Brickyard Healthcare - Terrace Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in La Porte, Indiana.
- Location
- 1900 Andrew Ave, La Porte, Indiana 46350
- CMS Provider Number
- 155136
- Inspections on file
- 38
- Latest survey
- December 2, 2025
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Brickyard Healthcare - Terrace Care Center during CMS and state inspections, most recent first.
A resident with multiple medical conditions and a high risk for falls experienced two falls in one day, yet the care plan was not updated with new interventions as required by facility policy. The ADNS confirmed that no additional fall prevention measures were implemented following these incidents.
A resident with severe cognitive and physical impairments, requiring total assistance with ADLs, had incomplete incontinence documentation, with logs filled out only once per day on several occasions instead of every two hours as required by facility protocol. Staff interviews confirmed the expectation for more frequent checks, but this was not reflected in the records.
Surveyors found that urinals, bedpans, and wash basins were improperly stored in shared bathrooms without required containment, and that an RN failed to change gloves between wound care tasks and after incontinence care for a resident with pressure ulcers. Additionally, another RN did not wear an isolation gown while administering IV medication to a resident on Enhanced Barrier Precautions, contrary to facility policy.
The facility failed to follow physician orders for medication administration, did not consistently monitor or document skin conditions, and did not implement specialist recommendations for several residents. Insulin and blood pressure medications were given outside of ordered parameters, skin issues and frequent diarrhea were not properly documented or treated, and specialist-ordered labs and monitoring were not completed as directed.
A resident with a history of significant weight loss and multiple complex medical conditions, including dysphagia and recent hospitalization, did not have food consumption logs completed for numerous meals as required. Despite the need for close monitoring, documentation was missing for several breakfasts, lunches, and dinners, as confirmed by the DON.
A resident with respiratory failure and COPD was observed receiving oxygen at 3.5 L/min via nasal cannula, despite a physician's order and care plan specifying 2 L/min continuously. The DON confirmed the oxygen should have been set at the lower rate, resulting in a failure to provide respiratory care as ordered.
Surveyors identified failures in medication storage and labeling, including an RN leaving a pre-filled saline syringe unsecured in a resident's room after a PICC line flush, an expired emergency drug kit found in a medication room refrigerator, and an expired vial of insulin on a medication cart. Staff interviews confirmed a lack of awareness and adherence to the facility's medication storage policy.
Two residents were found self-administering medications, including eye drops, an inhaler, and lidocaine patches, without the required physician's orders or assessments for self-administration. One resident was cognitively intact, while the other had severe cognitive impairment. Staff confirmed that neither resident had the necessary documentation to support self-administration, contrary to facility policy.
A resident who was dependent for ADLs and had a history of kidney failure, ileostomy, and falls was left in a soiled bed after her incontinence brief was improperly applied overnight. The resident was unable to get out of bed to eat breakfast as preferred, due to delays in wound care and lack of timely assistance from staff, despite her care plan indicating the need for substantial help with toileting, transfers, and morning routines.
Three residents did not receive prescribed IV antibiotics as ordered, with multiple missed doses and no documentation explaining the omissions. One resident also did not have wound treatments completed and signed out as ordered. The DON confirmed there was no documentation or explanation for the missed medications or treatments.
A resident, who was cognitively intact and not considered at risk for elopement, exited the facility using a door code she learned from her daughter. The staff failed to conduct a head count after an exit alarm sounded, assuming it was related to ambulance activity. The resident was later found off the property with abrasions and was taken to the ER. The facility's policy on elopements was not adequately followed, leading to this incident.
A facility failed to notify all covered individuals of their obligation to report suspected crimes, leading to a deficiency related to an allegation of sexual abuse involving a resident with impaired cognition. The resident reported feeling scared and confused after a male nurse allegedly made inappropriate comments. The dialysis nurse reported the incident to the Dialysis Facility Administrator, who unsuccessfully attempted to contact the facility's DON due to a full voicemail. The facility was unaware of the allegation until the surveyor's investigation, and no annual notifications were sent to covered individuals about reporting obligations.
A resident discharged with orders for IV antibiotics and PICC line care did not receive necessary post-discharge medical care due to incorrect discharge instructions and lack of follow-up by the facility. The resident, who had osteomyelitis, was advised to go to the ER after reporting the issue.
The facility failed to ensure that food and drink were palatable, attractive, and served at a safe and appetizing temperature. Residents reported issues with raw and burnt bacon, discolored eggs, and hard sausage patties. The Dietary Food Manager planned to conduct an inservice on cooking and preparing breakfast food.
The facility failed to prepare a pureed diet correctly. A cook was observed adding excessive thickener to a watery cabbage mixture and indicated the recipe would not make enough servings. The DON confirmed the dietary recipe should have been followed.
The facility failed to serve meals as scheduled, causing residents to become impatient. Observations showed significant delays in meal service in both the main dining room and the Memory Lane Unit. Residents also reported consistent delays in meal service during a Resident Council interview. The Administrator confirmed that the dietary staff was a contracted service and meals should have been served on time.
The facility failed to complete self-medication administration assessments for two residents who had medications at their bedside. One resident had a medication cup with a solution, and another had acetaminophen and pain-relieving cream. Both residents were cognitively intact, but there were no assessments or physician's orders for self-administration. The DON acknowledged the oversight.
The facility failed to provide adequate ADL assistance to a dependent resident, specifically in relation to nail care and the removal of facial hair. Despite the resident's care plan indicating an ADL self-care deficit and the need for partial to moderate assistance with personal hygiene, observations confirmed that the resident's nails were long and dirty, and he was unshaven. The DON acknowledged the issue and expected nursing staff to address it.
The facility failed to complete non-pressure skin treatments and ensure the use of TED hose for two residents with edema. One resident had missed applications of prescribed cream, and another was observed multiple times without TED hose, despite physician orders. Interviews revealed a lack of awareness among staff regarding the residents' treatment needs.
A facility failed to ensure that a resident with limited ROM wore ankle braces as ordered. The resident was observed multiple times without the prescribed braces, and the physician's order was not documented in the Medication or Treatment Administration Records. The care plan also lacked information on the use of ankle braces, and the Director of Nursing indicated that therapy was supposed to discontinue the order without proper documentation.
A resident with a history of falls was left alone in the shower room, resulting in a fall due to an unlocked shower chair. The resident required partial assistance with showering, but staff failed to provide adequate supervision, leading to the incident.
A facility failed to ensure proper foley catheter care for a resident, as the catheter bag was observed resting on the floor multiple times. The resident had a history of cerebral palsy, high blood pressure, urine retention, acute kidney disease, and obstructive uropathy, and was being treated for a UTI. The care plan required the catheter bag to be kept off the floor, which was not followed.
The facility failed to ensure correct oxygen flow rates for three residents, with observed rates not matching physician orders. The Director of Nursing acknowledged the discrepancies but had no additional information to provide.
The facility failed to ensure medications were labeled with a date opened and not expired. A multi-dose vial of Novolog insulin was found expired on the Rainbow unit, and Basaglar and Lantus insulin pens were observed without any date opened on the Reflections unit. Staff interviews confirmed the labeling and discarding requirements were not met.
A resident with multiple health issues indicated that his dentures needed tightening. Despite a care plan noting dental problems and a recommendation for dentures, there were no follow-up visits or documented conversations about continuing the dental plan. The resident had declined dental services in the past but did not refuse a January 2023 dental appointment.
The facility failed to ensure complete and accurate documentation of insulin administration for a resident with type 2 diabetes and cognitive impairment. The MAR showed missing entries for insulin administration on multiple occasions, which the DON confirmed was due to a nurse not signing it out.
A facility failed to implement fall interventions for a resident with Alzheimer's dementia and a history of falls. The resident was observed without the required defined perimeter mattress and floor mat, despite these being specified in the care plan. The DON confirmed the absence of these interventions.
Failure to Update Fall Prevention Interventions After Multiple Resident Falls
Penalty
Summary
A deficiency was identified when the facility failed to update and implement fall prevention interventions for a resident who experienced two falls in one day. The resident, who had diagnoses including dysphagia, weakness, anxiety, osteoarthritis, diabetes, and hypertension, was assessed as cognitively intact but required substantial to maximum assistance with activities of daily living. The care plan, established upon admission, identified the resident as being at risk for falls due to deconditioning and balance problems, with interventions such as maintaining a well-lit and clutter-free environment and keeping personal items within reach. However, after the resident experienced two separate falls in one day—one during therapy and another during a bathroom transfer—there were no updates or revisions made to the care plan to address these incidents. Facility policy required that the care plan be reviewed and updated following any fall. Despite this, the Assistant Director of Nursing Services confirmed that no new interventions were added to the care plan after the falls occurred. This lack of timely care plan revision and implementation of additional fall prevention measures constituted a failure to ensure adequate supervision and accident hazard prevention for the resident.
Incomplete Incontinence Documentation for Dependent Resident
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident with significant ADL self-care deficits, specifically regarding incontinence documentation. The resident, who had diagnoses including Alzheimer's, diabetes, weakness, depression, and dysphagia, was assessed as severely impaired in daily decision-making and required total assistance with toileting and other ADLs. The care plan required incontinence care as needed and documentation of any significant decline in function. However, review of the incontinence logs for October and November showed that documentation was only completed once per day on several dates, rather than every two hours as expected. Multiple staff interviews confirmed that the standard practice was to check and change residents every two hours or as needed, but this was not reflected in the documentation for the resident in question. The Director of Nursing Services acknowledged the documentation concern but did not provide additional information. The deficiency was identified through observation, record review, and staff interviews, indicating a failure to maintain clinical records in accordance with accepted professional standards.
Infection Control Lapses in Storage, Wound Care, and PPE Use
Penalty
Summary
Surveyors identified multiple infection control deficiencies within the facility. During an environmental tour, urinals, bedpans, and wash basins were observed improperly stored in shared bathrooms, including being hung from grab bars or placed on the floor, and not contained in plastic bags as required by facility policy. These items were accessible in areas shared by two residents per bathroom. The facility's policy specified that such items should be stored in a resident's bedside cabinet or drawer after being placed in a plastic bag, but this was not followed. Additionally, during wound care for a resident with pressure ulcers, an RN failed to change gloves between treating different wound sites and after providing incontinence care, despite facility policy requiring glove changes between each dressing change and after removing soiled dressings. The RN also placed linen and heel boots on the floor during the procedure. In a separate incident, another RN administered IV medication to a resident on Enhanced Barrier Precautions without donning an isolation gown, as required by both signage and facility policy. These lapses were confirmed through interviews with facility leadership and staff.
Failure to Follow Physician Orders and Monitor Resident Conditions
Penalty
Summary
The facility failed to follow physician orders and care plans for multiple residents, resulting in deficiencies related to medication administration, skin condition monitoring, and implementation of specialist recommendations. For one resident with type 2 diabetes and Parkinson's disease, insulin was administered despite blood glucose levels being below the physician-ordered threshold for holding the medication. Similarly, another resident with hypertension received Metoprolol even when blood pressure readings were below the parameters set by the physician, indicating a failure to hold the medication as ordered. In addition, the facility did not adequately monitor or document skin conditions for residents at risk. One resident on anticoagulant therapy had a large area of purplish discoloration on the hip, but this was not consistently documented in weekly skin reviews as required by facility policy. Another resident with a history of vascular dementia and bowel incontinence experienced frequent episodes of diarrhea, which were reported by CNAs but not documented in nursing notes or addressed with appropriate medication orders. A further resident with a venous stasis ulcer had an open, raw area on the leg that was not treated or care planned for several days, despite visible symptoms and the resident's own report of the condition. The facility also failed to carry out recommendations from specialty physicians for a resident with heart failure and COPD. Orders from a nephrologist to log and fax blood pressures, and from an oncologist to complete specific lab work, were not documented as completed. Additionally, the administration of midodrine for this resident did not consistently follow the ordered blood pressure parameters, with doses given when blood pressure was above the specified threshold and some doses held without documentation of blood pressure readings. These failures were confirmed by interviews with the Director of Nursing, who acknowledged the deficiencies and lack of documentation.
Failure to Complete Food Consumption Logs for Resident with Weight Loss
Penalty
Summary
The facility failed to ensure that food consumption logs were completed for a resident with a history of weight loss. Record review and interviews revealed that for one resident with multiple diagnoses, including pneumonitis due to inhalation of food and vomit, dementia, Huntington's disease, Parkinson's disease, bipolar disorder, chronic kidney disease, high blood pressure, depression, and dysphagia, there were significant gaps in the documentation of meal intake. The resident had experienced a significant weight loss of more than 5% in 30 days, as noted by a registered dietitian, which was related to a recent hospitalization. Despite the resident's complex medical history and dietary needs, food consumption logs were found to be incomplete for multiple meals across several dates. The Director of Nursing confirmed that these logs were required to be completed after every meal, but review of the CNA task section showed missing documentation for breakfast, lunch, and dinner on numerous occasions. This lack of documentation occurred even though the resident was identified as being at risk due to recent weight loss and ongoing health concerns.
Oxygen Therapy Not Administered at Ordered Flow Rate
Penalty
Summary
The facility failed to ensure that a resident received oxygen therapy at the correct flow rate as ordered by the physician. Observations on multiple occasions showed the resident using oxygen via nasal cannula with the concentrator set at 3.5 liters per minute. However, the resident's care plan and current physician's order specified that oxygen should be administered at 2 liters per minute continuously. The resident had diagnoses including acute and chronic respiratory failure with hypoxia, COPD, and dyspnea, and was cognitively intact. The Director of Nursing confirmed that the oxygen should have been set at 2 liters per minute, indicating the resident was not receiving respiratory care as ordered.
Medication Storage and Labeling Deficiencies
Penalty
Summary
Surveyors observed multiple deficiencies related to medication storage and labeling. During a medication pass, an RN prepared to administer an IV antibiotic to a resident with a PICC line and left a pre-filled normal saline syringe unsecured on the resident's over bed table after flushing the line. The RN later stated she was unaware that the syringe should not have been left in the resident's room. Additionally, in the Memory Unit medication room, a locked refrigerator contained an emergency drug kit (EDK) box that was found to be expired. The RN present indicated that the pharmacy was responsible for checking the medication room weekly, and the Director of Nursing confirmed that the pharmacy was supposed to check the EDK box during their visits. Further, on the Rainbow Unit, a medication cart was found to contain a multi-dose vial of Lispro Insulin that was past its expiration date. The Director of Nursing acknowledged that the expired insulin should have been discarded. The facility's current medication storage policy requires all drugs and biologicals to be stored in locked compartments or under direct observation during medication passes, and that expired medications should not be present. These observations demonstrate failures to adhere to proper medication storage and labeling protocols.
Failure to Ensure Physician Orders and Assessments for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that residents who self-administered medications had the required physician's orders and assessments in place. In one instance, a resident with heart failure and COPD was observed keeping and self-administering both eye drops and an inhaler at his bedside. Although the resident was cognitively intact and had physician's orders for the medications themselves, there was no order or assessment authorizing self-administration. Staff confirmed that neither the required assessment nor the order for self-administration was present in the resident's record. In another case, a resident with encephalopathy, dementia, and a history of opioid abuse, who was assessed as having severe cognitive impairment, was observed keeping and applying lidocaine patches independently. The resident had a physician's order for the medication but not for self-administration, and no assessment had been completed to determine if self-administration was clinically appropriate. Staff interviews confirmed the absence of the necessary documentation and assessments for both residents, despite facility policy requiring interdisciplinary team determination for safe self-administration.
Failure to Provide Timely Incontinence Care and Assistance with ADLs
Penalty
Summary
A dependent resident with diagnoses including kidney failure, ileostomy status, weakness, and a history of falls was observed lying in bed with a covered breakfast tray on her bedside table, unable to eat because she was waiting for wound care. The resident expressed a preference to get out of bed to eat and reported being told she would be assisted after wound care, which had not yet occurred. The resident also reported that her incontinence brief had been put on incorrectly during the night, resulting in her wetting the bed throughout the night and remaining in a soiled bed. Upon observation, a large wet spot was visible on the bed, although the resident's brief had been changed that morning and was dry at the time of observation. Certified nursing assistant (CNA) 1 acknowledged awareness of the soiled bed and stated she had changed the resident's brief but did not change the bed linens, as she intended to do so after the resident was assisted out of bed for wound care. Despite knowing the resident's condition, CNA 1 did not return to the room to provide further assistance and instead attended to another resident. The resident's care plan indicated a need for assistance with dressing, grooming, toileting, and transfers, and the Minimum Data Set assessment documented frequent incontinence and substantial assistance needs for activities of daily living.
Failure to Administer IV Antibiotics and Complete Wound Treatments as Ordered
Penalty
Summary
The facility failed to administer prescribed intravenous antibiotics as ordered for three residents and did not ensure wound treatments were completed and documented for one resident. For one resident with a history of prosthetic hip infection and recent surgery, the required six-week course of IV antibiotics was not provided after admission. Documentation showed that only one dose was given, and subsequent doses were missed or discontinued without proper follow-up or clarification with the prescribing physician. There was also a lack of documentation for wound care treatments on several days, and no evidence of communication with the surgeon or infectious disease specialist regarding the antibiotic regimen. Another resident with a chronic non-pressure ulcer and osteomyelitis had multiple missed doses of IV Cefazolin, with no documentation explaining the omissions. The resident's care plan required administration of antibiotics and wound treatment as ordered, but the medication administration record showed several unsigned doses, and the DON was unable to provide reasons for the missed doses. A third resident with osteomyelitis and other comorbidities also had several missed doses of IV Ampicillin-Sulbactam, again with no documentation for the missed administrations. The care plan for this resident included administration of antibiotics per physician orders, but the medication administration record indicated multiple unsigned doses. Interviews with the DON confirmed the lack of documentation or explanation for these missed medications.
Resident Elopement Due to Inadequate Supervision and Alarm Response
Penalty
Summary
The facility failed to ensure the safety of a resident, identified as Resident C, after an exit alarm was triggered. Resident C, who was cognitively intact and used a walker for ambulation, was not considered at risk for elopement according to her Elopement Risk Evaluation. On the night of the incident, Resident C exited the facility by entering a door code, which she had learned from her daughter, and was later found to have fallen off the property. She sustained abrasions to her face and finger and was taken to the ER for evaluation and treatment. The incident occurred when the resident exited the building through the ambulance bay door, which she accessed using a code she had overheard from her daughter. The staff did not have a care plan related to wandering for Resident C, as she had no history of wandering or behaviors indicating such a risk. On the night of the incident, a CNA had last seen the resident between 10:00 p.m. and 10:15 p.m., and nothing seemed unusual at that time. However, when the alarm sounded later, the staff assumed it was related to ambulance activity and did not conduct a head count or verify the whereabouts of the residents. The Interim DON confirmed that the staff responded to the alarm but failed to perform a resident head count, which should have been done. The facility's policy on elopements and wandering residents emphasized the importance of door alarms and necessary supervision, but in this case, the staff did not follow through with the required procedures to ensure resident safety. The lack of a systematic approach to monitoring and managing residents at risk for elopement contributed to the incident involving Resident C.
Failure to Report Alleged Abuse and Notify Authorities
Penalty
Summary
The facility failed to ensure that all covered individuals were notified annually of their obligation to report reasonable suspicion of crimes against residents. This deficiency was identified in relation to an allegation of sexual abuse involving a resident, referred to as Resident B. During an observation, Resident B, who was not cognitively intact and had impaired cognition and dementia, expressed fear and confusion about a male entering her room at night. The resident had a history of refusing medications and treatments, and during a dialysis session, she reported to a nurse that a male nurse had attempted to force her to take medication and made inappropriate sexual comments. The incident was reported by the dialysis nurse to the Dialysis Facility Administrator, who attempted to notify the long-term care facility's Director of Nursing (DON) but was unable to reach them due to a full voicemail. Despite multiple attempts over several days, the dialysis administrator and social worker could not leave a message or speak directly with the DON. Consequently, the long-term care facility was not informed of the allegation until the surveyor's investigation, and the local police were not notified. The facility's President of Operations confirmed that no annual notifications had been sent to covered individuals regarding their obligation to report suspicious crimes. This lack of communication and failure to notify the appropriate authorities in a timely manner contributed to the deficiency, as the facility did not have a protocol in place to ensure that such allegations were promptly reported and investigated.
Failure to Ensure Continuity of Care Post-Discharge
Penalty
Summary
The facility failed to ensure continuity of care for a resident discharged home with orders for intravenous (IV) antibiotic medications and the care of a peripherally inserted central catheter (PICC) line. The resident, who was cognitively intact, had been admitted with osteomyelitis of the left ankle and foot, among other diagnoses, and required IV antibiotic therapy for six weeks. Upon discharge, the resident was to continue this therapy at home, but the discharge instructions did not include the correct home health agency or pharmacy contact information. The social worker (SW) attempted to arrange for home health services but faced challenges as several agencies would not accept the resident's commercial insurance. Ultimately, the SW reverted to the resident's previous home health agency, which had issues in the past. Although the SW faxed necessary information to the home health and pharmacy agencies, there was no confirmation of receipt, and the SW did not follow up the next day to ensure the resident would receive the required IV antibiotics and PICC line care. The resident contacted the facility after discharge, reporting that he had not received his antibiotics. The facility's administrator and MDS coordinator advised the resident to go to the emergency room for treatment. The resident expressed frustration and questioned whether the facility would cover the ER bill. The lack of follow-up and incorrect discharge instructions contributed to the resident not receiving necessary medical care post-discharge.
Facility Fails to Ensure Palatable and Attractive Food
Penalty
Summary
The facility failed to ensure that food and drink were palatable, attractive, and served at a safe and appetizing temperature. During a Resident Council interview, over half of the residents indicated that the breakfast meal was not good, with complaints about raw and burnt bacon, discolored eggs, and hard sausage patties. One resident compared the eggs to those in the Dr. Seuss book 'Green Eggs and Ham.' The Administrator acknowledged the concerns and mentioned that the facility had a new Dietary Food Manager who would address these issues. Further observations and interviews revealed that residents found the food to be overcooked or undercooked. One resident described the chicken served for lunch as tough and inedible, and another resident's breakfast tray contained an overcooked egg and undercooked bacon. The Dietary Food Manager observed the issues and planned to conduct an inservice on cooking and preparing breakfast food. The Administrator noted that the dietary staff were contracted and suggested it was time for a change.
Failure to Prepare Pureed Diet Correctly
Penalty
Summary
The facility failed to prepare a pureed diet designed to meet the needs of the residents. On 4/17/24 at 11:12 a.m., Cook 1 was observed preparing a pureed cabbage braised recipe. Cook 1 added 10 scoops of cabbage to the mixer and turned on the mix cycle, then added 2 cups of sauerkraut juice, resulting in a watery mixture. Cook 1 added a total of 7 tablespoons of thickener to achieve the appropriate consistency. During an interview, Cook 1 indicated the cabbage was too watery and the recipe would not make 10 servings, requiring her to make more. The Director of Nursing (DON) confirmed that the dietary recipe should have been followed. The provided recipe indicated that water should be added if the product needs thinning.
Failure to Serve Meals on Time
Penalty
Summary
The facility failed to ensure meals were served as scheduled for two meal observations. On 4/16/24, residents were observed seated in the main dining room at 12:20 p.m., but the first tray was not served until 1:15 p.m., causing residents to become impatient. On 4/17/24, the first tray in the main dining room was served at 1:11 p.m., despite the posted meal time being 1:00 p.m. Additionally, a food cart was delayed in reaching the Memory Lane Unit, which was supposed to be served at 12:30 p.m. During a Resident Council interview, residents reported that breakfast was served late on Sunday morning and lunch was late on the day of the interview. They also mentioned that dinner was sometimes served late on bingo night. The Administrator confirmed that the dietary staff was a contracted service and meals should have been served on time.
Failure to Complete Self-Medication Administration Assessment
Penalty
Summary
The facility failed to ensure a self-medication administration assessment was completed for residents with medications at the bedside. Resident 105 was observed with a medication cup containing a small amount of medication solution on her bedside table. Her record indicated she was cognitively intact and had a physician's order for a daily supplement, but there was no self-medication administration assessment or physician's order to self-administer medications. The Director of Nursing (DON) acknowledged that the medication should not have been left at the bedside and had no additional information to provide. Similarly, Resident 2 was observed with a bottle of acetaminophen and tubes of pain-relieving cream on her bedside table. Her record showed she was cognitively intact and had a physician's order for acetaminophen as needed for pain, but there was no self-medication administration assessment or physician's order to self-administer medications or for the topical pain cream. The DON again acknowledged that the medication should not have been left at the bedside and had no additional information to provide.
Failure to Provide Adequate ADL Assistance
Penalty
Summary
The facility failed to provide adequate ADL assistance to a dependent resident, specifically in relation to nail care and the removal of facial hair. Resident 41, who has diagnoses including senile degeneration, high blood pressure, hallucinations, anxiety, and pain, reported that his nails were long and dirty and had not been cleaned in a while. Observations on multiple occasions confirmed that the resident's nails were long and dirty, and he was unshaven. The resident's care plan indicated an ADL self-care deficit, and the Quarterly MDS assessment noted that he needed partial to moderate assistance with personal hygiene. Despite this, documentation showed that his nails had only been clipped on two occasions earlier in the month, with no record of further nail care or shaving. The Director of Nursing acknowledged that the resident received hospice services and that the CNA was only visiting once a week, but expected nursing staff to ensure the resident's nails were clipped and cleaned and that he was shaved.
Failure to Complete Non-Pressure Skin Treatments and Use TED Hose
Penalty
Summary
The facility failed to ensure non-pressure skin treatments were completed as ordered and TED hose were in use for two residents with edema. Resident 64 was observed with dry, scaly, and red lower legs, and the treatment administration record (TAR) indicated missed applications of Clotrimazole-Betamethasone cream on multiple occasions. The Director of Nursing acknowledged that the treatment should have been completed as ordered, regardless of whether a Qualified Medication Aide (QMA) was on duty. Resident 64's medical history included stroke, heart failure, cellulitis, high blood pressure, and atrial fibrillation, and the resident was not cognitively intact for daily decision-making. Resident 122 was observed multiple times without TED hose, despite a physician's order for daily use to manage edema. The resident's lower extremities were dry, scaly, red, and swollen, with 4+ pitting edema. The TAR indicated that the TED hose were not signed out as being on for several days. Interviews with CNAs revealed a lack of awareness regarding the resident's need for TED hose. The Memory Unit Manager was also unaware of the issue and took immediate action to provide a new set of TED hose and alternate intervention orders. Resident 122's medical history included heart failure, respiratory failure with hypoxia, bipolar disorder, anxiety, cellulitis, and neuropathy, and the resident was moderately impaired for daily decision-making.
Failure to Apply Ankle Braces as Ordered
Penalty
Summary
The facility failed to ensure that ankle braces were applied as ordered for a resident with limited range of motion (ROM). Over several days, the resident was observed multiple times without the prescribed ankle braces while seated in a broda chair. The resident's right and left feet were noted to be leaning on the sides of the foot rest, indicating a lack of proper support. The resident's medical record indicated a diagnosis of spastic cerebral palsy and intellectual disabilities, and a physician's order from June 2023 required the resident to wear bilateral ankle braces for 3-4 hours at a time with skin checks every shift. However, this order was not transcribed onto the Medication or Treatment Administration Records from June 2023 through April 2024, and there was no indication that the ankle braces had been applied in the last 30 days. The resident's care plan did not include any information related to the use of ankle braces, and the Director of Nursing indicated that therapy was supposed to discontinue the order, but there was no documentation to support this. The lack of adherence to the physician's order and the absence of proper documentation and care planning led to the deficiency. The facility's failure to apply the ankle braces as ordered compromised the resident's care and did not support the maintenance or improvement of the resident's ROM and mobility.
Inadequate Supervision in Shower Room Leads to Resident Fall
Penalty
Summary
The facility failed to provide adequate supervision for a resident in the shower room, resulting in a fall. Resident 34, who has a history of falling and requires partial to moderate assistance with showering, was left alone in the shower room. The resident attempted to stand up to clean herself, but the shower chair's wheels were not locked, causing her to slip and fall. The incident was not witnessed, and the resident indicated that staff had left her alone after initially assisting her. The resident's care plan indicated she needed assistance with transfers during showering, but this was not adhered to during the incident. The resident's fall was documented in a Change of Condition report and a Post Fall Evaluation, both noting that the shower chair's wheels were not locked. An IDT Fall Note confirmed the resident's account of the fall and recommended additional assistance during showers. However, there was no investigation into the resident's claims of being left alone or the unlocked wheels on the shower chair. The Director of Nursing confirmed the resident's account but had no further information to provide.
Failure to Maintain Proper Foley Catheter Care
Penalty
Summary
The facility failed to ensure that foley catheter bags and tubing were kept off the floor for one resident reviewed for catheters. Resident 53 was observed multiple times with the foley bag resting on the ground underneath his wheelchair. These observations occurred on three separate occasions on the same day, indicating a consistent issue with the placement of the catheter bag. The resident's medical history included cerebral palsy, high blood pressure, urine retention, acute kidney disease, and obstructive uropathy. The resident was cognitively intact and dependent on toileting hygiene, as indicated by the Quarterly Minimum Data Set (MDS) assessment dated 1/17/24. The care plan for the resident, dated 2/19/24, specifically included interventions to keep the drainage bag off the floor and below the level of the bladder at all times, which were not followed. Additionally, the resident had a recent urinary tract infection (UTI) and was on antibiotics as per physician's orders dated 4/10/24 and 4/11/24. During an interview, the Director of Nursing (DON) acknowledged the concern but had no additional information to provide.
Failure to Ensure Correct Oxygen Flow Rates
Penalty
Summary
The facility failed to ensure that oxygen was set at the correct flow rate for three residents. Resident 228 was observed multiple times with oxygen set below the prescribed 3 liters per minute, despite physician orders indicating continuous oxygen at this rate. The resident's care plan required oxygen therapy related to chronic respiratory failure, but the observed flow rates did not match the physician's orders. The Director of Nursing confirmed that the oxygen should be administered as ordered by the physician. Resident 37 was observed with varying oxygen flow rates, none of which matched the physician's order of 2 liters per minute. The resident's care plan did not include oxygen use, and there were no orders for oxygen until after the observations were made. Similarly, Resident 116 was observed with inconsistent oxygen flow rates, ranging from 1.5 to 4.5 liters per minute, without corresponding physician orders during the observations. The Director of Nursing acknowledged the discrepancies but had no additional information to provide.
Failure to Properly Label and Discard Medications
Penalty
Summary
The facility failed to ensure medications were labeled with a date opened and not expired. During an observation of the Rainbow unit's medication cart, a multi-dose vial of Novolog insulin was found with an open date that exceeded the 28-day discard period. Additionally, on the Reflections unit, Basaglar and Lantus insulin pens were observed without any date opened. Interviews with the Rainbow Unit Manager and an LPN confirmed that the medications should have been labeled with the date opened and discarded appropriately. The Nurse Consultant also confirmed that the Novolog vial was expired and that the facility's policy required labeling and discarding of multi-use vials within 28 days unless specified otherwise by the manufacturer.
Failure to Provide Dental Services
Penalty
Summary
The facility failed to provide dental services to a resident who requested dentures. Resident 19, who had diagnoses including high blood pressure, transient cerebral ischemic attack, type 2 diabetes, major depressive disorder, and acute respiratory failure, indicated that his dentures needed to be tightened. An observation confirmed that the resident's upper denture was loose. The resident's care plan, updated in February 2024, noted oral/dental problems, and a dental visit in January 2023 recommended extracting all remaining teeth and making complete upper and lower dentures. However, there were no follow-up visits or documented conversations with the resident regarding the continuation of the dental plan. The Social Service Director noted that the resident had declined dental services in October 2020 and again in October 2023, but the resident did not refuse to be seen by the dentist in January 2023.
Incomplete Documentation of Insulin Administration
Penalty
Summary
The facility failed to ensure clinical records were complete and accurately documented for a resident with type 2 diabetes mellitus and mild cognitive impairment. The resident's Significant Change Minimum Data Set (MDS) assessment indicated severe impairment in daily decision-making and the need for insulin administration. A physician's order specified a sliding scale for Lispro Insulin administration before meals and at bedtime. However, the Medication Administration Record (MAR) showed that the insulin was not signed out as given on multiple occasions in March and April 2024. The Director of Nursing confirmed that a Qualified Medication Aide (QMA) was scheduled on those dates, and the nurse administered the insulin but failed to document it.
Failure to Implement Fall Interventions for Resident
Penalty
Summary
The facility failed to ensure fall interventions were in place as care planned for a resident with a history of falls. Resident B, who has Alzheimer's dementia, osteoporosis, and a history of falls, was observed without the required fall prevention measures. Specifically, the resident's care plan indicated the need for a defined perimeter mattress and a low bed with a mat, but observations on two occasions showed the resident on a standard mattress without a floor mat. The resident had previously fallen on 1/30/24, sustaining minor injuries. The Director of Nursing confirmed the absence of the required interventions during an interview.
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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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