-month period, with no documentation indicating that the resident was notified in advance. The resident's clinical record showed diagnoses including chronic kidney disease, pleural plaque, left ventricular failure, anemia, hypertensive heart disease, and respiratory failure with hypoxia. The resident was assessed as moderately impaired for daily decision-making but was able to make themselves understood and understand others. Facility policy requires support of resident choice and notification regarding significant aspects of their life, including appointments, but this was not followed in this case.
Failure to Develop Care Plan for Resident with Foot Infection
Penalty
Summary
A deficiency was identified when the facility failed to develop and implement a comprehensive care plan for a resident with a foot infection. The resident, who had diagnoses including diabetes with neuropathy and abnormal gait, was noted to be cognitively intact and required a wheelchair for mobility. Clinical records showed that the resident had cellulitis of the left second toe, was prescribed antibiotics, and received dressing changes. Despite these interventions and ongoing infection, there was no care plan documented in the clinical record addressing the cellulitis. During interviews, the Infection Preventionist acknowledged that tracking the resident's cellulitis and antibiotics was her responsibility, including ensuring that a care plan was developed. The facility's policy requires a comprehensive, person-centered care plan with measurable objectives and timeframes for all identified needs, as determined by the resident's assessment. The absence of a care plan for the resident's cellulitis constituted noncompliance with this policy and regulatory requirements.
Failure to Track and Monitor Antibiotic Use for Cellulitis
Penalty
Summary
The facility failed to follow and implement its antibiotic stewardship policies and protocols for one resident who was being treated for cellulitis. The resident, who had diagnoses including diabetes with neuropathy and required a wheelchair for mobility, developed cellulitis on her left foot and was prescribed antibiotics on two separate occasions. Despite these treatments, there was no documentation of infection tracking or mapping for this resident in the infection control records for the relevant months. The Infection Preventionist, who had recently started in her role, confirmed that she did not track the resident's cellulitis or antibiotic use, which was part of her responsibility according to facility policy. The facility's policy on antibiotic stewardship required the Infection Preventionist to track antibiotic starts, monitor adherence to evidence-based criteria, and ensure proper care planning for infections. However, the Infection Preventionist acknowledged that she did not enter the resident's infection or antibiotic use into the tracking system, nor did she ensure that the care plan was developed for the issue. This lapse resulted in the facility not adhering to its own antibiotic stewardship program as outlined in its policy.
Failure to Investigate Allegations of Sexual Abuse
Penalty
Summary
The facility failed to initiate an investigation into allegations of sexual abuse involving three residents, despite clear indications of inappropriate behavior. Resident 50, diagnosed with Alzheimer's disease and dementia, exhibited sexually inappropriate behaviors, such as entering male residents' rooms and making sex-related comments. Her care plan included interventions like redirection and notifying her physician, but there was no assessment of her capacity to consent to sexual activity. Similarly, Resident 74, also severely cognitively impaired, demonstrated sexually inappropriate behaviors, including allowing a male resident to grope her in public areas. Despite interventions to separate and redirect, these measures were ineffective, and there was no evaluation of her capacity to consent. Resident 56, with Alzheimer's disease and dementia, displayed sexually inappropriate behaviors, such as touching and making explicit comments. His care plan lacked adequate supervision to prevent resident-to-resident abuse. On multiple occasions, he was observed engaging in inappropriate touching with female residents, including Residents 50 and 74. Staff interventions to separate the residents were ineffective, and there was no documentation of new interventions being implemented when existing ones failed. Interviews with staff revealed a lack of awareness and training on handling such behaviors, with some staff believing the interactions were care planned and families were informed. The facility's failure to investigate and address these behaviors resulted in ongoing inappropriate interactions between residents. Interviews with family members indicated they were not adequately informed about the extent of the behaviors. The facility's policy on abuse, neglect, and exploitation required immediate investigation and protection of residents, but these protocols were not followed. The lack of adequate supervision and failure to assess residents' capacity to consent contributed to the deficiency, highlighting a significant oversight in ensuring resident safety and compliance with regulatory standards.
Failure to Prevent Resident-to-Resident Sexual Abuse in Alzheimer's Care Unit
Penalty
Summary
The facility failed to ensure residents were free from sexual abuse on the Alzheimer's Care Unit, affecting three residents. Resident 50, diagnosed with Alzheimer's disease and dementia, exhibited sexually inappropriate behaviors, such as entering male residents' rooms and making sex-related comments. Despite having a behavior care plan, there was no assessment indicating her capacity to consent to sexual activity. Similarly, Resident 74, also severely cognitively impaired, demonstrated sexually inappropriate behaviors, including wandering into male residents' rooms and inappropriate touching. Observations noted that she allowed a male resident to grope her in public areas, and interventions to separate and redirect her were ineffective. Resident 56, with Alzheimer's disease and dementia, displayed sexually inappropriate behaviors, believing female residents were his significant others. His behavior care plan lacked interventions for adequate supervision to prevent resident-to-resident abuse. On multiple occasions, he was observed engaging in inappropriate touching with female residents, including groping and kissing. Staff interventions to separate him from female residents were ineffective, and there was no documentation of new interventions being initiated when existing ones failed. Interviews with staff revealed a lack of awareness and training regarding the residents' behaviors and the facility's policies on abuse prevention. The Alzheimer's Care Director and other staff members did not consider the behaviors as inappropriate, and families were not adequately informed about the incidents. The facility's policies on dementia care and abuse prevention were not effectively implemented, leading to repeated incidents of resident-to-resident sexual abuse without proper intervention or supervision.
Failure to Report and Address Sexual Abuse Allegations
Penalty
Summary
The facility failed to notify the Administrator immediately of allegations of sexual abuse on the Alzheimer's Care Unit for three residents. Resident 50, who had Alzheimer's disease and severe cognitive impairments, demonstrated sexually inappropriate behaviors, such as entering male residents' rooms and making sex-related comments. Despite these behaviors being documented in her care plan, there was no assessment indicating her capacity to consent to sexual activity. Similarly, Resident 74, also with severe cognitive impairments, exhibited wandering and sexually inappropriate behaviors, including allowing a male resident to grope her. Her care plan lacked an assessment of her capacity to consent to sexual activity. Resident 56, diagnosed with Alzheimer's disease and dementia, displayed sexually inappropriate behaviors, such as believing other residents were his significant other and engaging in inappropriate touching. His care plan did not include interventions to provide adequate supervision to prevent resident-to-resident abuse. On multiple occasions, Resident 56 was observed engaging in sexual behaviors with Resident 74, such as rubbing her buttocks and breasts, and kissing her. These incidents were documented by an LPN, who noted that interventions to separate the residents were ineffective. Interviews with staff revealed that the behaviors of Resident 56 were known to some staff members, but the Administrator and DON were unaware of the specific incidents on the day in question. The facility's policy on abuse, neglect, and exploitation required immediate reporting of such incidents, but this was not followed. The lack of adequate supervision and failure to report the incidents in a timely manner contributed to the deficiency in handling allegations of sexual abuse in the facility.
Inadequate Monitoring and Implementation of Care Plans for Residents with Dementia
Penalty
Summary
The facility failed to implement behavior care plans and provide adequate monitoring and supervision for residents with dementia, leading to inappropriate interactions and behaviors among residents. Resident 50, diagnosed with Alzheimer's disease, anxiety, and insomnia, exhibited sexually inappropriate behaviors, such as entering male residents' rooms and making sex-related comments. Despite having a behavior care plan, there was no documentation of interventions being implemented or the physician being informed of her behaviors. Similarly, Resident 74, with severe cognitive impairment, demonstrated wandering and sexually inappropriate behaviors, but her care plan interventions were not effectively implemented, and her physician was not informed of her behaviors. Resident 56, diagnosed with Alzheimer's disease and dementia, displayed sexually inappropriate behaviors and aggression towards staff. His behavior care plan lacked adequate supervision interventions, and there was no documentation of informing his physician about his behaviors. The facility's physical setup made it challenging to monitor residents effectively, contributing to the failure to prevent resident-to-resident abuse. Additionally, Resident 11, with vascular dementia, exhibited confrontational behavior, and Resident 57, with Alzheimer's disease, showed increased anger and physical aggression towards other residents. The facility's staffing issues further hindered effective monitoring and supervision. The facility's policies on behavioral health services and dementia care were not adequately followed, as care plans were not reviewed or revised when interventions were ineffective. The interdisciplinary team approach was not effectively implemented, and appropriate referrals were not made when current interventions failed. The lack of communication with physicians and mental health providers, combined with inadequate supervision and monitoring, led to repeated incidents of inappropriate resident interactions and behaviors.
Failure to Maintain Resident Dignity and Timely Care
Penalty
Summary
The facility failed to maintain the dignity of Resident 2, who required assistance with eating and dressing. Despite being cognitively impaired and needing substantial to maximum assistance with dressing, Resident 2 was found by a family member with dried oatmeal on her clothing and a missing gripper sock. The family member reported that this was not an isolated incident, as she often found food debris on Resident 2's clothing and in her room. A grievance was filed by the family member, but she did not receive any follow-up. A staff member admitted to assisting Resident 2 on the day of the incident but did not notice the oatmeal due to being unusually busy. Another resident, who was cognitively intact but dependent on staff for toileting, reported having to wait almost 45 minutes for their call light to be answered. This delay resulted in the resident soiling themselves and feeling disgusted and humiliated. The Director of Nursing acknowledged that residents should be treated with dignity and respect, and that staff are responsible for cleaning residents and their clothing after meals and responding to call lights promptly.
Failure to Maintain a Clean Environment for Residents
Penalty
Summary
The facility failed to maintain a clean environment for three residents, leading to deficiencies in providing a safe, clean, comfortable, and homelike environment. Resident 2, who was cognitively impaired and diagnosed with heart failure, was observed with dried oatmeal debris on her recliner, which remained uncleaned despite a formal grievance filed by her family member. The family member reported multiple instances of finding Resident 2 covered in food and with food spilled in her room, indicating a lack of timely cleaning and follow-up on grievances. Resident 17, who was cognitively impaired and required oxygen due to respiratory failure, had a box fan with heavy dust buildup in his room, which was not addressed over several days. Additionally, Resident 54, who was cognitively intact and diagnosed with diabetes with neuropathy, had food debris and dust buildup on his motorized scooter, which he was unable to clean himself. Despite the facility's policy to provide a clean environment, these issues persisted, as confirmed by observations and interviews with housekeeping staff and the Director of Nursing.
Inaccurate MDS Assessments for Hospice Status
Penalty
Summary
The facility failed to accurately encode Minimum Data Set (MDS) assessments for two residents regarding their hospice status and prognosis. Resident 17, who had a medical diagnosis of respiratory failure, was cognitively impaired and was receiving hospice services as per a physician order dated March 21, 2023. However, the Annual MDS Assessment dated March 28, 2024, inaccurately indicated that Resident 17 did not have a life expectancy of six months or less, despite a hospice standing order confirming a terminal illness with such a prognosis. Similarly, Resident 54, diagnosed with diabetes with neuropathy, was cognitively intact and had a physician order dated June 3, 2024, to receive hospice services. However, the Significant Change MDS Assessment dated June 5, 2024, incorrectly stated that Resident 54 did not receive hospice services, even though a hospice standing order dated May 31, 2024, confirmed a terminal illness with a life expectancy of six months or less. The Registered Nurse Assessment Coordinator acknowledged the errors in encoding these assessments during an interview.
Failure to Assist Residents with Eating and Grooming
Penalty
Summary
The facility failed to provide adequate assistance to Resident 2 with eating, as observed and reported by Family Member 12. Resident 2, who was cognitively impaired and required substantial to maximum assistance with dressing, was found by her family member with food spilled on her clothing and in her room, and her breakfast tray still present when the family member arrived. On one occasion, staff did not return to assist Resident 2 with her lunch, assuming that Family Member 12 would help, which led to the family member assisting her mother 45 minutes after the meal was served. A grievance form indicated that staff believed the family member would assist with eating, and a confidential staff interview confirmed that assistance was not offered due to the assumption that the family member would help and because of a busy day. The facility also failed to assist Resident 54 with shaving according to his preference. Resident 54, who was cognitively intact but had physical impairments including hemiplegia and a contracture in his left hand, expressed a preference to be clean-shaven. However, observations noted that he had a moderate amount of facial hair and later a long beard, indicating a lack of grooming assistance. The Director of Nursing Services stated that shaving should be offered with every shower or bath, but this was not consistently provided to Resident 54, as evidenced by the observations made during the survey.
Failure to Change Oxygen Humidification
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident by not changing the humidification for the resident's oxygen concentrator as required. The resident, who was cognitively impaired and diagnosed with heart failure, had a physician's order to change the prefilled bottles on her oxygen concentrator weekly and as needed. However, observations on multiple occasions revealed that the humidification bottle was empty and had not been changed since 6/6/2024, despite the requirement for weekly changes. An LPN confirmed the oversight and acknowledged that the humidification setup should have been changed weekly, as per the facility's policy and the physician's order.
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Surveyors observed that dietary staff repeatedly worked in kitchen and meal service areas with uncovered facial hair, despite facility policy and state sanitation requirements mandating effective hair restraints. Two dietary aides with short beards or mustaches were seen walking through food preparation areas, taking food temperatures, handling food, and plating meals at steamtables in dining rooms without any facial hair coverings, while the current policy required all hair, including facial hair, to be restrained to prevent contamination.
The facility failed to consistently provide and document required bed-hold policy notices when several residents were transferred to the hospital. In multiple cases, residents with dementia, psychotic disorders, COPD, chronic respiratory failure, altered mental status, and cerebral infarction were sent out for acute changes in condition, and while transfer notes reflected physician and family notifications, they lacked documentation that the bed-hold policy was discussed with the resident or responsible party. Notices of Transfer or Discharge often indicated a copy of the bed-hold policy was sent with the resident, but the records did not show signed and dated acknowledgment by the resident or appropriate representative, including in situations where a resident had moderate cognitive impairment, short-term memory issues, or a documented need for a proxy and a financial POA authorizing an agent for health care decisions.
Surveyors found that the facility failed to provide trauma‑informed and culturally competent care by not incorporating two residents’ extensive trauma histories and specific behavioral triggers into their care plans. One resident with documented homelessness, polysubstance abuse, severe accidents with multiple fractures, viral encephalitis with coma, physical and sexual abuse, loss of family contact, and a past suicide attempt had multiple behavior‑focused care plans that referenced identifying triggers but listed none and did not mention their physical, sexual, medical, or psychosocial trauma. Another resident with TBI from being struck by a truck, an 11‑month coma, long‑term state hospital residence, alleged shooting of a parent, and diagnoses including intermittent explosive disorder and borderline personality disorder had a PASRR identifying a specific trigger and notes of inappropriate sexual behavior, yet their care plans omitted these traumatic events, the identified trigger, and the sexual behavior. Staff interviews confirmed that residents were screened for trauma, but the trauma histories and triggers were not reflected in the individualized plans of care.
A resident with schizophrenia, post‑stroke hemiparesis, and mild cognitive impairment expressed feeling down and wanting to kill himself, but staff did not document asking about a specific plan, did not notify the physician or psychiatric NP as expected, and did not develop or update a care plan addressing depression or suicidal ideation. The SSD documented offering support and initiating 15‑minute checks once, but there was no further follow‑up or documentation of interventions after subsequent suicidal statements made in a care plan meeting with the resident’s father. The DON and Administrator reported that facility policy requires immediate notification of key staff, assessment for a plan and means of self‑harm, and thorough documentation, which were not carried out or reflected in the medical record for this resident.
A resident with schizophrenia, post-stroke hemiparesis, and mild cognitive impairment verbalized suicidal ideation, but the care plan did not address depression or suicidal thoughts, and required assessments and services were not accurately or timely documented. An SSD note recorded the resident saying he wanted to kill himself and referenced 15‑minute checks and a care plan update, yet the active care plan lacked depression/suicidal ideation interventions. Multiple late-entry Social Services notes were later added, describing follow-up visits and the resident denying suicidal ideation, but the SSD later reported she did not typically ask about a suicide plan and did not personally provide individual follow-up visits as described. These practices conflicted with the facility’s policy requiring factual, first-hand, and timely documentation of assessments and services.
A resident was observed with an Albuterol inhaler on an overbed table and later reported keeping the inhaler in a nightstand drawer, with no staff present during these observations. Record review showed the resident had no cognitive impairment on the admission MDS but lacked any documented self-medication administration assessment. The DON acknowledged that the required assessment had not been completed, despite facility policy requiring staff and the practitioner to evaluate each resident’s mental and physical abilities before allowing self-administration of medications.
Surveyors found that the facility submitted inaccurate direct care staffing data to CMS through the PBJ system over multiple days in a quarter. CASPER reports showed apparent gaps in 24-hour licensed nurse coverage, low weekend staffing, and a 1-star staffing rating, while internal staffing sheets documented that licensed nurses were present and the facility was fully staffed on those days. The Administrator reported that the discrepancies were due to PBJ data entry errors, despite a facility policy requiring all PBJ entries to be accurate, auditable, and verifiable against payroll, invoices, or contracts.
Surveyors found that the facility did not provide or document required written transfer/discharge notices and bed-hold policy information for four residents who were sent to the hospital, including individuals with conditions such as dementia, CHF, chronic respiratory failure, and CKD. In each case, progress notes showed that the resident was transferred for acute issues, but the clinical records lacked evidence that written notices were given to the residents or their representatives, and in one case lacked documentation that required information was sent to the receiving provider. Facility leadership, including the ADON, DON, and Administrator, acknowledged that the records did not contain the required documentation, despite a written policy requiring such notices and information exchange.
A resident with Alzheimer’s disease and depression, previously on an antidepressant, exhibited intermittent refusals of medications and care, occasional yelling at staff, and reports of unusual perceptions, such as believing men were in or near her room. Nursing notes over several months documented these refusals and complaints but did not show that the behaviors were evaluated or recorded as dangerous, non-redirectable, or causing significant distress, nor did they document specific non-pharmacological interventions attempted or their outcomes. Despite this, a psychiatric NP later added new diagnoses of schizoaffective disorder, borderline personality disorder, and delusional disorder and ordered an antipsychotic (Seroquel) without a comprehensive evaluation in the record to support these diagnoses. The facility’s psychotropic medication policy, which requires identification and documentation of target behaviors, use of nonpharmacological interventions, and ongoing behavior monitoring, was not followed for this resident.
The facility failed to keep PASARR Level I screenings accurate and current for three residents when new mental health diagnoses and psychoactive medications were initiated. One resident’s PASARR omitted a PTSD diagnosis and an added antidepressant, despite documentation of PTSD on the MDS and care plan and a physician order for Pristiq. Another resident’s PASARR listed only depression and dementia, even after additional diagnoses such as borderline personality disorder, delusional disorder, and schizoaffective disorder were added and an antipsychotic (quetiapine) was ordered, with the MDS later reflecting psychotic disorder, schizophrenia, and depression with antipsychotic and antidepressant use. A third resident’s PASARR did not include a depression diagnosis or newly ordered escitalopram and lorazepam, although the admission MDS documented depression with antianxiety and antidepressant use. These omissions occurred despite facility policy requiring a new Level I review after significant mental status changes, including new mental health diagnoses or new psychotropic medications.
Uncovered Facial Hair During Food Preparation and Meal Service
Penalty
Summary
The deficiency involves the facility’s failure to ensure that food was served in a sanitary and safe manner in accordance with professional standards and facility policy during multiple kitchen and meal service observations. During an initial kitchen observation, two dietary aides were seen walking through the kitchen food preparation area with uncovered facial hair. One aide had facial hair above and below the lip and along the jaw line, approximately one-fourth inch in length, and the other had a mustache of similar length; neither used any facial hair covering. These observations occurred while staff were present in the kitchen area where food was stored and prepared. During subsequent observations on the same day, the same two dietary aides were again observed with uncovered facial hair while directly involved in meal preparation and service. One aide walked through the kitchen while the noon meal was being prepared and placed into a transport cart for service in the south dining room, and later was observed plating the noon meal at the steamtable in that dining room, still without a facial hair covering. The other aide walked through the kitchen while the noon meal was being prepared and placed into the steamtable for the north dining room, took food temperatures, assisted with plating meals at the steamtable, and retrieved food items and supplies from the kitchen, all while having an uncovered mustache approximately one-fourth inch in length. The Dietary Manager stated that staff hair was to be covered when in the kitchen and during meal service, and the facility’s written policy and the cited Indiana Food Establishment Sanitation Requirements both required effective hair restraints, including for facial hair, to prevent contamination of food, equipment, and utensils.
Failure to Provide and Document Bed-Hold Policy at Time of Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure that required bed-hold policy information was provided and documented for four residents transferred to the hospital. For a resident with dementia, psychotic disorder, and autistic disorder who had a BIMS score of 0 indicating severe cognitive impairment, progress notes documented physician notification and guardian notification when the resident was sent to the hospital, but there was no documentation that the bed-hold policy was provided to the responsible party. A Notice of Transfer or Discharge later indicated a copy of the bed-hold policy was sent with the resident. Another resident with COPD and chronic respiratory failure, cognitively intact with a BIMS score of 13, experienced a decline in condition and was transferred to the hospital by ambulance; progress notes documented family notification but did not document any discussion of the bed-hold policy, although a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident. A third resident with altered mental status and cerebral infarction, with a BIMS score of 10 indicating moderate cognitive impairment and documented short-term memory impairment, experienced changes in condition and was transferred to the hospital. Progress notes stated the resident was their own responsible party and that no other notification was completed, and transfer documentation did not include the bed-hold policy, although an untimed Notice of Transfer or Discharge indicated a copy of the bed-hold policy was signed by the resident. A financial power of attorney document in the record showed the resident had designated an agent to act in consent or refusal of health care. For a fourth resident with dementia and osteomyelitis, transfer documentation and a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident, and the transfer form noted the resident required a proxy for decision making. The facility’s policy required that at the time of transfer to a hospital, written notice specifying the duration of the bed-hold policy and information on return to the next available bed be provided, and that a signed and dated copy of the bed-hold notice given to the resident or representative be kept in the resident file, which was not consistently documented for these residents.
Failure to Integrate Trauma Histories and Behavioral Triggers Into Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to identify and incorporate residents’ trauma histories and specific behavioral triggers into their care plans, despite documented histories of significant trauma and behavioral health issues. For one resident, extensive social service and progress notes documented homelessness, polysubstance abuse, major depressive and anxiety disorders, chronic pain, a history of severe car accidents with multiple fractures, viral encephalitis resulting in a three‑month coma, loss of child custody, multiple divorces, physical abuse by a spouse, the death of a fiancé who was struck by a car while in a wheelchair, lack of family contact, and a past suicide attempt by Valium overdose. Additional documentation noted a history of rape by a brother at age eight and prior placement under direct supervision and 15‑minute checks related to suicidal ideation. Despite these documented traumatic events and behavioral health concerns, the resident’s care plans did not identify a history of physical trauma, sexual trauma, homelessness, substance abuse, medical trauma, or attempted suicide. For this same resident, the MDS showed no cognitive deficit and identified behaviors such as verbal aggression and rejection of care, along with diagnoses including seizure disorder, depression, chronic pain syndrome, homelessness, and anxiety disorder. Multiple care plans addressed behaviors such as drug‑seeking, pretending to have seizures for attention or medication, making false allegations, verbal aggression when unable to smoke, and a desire for intimate relationships with consenting male residents. These care plans referenced goals such as effective coping skills, seeking staff support, and compliance with the smoking policy, and they called for identification and reduction of behavioral triggers. However, none of these care plans actually listed any specific triggers. The care plan addressing the resident’s right to consensual intimate relationships focused on assessment and education regarding consent but did not integrate the resident’s extensive trauma history. Staff interviews indicated the resident had displayed sexual behaviors since admission, including an incident where the resident expressed anger at another resident for not buying a soda after engaging in sexual acts. A second resident with a documented history of traumatic brain injury (TBI), dementia, seizure disorder, borderline personality disorder, anxiety, intermittent explosive disorder, tobacco use, and other behavioral/emotional disorders was also affected by the same deficiency. Social history and progress notes documented that this resident sustained a TBI after being hit by a semi‑truck while riding a bicycle at age 18, resulting in an 11‑month coma, followed by 13 years in a state hospital and subsequent residence in a group home. Additional documentation indicated the resident allegedly shot their father at age 26 after being sworn at and had a PASRR identifying TBI, intermittent explosive disorder, and borderline personality disorder, with a specific trigger of hearing the name of the current U.S. President. Progress notes also described inappropriate sexual behavior toward staff, including touching themselves intimately during personal care and refusing to stop when redirected. Despite this, the resident’s care plans, which addressed explosive disorder and history of altercations, risk for decreased psychosocial well‑being, and refusal to bathe or shower, did not list any specific behavioral triggers, did not reference the traumatic events such as being hit by a truck or shooting their father, and did not document the inappropriate sexual behavior. The Administrator and Social Service Director acknowledged that residents were to be screened for trauma and that trauma responses and PTSD should be added to care plans, but the specific trauma histories and triggers for these two residents were not incorporated into their plans of care.
Failure to Assess and Care Plan for Resident Suicidal Ideation
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess, investigate, and care plan for a resident’s suicidal ideation in accordance with its own policy and staff expectations. The resident had diagnoses including schizophrenia, cerebral edema, and hemiparesis/hemiplegia following a cerebral infarction, and a current MDS showed mild cognitive impairment (BIMS score 12). A progress note documented that the resident told the Social Services Director (SSD) he was feeling down and wanted to kill himself; the SSD offered assistance, activities, and initiated 15‑minute checks, and the note stated the care plan was updated. However, the note did not indicate that the SSD asked whether the resident had a plan to kill himself, and there were no additional notes regarding suicidal ideation or follow‑up. Review of the current care plan showed no problem, goal, or interventions addressing depression or suicidal ideation, and progress notes over the following month contained no documentation of physician notification related to the suicidal statement. Further record and interview evidence showed that the care plan conference summary did not document interventions for suicidal ideation, and the SSD acknowledged she did not normally ask residents expressing suicidal ideation if they had a plan. The SSD reported that the resident had admission paperwork mentioning suicidal ideation related to depression after a stroke and that the resident again vocalized suicidal ideation during a care plan meeting with his father, after which emotional support was offered and the father took the resident out on a leave of absence; no further visits or follow‑up were done. The DON stated that, upon notification of suicidal verbalization, staff should assess the resident, ask if there is a plan, remove potential means of self‑harm, immediately notify the psychiatric NP, and document the occurrence, and that a detailed progress note and updated care plan were expected but not present for this resident. The Administrator similarly stated that staff should ask about a plan, document interventions, notify the physician and family, and update the care plan, and indicated the resident should have had a care plan addressing depression with suicidal ideation. The facility’s written policy required immediate notification of the DON, SSD, and physician, an interview including asking about a plan and assessing mood and means for self‑harm, and thorough documentation of mood, behavior, and all actions taken, which were not reflected in the resident’s record.
Incomplete and Inaccurate Documentation of Suicidal Ideation and Follow-Up
Penalty
Summary
The facility failed to ensure accurate, complete, and timely documentation of assessments and services for a resident who verbalized suicidal ideation. Resident 6, who had schizophrenia, cerebral edema, and right-sided hemiparesis/hemiplegia following a cerebral infarction, had a BIMS score of 12 indicating mild cognitive impairment. The resident’s admission paperwork mentioned suicidal ideation related to depression after a stroke, and a Social Services note on 3/11/2026 documented that the resident was feeling down and said he wanted to kill himself. The Social Services Director (SSD) documented that she talked with the resident, coordinated with Activities, advised the resident to contact SSD or nursing if he wanted to talk, and that the resident was scheduled for 15-minute checks and the care plan was updated. However, the current care plan initiated on 2/26/2026 did not address depression or suicidal ideation. Multiple Social Services progress notes were later entered as late entries in April, with effective dates in March, stating that the resident had no plan and no longer had suicidal ideation, that he felt much better after 1:1 time, and that he continued his daily routine and therapy. These late entries described follow-up visits and reassessments of suicidal ideation on several consecutive days, but in interviews the SSD stated she did not normally ask residents about having a plan when they verbalized suicidal ideation and did not recall any other occurrences beyond the initial event. She further indicated she did not personally provide individual follow-up visits with this resident regarding suicidal ideation, despite the late-entry notes describing such visits. The DON acknowledged that late entries had been added to address concern about suicidal verbalization, and the Administrator stated that upon suicidal statements staff should ask about a plan, notify the physician and family, and update the care plan, and that this resident should have had a care plan addressing depression with suicidal ideation. The facility’s documentation policy required factual, first-hand, timely documentation, which was not followed in this case.
Failure to Complete Required Self-Administration Assessment for Inhaler Kept at Bedside
Penalty
Summary
Surveyors identified that a resident was allowed to keep and access an Albuterol inhaler without the facility completing the required self-administration medication assessment. During an initial tour, the resident was observed sitting in a wheelchair with a handheld Albuterol inhaler on the overbed table and no staff present in the room or hallway. On a subsequent observation, the resident again was in a wheelchair and reported that the Albuterol inhaler was stored in the top drawer of the nightstand, where it was found. Review of the clinical record showed an admission MDS indicating no cognitive impairment, but there was no documentation of a self-medication administration assessment. In an interview, the DON confirmed that the resident did not have the required self-medication assessment, despite the facility’s policy stating that staff and the practitioner must assess each resident’s mental and physical abilities to determine whether self-administering medications is clinically appropriate. This failure to complete and document a self-administration medication assessment for a resident who had an Albuterol inhaler kept at bedside constituted noncompliance with the facility’s own policy and with 410 IAC 16.2-3.1-11(a).
Inaccurate PBJ Staffing Data Submission to CMS
Penalty
Summary
The deficiency involves the facility’s failure to electronically submit complete and accurate direct care staffing information to CMS through the Payroll-Based Journal (PBJ) system for 22 days in a fiscal quarter. A CASPER report review on 4/6/26 showed that, according to PBJ data, the facility did not have licensed nursing coverage 24 hours per day on multiple specific dates across three months, had low weekend staffing, and held a 1-star staffing rating. However, review of the facility’s internal staffing sheets for that quarter indicated the facility was fully staffed and had licensed nurse coverage on all of the dates in question. During an interview, the Administrator stated that the PBJ information must have contained data entry errors, as she had verified licensed staff coverage on the timesheets. The facility’s PBJ policy in effect stated that all staffing data entered into the PBJ system would be auditable and verifiable through payroll, invoices, or contracts, but the submitted PBJ data did not accurately reflect the facility’s actual licensed nurse staffing as documented on internal records. No specific residents or clinical conditions were mentioned in the report, and the deficiency centers solely on inaccurate staffing data submission rather than direct resident care events.
Failure to Provide and Document Required Transfer/Discharge and Bed-Hold Notices
Penalty
Summary
The deficiency involves the facility’s failure to provide and document required written notices of transfer/discharge and bed-hold policies, as well as required information to receiving providers, for four residents who were transferred or discharged to the hospital. For a resident with generalized anxiety disorder, major depressive disorder, and dementia, progress notes showed that the resident was sent to the hospital via 911 for chest pain, lower back pain, and shortness of breath and later returned to the facility, but the clinical record lacked documentation that a written Notice of Transfer/Discharge and the bed-hold policy were provided to the resident or representative, and lacked documentation that required information was conveyed to the receiving facility. The ADON and the Administrator both confirmed there was no documentation that these written notices were provided. For a resident with congestive heart failure and muscle weakness who was sent to the emergency room for painful urination and bloody urine, the clinical record lacked documentation that a Notice of Transfer/Discharge or bed-hold policy was given to the resident or representative, which the DON confirmed. Another resident with chronic respiratory failure and diabetes was discharged to the hospital for respiratory failure, and a resident with chronic kidney disease and dementia was discharged to the hospital, but in both cases there was no documentation that a written notice of transfer/discharge or bed-hold policy was provided to the residents or their representatives. Review of the facility’s Transfer and Discharge policy, dated 1/15/26, showed that the policy required the facility to provide written transfer/discharge notices and bed-hold information to residents and representatives and to provide specified information to receiving providers, but the records for these four residents did not contain the required documentation.
Failure to Document Target Behaviors and Non-Pharmacological Interventions Before Initiating Antipsychotic
Penalty
Summary
The deficiency involves the facility’s failure to document how a resident’s behaviors presented danger or distress to self or others, and failure to document non-pharmacological interventions attempted prior to initiating an antipsychotic medication. Resident 6 had documented diagnoses of Alzheimer’s disease, depression, and severe cognitive impairment, and was receiving sertraline for depression. A PASSAR identified only depression and dementia, and the admission MDS listed Alzheimer’s disease and depression as active diagnoses. Over several months, nursing progress notes documented that the resident intermittently reported unusual perceptions, such as believing there were men causing trouble, a man in her room, or a man wanting to marry her and yelling through the walls, but there was no documentation that these episodes caused danger to the resident or others or that they resulted in unmanageable distress. From late April through mid-July, nursing notes primarily described the resident’s frequent refusals of evening and morning medications, blood sugar checks, blood pressure checks, insulin administration, hygiene care, and showers. Staff documented that the resident sometimes yelled at staff, said “Get out!”, was visibly upset by a room move, was leery of staff and asked to see name badges, and became upset about a pillow under her head until it was removed, after which she calmed down. The notes also recorded instances where the resident believed housekeeping had not cleaned her room or that she had not received medications when she had. However, there were no progress notes or assessments indicating that these behaviors were evaluated as dangerous, non-redirectable, or causing significant distress or functional impairment, and no detailed behavior monitoring logs were present as required by facility policy. On a psychiatric NP visit for initial psychotropic medication management, new mental health diagnoses of schizoaffective disorder, borderline personality disorder, and delusional disorder were added, and Seroquel 25 mg, an antipsychotic, was ordered. The clinical record did not contain a comprehensive evaluation to support these new diagnoses, and there was no documentation of target behaviors meeting the facility’s policy criteria for psychotropic use, such as behaviors representing danger to self or others, causing distress and impairment in functional abilities, or clearly attributable to psychosis or mania. The resident’s representative reported that the resident had no prior history of mental health disorders or psychiatric hospitalization and was unaware of the new diagnoses. The facility’s own psychotropic medication policy required identification and documentation of specific target behaviors, use and documentation of nonpharmacological interventions, and ongoing monitoring of behaviors and interventions, which were not reflected in the record for this resident.
Failure to Update PASARR Screens for New Mental Health Diagnoses and Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that Preadmission Screening and Resident Review (PASARR) Level I screenings were accurate and updated when new mental health diagnoses and psychoactive medications were initiated for multiple residents. For one resident with dementia, anxiety, depression, and post-traumatic stress disorder (PTSD), the PASARR completed on admission listed anxiety, depression, and dementia with sertraline and quetiapine, but did not include the PTSD diagnosis or the antidepressant Pristiq, despite the admission MDS and care plan documenting PTSD and a subsequent physician’s order for Pristiq. For another resident with Alzheimer’s disease, borderline personality disorder, delusional disorder, schizoaffective disorder, and depression, the PASARR only reflected depression and dementia with sertraline, even though additional mental health diagnoses were added later and an antipsychotic (quetiapine) was ordered for borderline personality disorder, and the quarterly MDS documented psychotic disorder, schizophrenia, and depression with antipsychotic and antidepressant use. A third resident had diagnoses including Alzheimer’s disease, depression, anxiety disorder, irritability and anger, and nonrheumatic aortic valve stenosis. The PASARR for this resident listed dementia and anxiety with Risperdal but omitted the diagnosis of depression and the medications escitalopram and lorazepam, although physician’s orders were in place for escitalopram for depression and lorazepam for anxiety, and the admission MDS documented depression with antianxiety and antidepressant use. Interviews with the Assistant Director of Nursing confirmed that new Level I PASARR screens should have been completed when new mental health diagnoses and psychoactive medications were added, and that the PASARR for one resident, completed prior to arrival, should have included all mental health diagnoses and medications. The facility’s own policy required notification of the state mental health authority within 14 days after a significant change in mental condition and specified that a new Level I screen is required for new mental health diagnoses or newly prescribed psychotropic medications, which was not followed in these cases.
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