Brickyard Healthcare - Muncie Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Muncie, Indiana.
- Location
- 2701 Lyn-mar Dr, Muncie, Indiana 47304
- CMS Provider Number
- 155687
- Inspections on file
- 36
- Latest survey
- January 28, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Brickyard Healthcare - Muncie Care Center during CMS and state inspections, most recent first.
A cognitively impaired resident with a history of wandering and behavioral issues was physically assaulted by another cognitively impaired resident known to be paranoid and aggressive toward others. Earlier that day, staff had observed verbal conflict and agitation between the two residents related to one resident’s fear that others were entering his room. Later in the evening, while staff were assisting other residents after a meal, yelling was heard and staff found one resident on the floor in a fetal position while the aggressive resident was cursing, kicking, and stomping on his head, back, and ribs. The victim sustained a forehead hematoma, facial abrasion, and red areas on his back, and reported pain, while the aggressor continued to attempt to hit and kick staff when they intervened.
A resident with a court-appointed legal health care representative was admitted with multiple diagnoses, including schizoaffective disorder and cirrhosis. Despite staff being aware that the resident's daughter was not the authorized representative, she was asked to sign medical consent forms while the legal representative was unavailable, resulting in consents being signed by an unauthorized individual.
A resident with a history of hypertension and recent stroke experienced multiple episodes of significantly elevated blood pressure over a month, but the physician was not notified as required. Nursing staff interviews revealed inconsistent practices and lack of a clear protocol for physician notification, despite facility policy mandating prompt notification for changes requiring intervention.
A CNA failed to follow proper infection control procedures during catheter care for a resident with an indwelling catheter, including not wearing a required gown, not performing hand hygiene between glove changes, and using contaminated gloves to handle both clean and soiled items. The resident had a history of urinary tract issues and required enhanced barrier precautions, but facility protocols were not followed during the observed care.
A resident with multiple chronic conditions experienced significant weight loss while on a carbohydrate-controlled diet. Despite repeated recommendations from the IDT to discontinue the carbohydrate control portion of the diet and notify the physician, there was no documentation of physician notification or diet change. The DON was unaware of the recommendations due to reliance on incomplete reports, and the facility's policy requiring physician notification for significant weight changes was not followed.
A resident with severe cognitive impairment and a feeding tube did not receive care according to facility policy when an LPN failed to check tube placement before flushing and did not maintain proper hand hygiene or glove changes during site care. Supplies were placed on an unprotected surface, and contaminated gloves were used to handle multiple items and apply ointments, resulting in breaches of infection control protocols.
A resident with chronic respiratory conditions was repeatedly given oxygen at a higher flow rate than ordered, and the humidification bottle was left empty despite orders for regular changes. Nursing staff did not notify the physician when the resident's oxygen needs changed, and documentation of these changes was lacking, contrary to facility policy and physician orders.
A resident with dementia and multiple mental health diagnoses was maintained on several psychoactive medications, despite documentation showing that most behavioral events were effectively managed with non-chemical interventions. The care plans were not updated to reflect these successful approaches or to identify resolved behavioral issues, and lacked assessment of behavior triggers and personalized interventions. Staff interviews confirmed the resident responded well to individualized, non-pharmacological strategies, but the facility did not consistently implement or document these in the care plan.
Surveyors found that shift-to-shift narcotic reconciliation was not consistently completed for five medication carts, with numerous missing signatures on Controlled Drugs-Count Records across multiple units and shifts. Interviews with nursing staff and the DON confirmed that the facility's policy requires two licensed nurses to verify and sign off on narcotic counts at each shift change, but this was not consistently documented as required.
Surveyors found that insulin vials and pen-injectors on a medication cart were not properly labeled with opening dates or resident information, and some were not discarded after expiration. An LPN confirmed that these items should have been labeled and disposed of according to facility policy and manufacturer recommendations, but this was not done.
A resident with chronic respiratory conditions and a history of Pneumovax 23 vaccination declined the Pneumococcal vaccine upon admission after receiving education. The facility did not re-offer the vaccine at later eligible intervals, as confirmed by interviews with the Infection Preventionist and DON, despite policy and CDC guidance requiring ongoing vaccine offerings and education.
A resident with chronic respiratory conditions, who was cognitively intact, declined the COVID-19 vaccine upon admission after receiving education. The facility did not re-offer the vaccine or provide updated education in accordance with CDC guidance, as confirmed by staff interviews and a review of the clinical record.
A facility failed to follow physician-ordered parameters for medication administration for a resident with heart failure and hypertension. Metoprolol was held without documented reason despite being within parameters, and hydralazine was administered when SBP was below the threshold. The DON confirmed medications should be administered per orders, and the facility's policy requires holding medications if vital signs fall outside prescribed parameters.
The facility failed to designate a qualified Infection Preventionist, as the ADON acted in the role without certification until recently, and the certified RN 13 had not been involved since early in the year. This deficiency potentially affected all 98 residents.
The facility failed to implement proper infection control practices for three residents, leading to deficiencies in contact isolation, enhanced barrier precautions, and diagnostic testing. An LPN entered rooms without wearing required gowns, and a resident with loose stools was not placed in contact isolation while awaiting C. diff test results. These lapses highlighted significant issues in infection control protocols.
The facility failed to implement its antibiotic stewardship program, affecting all 98 residents. The Infection Control Surveillance Binder for May and June 2024 lacked necessary documentation, such as resident names, infection types, and treatment criteria. The ADON, responsible for infection prevention, did not complete or review forms and did not confirm appropriate antibiotic use, contrary to the facility's policy.
Two residents with urinary catheters experienced inconsistent management of their urinary drainage devices, with bags not being emptied regularly, leading to overfilling and leakage. Observations and interviews revealed that staff failed to adhere to the facility's policy of emptying bags when half-full or every 3 to 6 hours, resulting in deficiencies in care.
The facility failed to complete Significant Change MDS assessments within 14 days for two residents admitted to hospice services. One resident with COPD and another with Alzheimer's Disease did not receive the required assessments following their hospice admissions. The MDS Coordinator acknowledged the oversight, noting the use of the RAI manual for guidance.
A facility failed to complete Quarterly MDS assessments on time for a resident with heart failure, paranoid schizophrenia, bipolar disorder, and anxiety disorder. The assessments were completed 15 days and one day late, respectively. The MDS Coordinator, new to the role, acknowledged the delays, which were not in compliance with the RAI manual's requirement for completion within 14 days after the ARD.
A facility failed to submit a resident's MDS assessment on time. The resident, with conditions like heart failure and schizophrenia, had a Quarterly MDS assessment completed on time but lacked a transmission date. The MDS Coordinator was unaware of the issue, suspecting a program error, and planned to consult for guidance. The RAI manual requires submission within 14 days of completion.
A resident with ESRD and heart failure on a fluid restriction was not properly monitored for fluid intake, despite physician orders and care plans. Observations showed excess fluids at the bedside, and staff interviews revealed a lack of awareness and documentation. The facility's policy on fluid restriction was not adhered to, leading to a deficiency in care.
Failure to Prevent Resident‑to‑Resident Physical Abuse Involving Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively impaired resident who wandered from resident‑to‑resident physical abuse by another resident known to be aggressive. Resident C had documented diagnoses of moderate vascular dementia with agitation, severe dementia with agitation, anxiety, and mood disorder, and was care planned as having the potential to be aggressive, with behaviors including arguing with other residents, verbal aggression, yelling, name calling, and physical aggression when he believed others were somewhere they should not be. His care plan identified that he could become agitated and aggressive if he thought other residents were near or entering his room, and interventions included one‑on‑one supervision while awake and 15‑minute checks while asleep, as well as early intervention and removal from distressing situations. Progress notes shortly before the incident documented that Resident C was very paranoid and aggressive during a psychiatric visit and that he remained preoccupied and worried about a particular male resident going into his room. Resident B, the victim of the abuse, had severe vascular dementia with agitation, major depressive disorder, difficulty walking, and lower back pain, and was assessed as severely cognitively impaired with wandering behavior and a need for supervision while walking. His care plans documented wandering and elopement risk, including wandering into other residents’ rooms, and multiple behavior problems such as physical and verbal aggression, putting himself on the floor, wandering around the unit, cursing staff, and throwing items. He was on 15‑minute checks and had a history of wandering into other residents’ rooms, including an incident where he wandered into another resident’s room to urinate. On the day of the altercation, earlier in the morning, Resident B and Resident C had a “cursing match” when Resident B was close to the room of another male resident, and Resident C became agitated, believing another resident was in his room. Staff redirected both residents, and no physical contact occurred at that time. Later that same day, after mealtime, Resident B and Resident C were in or near the dining room while staff were assisting other residents to their rooms. Staff then heard yelling or a commotion from the dining area or hallway. When staff entered the hallway, they observed Resident B on the floor in a fetal position with his hands over his head, and Resident C standing over him, cursing, kicking, and stomping on Resident B’s back, sides, ribs, and head. Multiple staff witnesses consistently described Resident C as stomping and kicking Resident B in the head and rib area, with Resident B grabbing his ribs. Resident B sustained a hematoma to the right forehead, an abrasion to the left side of his face, red areas on his back, and reported generalized pain rated five out of ten. The beginning of the altercation was unwitnessed. The DON later stated that Resident C was abusive to Resident B by stomping and hitting him and that the facility should have prevented the resident‑to‑resident abuse. The Administrator acknowledged that the facility had knowledge of agitation between Resident B and Resident C earlier in the day prior to the physical assault.
Failure to Obtain Proper Medical Consents from Legal Health Care Representative
Penalty
Summary
The facility failed to ensure that the designated legal health care representative signed medical consent forms for a resident who had been declared legally incompetent. The resident, who had diagnoses including schizoaffective disorder, bipolar disorder, and cirrhosis of the liver, was admitted with a court order appointing a non-family member as the legal health care representative with full authority to make health care decisions. Despite this, the resident's daughter, who was not the legal health care representative, signed multiple consent forms, including mental health consent, psychotropic medication informed consent, and a POST form, after informing staff she was not the authorized representative. Facility staff were aware that the legal health care representative was unavailable due to being on vacation and made attempts to contact him, including leaving a voicemail and speaking with his appointed contact person. However, the necessary consent forms were not sent to the legal health care representative by email, and the daughter was asked to sign the forms in the interim. The facility did not obtain the required signatures from the court-appointed representative prior to executing medical consents.
Failure to Notify Physician of Elevated Blood Pressures
Penalty
Summary
The facility failed to notify the physician of multiple instances of elevated blood pressure readings for a resident with a history of malignant neoplasms and essential hypertension. The resident was prescribed several antihypertensive medications and had a recent hospital admission for a stroke. Blood pressure readings documented over a one-month period showed several significantly elevated values, including readings as high as 222/138 mmHg. Despite these abnormal findings, there was no documentation in the clinical record that the physician had been notified of these elevated blood pressures. Interviews with nursing staff revealed inconsistency and lack of clarity regarding when to notify the physician about abnormal blood pressure readings. One LPN stated there was no standard protocol for physician notification, while another indicated she would notify the physician for blood pressures over 140, although there was no specific order for this. The DON confirmed there was no standing protocol for physician notification of abnormal vital signs unless directly ordered by the physician, but acknowledged that the physician should have been notified for blood pressures outside the resident's baseline. The facility's policy required prompt physician notification for changes requiring intervention or alteration of treatment, but this was not followed in the resident's case.
Failure to Follow Proper Catheter Care and Infection Control Procedures
Penalty
Summary
A certified nursing assistant (CNA) failed to provide catheter care in a manner that reduced the risk of contamination for a resident with an indwelling catheter. During the observed care, the CNA donned gloves but did not wear a gown as required for enhanced barrier precautions. After emptying the resident's catheter bag and removing gloves, the CNA did not perform hand hygiene before donning a new pair of gloves, which were taken from her pocket. Throughout the catheter care process, the CNA repeatedly used the same pair of gloves to touch various contaminated surfaces, including the resident's clothing, walker, soiled brief, trash can, and privacy curtain, before and during the cleaning of the resident's genitalia and catheter tubing. The CNA also handled clean supplies and applied a new brief with the same contaminated gloves, only removing them and performing hand hygiene at the end of the procedure. The resident involved had a history of malignant neoplasm of the prostate, benign prostatic hyperplasia with urinary tract symptoms, a history of urinary tract infections, and schizophrenia. Physician orders required regular catheter care and monitoring for signs and symptoms of urinary tract infection. Facility policy and signage indicated that both gown and gloves were required for all interactions with residents on enhanced barrier precautions, especially those with indwelling medical devices. The CNA was unsure about the need for hand hygiene after glove removal and acknowledged forgetting to don a gown, which was confirmed as a requirement by the facility's infection preventionist.
Failure to Notify Physician and Implement Dietitian Recommendations for Significant Weight Loss
Penalty
Summary
The facility failed to follow Registered Dietitian recommendations and notify the physician regarding a resident who experienced significant weight loss. The resident, who had diagnoses including essential hypertension, morbid obesity, and type 2 diabetes, was on a carbohydrate-controlled diet and had a documented 7% weight loss in 30 days. Despite multiple Interdisciplinary Team (IDT) Nutrition At Risk (NAR) notes recommending discontinuation of the carbohydrate control portion of the diet to improve intake, there was no documentation that the physician was notified of the significant weight loss or that the diet was changed as recommended. The resident's weight continued to decline over several months, and the care plan and orders were not updated to reflect the recommendations. Interviews with staff revealed that the Director of Nursing (DON) was unaware of the IDT NAR notes in the electronic medical record and relied solely on emailed reports from the Registered Dietitian, which did not include this resident. The DON acknowledged that physician notification should have occurred and that the NAR program was ineffective if recommendations were not communicated. The facility's policy required physician notification for significant changes in weight or nutritional status, but this was not documented in the resident's clinical record.
Failure to Follow Feeding Tube Placement and Infection Control Protocols
Penalty
Summary
A deficiency was identified when a nurse failed to follow proper procedures during feeding tube site care for a resident with a history of hemiplegia, dysphagia, and malnutrition. The resident, who had severe cognitive impairment and required assistance with all activities of daily living, had orders for checking tube placement prior to medication administration, flushing the tube with water every shift, and maintaining the site with a split drain sponge and antibiotic ointment. During an observed care episode, the LPN performed hand hygiene and donned PPE before entering the room, but placed care supplies on an unprotected chair instead of a clean barrier. The nurse did not check the feeding tube placement before flushing it, as required by facility policy and physician orders. Additionally, after removing the old dressing, the nurse failed to perform hand hygiene or change gloves before handling supplies, touching the resident's drawer, and applying ointments to the feeding tube site, resulting in multiple breaches of infection control protocol. Interviews with the LPN and the DON confirmed that the nurse did not follow required procedures for verifying tube placement and maintaining hand hygiene and glove changes after contact with potentially contaminated surfaces. Facility policies specified the need for clean technique, use of barriers, and hand hygiene at specific steps, all of which were not followed during the observed care, placing the resident at risk for infection.
Failure to Follow Physician Orders for Oxygen Therapy and Humidification
Penalty
Summary
Facility staff failed to follow physician orders regarding oxygen therapy for a resident with chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia and hypercapnia, and dependence on supplemental oxygen. The resident was observed multiple times with oxygen administered at five liters per minute via nasal cannula, despite a physician order specifying four liters per minute. The resident was cognitively intact and dependent on staff for most activities of daily living, and there was no evidence that she or her family adjusted the oxygen flow rate. Additionally, the humidity bottle attached to the oxygen concentrator was repeatedly found empty and not changed as required by physician order and facility policy, which called for weekly changes and as-needed replacement every shift. Nursing documentation indicated that the resident experienced a drop in oxygen saturation to 87 percent, prompting an increase in oxygen flow to five liters per minute and administration of an inhaler. However, there was no documentation that the physician was notified of this change in respiratory status or the adjustment in oxygen flow rate, as required by both physician order and facility policy. Staff interviews confirmed that the oxygen flow rate and humidification were not maintained per orders, and the physician was not notified of the changes. The facility's policy required oxygen to be administered according to physician orders and for staff to notify the physician of any changes in the resident's condition or oxygen administration.
Failure to Provide Individualized Dementia Interventions and Update Care Plans
Penalty
Summary
The facility failed to provide individualized interventions for dementia care to reduce or eliminate the need for psychoactive medications for a resident diagnosed with dementia and other mental health conditions. The resident had multiple diagnoses, including dementia with agitation, diabetes mellitus, insomnia, major depressive disorder, generalized anxiety disorder, and delusional disorder. The resident was prescribed several psychoactive medications, including antipsychotics, antidepressants, and anti-anxiety medications. Despite the use of these medications, the resident continued to display behavioral symptoms such as aggression, resistance to care, and agitation. Over a five-month period, documentation showed that the majority of the resident's behavioral events were successfully managed with non-chemical interventions, such as redirection, snacks, changing caregivers, and removing the resident from overstimulating environments. However, the care plans for the resident were not updated to reflect these effective non-pharmacological approaches, nor were resolved behavioral issues identified as such. The care plans also lacked new or personalized interventions, and there was no assessment of possible triggers for the resident's behaviors. Many care plan problems had not been updated for extended periods, and no new approaches were added despite changes in the resident's behavior and the effectiveness of non-chemical interventions. Interviews with staff confirmed that the resident responded well to individualized, non-pharmacological interventions, such as conversation, snacks, movies, and switching caregivers. Staff also noted that the resident did not experience hallucinations or delusions during the assessment period, and that most behaviors were typical of dementia. Despite this, the facility continued to justify the ongoing use of psychoactive medications without updating the care plan to reflect the resident's current needs and effective interventions. The facility's policy required person-centered, individualized care, but this was not consistently implemented for the resident in question.
Failure to Complete Shift-to-Shift Narcotic Reconciliation for Multiple Medication Carts
Penalty
Summary
The facility failed to ensure that shift-to-shift narcotic reconciliation was consistently completed for five out of six medication carts reviewed. During medication storage observations and record reviews, surveyors identified multiple instances across several units where the Controlled Drugs-Count Record lacked required signatures for shift-to-shift reconciliation of controlled substances. These omissions were noted on various dates and shifts, including day, evening, and night shifts, spanning several months and affecting the C Unit 1 and 2 hall carts, Advanced Acute Care Unit (AACU) cart, and both the short and long hall carts in the Acute Care Unit (ACU). Interviews with nursing staff and the Director of Nursing (DON) confirmed that the facility's expectation and policy require two licensed nurses to complete and sign the narcotic count at the start of each shift and during the exchange of keys. This process is intended to verify the accuracy of the controlled substance inventory and prevent drug diversion. However, the review of the Controlled Drugs-Count Records revealed numerous dates where this process was not documented as completed, indicating a failure to follow established procedures. The facility's policy, provided by the DON, outlines the requirement for clear, legible documentation of all controlled substances and mandates that two licensed nurses account for all controlled substances and access keys at the end of each shift. Despite this policy, the observed and documented lapses in shift-to-shift reconciliation demonstrate noncompliance with both facility policy and regulatory requirements for controlled substance accountability.
Failure to Label and Discard Insulin per Policy and Manufacturer Guidelines
Penalty
Summary
Surveyors observed that the facility failed to ensure proper labeling and timely disposal of insulin medications on one of three medication carts reviewed. During an inspection of the ACU Medcart with an LPN, several insulin products were found to be either undated, unlabeled, or not discarded after expiration. Specifically, a Lantus vial for a resident was opened and dated, but not discarded after the 28-day expiration period. Additionally, a Humalog vial and a Dulaglutide pen-injector for two other residents were found opened but undated, and an Insulin NPH pen-injector was opened and unlabeled. The LPN confirmed that insulin should be labeled with the date opened and discarded after 30 days, and that these items did not meet those requirements. Manufacturer recommendations for both Lantus and Humalog indicate that opened vials should be stored at room temperature or refrigerated for up to 28 days. The facility's own policy requires insulin pens to be clearly labeled with specific information, including the date dispensed and expiration date, and mandates disposal after 28 days or per manufacturer guidelines. The observed deficiencies were in direct violation of both manufacturer instructions and facility policy, as insulin products were not properly labeled or discarded in a timely manner.
Failure to Re-Offer and Educate on Pneumococcal Vaccination per CDC Guidance
Penalty
Summary
The facility failed to offer and educate a resident regarding Pneumococcal vaccines in accordance with CDC guidance. The resident, who had diagnoses including chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia and hypercapnia, and was dependent on supplemental oxygen, had previously received a Pneumovax 23 vaccine prior to admission. Upon admission, the resident was cognitively intact and received education about the vaccine, subsequently declining it. However, the clinical record did not show that the vaccine was offered again after the initial refusal, despite CDC recommendations for re-offering at appropriate intervals. Interviews with the Infection Preventionist and the DON confirmed that residents who refused the Pneumococcal vaccine on admission were not re-offered the vaccine when they became eligible for subsequent doses. The facility's policy stated that immunizations would follow current CDC guidance and be offered as per federal, state, and local requirements, but the practice did not align with this policy, resulting in a failure to ensure ongoing vaccine offerings and education for the resident.
Failure to Re-offer COVID-19 Vaccine and Provide Ongoing Education
Penalty
Summary
The facility failed to provide ongoing education and offer COVID-19 vaccination to a resident in accordance with CDC guidance. The resident, who had diagnoses including chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia and hypercapnia, and was dependent on supplemental oxygen, was cognitively intact at the time of assessment. Upon admission, the resident declined the COVID-19 vaccine after receiving education, with documentation indicating that the resident could change their mind and receive the vaccine at a later time with updated education. However, the clinical record did not show any further offerings of the COVID-19 vaccine to the resident after the initial declination in 2023. Interviews with the Infection Preventionist and the DON confirmed that residents who refused the vaccine on admission were not subsequently re-offered the vaccine when eligible for additional doses, contrary to CDC guidance and the facility's own immunization policy.
Failure to Follow Physician-Ordered Medication Parameters
Penalty
Summary
The facility failed to adhere to physician-ordered parameters for medication administration for a resident with a history of heart failure, hypertension, constipation, dementia, and schizoaffective disorder. The resident was prescribed metoprolol succinate extended release to be administered in the evening, with instructions to hold the medication if the systolic blood pressure (SBP) was below 100 or the heart rate (HR) was less than 60 beats per minute (BPM). On one occasion, the resident's SBP was 110 and HR was 62 BPM, yet the medication was held without documentation of the reason. Additionally, the resident was prescribed hydralazine hydrochloride with instructions to hold the medication if the SBP was below 110 or HR was below 60 BPM. Despite these parameters, the medication was administered on multiple occasions when the SBP was below the threshold, and there was no documentation indicating the medication was held. The Director of Nursing (DON) confirmed that medications should be administered or held according to physician orders and within the prescribed parameters. The facility's policy on medication administration requires obtaining and recording vital signs and holding medications if vital signs fall outside the physician's prescribed parameters. The deficiency was identified during a review of the resident's closed clinical record and was related to complaints IN00451394 and IN00451774.
Failure to Designate Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified Infection Preventionist to oversee the infection prevention and control program, as required. During the survey, it was found that the facility did not have a certified Infection Preventionist for two of the five days of the survey and had not had one since February 5, 2024. The Administrator initially indicated that RN 12 was the Infection Preventionist, but it was later revealed that the Assistant Director of Nursing (ADON) had been acting in that role since January 2024 without the necessary certification until July 10, 2024. Further interviews revealed that RN 13, who was certified, had not been actively involved in the infection control program since February 5, 2024, despite being expected to train and consult for the program. The facility's policy required the Infection Preventionist to have completed specialized training, which the ADON only completed during the survey. This lack of a qualified Infection Preventionist had the potential to affect all 98 residents in the facility.
Infection Control Deficiencies in Isolation and Precautions
Penalty
Summary
The facility failed to implement and utilize proper infection prevention and control practices for three residents, leading to deficiencies in contact isolation, enhanced barrier precautions (EBP), and diagnostic testing. Resident B was observed with both an EBP sign and a contact isolation sign on their door, yet an LPN entered the room without wearing a gown, despite the requirement for gown and gloves for all interactions. Resident B had a diagnosis of MRSA and was on antibiotic treatment, necessitating strict adherence to contact isolation protocols. Similarly, Resident C was in an EBP room, and an LPN was observed handling the resident's urinary drainage bag without wearing a gown, contrary to the physician's order for gown and gloves during all interactions. Resident C had diagnoses that included obstructive and reflux uropathy and required enhanced precautions due to the presence of an indwelling catheter and bowel incontinence. Resident 99, who was experiencing loose stools potentially due to antibiotic use, was not placed in contact isolation while awaiting C. diff test results. The clinical record lacked documentation of the stool specimen collection, and the resident was not restricted to her room, increasing the risk of infection spread. The facility's failure to collect the specimen and notify the physician of the oversight, along with the lack of appropriate isolation measures, highlighted significant lapses in infection control practices.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program as per its policy, which had the potential to affect all 98 residents. A review of the Infection Control Surveillance Binder for May and June 2024 revealed deficiencies in documentation and monitoring. In June, the binder noted 19 infections with 19 residents receiving antibiotics, but lacked details such as resident names, infection types, and criteria for treatment. Similarly, in May, the binder recorded 18 infections with 18 residents receiving antibiotics, but the documentation was incomplete, missing information on symptoms, infection types, and whether the criteria for antibiotic treatment were met. The Assistant Director of Nursing (ADON), who served as the facility's infection preventionist, admitted during an interview that she did not complete or review the necessary forms herself. She relied on unit managers to fill out the Revised McGeer Criteria for Infection Surveillance Checklist forms when an infection was suspected, but she did not receive any forms in June and did not follow up with the unit managers. Her role was limited to generating the monthly report, and she did not confirm the appropriateness of antibiotic usage. The facility's policy on the Antibiotic Stewardship Program outlined responsibilities for tracking antibiotic use and monitoring adherence to evidence-based criteria, which were not fulfilled.
Inconsistent Urinary Drainage Device Management
Penalty
Summary
The facility failed to provide consistent interventions for maintaining urinary drainage devices for two residents, identified as Residents B and C. Resident B, who had a urostomy due to obstructive uropathy and other medical conditions, was found to have his urinary drainage bag not emptied regularly, leading to it being excessively full on multiple occasions. Observations revealed that the bag was not emptied until it was completely full, with volumes reaching up to 3050 milliliters. Staff interviews confirmed that the aides were responsible for emptying the bags every shift, but this was not consistently done, as evidenced by the resident's reports and the observations made by the surveyors. Resident C, who had a suprapubic urinary catheter, also experienced similar issues with his urinary drainage bag not being emptied regularly. During an observation, it was noted that the bag had leaked onto the floor, and the resident reported that the staff allowed the bag to become very full before emptying it. The resident's clinical records indicated a lack of monitoring of the catheter output on several occasions, and the resident expressed concerns about the night shift not emptying the bag as required. The facility's policy on catheter care required that drainage bags be emptied when half-full or every 3 to 6 hours, but this was not adhered to in the cases of Residents B and C. Interviews with the Director of Nursing and other staff confirmed that the urinary drainage bags should have been emptied every shift and that any issues with leaking should be reported immediately. The failure to follow these protocols resulted in the deficiencies observed during the survey.
Failure to Complete Timely Significant Change MDS Assessments
Penalty
Summary
The facility failed to complete a Significant Change Minimum Data Set (MDS) assessment within 14 days of a determined status change for two residents. Resident 18, diagnosed with Chronic Obstructive Pulmonary Disorder (COPD), morbid obesity, and dependent on supplemental oxygen, was admitted to hospice services as per a physician's order. However, the facility did not complete a Significant Change MDS assessment following this change, instead conducting an annual MDS assessment, which was not appropriate for the status change. The MDS Coordinator, who started her position in April 2024, acknowledged the oversight and indicated that the Resident Assessment Instrument (RAI) manual was used for guidance. Similarly, Resident 203, with diagnoses including Alzheimer's Disease, protein-calorie malnutrition, and diastolic heart failure, was admitted to hospice services. The clinical record lacked a Significant Change assessment for this new hospice service. The MDS Coordinator confirmed that a Significant Change assessment was necessary following the new hospice order. Although an appropriate assessment was completed when the resident was removed from a previous hospice provider, the subsequent status change was not properly assessed. The RAI manual specifies that a Significant Change in Status Assessment must be completed within 14 days of a hospice election, which was not adhered to in these cases.
Failure to Timely Complete Quarterly MDS Assessments
Penalty
Summary
The facility failed to ensure the timely completion of Quarterly Minimum Data Set (MDS) assessments for a resident, as required every three months. Resident 65, who has diagnoses including heart failure, paranoid schizophrenia, bipolar disorder, and anxiety disorder, had two instances of late MDS assessments. The first assessment, with an Assessment Reference Date (ARD) of 12/13/23, was completed 15 days late on 1/11/24. The second assessment, with an ARD of 9/12/23, was completed one day late on 9/27/23. During an interview, the MDS Coordinator, who started her role in April 2024, acknowledged the late completion of these assessments. The current Resident Assessment Instrument (RAI) manual specifies that the Quarterly MDS completion date must be no later than 14 days after the ARD.
Failure to Transmit MDS Assessment Timely
Penalty
Summary
The facility failed to ensure the timely submission of Minimum Data Set (MDS) assessments for a resident reviewed for assessment submission. The resident, who had diagnoses including heart failure, paranoid schizophrenia, bipolar disorder, and anxiety disorder, had a Quarterly MDS assessment with an Assessment Reference Date (ARD) of May 6, 2024, which was completed on May 13, 2024. Although the assessment was completed on time, the record lacked a transmission date. During an interview, the MDS Coordinator indicated she was unaware that this assessment had not been transmitted and suggested it might be an error in the program, as the document was marked as not required for transmission. She planned to consult with her consultant for further direction. According to the current RAI manual, the Quarterly MDS submission date must be no later than the completion date plus 14 calendar days.
Failure to Monitor Fluid Intake for Dialysis Resident
Penalty
Summary
The facility failed to monitor the fluid intake of a resident with end-stage renal disease (ESRD) who was on a fluid restriction. The resident, who also had heart failure and was dependent on renal dialysis, had a physician's order for a 1500 ml fluid restriction, with specific allocations for dietary and nursing. Despite this, observations revealed multiple Styrofoam cups and soda cans at the resident's bedside, indicating a lack of adherence to the fluid restriction. The care plans in place highlighted the need for fluid restriction and monitoring, yet the electronic medical record lacked documentation of fluid intake amounts. Interviews with staff, including an LPN and the Director of Nursing (DON), revealed a lack of awareness and monitoring of the resident's fluid intake. The facility's policy on fluid restriction, which required recording fluid intake in accordance with physician orders, was not followed. The bedside report and point of care charting also failed to indicate the resident's fluid restriction, contributing to the deficiency in care.
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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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