Brickyard Healthcare - Willow Springs Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Indianapolis, Indiana.
- Location
- 2002 West 86th Street, Indianapolis, Indiana 46260
- CMS Provider Number
- 155834
- Inspections on file
- 33
- Latest survey
- July 23, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Brickyard Healthcare - Willow Springs Care Center during CMS and state inspections, most recent first.
A resident was not adequately prepared for a safe transfer or discharge, and the facility did not ensure that the process met the resident's needs and preferences, resulting in a deficiency related to proper transition planning.
A resident with complex behavioral and psychiatric needs was re-admitted multiple times from psychiatric hospital stays, but the IDT did not review or update the care plan to reflect new or modified interventions as required by facility policy. The clinical record lacked documentation of team discussions or care plan revisions following each re-admission.
A resident with a history of stroke, hemiplegia, and bladder incontinence was found without access to a call light, despite being alert and able to voice needs. The call light was discovered out of reach, and staff confirmed it should have been accessible according to facility policy and the resident's care plan.
The facility did not accurately code MDS assessments for three residents, including failing to document dialysis treatment for a resident with end stage renal disease and omitting bed rail use for two residents who were observed using them. Care plans for these residents also lacked interventions related to bed rail use, despite confirmation from staff and resident interviews.
A resident with serious mental health diagnoses remained in the facility beyond the 60-day temporary PASARR approval period without a new Level I PASARR being completed, as required. Staff interviews confirmed the oversight, and facility policy mandates were not followed regarding timely rescreening for continued stay.
A resident with epilepsy and a history of stroke, who was prescribed multiple anti-seizure medications, did not have a seizure care plan in their current record. The DON confirmed the care plan was missing from the current system, despite facility policy requiring comprehensive, person-centered care plans for all identified needs.
A resident with a history of frequent elopement was not properly assessed for elopement risk upon admission, despite documentation from a caregiver and hospital records indicating prior incidents. The elopement assessment was completed incorrectly by a nurse, resulting in the resident not being included in the facility's elopement monitoring system, contrary to facility policy.
Staff did not consistently follow facility policy for controlled substance reconciliation, as evidenced by missing required nurse signatures on shift change count records for two medication carts. Despite policy requiring two licensed nurses to count and sign for narcotics at each shift change, documentation showed repeated omissions of signatures, indicating lapses in controlled substance accountability.
Two residents prescribed antipsychotic medications did not receive baseline AIMS assessments as required by facility policy. Both had care plans and physician orders indicating the need to monitor for adverse reactions, but documentation showed that AIMS testing was not completed. The DON confirmed the assessments were missed upon admission.
Surveyors found that medications on two medication carts were not properly stored or labeled, with missing open dates, loose pills in drawers, and discontinued or resident-specific medications not removed after discharge. Staff confirmed these practices did not follow facility policy, which requires proper labeling and timely removal of unused or expired medications.
Staff failed to follow enhanced barrier precautions and infection control protocols for three residents, including not posting EBP signs, not wearing required PPE during wound care, and handling medications in an unsanitary manner. Residents with wounds did not have appropriate care plans or timely implementation of EBP, and staff were unaware of required procedures.
The facility did not document that bed hold policy information was provided to three residents with complex medical needs when they were transferred to the hospital, and failed to notify the ombudsman after a resident's discharge. Staff interviews confirmed that while forms were reportedly sent with residents, there was no documentation in the health record or on notification lists to verify compliance with required procedures.
Two residents were found wearing hospital gowns due to missing personal clothing, violating their rights to dignity and respect. Resident 46's clothes were missing from the laundry, and Resident 42's shirts were lost shortly after admission. The facility's policy on personal belongings was not followed, leading to inadequate inventory management and prolonged periods without personal clothing.
A facility failed to update a resident's code status after hospitalization, leading to a discrepancy between the hospital discharge summary and a previous POST form. The resident, with multiple health conditions, was listed as a full code upon return, despite expressing a desire to be a no code. The facility did not follow its policy to review and clarify advance directives during care planning.
A facility failed to notify the ombudsman when a resident with multiple health issues, including respiratory failure and pressure ulcers, was transferred to the hospital and later discharged. The facility's policy required notification to the ombudsman for emergency transfers and discharges, but no such notice was found in the resident's records. The Clinical Support Nurse confirmed the omission during an interview.
The facility failed to provide the bed hold policy to two residents during their transfer to a hospital. One resident with respiratory failure and other conditions was not given the policy upon transfer or discharge. Another resident with dementia and pneumonia was also not provided the policy during their hospital transfer. The Clinical Support Nurse confirmed the absence of the required documents in both cases.
A facility failed to monitor blood sugar levels for a diabetic resident due to the absence of a glucose monitoring sensor. The resident, who had a periprosthetic fracture, a stage 4 pressure ulcer, and type 2 diabetes, reported that her sensor had not been in place for over a week, and no staff had checked her blood sugar. The facility's policy required routine glucose monitoring and maintaining an adequate supply of sensors, but these were not followed, as confirmed by staff interviews and record reviews.
A resident with a colostomy experienced a delay in care after their colostomy bag ruptured, leaving them in discomfort and with a stool-stained shirt. Despite the resident's repeated calls for help, the LPN delayed assistance, and the CNA was occupied with another resident. The resident, who required assistance from two staff members for transfers, was not attended to for 42 minutes. The facility lacked a formal incontinence program policy.
A resident with chronic respiratory failure and other health issues did not receive the prescribed continuous oxygen therapy due to an empty portable tank and disconnected tubing. Staff interviews revealed a lack of adherence to the physician's order for 2 liters of oxygen per nasal cannula, with a CNA noting the resident received only 1.5 liters. A nurse also failed to notice the disconnection of the oxygen supply, contrary to the facility's policy on oxygen administration.
The facility failed to complete side rail assessments and obtain consents for two residents before using side rails, leading to a deficiency. One resident had raised side rails without a physician's order or consent, and the Clinical Support Nurse suggested possible bed switching by staff. Another resident also had raised side rails without documentation, despite having a care plan for multiple conditions. The facility's policy required informed consent and a physician's order, which were not followed.
A facility failed to provide a clinical rationale for declining a gradual dose reduction of an antipsychotic medication for a resident with multiple health conditions. Despite a pharmacist's recommendation for dose reduction, the form only noted contraindication by a nurse practitioner without supporting documentation, contrary to the facility's policy requiring clinical justification.
The facility failed to properly label and store medications on the second and third-floor carts. Observations revealed open bottles of amantadine, Nystatin, diazepam, Tussin, and morphine sulfate without open dates, and some with illegible labels or expired. The DON and LPNs confirmed that medications should be dated when opened and expired medications should be removed, as per facility policy.
A resident with multiple health issues requested dental services, including extractions and dentures, but the facility failed to follow up on dental recommendations. The care plans did not address the resident's oral care needs or her request for extractions, and the Social Services Designee was unaware of the dentist's advice. The facility's policy required documentation of dental care needs, which was not done, leading to a deficiency.
The facility failed to ensure accurate documentation in the MAR/TAR for two residents. One resident's G-tube orders were signed off as completed despite the tube being dislodged, with LPNs citing reasons such as not wanting to go against the MAR and moving too fast. Another resident had missing documentation for several medications on specific dates. The facility's policy emphasizes timely and accurate documentation.
A facility failed to properly transcribe and communicate a hospice medication order, leading to a resident receiving excessive morphine doses. The hospice provider ordered morphine every 6 hours, but the facility's MAR indicated every 2 hours, resulting in four doses within 10.5 hours. Additionally, the facility did not document or communicate a potential fall incident when the resident was found deceased on the floor. Interviews revealed a lack of communication and awareness among staff regarding the transcription error and the resident's condition.
The facility failed to monitor and maintain refrigerator temperatures below 41°F for two out of three kitchen refrigerators. One refrigerator was at 48°F, and another lacked an internal thermometer and was warm. Temperature logs were missing for several days. The Dietary Manager and Dietitian confirmed issues with the refrigerators, which contradicted the facility's food safety policy requiring daily monitoring.
Failure to Ensure Resident-Centered and Safe Transfer/Discharge
Penalty
Summary
The facility failed to ensure that the transfer or discharge process met the resident's needs and preferences, and did not adequately prepare the resident for a safe transfer or discharge. The report identifies that the necessary steps to assess and address the resident's individual requirements and preferences during the transfer or discharge process were not followed, resulting in a deficiency related to resident-centered care and safe transition planning.
Failure to Update Care Plan After Resident's Psychiatric Re-admissions
Penalty
Summary
The facility failed to ensure that a person-centered, comprehensive care plan was reviewed and updated by the Interdisciplinary Team (IDT) to reflect the behavioral care needs of a resident with multiple diagnoses, including Parkinson's disease, dementia, metabolic encephalopathy, and bipolar disorder. The resident exhibited behavioral symptoms such as racial slurs, derogatory comments, verbal and physical aggression, throwing items, and refusing care. The care plan included various interventions to address these behaviors, such as administering medications, providing care in pairs, and monitoring behavior episodes. Despite multiple re-admissions from psychiatric hospital stays, the clinical record lacked documentation of IDT progress notes after each re-admission to indicate that the care plan had been reviewed and revised with new or modified interventions. Facility policy required the care plan to be reviewed and updated upon a resident's status change, with team discussions documented in the nursing progress notes. However, this process was not followed for the resident in question, as evidenced by the absence of updated care plan documentation after each hospital re-admission.
Failure to Ensure Call Light Accessibility for Resident with Mobility Impairment
Penalty
Summary
The facility failed to ensure that the call system was within reach for a resident who required assistance, as observed and confirmed during interviews and record review. The resident, who had a history of hypertension, weakness, and left-sided hemiplegia and hemiparesis following a stroke, reported being left wet and not changed as often as needed. During an observation, the resident was found sitting in her wheelchair, alert and able to voice her needs, but without the call light in view or within reach. The call light was later found behind the resident and out of reach by a CNA, who acknowledged that it should have been accessible. The resident's care plan indicated a communication problem and specified that the call light should be left within reach, but the care plan for bladder incontinence did not address call light accessibility. Facility policy required staff to ensure the call light was within reach and secured as needed.
Inaccurate MDS Assessments and Omitted Bed Rail Documentation
Penalty
Summary
The facility failed to ensure accurate completion of the Minimum Data Set (MDS) assessments for three residents. For one resident with diagnoses including hypertension, end stage renal disease, and hyperlipidemia, the MDS assessment did not indicate that the resident received dialysis, despite nursing documentation and staff interview confirming that dialysis was provided. The MDS Coordinator acknowledged that the assessment should have reflected the resident's dialysis treatment. Additionally, two residents were observed using bilateral bed rails, but their MDS assessments did not indicate the use of bed rails. Both residents' care plans also lacked interventions related to bed rail use, despite observations and resident interviews confirming their use for mobility and support. The Director of Nursing stated that care plans should indicate bed rail use, but this was not documented. The facility did not ensure that staff had the requisite knowledge to complete accurate assessments as required.
Failure to Complete Timely PASARR Rescreening After Temporary Approval Expired
Penalty
Summary
A deficiency occurred when the facility failed to ensure a new Pre-Admission Screening and Resident Review (PASARR) was completed after the expiration of the approved 60-day period for a resident with diagnoses including bipolar disorder, post-traumatic stress disorder (PTSD), and autistic disorder. The clinical record showed that the initial PASARR Level I screen outcome provided only a temporary approval for 60 days, with clear instructions that a new Level I screen must be submitted if the resident's stay exceeded the approved period. Interviews with facility staff, including the Social Services Director and the MDS Coordinator, confirmed that a new PASARR was not completed after the initial approval expired. Additionally, a PASARR help desk staff member clarified that the expired Level I PASARR was no longer valid and required resubmission. The facility's policy also required all applicants to be screened in accordance with state Medicaid rules, but this was not followed in this instance.
Failure to Develop and Implement Comprehensive Seizure Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident diagnosed with epilepsy and other neurological conditions. The resident's clinical record showed diagnoses including epilepsy with status epilepticus, aphasia following a stroke, and hemiplegia/hemiparesis. The resident was prescribed multiple anti-seizure medications, including Depakote Sprinkles, lacosamide, and levetiracetam, as indicated by physician orders. Despite these diagnoses and treatments, there was no seizure care plan found in the resident's current record. During an interview, the Director of Nursing confirmed that a seizure care plan previously existed in the facility's old system but was not present in the current system. The facility's policy requires the development and implementation of a comprehensive, person-centered care plan with measurable objectives and timeframes for all identified needs. The absence of a seizure care plan for this resident constituted a failure to meet this policy and regulatory requirement.
Failure to Accurately Assess and Monitor Elopement Risk
Penalty
Summary
The facility failed to accurately complete an elopement assessment for a resident with a history of frequent elopement from home, as documented by both a hospital discharge report and a caregiver statement. Despite clear evidence that the resident had previously eloped and was missing for several days prior to admission, the facility's elopement assessment incorrectly indicated no such history. The Social Services Director confirmed that the resident was not included in the elopement monitoring system due to this error, and the nurse responsible for the assessment did not document the resident's known elopement risk. Facility policy required that all residents be assessed for elopement risk upon admission and throughout their stay, but this was not followed in this case.
Failure to Consistently Reconcile and Document Controlled Substances at Shift Change
Penalty
Summary
The facility failed to ensure staff followed established policy and procedure for the reconciliation of controlled substances on two of six medication carts reviewed. During observations of medication storage, multiple instances were identified where the required signatures of on-coming and off-going nurses were missing from the Controlled Substance Shift Change Count Records for the South and Southwest medication carts. These missing signatures occurred across several dates in February, April, and May, indicating that the process for jointly counting and signing for controlled substances at shift changes was not consistently followed. Interviews with staff confirmed that the expectation was for two licensed nurses to count narcotics together and sign the log at each shift change, as outlined in facility policy. The reviewed policy documents also specified that two licensed nurses must account for all controlled substances and access keys at the end of each shift. Despite these requirements, the observed documentation showed repeated failures to obtain the necessary signatures, demonstrating noncompliance with the facility's controlled substance accountability procedures.
Failure to Complete Baseline AIMS Assessments for Residents on Antipsychotics
Penalty
Summary
The facility failed to complete baseline Abnormal Involuntary Movement Scale (AIMS) assessments for two residents who were prescribed antipsychotic medications. For one resident with diagnoses including acute and chronic respiratory failure with hypoxia and major depressive disorder, Latuda was ordered, and the care plan included monitoring for adverse reactions such as tardive dyskinesia. However, no baseline AIMS assessment was documented from the time of the antipsychotic prescription through the review period. Similarly, another resident with diagnoses of insomnia and major depressive disorder was prescribed Aripiprazole, with orders and care plans specifying monitoring for side effects, including extrapyramidal symptoms. Despite these directives, no baseline AIMS assessment was completed for this resident during the relevant timeframe. The DON confirmed that AIMS assessments were not performed upon admission for either resident. Facility policy required AIMS testing for residents receiving antipsychotic medications, but this was not followed in these cases.
Medication Storage and Labeling Deficiencies Identified
Penalty
Summary
Surveyors observed that the facility failed to ensure proper storage and labeling of medications on two of three medication carts reviewed. Specifically, medications were not stored in their original packaging, open dates were missing on several medications, and discontinued medications were not removed from the carts. On the 200-unit cart, there was a bottle of latanoprost eye drops without an open date, a bottle of liquid protein without a resident's name that belonged to a discharged resident, and 19 loose pills found in the drawers. Staff interviews confirmed that the eye drops should have been dated when opened, the liquid protein should have been discarded or given to the discharged resident, and loose pills should not be present in the cart. On the 300-unit north cart, similar issues were found, including multiple bottles of eye drops and other medications without open dates, a medication for a discharged resident that had not been removed, a discontinued medication still present, and 16 loose pills in the drawers. Staff interviews confirmed that open dates were required on medications and that discontinued or resident-specific medications should have been removed from the cart. Facility policies reviewed indicated requirements for proper labeling and disposal of unused, contaminated, or expired medications.
Failure to Implement Enhanced Barrier Precautions and Infection Control Practices
Penalty
Summary
The facility failed to implement and maintain proper infection prevention and control practices for residents requiring enhanced barrier precautions (EBP) and during medication administration. For one resident with a pressure wound, an LPN performed wound care without wearing a gown, did not follow correct wound cleaning technique by reusing the same gauze on the wound bed, and used a towel from the bedside table to pat the wound dry. There was no EBP sign posted outside the resident's room, and the care plan did not address the use of EBP, despite a physician's order requiring these precautions. The LPN was unaware of the required PPE for EBP, and the Director of Nursing confirmed the absence of the sign and staff awareness. In another instance, an RN was observed preparing medications and, after dropping a tablet onto the medication cart, picked it up with her fingers and placed it into the medication cup, contrary to infection control procedures and facility policy, which prohibit touching medications with bare hands. The RN acknowledged this was not the correct procedure and that the medication should have been replaced. Additionally, a resident with wounds on the vagina and buttocks had wound care supplies stored on top of the dresser in her room. The resident reported that staff only wore gloves, not gowns, during wound care. There was no EBP sign on the door or PPE available outside the room, despite a physician's order for EBP. The care plan did not include EBP at the time wound care was initiated, and the order for EBP was delayed. Interviews with staff confirmed that EBP should have been implemented earlier and that proper signage and PPE availability were lacking.
Failure to Document Bed Hold Policy and Notify Ombudsman After Resident Transfers and Discharges
Penalty
Summary
The facility failed to provide required documentation and notifications related to bed hold policies and ombudsman notification for three residents who were hospitalized or discharged. For one resident with cognitive communication deficit and muscle weakness, there was no documentation that bed hold information was provided at the time of transfer to the hospital following an acute episode. Similarly, another resident with respiratory failure and hemiplegia was transferred to the hospital without documentation of bed hold information being given, and a completed transfer form was not found in the record. Additionally, a resident with chronic respiratory failure and end stage renal disease was discharged and later returned, but the ombudsman was not notified of the discharge as required, and there was no documentation that the bed hold policy was provided during a subsequent hospital transfer. Interviews with staff confirmed that while transfer forms and bed hold policies were reportedly sent with residents, there was no documentation in the electronic health record to verify this, and the ombudsman notification list did not include the resident in question. Facility policies require written information on bed hold practices to be provided and documented, and for the ombudsman to be notified of transfers and discharges, but these procedures were not followed for the residents reviewed.
Failure to Maintain Resident Clothing Inventory
Penalty
Summary
The facility failed to ensure that residents were dressed in their own clothing instead of hospital gowns, which violated their rights to be treated with respect and dignity. Resident 46 was observed wearing a hospital gown because his clothes were missing from the laundry. The Social Services Designee was unaware of this situation, and the resident's personal inventory list was not updated in the electronic health record. The Director of Nursing later found clothes that did not belong to any resident and provided them to Resident 46, who had been without his own clothes for a long time. Resident 42 also experienced a similar issue, as he was observed wearing a hospital gown due to missing shirts. His clothing was labeled upon admission, but many items went missing shortly after. The resident's mother had to start doing his laundry to prevent further loss. Despite efforts to locate the missing items, most of his shirts remained unaccounted for until the facility found all but two shirts and completed a new inventory sheet. The facility's policy on resident personal belongings emphasizes the protection of residents' rights to possess personal items and the responsibility to maintain an inventory of these belongings. However, the facility failed to adhere to this policy, resulting in the loss of personal clothing for the residents. The lack of proper labeling and inventory management contributed to the deficiency, as residents were left without their personal clothing for extended periods.
Failure to Update Resident's Code Status Post-Hospitalization
Penalty
Summary
The facility failed to ensure that a resident's code status was reviewed and updated after returning from an inpatient hospitalization. The clinical record for a resident, who had multiple diagnoses including muscle atrophy, type 2 diabetes mellitus, and various mental health disorders, was reviewed. A hospital discharge summary indicated the resident was a full code, while a previous POST form indicated the resident was a no code. The resident's face sheet also showed the resident as a full code. During an interview, the Director of Nursing indicated that the resident was listed as a full code upon returning from the hospital, and there was no documentation in the electronic health record to show that the resident's code status and POST form were reviewed after hospitalization. The resident expressed a desire to be a no code, consistent with the POST form dated prior to hospitalization. The facility's policy on residents' rights regarding treatment and advance directives was not followed, as it requires the review and clarification of advance directives during the care planning process.
Failure to Notify Ombudsman of Resident Transfer and Discharge
Penalty
Summary
The facility failed to notify the ombudsman when a resident was hospitalized and subsequently discharged. Resident 254, who had diagnoses including respiratory failure with hypoxia, an unstageable pressure ulcer, anxiety disorder, depression, bradycardia, and anemia, was transferred to the hospital. A nursing progress note documented the transfer, and the Nurse Practitioner and Director of Nursing were informed. However, the electronic medical record lacked evidence of notification to the Office of the State Long-Term Care Ombudsman at the time of the transfer or upon discharge. During an interview, the Clinical Support Nurse confirmed that no notice to the ombudsman was found or provided. The facility's policy required that copies of notices for emergency transfers be sent to the ombudsman, and in cases where the facility decided to discharge a resident while hospitalized, a discharge notice should also be sent to the ombudsman.
Failure to Provide Bed Hold Policy During Resident Transfers
Penalty
Summary
The facility failed to provide the bed hold policy to two residents during their transfer to a hospital, which is a requirement during such events. Resident 254, who had multiple diagnoses including respiratory failure and an unstageable pressure ulcer, was transferred to the hospital on June 14, 2024. However, the facility did not provide the bed hold policy to the resident or their representative at the time of transfer or upon discharge. This was confirmed during an interview with the Clinical Support Nurse, who indicated that the necessary paperwork, including the bed hold policy, was not found in the resident's records. Similarly, Resident 154, who had conditions such as dementia, diabetes with foot ulcer, and pneumonia, was sent to the emergency room on June 7, 2024, and later returned to the facility. The facility again failed to provide the bed hold policy to the resident or their representative. The Clinical Support Nurse confirmed that no transfer documents or bed hold policy were found in the electronic health record. The facility's current policy requires that a notice of transfer and the bed hold policy be provided to residents and their representatives, but this was not adhered to in these cases.
Failure to Monitor Blood Sugar in Diabetic Resident
Penalty
Summary
The facility failed to ensure routine blood sugar monitoring for an insulin-dependent diabetic resident, identified as Resident 260. The resident reported that her glucose monitoring system sensor had not been in place for over a week, and no staff had been checking her blood sugar levels. The clinical record review revealed that the resident had a periprosthetic fracture, a stage 4 pressure ulcer, and type 2 diabetes mellitus. Physician's orders included the application of a continuous blood glucose monitoring sensor every 14 days, insulin injections, and oral diabetes medication. However, the electronic medical record showed only two blood sugar readings for the month of June, indicating a lack of routine monitoring. Interviews with facility staff, including the Unit Manager and Clinical Support Nurse, confirmed the absence of routine glucose checks and the lack of documentation regarding the unavailability of the sensor. The Unit Manager was unaware of the sensor's absence and acknowledged that staff should have used the facility glucometer to monitor the resident's blood sugar in the interim. The Clinical Support Nurse found no orders for routine glucose checks or documentation of physician notification about the sensor issue. The facility's policy on continuous glucose monitors emphasized the need for recording glucose values as part of daily vital signs and maintaining an adequate supply of sensors, which was not adhered to in this case.
Delayed Colostomy Care for Resident
Penalty
Summary
The facility failed to provide timely colostomy care for a resident, identified as Resident 42, who returned from therapy with a ruptured colostomy bag. The resident was observed in a wheelchair with a stool-stained shirt and expressed discomfort and urgency for assistance. Despite acknowledging the situation, LPN 8 delayed attending to the resident, indicating she would return once a CNA was available. The resident continued to call for help, but LPN 8 remained at the nurse's station, and CNA 9 was occupied with another resident. It was not until 42 minutes later that CNA 9 attended to the resident with the necessary equipment. Resident 42's clinical record revealed multiple health issues, including anoxic brain damage, a stage 4 pressure ulcer, diabetes with neuropathy, and a colostomy. The resident was dependent on staff for transfers and hygiene, requiring assistance from two staff members with a mechanical lift. The care plan specified regular and as-needed ostomy care, but the facility lacked a formal incontinence program policy. Interviews indicated that staff were often too busy to respond promptly, although additional help could be summoned from other units if necessary.
Failure to Provide Ordered Oxygen Therapy
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, identified as Resident 10, who required continuous oxygen therapy. During an observation, the resident was found with an empty portable oxygen tank while sitting in her wheelchair, and on another occasion, the oxygen tubing was disconnected and lying on the floor while the resident was in bed. The resident's clinical record indicated a physician's order for continuous oxygen at 2 liters per nasal cannula, with instructions to contact the physician if oxygen saturation fell below 90%. Interviews with staff revealed a lack of awareness and adherence to the prescribed oxygen flow, as a CNA noted the tank was empty and the resident was receiving only 1.5 liters, contrary to the physician's order. Additionally, a nurse failed to notice the disconnection of the oxygen supply during her visit to the resident's room. The facility's policy on oxygen administration requires adherence to physician orders, except in emergencies, which was not followed in this case.
Failure to Obtain Consent and Assessment for Bed Rail Use
Penalty
Summary
The facility failed to complete side rail assessments and obtain consents before using side rails for two residents, leading to a deficiency in ensuring safety and compliance with policies. Resident 46 was observed with raised side rails, despite not having a physician's order or documented consent for their use. The resident's clinical record, which included diagnoses such as generalized anxiety disorder and cerebral infarction, lacked any side rail assessment or consent documentation. The Clinical Support Nurse acknowledged the absence of consent and assessment, attributing the situation to possible bed switching by staff, although she was uncertain about the exact cause. Similarly, Resident 22 was observed with raised side rails on multiple occasions without a corresponding physician's order or consent in the electronic medical record. The resident's care plan, which included conditions like a fracture of the left femur, dementia, and a history of traumatic brain injury, did not mention side rails. The Clinical Support Nurse confirmed the lack of a signed consent or order for the bed rails. The facility's policy on the proper use of bed rails emphasized the need for informed consent and a physician's order, which were not adhered to in these cases.
Lack of Clinical Rationale for Antipsychotic Dose Reduction Decline
Penalty
Summary
The facility failed to provide a clinical rationale for declining a gradual dose reduction of an antipsychotic medication for a resident. The resident, who had multiple diagnoses including malignant neoplasm of the prostate, type 2 diabetes with kidney complications, dysphagia, dementia with anxiety and behavioral disturbances, bilateral osteoarthritis of the hip, and depression, was prescribed Seroquel (quetiapine) 25 mg twice daily. A pharmacist recommended a dose reduction, and the report was provided to the Medical Director and DON. However, the form only contained a handwritten note indicating the dose reduction was contraindicated per a nurse practitioner, without any clinical rationale provided. Upon review of the resident's clinical record and during an interview with the Clinical Support Nurse, it was confirmed that there were no progress notes or documentation to support the contraindication of the dosage reduction. The facility's policy on the use of psychotropic medication stated that residents should receive gradual dose reductions unless clinically contraindicated, but in this case, the necessary clinical justification was absent.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications on the second and third-floor medication carts. During an observation, an open bottle of amantadine was found without an open date, and the Director of Nursing subsequently dated it as opened on 6/1/24. Additionally, an open bottle of Nystatin was found without an open date. The Director of Nursing confirmed that liquid medications should be dated when opened. On the third-floor north cart, a bottle of diazepam was found opened without a date and with an illegible label. The resident associated with this medication had been discharged on 5/29/24, and the LPN acknowledged that the bottle should have been labeled with an open date. Further observations on the third-floor west medication cart revealed an open bottle of Tussin without an open date and a bottle of morphine sulfate with an expired manufacturer's date of 1/14/24. Another sealed bottle of morphine sulfate was found with an expiration date of 6/11/24. The LPN confirmed that open bottles should be labeled with an open date and expired medications should be removed. The facility's policy on medication storage, revised in 2/24, indicated that discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels should be destroyed according to the Destruction of Unused Drugs Policy.
Failure to Follow Up on Dental Recommendations
Penalty
Summary
The facility failed to follow up with dental recommendations for a resident who had requested dental services, including the extraction of teeth and the provision of dentures. The resident, who had a history of type 2 diabetes mellitus, depressive disorder, agoraphobia, and diabetic polyneuropathy, expressed her desire to have her teeth pulled and replaced with dentures supported by implants. Despite the resident's request and the presence of dental issues such as missing teeth, a fractured tooth with an abscess, and poor oral hygiene, the care plans did not address her need for assistance with oral care or her request for extractions. Additionally, the resident experienced pain while chewing, which was not documented in the care plans. The Social Services Designee (SSD) was unaware of the dentist's recommendations against full mouth extraction and did not follow up on the dental notes after the resident's appointment. The Director of Nursing (DON) indicated that she would have ensured a dental appointment if she had known about the resident's request for extractions. The facility's policy on dental services required documentation of oral and denture care needs in the resident's plan of care, but this was not done. The lack of follow-up and documentation led to the deficiency in providing appropriate dental care for the resident.
Inaccurate MAR/TAR Documentation for Two Residents
Penalty
Summary
The facility failed to ensure accurate documentation in the Medication and Treatment Administration Record (MAR/TAR) for two residents. For Resident 6, despite the G-tube being dislodged on 6/17/24, the MAR indicated that the G-tube related physician's orders were signed off as completed from 6/18/24 through 6/24/24. Interviews with LPNs revealed that they signed off on the MAR/TAR without verifying the presence of the G-tube, citing reasons such as not wanting to go against the MAR and moving too fast. The Nurse Practitioner did not discontinue the G-tube orders as she was unaware of them. For Resident 45, there was a lack of documentation for the administration of several medications on 6/18/24, including Melatonin, Tamsulosin, Trazadone, acetaminophen, and oxycodone. Additionally, there was no documentation for the administration of oxycodone on 6/19/24 at 10:00 p.m. The Corporate Support Nurse indicated that medication should be documented after administration unless an urgent issue arises, but it still needs to be documented. The facility's policy on documentation emphasizes that it should be completed at the time of service or no later than the shift in which the care service occurred, and false information should not be documented.
Failure in Transcription and Communication of Hospice Orders
Penalty
Summary
The facility failed to ensure proper transcription and communication of a hospice medication order for a resident receiving end-of-life care. The hospice provider had ordered morphine concentrate 20 mg/ml, 15 mg every 6 hours as needed for pain, but the facility's medication administration record (MAR) incorrectly indicated the medication should be given every 2 hours. As a result, the resident received four doses of morphine within a 10.5-hour period, exceeding the prescribed amount. This discrepancy was identified during a hospice visit, and new orders were communicated to the facility. Additionally, the facility did not effectively communicate or document a potential fall incident involving the resident. The resident was found deceased on the floor next to her bed, but the facility's progress note did not specify the position in which the resident was found or whether it was a result of a fall. The hospice note also failed to mention that the resident was found on the floor, and the hospice nurse was not informed of a potential fall during the report of the resident's death. Interviews with facility and hospice staff revealed a lack of communication regarding the resident's condition and the transcription error. The hospice nurse and clinical manager were unaware of the resident being found on the floor, and the facility's LPN confirmed the transcription error in the morphine order. The facility's policy on coordination of hospice services emphasizes the importance of communication and coordination between the facility and hospice provider, which was not adequately followed in this case.
Refrigerator Temperature Monitoring Deficiency
Penalty
Summary
The facility failed to ensure that refrigerator temperatures were monitored and maintained below 41 degrees Fahrenheit for two out of three refrigerators in the kitchen. During an observation, one refrigerator across from the walk-in refrigerator was found to have a temperature of 48 degrees Fahrenheit. Another refrigerator, located across from the dishwasher area and used for storing drinks, lacked an internal thermometer and was warm to the touch. Temperature logs for these refrigerators showed missing entries for several consecutive days, from June 19 to June 24, 2024. In an interview, the Dietary Manager and Dietitian confirmed that the drinks had been removed from the malfunctioning refrigerator, which was also noted to have a pan collecting a clear fluid underneath it. The facility's current policy on food safety requirements, dated 2024, mandates that staff inspect all food and beverages for safe transport and quality upon delivery and ensure timely and proper storage. It also requires monitoring food temperatures and the functioning of refrigeration equipment daily and at routine intervals during all hours of operation.
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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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