Casa Of Hobart
Inspection history, citations, penalties and survey trends for this long-term care facility in Hobart, Indiana.
- Location
- 4410 W 49th Ave, Hobart, Indiana 46342
- CMS Provider Number
- 155469
- Inspections on file
- 47
- Latest survey
- February 3, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Casa Of Hobart during CMS and state inspections, most recent first.
A resident receiving IV vancomycin for cellulitis had an initial vancomycin trough level that was low, and nursing documentation indicated a follow-up trough was to be obtained on a specified later date. However, no corresponding physician order for the follow-up trough was entered, and there was no evidence the lab test was completed. During interview, the ED and DON stated that a nurse had filled out a lab requisition but failed to enter the order, resulting in the vancomycin trough not being performed, while the resident had multiple comorbidities including DM, atrial fibrillation, and osteoarthritis.
Two residents dependent on staff for ADLs, including bathing, did not receive scheduled showers as required by their care plans. Documentation showed multiple missed showers without records of refusals or attempts, and interviews with the DON and Nurse Consultant confirmed the expectation for at least two showers per week.
An LPN was observed opening a Gabapentin capsule with bare hands and emptying its contents into a medication cup with other crushed medications for a resident, without using gloves. The ADON and DON both acknowledged the concern, with the DON stating the LPN thought it was acceptable to touch the capsule exterior.
A glucometer was not sanitized after use by an LPN before being stored, contrary to facility policy. In a separate incident, a CNA provided incontinence care to a resident on Enhanced Barrier Precautions for dialysis without wearing the required gown, despite clear signage and care plan instructions. Both actions failed to meet infection prevention and control protocols.
A resident with kidney failure, hypotension, and heart failure did not receive prescribed Midodrine on several occasions due to elevated BP readings, but there was no documentation that the physician was notified when the medication was held. An RN expressed uncertainty about administering the medication without clear parameters, and the DON acknowledged the issue.
An LPN failed to follow professional standards during a medication pass by preparing medications for one resident but administering them to another, without informing the surveyor of the switch. The error occurred after the LPN placed multiple residents' medication cups in the cart and later administered the wrong set, despite facility policy requiring medications to be given immediately after preparation and not pre-poured.
A resident with end stage renal disease, stroke history, and total dependence for ADLs did not receive timely incontinent care after activating the call light. The call was not answered for over 30 minutes, during which the resident remained soiled. The care plan indicated a risk for skin breakdown and required staff assistance for incontinence, but the delay in response resulted in a failure to provide prompt care.
Three residents did not receive care and treatment as ordered, including missed blood sugar checks, insulin doses not given, lack of documentation for omitted treatments, and administration of blood pressure medication despite low readings. The DON confirmed these lapses, and facility policy required adherence to prescriber orders.
Surveyors found that a medication cart contained multiple medications, including Albuterol sulfate inhalation packets and inhalers, that were not properly labeled or stored. An RN was unable to identify the intended residents for some medications, and some items lacked administration instructions. The DON confirmed a recent pharmacy audit but could not explain the labeling deficiencies.
A resident with multiple medical conditions and increased confusion had physician orders for a urinalysis due to suspected UTI. Despite education and attempts, the resident refused straight cath and a bedpan attempt was unsuccessful, with poor documentation of further attempts or refusals. The resident was later hospitalized with acute cystitis, and the DON confirmed documentation was lacking.
The facility failed to ensure proper medication storage and handling. An LPN left a medication cart unattended with pre-poured medications and keys on top. Pre-filled saline syringes were improperly stored in a resident's room. Unlabeled and undated insulin pens, loose pills, and unlabeled syringes were found in a medication cart, violating facility policy.
A long-term care facility was found deficient in infection control practices. An IV nurse improperly handled soiled gloves, a Nurse Practitioner failed to perform hand hygiene after glove removal, an LPN disposed of a lancet incorrectly, and a CNA did not follow Enhanced Barrier Precautions. These actions violated the facility's infection prevention policies, potentially compromising resident safety.
The facility was found to have multiple environmental deficiencies, including smeared feces on a room divider, feces-stained bed linen, marred walls, and missing toilet paper holders. Additionally, hot water temperatures exceeded safe levels, and a call light was not functioning. These issues were observed across all units during an environmental tour with the Maintenance Director.
A facility failed to assess a resident for self-administration of medication and did not have a physician's order for the resident to self-administer an Albuterol inhaler. The resident, who used the inhaler daily for rescue breathing, was cognitively intact but had no documented assessment or authorization for self-administration, contrary to facility policy.
A resident's privacy was compromised when an NP assessed their peg tube in a hallway, exposing the resident's stomach in a common area. The resident, who has a peg tube and complex medical history, was not moved to a private area for the assessment. The incident was reported to the NP's physician supervisor by the DON.
A resident reported a missing teal blue outfit to multiple staff members over two months, but no grievance form was filed, and the issue was not resolved. The resident, who is cognitively intact and uses a wheelchair due to hemiplegia, spoke with laundry staff who acknowledged the missing item but did not take further action. The DON confirmed that a grievance should have been filed.
A facility failed to inform a resident, who was cognitively intact, about new medications prescribed for high blood pressure and flu prophylaxis. Despite the resident's multiple health conditions, there was no documentation that they were made aware of changes in their medication regimen. Interviews with staff confirmed the oversight.
The facility failed to provide scheduled showers for two residents and supervised eating for another resident. One resident, who was cognitively intact, did not receive showers twice a week as required. Another resident, dependent on staff for ADLs, also missed scheduled showers. A third resident, requiring supervision for eating due to visual impairment and confusion, was observed eating unsupervised, posing a choking risk.
The facility failed to monitor and assess non-pressure skin conditions, post-surgical care, and blood pressure parameters for residents. A resident experienced double vision post-cataract surgery without documented follow-up, while another had a soiled bandage on a renal abscess drain site that was not changed as needed. Additionally, blood pressure medication was administered outside prescribed parameters.
A facility failed to administer pressure ulcer treatments and IV antibiotics as ordered for a resident with multiple medical conditions, including sepsis and pressure ulcers. Observations and records showed missed IV antibiotic doses and incomplete documentation of wound care treatments. Staff interviews confirmed the expectation to follow physician orders, but documentation gaps and missed treatments led to the deficiency.
A resident with end-stage renal disease and diabetes expressed multiple times that his toenails were too long and needed trimming. Despite being cognitively intact and aware of his needs, his requests were ignored, and his toenails remained unkempt. The last podiatry assessment was months prior, and no podiatry visits were recorded for January, with no documentation of a missed or rescheduled appointment.
The facility failed to secure smoking materials for two residents, who were found with vapes and cigarettes in their rooms, contrary to policy. Additionally, a resident with a history of falls did not have the prescribed bed halos installed, despite a recent fall. Both deficiencies were confirmed by staff interviews.
Two residents in an LTC facility experienced deficiencies in catheter care and infection control. One resident had a Foley catheter bag improperly positioned and tubing on the floor, with a CNA failing to perform hand hygiene and wear an isolation gown. Another resident reported inadequate catheter drainage and site care, with observations confirming a dirty catheter and dried blood. The facility's policies on catheter care and infection prevention were not followed, leading to potential risks for the residents.
The facility failed to document and provide adequate nutrition for two residents with weight loss histories. One resident, with multiple health issues, reported inadequate meal portions and significant weight loss, while another resident's meal consumption was not properly monitored, despite requiring a therapeutic diet and supplements. The facility did not adhere to its policy of documenting meal and supplement intake.
A facility failed to monitor a fluid restriction for a resident requiring dialysis. The resident, with conditions including end-stage renal disease, had a physician order limiting fluid intake to 1200 cc per day. However, there was no documentation of monitoring this restriction in the records for December and January. The DON confirmed the lack of documentation, despite the facility's policy requiring fluid management for such residents.
A resident with a history of anxiety, depression, kidney failure, and hypertension did not receive necessary dental services for decayed and broken teeth. Despite a dentist's recommendation for extractions over a year ago, there was no follow-up or dental care plan. The Social Service Director and DON confirmed the lack of follow-up.
A resident with depression and visual impairments was not provided with a personalized activity program, leading to distress and lack of engagement. Observations showed the resident often without stimulation, such as music or television, and no activity care plan was in place. The DON acknowledged the oversight.
A facility failed to offer a resident their prescribed inhaler during medication administration. An LPN administered five tablets but did not provide the inhaler, citing the resident's usual refusal. The DON stated the inhaler should have been offered, allowing the resident to choose whether to accept or refuse it.
A facility failed to monitor and document a resident's ongoing sexual behaviors adequately, leading to a deficiency in behavioral health care. The resident, with multiple diagnoses, exhibited inappropriate sexual actions, but documentation was inconsistent, with only one entry in POC charting and two Behavior Observations in 2024. Staff interviews revealed daily occurrences of inappropriate behaviors, yet behavior charting was lacking in the MAR and Nursing Notes.
The facility failed to provide timely medications for two residents. A resident did not receive prednisone as it was thought to be unavailable, though it was in the Capsa machine. Another resident was out of Miralax, which was not stocked in the Capsa machine, and the DON indicated it should be resident-specific. The physician was notified in both cases, and administration was approved upon medication arrival.
A facility failed to document a resident's discharge against medical advice (AMA) and did not provide necessary information for continuation of care. The resident, who had undergone cervical surgery, signed an AMA form but there was no record of notifying the physician, the resident's status at discharge, or if medication orders were provided. Staff interviews revealed communication and documentation lapses, with the facility's policy indicating no further obligation once a resident leaves AMA.
A resident's dignity was compromised when their foley catheter drainage bag was left uncovered and visible from the doorway on multiple occasions. Despite having a care plan due to chronic kidney disease and a pressure ulcer, the facility did not use a dignity bag to cover the drainage bag, as confirmed by a nurse consultant.
A facility failed to ensure a Physician's Order and assessment for self-administration of medications for a resident. An LPN left a medicine cup with Methadone pills for the resident, who self-administered the medication without an order. The resident's record showed no self-administration orders or assessments, despite facility policy requiring IDT determination for self-administration.
A facility failed to provide timely incontinence care for a resident dependent on staff for ADLs. The resident reported not being changed all day, and observations confirmed a saturated brief and wet blanket. The resident, with diagnoses including morbid obesity and heart failure, was cognitively intact but dependent on staff for toileting. Staff interviews revealed reliance on the resident to request changes, and the DON acknowledged the need for more timely care.
A facility failed to follow treatment orders for a resident with a non-pressure skin condition. The resident had a hydrocolloid bandage applied without an order, contrary to the physician's instructions to cleanse the area and apply betadine. The resident, who was cognitively intact and dependent on staff, had a history of morbid obesity, cellulitis, and heart failure. The Director of Nursing confirmed the treatment should have been completed as ordered.
A resident with a history of falls was observed with their bed at medium height instead of the lowest position as required by their care plan. The resident, who was moderately impaired and dependent on staff for mobility, had previously fallen out of bed and sustained injuries. Staff indicated the bed could be lowered further but was not due to concerns about the resident's foley catheter drainage bag touching the ground.
A resident with a history of UTIs and a suprapubic catheter had their drainage bag placed on the floor multiple times, despite requests for a wash basin to prevent this. The resident's care plan did not address this issue, and the facility failed to ensure the bag was properly positioned, leading to a deficiency.
A facility failed to ensure complete and accurate documentation of insulin administration for a resident with type 2 diabetes and vascular dementia. The resident's MAR showed missing signatures for insulin administration on several dates. The DON indicated that a QMA was unable to administer the insulin, and the nurse on duty did not sign the MAR as required by facility policy.
The facility failed to ensure employees reported allegations of abuse by an employee towards residents in the Memory Care Unit to the Administrator. Employee 7 was accused of making fun of residents, using derogatory names, and threatening staff to prevent reporting. Terminated Employee 6 claimed her hours were cut after reporting to the DON, who denied receiving any reports. The Administrator was only informed on the day of the interview and initiated an investigation.
A facility failed to ensure correct PPE use by a staff member when caring for a resident under Enhanced Barrier Precautions (EBP). The resident, with a urinary catheter, required gown and gloves as per facility policy. However, RN 8 only wore gloves, despite the EBP sign on the door, indicating a breach in protocol.
A resident with a history of a left femur fracture experienced a fall due to the facility's failure to timely implement care-planned interventions, specifically the installation of anti-roll back brakes on the resident's wheelchair. Despite being part of the fall prevention care plan, the brakes were not in place during several observations, leading to the resident's fall and subsequent injury.
A facility failed to properly assess and document a resident's urinary catheter care, leading to inconsistent records and lack of monitoring. The resident was admitted with a catheter, but the admission assessment incorrectly noted continence, and there were no physician orders or care plans for the catheter. CNA documentation varied, and interviews with staff revealed uncertainty about the catheter's presence. The facility's policy required catheter drainage bags to be emptied once per shift, but output monitoring was not completed.
A facility failed to ensure correct PPE use by staff during care for a resident under Enhanced Barrier Precautions (EBP). A CNA and Wound Nurse initially did not wear gowns as required, and the CNA touched clean surfaces with soiled gloves after providing care. The incident highlighted a lapse in adherence to EBP guidelines, despite staff training.
A resident, who required moderate assistance for toileting due to a stroke, was not assisted to the bathroom upon request. Despite activating the call light and informing staff of her need, she was told to wait and attempted to transfer herself, risking a fall. Eventually, a CNA assisted her, but the delay highlighted a failure in respecting the resident's dignity and care needs.
A resident with vascular dementia and bilateral amputations, requiring maximum assistance for toileting, did not receive timely incontinent care. Despite the resident's report of infrequent checks, staff delayed responding to her call light, resulting in prolonged neglect. The facility's incontinence policy was not followed, as evidenced by dried bowel movement and urine on the resident's bed linens.
A resident with a history of falls and a fractured left femur was found on the floor, complaining of hip pain. Initial X-rays showed no fractures, and follow-up assessments did not indicate injury. Days later, further imaging revealed a hip fracture, leading to hospital transfer. The facility failed to investigate the cause of the injury after the initial negative X-ray, contrary to their fall prevention policy.
The facility failed to implement fall prevention interventions for two residents. One resident, at high risk for falls, lacked a floor mat and anti-roll brakes on the wheelchair, despite these being care plan interventions. Another resident, with a history of falls, did not receive a required urinalysis after a fall, as confirmed by the DON and Corporate Nurse Consultant.
The facility failed to provide effective pressure ulcer prevention and care for two residents, resulting in one resident developing a stage four pressure ulcer requiring surgical debridement and another resident developing a stage three pressure ulcer with incomplete treatment documentation.
A resident with type 2 diabetes mellitus and asthma was observed self-administering an inhaler without a Physician's Order or a self-administration assessment. The facility's policy requires an Interdisciplinary Team to determine the safety of self-administration before allowing it.
The facility failed to notify a resident's Responsible Party of a new pressure ulcer, despite the resident having significant medical conditions and the facility's policies requiring such notification.
Failure to Complete Ordered Vancomycin Trough Laboratory Test
Penalty
Summary
The facility failed to ensure that ordered laboratory tests were completed as required when a vancomycin trough level was not obtained for one resident receiving IV vancomycin for cellulitis. The resident, who had diagnoses including cellulitis, diabetes mellitus, atrial fibrillation, and osteoarthritis and was cognitively intact with a need for moderate assistance with transfers, had a physician’s order dated 1/14/26 for vancomycin 1 gram IV daily. A lab result from the same date showed a vancomycin trough of less than 3.0, and a nurse’s note on 1/15/25 documented that the trough result was communicated to the pharmacy and that the next vancomycin trough should be done on 1/19/26. However, there was no corresponding physician’s order for the follow-up trough in the record and no indication that the trough was completed on 1/19/26. During interview, facility leadership reported that the nurse had filled out a lab requisition for the test but had not entered the order, and the test was not performed. The resident was later discharged to the hospital on 1/20/26 due to abnormal labs.
Failure to Provide Scheduled Showers for Dependent Residents
Penalty
Summary
The facility failed to ensure that activities of daily living (ADLs), specifically bathing, were completed for dependent residents. For one resident with diagnoses including epilepsy, psychotic disorder, hypertension, and alcohol dementia, records showed the resident was not cognitively intact and was dependent on staff for bathing. The care plan required staff assistance with ADLs, and the resident was scheduled to receive showers twice weekly. However, documentation revealed that showers were missed on multiple scheduled dates. Another resident, with diagnoses such as osteomyelitis, diabetes, COPD, asthma, and hypertension, was also dependent on staff for bathing, toileting, personal hygiene, and oral hygiene. The care plan specified assistance with bathing, offering showers at least twice weekly, and providing a bed bath on non-shower days or upon refusal. Documentation indicated that this resident did not receive showers on numerous dates, and there was no record of refusals or attempts to offer showers. Interviews with the DON and Nurse Consultant confirmed the expectation for at least two showers per week and acknowledged the lack of documentation for missed showers.
Failure to Use Gloves During Medication Administration
Penalty
Summary
During a medication administration observation, an LPN was seen opening a Gabapentin 300 mg capsule with her bare hands and emptying the powder contents into a medication cup along with another crushed medication for a resident who received medications in crushed form. The LPN did not use gloves while handling the medication capsule. The Assistant Director of Nursing acknowledged awareness of the concern but did not provide additional information. The Director of Nursing also acknowledged the issue, noting that the LPN believed it was acceptable to touch the outside of the capsule as long as the inside contents were not touched.
Failure to Sanitize Glucometer and Adhere to Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain a safe and sanitary environment to prevent the transmission of communicable diseases and infections. During an observation, an LPN performed a glucometer test on a resident and, after completing the test, did not sanitize the glucometer before placing it back in the medication cart. The LPN acknowledged that the glucometer should be sanitized after each use, and the facility's policy confirmed that cleaning and disinfecting between each resident test was required. Additionally, a CNA provided incontinence care to a resident who was under Enhanced Barrier Precautions (EBP) without donning the required gown, despite a sign indicating EBP was necessary. The CNA was unsure which resident required EBP and proceeded with care using only gloves. The resident's records indicated diagnoses including end stage renal disease and dialysis, with care plans and physician orders specifying the need for EBP, including gown and gloves for high-contact care activities. The facility's EBP protocol also required these precautions during dressing, bathing, and other high-contact activities.
Failure to Notify Physician When Medication Was Held
Penalty
Summary
The facility failed to notify a resident's physician when a prescribed medication, Midodrine, was held on multiple occasions. The resident, who had diagnoses including kidney failure, hypotension, and heart failure, was cognitively intact and had a physician's order for Midodrine 5 mg three times daily for hypotension. On specific dates, the medication was not administered due to elevated blood pressure readings, as documented in the Medication Administration Record and nurses' notes. Despite the medication being withheld, there was no documentation that the resident's physician was informed of these omissions. During interviews, an RN expressed uncertainty about administering the medication due to the absence of specific parameters and confirmed that the dose was held when the resident's blood pressure was in the 150s. The Director of Nursing acknowledged the concern but did not provide additional information.
Failure to Ensure Medication Administration Met Professional Standards
Penalty
Summary
During a medication pass observation, an LPN prepared morning medications for one resident, which included potassium, a multivitamin, Cinacalcet, vitamin D, amlodipine, clonazepam, and hydrocortisone. After preparing the medications and placing them in a plastic cup, the LPN locked the cup in the medication cart to retrieve a glucometer. Upon returning, the LPN took a medication cup from the cart and administered the medications to the resident in the bed closest to the door, giving approximately half the medications at a time. The LPN then checked the resident's blood sugar and documented the administration in the Medication Administration Record (MAR). A subsequent review revealed that the resident who received the medications was not the intended recipient for whom the medications were prepared. The LPN had previously set up medications for another resident and, upon returning to the cart, mistakenly administered those medications instead. The LPN did not inform the surveyor of the switch during the observation. Facility policy required adherence to the five rights of medication administration and specified that medications should be administered at the time they are prepared and not pre-poured. The LPN had completed orientation to the medication pass routine prior to the incident.
Delay in Responding to Call Light for Dependent Resident Needing Incontinent Care
Penalty
Summary
A deficiency was identified when a dependent resident did not receive timely assistance with incontinent care. Observation showed that the resident's call light was activated at 5:15 a.m., but was not answered until 5:47 a.m. by the DON, who found the resident had experienced a bowel movement and required care. A CNA began providing care at 5:49 a.m. The resident's medical record indicated diagnoses including end stage renal disease requiring dialysis and a history of stroke, with a care plan noting risk for skin breakdown and the need for assistance with incontinent care. The resident was documented as always incontinent of bowel and bladder and dependent for all ADLs. The DON confirmed that care was provided after the call light was answered and had no further information regarding the delay.
Failure to Administer Medications and Monitor Blood Sugars as Ordered
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders and residents' needs for three residents with diabetes and hypotension. For one resident with insulin-dependent diabetes, there were multiple instances where blood sugar levels were not monitored as ordered, insulin doses were not administered, and there was a lack of documentation explaining these omissions. In several cases, when blood sugar readings were outside of the prescribed parameters, there was no evidence that the physician was notified, and in at least one instance of low blood sugar, there was no documentation of treatment, rechecking, or physician notification as required by facility guidelines. Another resident with diabetes had physician orders for blood sugar checks and insulin administration based on a sliding scale. The record showed that on several occasions, midday blood sugars were not checked and insulin was not administered, with no documentation in the nurses' notes to explain these omissions. The Director of Nursing confirmed that these required checks and treatments were not completed as ordered. A third resident with a diagnosis of hypotension had a physician order to hold a specific blood pressure medication if the blood pressure was below a certain threshold. Despite this, the medication was administered on multiple occasions when the resident's blood pressure was below the ordered limit. The Director of Nursing acknowledged that the medication should not have been given under these circumstances. The facility's medication administration policy required medications to be given in accordance with prescriber orders, which was not followed in these cases.
Improper Labeling and Storage of Medications on Medication Cart
Penalty
Summary
Surveyors observed that the Cherry Lane medication cart contained multiple medications that were not properly labeled or stored. Specifically, nine Albuterol sulfate inhalation packets in the bottom drawer lacked any labeling, and the RN present was unable to identify which residents they belonged to. Additionally, two inhalers in the top drawer had no name or label, and another inhaler was labeled only with a resident's name and room number but lacked administration instructions. An additional Albuterol sulfate inhalation packet in the top drawer was also found without a label. The RN was unsure why these medications were not labeled, despite a recent audit of the cart, and the DON confirmed that the pharmacy had recently audited all medication carts but could not provide further information.
Failure to Obtain and Document Ordered Urinalysis for Resident with Suspected UTI
Penalty
Summary
The facility failed to ensure that a urinalysis (UA) was collected as ordered for a resident with diagnoses including cellulitis, diabetes, and heart failure, who was cognitively intact. The resident's daughter reported increased confusion and suspected a urinary tract infection (UTI). Multiple physician orders were placed to obtain a UA due to the resident's altered mental status and increased confusion. Documentation shows that the resident was educated on the need for a urine sample and refused a straight catheterization, agreeing only to use a bedpan. Attempts to collect a sample were unsuccessful, including a bedpan spill and further refusals of straight catheterization. There was a lack of documented attempts, refusals, or notifications regarding obtaining the urine sample during several days in the period when the UA was ordered. The Director of Nursing acknowledged that refusals and education provided to the resident were not well documented. The resident was later admitted to the hospital with a primary diagnosis of acute cystitis. The deficiency centers on the facility's failure to ensure timely collection and documentation of the ordered laboratory test and communication with the practitioner.
Medication Storage and Handling Deficiencies
Penalty
Summary
The facility failed to ensure proper medication storage and handling, as observed during a survey. On one occasion, an unattended medication cart was found with pre-poured medications labeled only with residents' first names, medication cart keys, and various medications left unsecured on top of the cart. An LPN admitted to leaving these items unattended while using the bathroom, acknowledging the error in pre-pouring medications. The Director of Nursing confirmed that pre-pouring medications was against facility policy. Additionally, pre-filled saline syringes were improperly stored in a resident's room, contrary to the facility's medication storage policy, which mandates that all medications be stored in a locked cart. Further observations revealed unlabeled and undated insulin pens, loose pills, and unlabeled syringes in a medication cart. The Director of Nursing indicated that these items needed to be disposed of and confirmed that insulin pens should be labeled with the resident's name and date opened, as per the facility's policy.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure proper infection control practices were implemented, as evidenced by multiple observations of staff not adhering to established protocols. In one instance, an IV nurse was observed leaving a resident's room wearing soiled gloves, walking down the hallway, and discarding them improperly at the nurses' station. This occurred despite the resident being on contact isolation due to an ESBL infection. The nurse's actions were contrary to the facility's infection prevention and control program, which mandates the appropriate disposal of personal protective equipment before leaving a resident's room. Another deficiency was noted when a Nurse Practitioner (NP) failed to perform hand hygiene after glove removal while examining a resident's PEG tube. The NP donned gloves without sanitizing her hands, touched the resident's PEG tube, and discarded the gloves without performing hand hygiene. This was a direct violation of the facility's policy, which requires hand hygiene before and after glove use, especially when moving from a contaminated to a clean site. Additionally, an LPN improperly disposed of a used lancet in a resident's room garbage can instead of a sharps container, as required by the facility's policy. Furthermore, a CNA failed to follow Enhanced Barrier Precautions (EBP) while emptying a resident's Foley catheter, neglecting to wear an isolation gown despite the resident being on EBP due to the presence of wounds and a PICC line. These actions demonstrate a lack of adherence to infection control protocols, potentially compromising resident safety.
Environmental Deficiencies in Facility
Penalty
Summary
The facility failed to maintain a clean and well-repaired environment for residents, staff, and the public, as observed during an environmental tour with the Maintenance Director. Issues identified included smeared feces on a room divider shared by two residents, feces-stained bed linen in a shared room, and marred walls in various rooms. Additionally, several rooms had marred and dirty heat registers, missing toilet paper holders, and cracked ceiling tiles. A call light was found not working, and hot water temperatures exceeded 120 degrees in multiple units, posing potential safety risks. The Maintenance Director acknowledged these deficiencies during the tour, noting that the hot water heater had been set higher due to a recent pipe burst in the kitchen. The report highlights that these issues were present across all five units of the facility, including Cherry Lane, Cherry Court, Blueberry Lane, Apple Lane, and Bakersfield Lane. The citation tag relates to specific complaints, indicating that these environmental concerns were part of ongoing issues within the facility.
Failure to Assess and Authorize Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a resident was properly assessed and had a physician's order to self-administer medication. During multiple observations, an Albuterol hand-held inhaler was seen on the over-bed table of a resident, identified as Resident G, who used it for rescue breathing at least daily. Despite the resident's cognitive intactness for daily decision-making, as indicated in the 11/14/24 Quarterly Minimum Data Set assessment, there was no documented self-administration assessment or physician's order allowing the resident to self-administer the inhaler. The resident's medical history included COPD, acute respiratory failure, Alzheimer's disease, anxiety disorder, high blood pressure, and bipolar disorder. The care plan, revised on 5/14/24, noted the resident's risk for complications due to COPD and included approaches for administering bronchodilators as ordered. However, the facility's policy required the Interdisciplinary Team (IDT) to determine the resident's capacity to self-administer medications, which was not done in this case. The Director of Nursing had no additional information to provide regarding the oversight.
Resident Privacy Breach During Medical Assessment
Penalty
Summary
The facility failed to maintain the privacy of a resident during a medical assessment conducted by a Nurse Practitioner (NP). The incident involved Resident C, who was observed in a common area when the NP assessed the resident's peg tube in the hallway, exposing the resident's stomach and peg tube to public view. This assessment was conducted without moving the resident to a private area, compromising the resident's privacy. Resident C has a complex medical history, including a peg tube for nutrition, falls, dysphagia, type 2 diabetes, palliative care, Parkinson's disease, psychotic disorder, severe dementia with agitation, high blood pressure, restlessness, and agitation. The resident is not cognitively intact and relies on staff for most activities of daily living. The NP did not provide additional information during an interview, and the Director of Nursing reported the incident to the NP's physician supervisor.
Failure to Address Resident Grievance for Missing Personal Items
Penalty
Summary
The facility failed to honor a resident's right to voice grievances without discrimination or reprisal, as required by regulations. Resident 23, who is cognitively intact and uses a wheelchair due to hemiplegia, reported a missing teal blue outfit to multiple staff members over a period of more than two months. Despite her efforts, no grievance form was filed, and the issue was not resolved. The resident had spoken with laundry staff, who acknowledged the missing item but did not take further action to file a grievance or replace the clothing. The Director of Nursing confirmed that a grievance should have been filed for the missing items.
Failure to Inform Resident of New Medications
Penalty
Summary
The facility failed to ensure that residents were involved in decisions about their care, specifically regarding the communication of new medications. Resident D, who was cognitively intact and required assistance with daily activities, reported not being informed about new medications or physician's orders. The resident's medical record, reviewed on January 22, 2025, showed multiple diagnoses, including acute respiratory failure, COPD, type 2 diabetes, heart failure, high blood pressure, chronic kidney disease, osteoarthritis, and depression. Despite new physician's orders for medications such as Amlodipine, Losartan Potassium, and Tamiflu, there was no documentation indicating that Resident D was informed of these changes. Interviews with the Unit Manager and the Director of Nursing confirmed the lack of documentation regarding the resident's awareness of the new medication regimen.
Failure to Provide Scheduled Showers and Supervised Eating
Penalty
Summary
The facility failed to ensure that activities of daily living (ADLs) were completed for dependent residents, specifically in providing showers and assistance with eating. Resident D, who was cognitively intact and required substantial assistance with bathing, reported not receiving showers on scheduled days. The record review confirmed that Resident D did not receive showers at least twice a week for several months. Similarly, Resident C, who was not cognitively intact and dependent on staff for ADLs, did not receive the scheduled showers twice a week as documented in the care plan. Resident E, who was cognitively intact but required supervision for eating due to impaired visual function and other health issues, was observed eating unsupervised, resulting in a potential choking hazard. The resident was experiencing increased confusion and had a recent physician's order for IV antibiotics due to a urinary tract infection. The Director of Nursing acknowledged that Resident E should have had supervised meal consumption. These deficiencies were identified during a complaint investigation.
Deficiencies in Resident Monitoring and Care
Penalty
Summary
The facility failed to ensure proper monitoring and assessment of non-pressure skin conditions, blood pressure parameters, and post-surgical care for residents. Resident G, who had undergone cataract surgery, reported experiencing double vision but there was no documentation of her surgery or any post-operative assessment and monitoring in her clinical record. Despite having physician's orders for post-surgery eye drops, there was no evidence of a care plan for her vision or any follow-up assessments after her surgeries. Resident 82 was observed with a soiled and foul-smelling bandage on his lower back, indicating a lack of proper wound care. The bandage, which covered a drain site for a renal abscess, had not been changed or monitored as required. The Wound Nurse confirmed that the bandage had not been changed prior to the observation, and the treatment was scheduled on an as-needed basis, which led to it being overlooked. The resident's medical records showed multiple instances where the drain site was not monitored as per the physician's orders. Additionally, the facility failed to adhere to blood pressure medication administration guidelines for Resident 82. The resident was prescribed Midodrine with specific blood pressure parameters, but the medication was administered even when the resident's blood pressure readings exceeded the prescribed limits. This oversight was not addressed by the Unit Manager, and there was no additional information provided regarding the medication administration issue.
Failure to Administer Pressure Ulcer Treatments and IV Antibiotics as Ordered
Penalty
Summary
The facility failed to ensure that pressure ulcer treatments and intravenous (IV) antibiotics were administered as ordered for a resident with multiple medical conditions, including sepsis, osteomyelitis, and pressure ulcers. Observations revealed that the resident, who had a peripherally inserted central catheter (PICC) line, did not receive IV antibiotics as scheduled. Specifically, there were instances where the IV antibiotics were not administered, and the medication administration record (MAR) was not signed to indicate that the antibiotics were given. The resident's care plan, which was revised to address skin impairments and the need for IV medication, was not followed as prescribed. The treatment administration record (TAR) showed multiple instances where pressure ulcer treatments were not documented as completed. The resident had several stage 3 pressure ulcers that were present on admission and had not healed, requiring specific wound care treatments that were not consistently administered. Interviews with facility staff, including the wound nurse and unit manager, confirmed that treatments and IV antibiotics were expected to be administered as ordered by the physician. However, the facility's failure to adhere to these orders was evident in the documentation gaps and missed treatments. The facility's policy required staff to initial the electronic TAR after each treatment, which was not consistently done, leading to the deficiency.
Failure to Provide Necessary Podiatry Care
Penalty
Summary
The facility failed to provide necessary foot care for a resident, identified as Resident 69, who was reviewed for podiatry care. On multiple occasions, the resident expressed a desire to have his toenails cut, indicating that they were too long and unkempt. Despite his repeated requests to staff members, his toenails remained untrimmed. The resident, who was cognitively intact, emphasized that he was aware of his needs and felt his requests were being ignored. Observations confirmed that his toenails were indeed long and unkempt. The resident's medical record revealed diagnoses including end-stage renal disease, dependence on renal dialysis, and type 2 diabetes mellitus with diabetic nephropathy. The last podiatry assessment, dated several months prior, indicated that the toenails were trimmed and debrided to the resident's tolerance, with a recommendation for recall as medically necessary but no sooner than 60 days. However, there were no podiatry visits recorded for January 2025, and the Social Service Consultant confirmed the absence of documentation for a missed or rescheduled podiatry appointment during that time.
Failure to Secure Smoking Materials and Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure that smoking materials were securely stored and not kept in residents' rooms, as observed with two residents. Resident G was found with a vape on her bed, which she admitted to keeping with her at all times, despite facility policy requiring smoking materials to be stored by the facility. Resident F was observed with two vapes, three packs of cigarettes, and two lighters in his nightstand drawer, even though he was not currently smoking due to cold weather. Both residents were cognitively intact, and their records indicated a need for the facility to store their smoking materials, yet these items were found in their possession. Additionally, the facility failed to implement necessary fall prevention measures for Resident H, who had a history of repeated falls. The resident's bed was observed without the prescribed halos, a bed mobility assist device, despite a recent fall where the resident slid out of bed. The interdisciplinary team had identified the need for halos as a new intervention to prevent further falls, but this intervention was not in place during observations. The Director of Nursing confirmed that the halos should have been installed to prevent falls.
Deficiencies in Catheter Care and Infection Control
Penalty
Summary
The facility failed to ensure proper care and maintenance of Foley catheters and adherence to Enhanced Barrier Precautions (EBP) for two residents. Resident 82 was observed multiple times with a Foley catheter bag improperly positioned on the arm of a wheelchair, above the waist, and with tubing on the floor. A CNA was observed emptying the catheter without performing hand hygiene and using inappropriate equipment, such as a wash basin instead of a urinal. The CNA also failed to wear an isolation gown despite the resident being on contact isolation due to ESBL in the urine. The resident's care plan indicated the need for contact isolation and proper positioning of the catheter bag, which was not followed. Resident 49 reported that staff did not drain his catheter bag regularly and had to call 911 for catheter exchange due to obstruction. Observations revealed a dirty catheter with dried blood around the insertion site, indicating a lack of proper site care. The resident's care plan required catheter care every shift, which was not adhered to, as evidenced by the resident's complaints and the condition of the catheter site. The Treatment Administration Record (TAR) indicated that catheter care was signed off as completed, despite evidence to the contrary. Interviews with the Director of Nursing and Unit Manager confirmed the deficiencies in catheter care and adherence to infection control protocols. The facility's policies on urinary catheter care and infection prevention were not followed, leading to potential risks for the residents involved. The lack of proper catheter care and failure to maintain EBP contributed to the deficiencies observed during the survey.
Deficiency in Nutritional Monitoring and Documentation
Penalty
Summary
The facility failed to ensure proper documentation and provision of food and supplements for residents with a history of weight loss, specifically affecting two residents. Resident F, who had multiple diagnoses including sepsis, osteomyelitis, and pressure ulcers, reported significant weight loss and inadequate meal portions, particularly at breakfast. Despite a physician's order for double portions, meal consumption logs showed numerous instances where meals were not documented, indicating a lack of monitoring and recording of the resident's nutritional intake. This oversight contributed to Resident F's weight dropping from 112 pounds to 92 pounds over a short period. Similarly, Resident 82, who had conditions such as acute myocardial infarction and end-stage renal disease, was observed with an untouched lunch tray, suggesting a lack of consumption monitoring. The resident's care plan required a therapeutic diet and renal liquid supplements, yet the meal logs frequently lacked documentation of meal consumption, and the Medication Administration Record did not specify the amount of supplement consumed. The facility's policy required detailed documentation of meal and supplement intake, which was not adhered to, leading to deficiencies in nutritional monitoring for both residents.
Failure to Monitor Fluid Restriction for Dialysis Resident
Penalty
Summary
The facility failed to monitor a fluid restriction for a resident who required dialysis. Resident 82, who was admitted with diagnoses including acute myocardial infarction, renal dialysis, and end-stage renal disease, was identified as being at risk for altered fluid balance due to dialysis and fluid restriction. A physician order dated 12/8/24 specified a daily fluid intake limit of 1200 cc, divided between dietary and nursing. However, there was no documentation in the Medication Administration or Treatment Administration Records for December 2024 and January 2025 to indicate that the nursing staff monitored or accounted for the fluid restriction. During an interview, the Director of Nursing confirmed the absence of documentation regarding the monitoring of the fluid restriction, despite the facility's policy requiring such management for residents with fluid restrictions.
Failure to Provide Routine Dental Services
Penalty
Summary
The facility failed to ensure that a resident received necessary dental services for decayed and broken teeth. Resident 73, who is cognitively intact and has a medical history including anxiety disorder, depression, kidney failure, and hypertension, reported that the facility was supposed to follow up with a dentist after she cracked her tooth. Although a dentist had recommended an extraction over a year ago, there was no follow-up. The resident's record showed a Dental Note from November 2023 indicating the need for an oral surgeon for extractions, but no dental care plan was in place. A Social Service Note from December 2023 mentioned awaiting a response from the oral surgeon, but by January 2025, there was no documentation of any follow-up appointment. Interviews with the Social Service Director and the Director of Nursing confirmed the lack of follow-up and additional information.
Failure to Provide Personalized Activity Program for Resident
Penalty
Summary
The facility failed to provide a personalized activity program for a cognitively impaired and dependent resident, identified as Resident 81. Observations over several days revealed that the resident was often left without any form of stimulation, such as television or music, and was not actively engaged in activities. The resident was seen crying, rocking back and forth, and screaming, indicating distress and a lack of engagement. Despite the presence of an Activity Director, there was no evidence of a personalized activity care plan for the resident, and the last documented one-on-one activity session occurred several days prior to the observations. The resident's medical history included depression, muscle weakness, cataracts, and encephalopathy, and she required varying levels of assistance with daily activities. Despite being cognitively intact for daily decision-making, the resident was not provided with adequate stimulation or invited to participate in activities, as confirmed by both family interviews and staff acknowledgment. The Director of Nursing recognized the oversight, noting that music or television should have been provided to the resident.
Failure to Offer Prescribed Inhaler to Resident
Penalty
Summary
The facility failed to ensure that a resident was given the opportunity to participate in their treatment, specifically regarding medication administration. During an observation, an LPN prepared and administered five tablets to a resident but did not offer the resident their prescribed inhaler, Anora Ellipta, which is used to treat chronic obstructive pulmonary disease. The LPN noted that the resident always refused the inhaler and therefore did not offer it. However, the Director of Nursing indicated that the inhaler should have been offered to the resident, allowing them the choice to accept or refuse it. This incident was related to a specific complaint investigation.
Inadequate Monitoring and Documentation of Resident's Sexual Behaviors
Penalty
Summary
The facility failed to adequately monitor and document the behaviors of a resident with ongoing sexual behaviors, leading to a deficiency in providing necessary behavioral health care and services. Resident C, who had diagnoses including multiple sclerosis, tachycardia, and mood disorder, exhibited inappropriate sexual behaviors, such as entering another resident's room and engaging in inappropriate actions. Despite being cognitively intact and requiring supervision for certain activities, the resident's behaviors were not consistently documented in the Medication Administration Record (MAR) or Nursing Notes, as required. The facility's documentation was insufficient, with only one entry related to sexual inappropriateness in the POC charting from 11/5/24 to 12/18/24, and only two Behavior Observations recorded in 2024. Interviews with staff revealed that the resident's inappropriate behaviors occurred almost daily, yet there was a lack of consistent behavior charting. The Regional Nurse Consultant indicated that behavior charting should be documented in the MAR or Nursing Notes, but the Director of Nursing noted that behaviors were charted in the aides' POC charting. The deficiency was highlighted by the lack of documentation and monitoring of the resident's behaviors, despite the resident's ongoing sexually inappropriate actions and the need for psychiatric monitoring and stabilization.
Medication Availability Issues for Two Residents
Penalty
Summary
The facility failed to ensure timely availability of medications for two residents during medication administration. For Resident G, a Qualified Medication Aide (QMA) discovered that the resident was out of prednisone 5 mg tablets. The QMA indicated she would notify the nurse. Later, a Licensed Practical Nurse (LPN) confirmed that prednisone was available in the Capsa machine, but the resident had not received it. The Director of Nursing (DON) was informed and ordered the medication from the pharmacy, notifying the physician who approved administration upon arrival. For Resident H, the QMA found that Miralax was unavailable and planned to inform the nurse. The LPN mentioned that Miralax was usually kept as house stock in the medication room, but the DON stated it should be resident-specific and was not stocked in the Capsa machine. A medication note indicated that the physician was notified and approved administration upon arrival. The facility's current medication administration policy requires notification of the attending physician, resident, and responsible party if a drug is unavailable.
Failure to Document AMA Discharge and Provide Continuation of Care Information
Penalty
Summary
The facility failed to properly document a resident-initiated discharge against medical advice (AMA) and did not provide necessary information for the resident's continuation of care. Resident B, who had undergone an anterior cervical discectomy and fusion, was admitted to the facility and later signed a Release of Responsibility for Discharge Against Advice form. However, there was no documentation indicating that the attending physician was notified of the resident's request for an AMA discharge. Additionally, there was no record of the resident's status at the time of discharge, with whom the resident left, or if current medication orders were provided for the resident's continued care. Interviews with facility staff revealed a lack of communication and documentation regarding the AMA discharge. The Director of Nursing (DON) acknowledged the absence of documentation in the progress notes and confirmed that the physician had not been informed of the impending discharge. LPN 1, the nurse on duty, was not aware of the discharge until the following day and indicated that Unit Manager (UM) 2 was supposed to handle the documentation, which UM 2 denied. The facility's policy stated that once a resident leaves AMA, the facility is under no further obligation, and all medications should be returned to the pharmacy. This incident was related to a specific complaint, IN00442760.
Failure to Cover Foley Catheter Drainage Bag
Penalty
Summary
The facility failed to maintain the dignity of a resident, identified as Resident H, by not covering the foley catheter drainage bag, which was visible from the doorway. Observations were made on multiple occasions over three consecutive days, where the resident was seen in their room with the catheter drainage bag containing yellow urine clearly visible. This lack of coverage was noted during observations at various times of the day, indicating a consistent oversight in maintaining the resident's dignity. Resident H's medical record indicated diagnoses of chronic kidney disease and a pressure ulcer of the sacrum, necessitating the use of a foley catheter. The resident was assessed as moderately impaired for daily decision-making and had an indwelling catheter as per the Quarterly Minimum Data Set assessment. A care plan was in place due to the risk of complications from the catheter use. Despite these considerations, the facility did not ensure the catheter drainage bag was covered, as confirmed by a nurse consultant who acknowledged that a dignity bag should have been used to cover the drainage bag.
Failure to Ensure Physician's Order for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure a Physician's Order for self-administration of medications and an assessment to self-administer medications was completed for Resident B. On the specified date, an LPN was observed leaving a medicine cup with 14 white circular pills on the bedside table in Resident B's room and then walked out, allowing the resident to self-administer the medication. During an interview, Resident B confirmed that the pills were Methadone and that they always took the medication independently. The LPN admitted to walking away from the resident during medication administration and acknowledged that there was no self-administration order for the resident. Resident B's medical record indicated diagnoses including end-stage renal disease, diabetes, hypertension, and renal dialysis, with a cognitive status noted as intact. A Physician's Order dated prior to the incident specified the administration of Methadone HCl, a narcotic pain medication, but did not include any orders for self-administration. Additionally, there were no assessments completed for the resident's self-administration of medications. The facility's policy required that self-administration of medications be determined by the Interdisciplinary Team, which was not adhered to in this case.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for a resident who was dependent on staff for activities of daily living. During an interview, the resident reported not being checked or changed every two hours and stated they had not been changed all day. Observations confirmed that the resident's brief was saturated with urine, and the bath blanket underneath was wet. The resident indicated that this was the first time they were changed for the day, with the last change occurring around 2:00 a.m. The resident's record showed diagnoses including morbid obesity, cellulitis, and heart failure, and the resident was cognitively intact but dependent on staff for toilet transfers and frequently incontinent. The care plan required assistance with ADLs, including toileting. Interviews with staff revealed that the assigned CNA had not provided incontinence care, relying on the resident to request changes. The Director of Nursing acknowledged that care should have been provided more timely, and the facility's policy required necessary services for toileting and elimination.
Failure to Follow Treatment Orders for Non-Pressure Skin Condition
Penalty
Summary
The facility failed to ensure that treatments were completed as ordered for a resident with a non-pressure skin condition. During an observation, it was noted that the resident had a hydrocolloid bandage on the left ischial area, which was dated a day prior. The CNA and LPN present confirmed the date on the dressing. However, the resident's medical record indicated a physician's order for a different treatment: cleansing the area with normal saline or wound cleanser, applying betadine, and leaving it open to air daily. This treatment was documented as completed on the day the hydrocolloid dressing was observed, despite no order for such a dressing being present. The resident, who was cognitively intact and dependent on staff for toilet transfers, had a history of morbid obesity, cellulitis, and heart failure. The wound was identified as non-pressure and resulting from trauma, with specific instructions for betadine application. A subsequent review by the wound physician led to a new order for hydrocolloid dressing, but this was after the initial observation. The Director of Nursing acknowledged that the treatment should have been completed as originally ordered.
Failure to Implement Fall Interventions for Resident
Penalty
Summary
The facility failed to ensure fall interventions were in place for a resident with a history of falls. Resident H, who was moderately impaired for daily decision-making and dependent on staff for transfers and bed mobility, was observed in their room with the bed positioned at medium height instead of the lowest position as required by their care plan. The care plan, dated 1/22/24 and reviewed on 6/1/24, indicated that the bed should be in the lowest position to prevent falls. However, observations on 8/14/24 and 8/15/24 showed the bed was not consistently in the low position, and the resident was able to adjust the bed height on their own. The resident had a history of falls, including an incident on 7/29/24 where they fell out of bed while reaching for the trash can. On 8/3/24, the resident was found on the floor with a one-inch laceration next to the left eyelid, requiring emergency room evaluation and sutures. During an interview, CNA 2 indicated that the bed could go lower but was not lowered all the way to prevent the resident's foley catheter drainage bag from touching the ground. Nurse Consultant 1 acknowledged that the bed should be in a low position and mentioned updating the care plan to reflect the resident's ability to adjust the bed height.
Improper Placement of Urinary Catheter Drainage Bag
Penalty
Summary
The facility failed to ensure proper care for a resident with a urinary catheter, leading to a deficiency. Resident F, who has a history of urinary tract infections and uses a suprapubic catheter, was observed with their catheter drainage bag placed on the floor on multiple occasions. The resident reported that the midnight shift did not empty the drainage bag or remove it from the floor. Despite the resident's request for a wash basin to prevent the bag from resting on the floor, this was initially denied. Observations on consecutive days confirmed that the drainage bag was either full or had been emptied but remained on the floor. The resident's medical records indicated a diagnosis of acute pyelonephritis and neuromuscular dysfunction of the bladder, with a care plan that included positioning the catheter bag below the bladder level. However, there was no specific care plan addressing the issue of the drainage bag being placed on the floor. The resident was receiving antibiotic treatment for a urinary infection, and nurses' notes documented the resident's preference for placing the bag on the floor for better drainage. The Director of Nursing acknowledged the lack of prior documentation regarding the resident's request for a wash basin.
Incomplete Insulin Administration Documentation
Penalty
Summary
The facility failed to ensure that clinical records were complete and accurately documented regarding insulin administration for a resident with type 2 diabetes and vascular dementia. The resident's care plan indicated a risk for complications related to diabetes, with interventions including diabetes medication as ordered by the physician. A physician's order specified that the resident was to receive Lantus insulin 10 units at bedtime. However, the Medication Administration Record (MAR) for July 2024 showed that the insulin was not signed out as administered on four specific dates. During an interview, the Director of Nursing (DON) revealed that a Qualified Medication Aide (QMA) was working the hall and could not administer the insulin, and the nurse on duty who administered the insulin did not sign it out on the MAR. The facility's medication administration policy required the individual administering the medication to initial the MAR after giving each medication.
Failure to Report Allegations of Abuse in Memory Care Unit
Penalty
Summary
The facility failed to ensure that employees reported allegations of abuse by an employee towards residents in the Memory Care Unit to the Administrator. This failure potentially affected 18 residents. During interviews, it was revealed that Employee 7 was accused of making fun of residents, using derogatory names, and threatening other staff members to prevent them from reporting her actions. Terminated Employee 6 reported that Employee 7 would use foul language, refuse to provide care, and make residents feel unwanted by their families. Despite these allegations, Terminated Employee 6 claimed that when she reported the abuse to the DON, her hours were cut, and her holiday pay was removed, and she was told to report it to the DON instead of the Administrator. The DON denied receiving any reports of abuse from Terminated Employee 6 and stated that any reported abuse would have been escalated to the Administrator and the Indiana Department of Health for investigation. The Administrator confirmed that she was only made aware of the allegations on the day of the interview and had initiated a full investigation. The facility's abuse policy requires employees to report any incidents or suspicions of abuse to the Administrator immediately, without fear of retaliation, and allows them to report directly to the state survey agency. The report relates to specific complaints filed against the facility.
Failure to Use Correct PPE for Resident Under Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure the correct use of Personal Protective Equipment (PPE) by a staff member, RN 8, when providing care to a resident, Resident D, who was under Enhanced Barrier Precautions (EBP). During an observation, RN 8 was seen handling a clear garbage bag containing an indwelling urinary catheter and drainage bag without wearing a gown, despite the EBP sign on the resident's door indicating that both gown and gloves were required. Resident D had an indwelling urinary catheter, as per a physician's order, and was diagnosed with a fracture of the left femur. The facility's policy, dated 3/20/24, required the use of gown and gloves for residents with indwelling medical devices, such as urinary catheters.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure that care-planned interventions to prevent falls were implemented in a timely manner for a resident. The deficiency was identified when it was observed that anti-roll back brakes were not installed on the resident's wheelchair, despite being a part of the fall prevention care plan. The resident, who had a history of a left femur fracture, was found on the floor between two nightstands, and later complained of left hip and leg pain. An X-ray initially showed no fractures, but a subsequent hospital X-ray confirmed a left femoral neck fracture. The care plan had been updated to include the use of anti-roll back brakes following the fall incident, but these were not in place during multiple observations. The Director of Nursing acknowledged that the brakes had been ordered but were not yet available, as indicated by an email communication. The lack of timely implementation of the anti-roll back brakes, which were identified as a necessary intervention to prevent falls, contributed to the resident's fall and subsequent injury.
Failure to Document and Monitor Urinary Catheter Care
Penalty
Summary
The facility failed to ensure proper assessment and documentation for a resident admitted with a urinary catheter. The resident, who had diagnoses including cellulitis and benign prostatic hyperplasia, was discharged from the hospital with a urinary catheter. However, the Admission Nursing Assessment incorrectly noted the resident as continent and did not document the presence of a urinary catheter. There were no physician orders or care plans indicating the need for or care of the catheter from the time of admission until the resident's transfer to the hospital. Nursing progress notes also lacked documentation of the catheter's presence or monitoring. Conflicting documentation from CNAs indicated varying statuses of the resident's urinary condition, with some shifts noting a catheter and others noting continence. Interviews with nursing staff revealed uncertainty and lack of documentation regarding the catheter's presence and care. The Director of Nursing acknowledged that output monitoring was not completed for residents with urinary catheters, and the facility's policy required catheter drainage bags to be emptied once per shift or as needed. This lack of consistent documentation and monitoring led to the deficiency cited in the report.
Failure to Adhere to Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure correct Personal Protective Equipment (PPE) was used by staff members when providing care to a resident under Enhanced Barrier Precautions (EBP). During an observation, a Certified Nursing Assistant (CNA) and a Wound Nurse were seen starting incontinent care for a resident without wearing the required gown, despite a sign on the door indicating EBP was necessary. The resident, who had end-stage kidney disease and required maximum assistance for daily activities, was incontinent of bowel movement and had menstrual/uterine bleeding. The CNA initially donned gloves but not a gown, and after being reminded, both staff members donned gowns to continue care. The deficiency was further compounded when the CNA, after providing incontinent care, failed to remove soiled gloves before touching clean surfaces, including the resident's closet, drawers, and wheelchair handle. The CNA was stopped before entering the roommate's area and then removed the gloves and gown, performed hand hygiene, and exited the room to obtain linens. The Director of Nursing (DON) confirmed that the room would be disinfected and stated that staff had been trained in EBP requirements. However, the incident indicated a lapse in adherence to the facility's EBP guidelines, which required the use of gown and gloves during high-contact resident care activities.
Failure to Assist Resident to Bathroom Upon Request
Penalty
Summary
The facility failed to ensure a resident was treated with respect and dignity by not assisting the resident to the bathroom upon request. On the morning of May 29, 2024, Resident G activated the call light at 8:02 a.m. and again at 8:12 a.m., indicating a need to use the bathroom. A staff member from Human Resources entered the room, acknowledged the resident's request, and promised to get assistance but left the call light on. Earlier, a male staff member had entered the room, was informed of the resident's need, but told her she would have to wait due to breakfast tray distribution and turned off the call light. Resident G, who had a history of stroke and required moderate assistance for toileting, attempted to transfer herself to a wheelchair to avoid an accident but fell back onto the bed. At 8:17 a.m., a Restorative CNA entered and assisted the resident to the bathroom. The Director of Nursing later confirmed that the resident should have been assisted when she first requested help. The resident was alert, cognitively intact, and always continent of bowel and bladder, as noted in her Baseline Care Plan and Occupational Therapy Progress Note.
Failure to Provide Timely Incontinent Care
Penalty
Summary
The facility failed to provide timely incontinent care for a resident who required maximum to dependent care. During an observation and interview, the resident was found lying in bed and reported that facility staff checked her for incontinence only 2-3 times a day. The resident's medical record indicated she had vascular dementia, bilateral above the knee amputations, and was always incontinent of bowel and bladder, requiring maximum assistance for toileting. Despite these needs, the resident reported that no one had checked on her all day, and she needed to go to the bathroom. When the resident activated the call light, the Wound Nurse entered the room but left to find assistance, leaving the resident unattended. The facility staff did not return promptly, and a family member had to intervene. The Wound Nurse and a CNA eventually provided care, revealing dried bowel movement on the resident's brief and dried yellow liquid on the bed linens, indicating prolonged neglect. The assigned CNA later claimed to have checked the resident before lunch, contradicting the resident's account. The facility's incontinence policy required appropriate treatment and services for incontinent residents, which was not adhered to in this case.
Failure to Investigate and Address Resident's Fracture After Fall
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, specifically related to a fracture after a fall that was not thoroughly investigated. Resident E, who had a diagnosis of a fractured left femur and a history of falls, was found on the floor in front of her wheelchair on 4/4/24. Despite the resident complaining of pain in the left hip, initial X-rays on 4/5/24 showed no fractures. Subsequent post-fall assessments over the next few days did not indicate any signs of injury or changes in the resident's condition. On 4/8/24, the resident again complained of left hip pain, prompting further imaging that revealed an acute impacted left hip fracture. The resident was then transferred to the hospital, where a CT scan confirmed the fracture. The facility's administrator acknowledged that the fracture was from the fall on 4/4/24 but admitted that no further investigation was conducted to rule out other causes of injury after the initial negative X-ray. The facility's fall prevention policy required assessment and implementation of appropriate interventions, which were not adequately followed in this case.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement care planned interventions to prevent injuries from falls for two residents. Resident D, who had a high risk for falls due to vascular dementia and bilateral above-knee amputations, was observed without a floor mat next to the bed and without anti-roll brakes on the wheelchair, despite these being specified interventions in the care plan. The resident had previously fallen from the bed, and the root cause was identified as rolling out of bed, leading to the intervention of placing a floor mat, which was not in place during the observations. Resident E, with a history of a fractured left femur and falls, was also not provided with the necessary intervention. The care plan required a urinalysis to be obtained following a fall from the wheelchair, which was not completed. The resident had fallen asleep in the wheelchair and slid to the floor, prompting the need for a urinalysis to investigate potential underlying causes. However, there was no documentation or evidence that the urinalysis was ordered or completed, as confirmed by the Director of Nursing and the Corporate Nurse Consultant.
Deficient Pressure Ulcer Care
Penalty
Summary
The facility failed to provide effective pressure ulcer prevention and care for Resident D, who was admitted without a pressure ulcer but developed a facility-acquired unstageable pressure ulcer on the sacrum. Despite being readmitted from the hospital with no skin impairments, the resident developed a pressure ulcer that was not properly assessed or treated in a timely manner. The clinical record lacked documentation of an assessment or treatment orders for the wound between the initial observation by staff and the resident's transfer to the hospital for further evaluation and treatment. The wound eventually required surgical debridement and was classified as a stage four pressure ulcer upon hospital assessment. Resident E also experienced inadequate pressure ulcer care, developing a facility-acquired stage three pressure ulcer on the sacrum. The resident's treatment orders for the wound, which included the application of Medi Honey, were not documented as completed on multiple occasions. The care plan for Resident E indicated the need for treatment administration and monitoring, but the treatment was not transcribed onto the Treatment Administration Record, leading to a lack of documentation and uncertainty about whether the treatment was provided as ordered. Interviews with facility staff, including the Nurse Consultant and Administrator, revealed that the facility's wound care program was not being implemented correctly. The Director of Nursing and Wound Nurse responsible for ensuring proper wound care were no longer employed at the facility. The facility's skin condition policy required wound assessments and documentation by a licensed nurse when skin conditions were identified, but this protocol was not followed, contributing to the deficiencies in pressure ulcer care for both residents.
Failure to Ensure Physician's Orders and Assessment for Self-Administration of Medication
Penalty
Summary
The facility failed to ensure a resident had Physician's Orders and an assessment to self-administer medication. Resident C, who has diagnoses including type 2 diabetes mellitus and asthma, was observed with a canister of fluticasone propionate and salmeterol on her over the bed table, which she indicated she self-administered. The resident's record lacked a Physician's Order and a self-administration of medication assessment. The Nurse Consultant confirmed that an assessment and order should have been in place. The facility's policy requires the Interdisciplinary Team to determine the safety of self-administration before allowing a resident to do so.
Failure to Notify Responsible Party of Pressure Ulcer
Penalty
Summary
The facility failed to ensure a resident's Responsible Party was notified of a change in condition related to pressure sores. Resident D, who had diagnoses including pneumonia, respiratory failure, and dementia, was readmitted from the hospital. A Nurse Practitioner observed an unstageable pressure ulcer on the resident's coccyx and notified the Wound Care Nurse and Director of Nursing. However, there was no documentation indicating that the family or Responsible Party was informed of the new pressure ulcer, contrary to the facility's skin condition and change of condition policies.
Latest citations in Indiana
Surveyors observed that dietary staff repeatedly worked in kitchen and meal service areas with uncovered facial hair, despite facility policy and state sanitation requirements mandating effective hair restraints. Two dietary aides with short beards or mustaches were seen walking through food preparation areas, taking food temperatures, handling food, and plating meals at steamtables in dining rooms without any facial hair coverings, while the current policy required all hair, including facial hair, to be restrained to prevent contamination.
The facility failed to consistently provide and document required bed-hold policy notices when several residents were transferred to the hospital. In multiple cases, residents with dementia, psychotic disorders, COPD, chronic respiratory failure, altered mental status, and cerebral infarction were sent out for acute changes in condition, and while transfer notes reflected physician and family notifications, they lacked documentation that the bed-hold policy was discussed with the resident or responsible party. Notices of Transfer or Discharge often indicated a copy of the bed-hold policy was sent with the resident, but the records did not show signed and dated acknowledgment by the resident or appropriate representative, including in situations where a resident had moderate cognitive impairment, short-term memory issues, or a documented need for a proxy and a financial POA authorizing an agent for health care decisions.
Surveyors found that the facility failed to provide trauma‑informed and culturally competent care by not incorporating two residents’ extensive trauma histories and specific behavioral triggers into their care plans. One resident with documented homelessness, polysubstance abuse, severe accidents with multiple fractures, viral encephalitis with coma, physical and sexual abuse, loss of family contact, and a past suicide attempt had multiple behavior‑focused care plans that referenced identifying triggers but listed none and did not mention their physical, sexual, medical, or psychosocial trauma. Another resident with TBI from being struck by a truck, an 11‑month coma, long‑term state hospital residence, alleged shooting of a parent, and diagnoses including intermittent explosive disorder and borderline personality disorder had a PASRR identifying a specific trigger and notes of inappropriate sexual behavior, yet their care plans omitted these traumatic events, the identified trigger, and the sexual behavior. Staff interviews confirmed that residents were screened for trauma, but the trauma histories and triggers were not reflected in the individualized plans of care.
A resident with schizophrenia, post‑stroke hemiparesis, and mild cognitive impairment expressed feeling down and wanting to kill himself, but staff did not document asking about a specific plan, did not notify the physician or psychiatric NP as expected, and did not develop or update a care plan addressing depression or suicidal ideation. The SSD documented offering support and initiating 15‑minute checks once, but there was no further follow‑up or documentation of interventions after subsequent suicidal statements made in a care plan meeting with the resident’s father. The DON and Administrator reported that facility policy requires immediate notification of key staff, assessment for a plan and means of self‑harm, and thorough documentation, which were not carried out or reflected in the medical record for this resident.
A resident with schizophrenia, post-stroke hemiparesis, and mild cognitive impairment verbalized suicidal ideation, but the care plan did not address depression or suicidal thoughts, and required assessments and services were not accurately or timely documented. An SSD note recorded the resident saying he wanted to kill himself and referenced 15‑minute checks and a care plan update, yet the active care plan lacked depression/suicidal ideation interventions. Multiple late-entry Social Services notes were later added, describing follow-up visits and the resident denying suicidal ideation, but the SSD later reported she did not typically ask about a suicide plan and did not personally provide individual follow-up visits as described. These practices conflicted with the facility’s policy requiring factual, first-hand, and timely documentation of assessments and services.
A resident was observed with an Albuterol inhaler on an overbed table and later reported keeping the inhaler in a nightstand drawer, with no staff present during these observations. Record review showed the resident had no cognitive impairment on the admission MDS but lacked any documented self-medication administration assessment. The DON acknowledged that the required assessment had not been completed, despite facility policy requiring staff and the practitioner to evaluate each resident’s mental and physical abilities before allowing self-administration of medications.
Surveyors found that the facility submitted inaccurate direct care staffing data to CMS through the PBJ system over multiple days in a quarter. CASPER reports showed apparent gaps in 24-hour licensed nurse coverage, low weekend staffing, and a 1-star staffing rating, while internal staffing sheets documented that licensed nurses were present and the facility was fully staffed on those days. The Administrator reported that the discrepancies were due to PBJ data entry errors, despite a facility policy requiring all PBJ entries to be accurate, auditable, and verifiable against payroll, invoices, or contracts.
Surveyors found that the facility did not provide or document required written transfer/discharge notices and bed-hold policy information for four residents who were sent to the hospital, including individuals with conditions such as dementia, CHF, chronic respiratory failure, and CKD. In each case, progress notes showed that the resident was transferred for acute issues, but the clinical records lacked evidence that written notices were given to the residents or their representatives, and in one case lacked documentation that required information was sent to the receiving provider. Facility leadership, including the ADON, DON, and Administrator, acknowledged that the records did not contain the required documentation, despite a written policy requiring such notices and information exchange.
A resident with Alzheimer’s disease and depression, previously on an antidepressant, exhibited intermittent refusals of medications and care, occasional yelling at staff, and reports of unusual perceptions, such as believing men were in or near her room. Nursing notes over several months documented these refusals and complaints but did not show that the behaviors were evaluated or recorded as dangerous, non-redirectable, or causing significant distress, nor did they document specific non-pharmacological interventions attempted or their outcomes. Despite this, a psychiatric NP later added new diagnoses of schizoaffective disorder, borderline personality disorder, and delusional disorder and ordered an antipsychotic (Seroquel) without a comprehensive evaluation in the record to support these diagnoses. The facility’s psychotropic medication policy, which requires identification and documentation of target behaviors, use of nonpharmacological interventions, and ongoing behavior monitoring, was not followed for this resident.
The facility failed to keep PASARR Level I screenings accurate and current for three residents when new mental health diagnoses and psychoactive medications were initiated. One resident’s PASARR omitted a PTSD diagnosis and an added antidepressant, despite documentation of PTSD on the MDS and care plan and a physician order for Pristiq. Another resident’s PASARR listed only depression and dementia, even after additional diagnoses such as borderline personality disorder, delusional disorder, and schizoaffective disorder were added and an antipsychotic (quetiapine) was ordered, with the MDS later reflecting psychotic disorder, schizophrenia, and depression with antipsychotic and antidepressant use. A third resident’s PASARR did not include a depression diagnosis or newly ordered escitalopram and lorazepam, although the admission MDS documented depression with antianxiety and antidepressant use. These omissions occurred despite facility policy requiring a new Level I review after significant mental status changes, including new mental health diagnoses or new psychotropic medications.
Uncovered Facial Hair During Food Preparation and Meal Service
Penalty
Summary
The deficiency involves the facility’s failure to ensure that food was served in a sanitary and safe manner in accordance with professional standards and facility policy during multiple kitchen and meal service observations. During an initial kitchen observation, two dietary aides were seen walking through the kitchen food preparation area with uncovered facial hair. One aide had facial hair above and below the lip and along the jaw line, approximately one-fourth inch in length, and the other had a mustache of similar length; neither used any facial hair covering. These observations occurred while staff were present in the kitchen area where food was stored and prepared. During subsequent observations on the same day, the same two dietary aides were again observed with uncovered facial hair while directly involved in meal preparation and service. One aide walked through the kitchen while the noon meal was being prepared and placed into a transport cart for service in the south dining room, and later was observed plating the noon meal at the steamtable in that dining room, still without a facial hair covering. The other aide walked through the kitchen while the noon meal was being prepared and placed into the steamtable for the north dining room, took food temperatures, assisted with plating meals at the steamtable, and retrieved food items and supplies from the kitchen, all while having an uncovered mustache approximately one-fourth inch in length. The Dietary Manager stated that staff hair was to be covered when in the kitchen and during meal service, and the facility’s written policy and the cited Indiana Food Establishment Sanitation Requirements both required effective hair restraints, including for facial hair, to prevent contamination of food, equipment, and utensils.
Failure to Provide and Document Bed-Hold Policy at Time of Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure that required bed-hold policy information was provided and documented for four residents transferred to the hospital. For a resident with dementia, psychotic disorder, and autistic disorder who had a BIMS score of 0 indicating severe cognitive impairment, progress notes documented physician notification and guardian notification when the resident was sent to the hospital, but there was no documentation that the bed-hold policy was provided to the responsible party. A Notice of Transfer or Discharge later indicated a copy of the bed-hold policy was sent with the resident. Another resident with COPD and chronic respiratory failure, cognitively intact with a BIMS score of 13, experienced a decline in condition and was transferred to the hospital by ambulance; progress notes documented family notification but did not document any discussion of the bed-hold policy, although a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident. A third resident with altered mental status and cerebral infarction, with a BIMS score of 10 indicating moderate cognitive impairment and documented short-term memory impairment, experienced changes in condition and was transferred to the hospital. Progress notes stated the resident was their own responsible party and that no other notification was completed, and transfer documentation did not include the bed-hold policy, although an untimed Notice of Transfer or Discharge indicated a copy of the bed-hold policy was signed by the resident. A financial power of attorney document in the record showed the resident had designated an agent to act in consent or refusal of health care. For a fourth resident with dementia and osteomyelitis, transfer documentation and a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident, and the transfer form noted the resident required a proxy for decision making. The facility’s policy required that at the time of transfer to a hospital, written notice specifying the duration of the bed-hold policy and information on return to the next available bed be provided, and that a signed and dated copy of the bed-hold notice given to the resident or representative be kept in the resident file, which was not consistently documented for these residents.
Failure to Integrate Trauma Histories and Behavioral Triggers Into Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to identify and incorporate residents’ trauma histories and specific behavioral triggers into their care plans, despite documented histories of significant trauma and behavioral health issues. For one resident, extensive social service and progress notes documented homelessness, polysubstance abuse, major depressive and anxiety disorders, chronic pain, a history of severe car accidents with multiple fractures, viral encephalitis resulting in a three‑month coma, loss of child custody, multiple divorces, physical abuse by a spouse, the death of a fiancé who was struck by a car while in a wheelchair, lack of family contact, and a past suicide attempt by Valium overdose. Additional documentation noted a history of rape by a brother at age eight and prior placement under direct supervision and 15‑minute checks related to suicidal ideation. Despite these documented traumatic events and behavioral health concerns, the resident’s care plans did not identify a history of physical trauma, sexual trauma, homelessness, substance abuse, medical trauma, or attempted suicide. For this same resident, the MDS showed no cognitive deficit and identified behaviors such as verbal aggression and rejection of care, along with diagnoses including seizure disorder, depression, chronic pain syndrome, homelessness, and anxiety disorder. Multiple care plans addressed behaviors such as drug‑seeking, pretending to have seizures for attention or medication, making false allegations, verbal aggression when unable to smoke, and a desire for intimate relationships with consenting male residents. These care plans referenced goals such as effective coping skills, seeking staff support, and compliance with the smoking policy, and they called for identification and reduction of behavioral triggers. However, none of these care plans actually listed any specific triggers. The care plan addressing the resident’s right to consensual intimate relationships focused on assessment and education regarding consent but did not integrate the resident’s extensive trauma history. Staff interviews indicated the resident had displayed sexual behaviors since admission, including an incident where the resident expressed anger at another resident for not buying a soda after engaging in sexual acts. A second resident with a documented history of traumatic brain injury (TBI), dementia, seizure disorder, borderline personality disorder, anxiety, intermittent explosive disorder, tobacco use, and other behavioral/emotional disorders was also affected by the same deficiency. Social history and progress notes documented that this resident sustained a TBI after being hit by a semi‑truck while riding a bicycle at age 18, resulting in an 11‑month coma, followed by 13 years in a state hospital and subsequent residence in a group home. Additional documentation indicated the resident allegedly shot their father at age 26 after being sworn at and had a PASRR identifying TBI, intermittent explosive disorder, and borderline personality disorder, with a specific trigger of hearing the name of the current U.S. President. Progress notes also described inappropriate sexual behavior toward staff, including touching themselves intimately during personal care and refusing to stop when redirected. Despite this, the resident’s care plans, which addressed explosive disorder and history of altercations, risk for decreased psychosocial well‑being, and refusal to bathe or shower, did not list any specific behavioral triggers, did not reference the traumatic events such as being hit by a truck or shooting their father, and did not document the inappropriate sexual behavior. The Administrator and Social Service Director acknowledged that residents were to be screened for trauma and that trauma responses and PTSD should be added to care plans, but the specific trauma histories and triggers for these two residents were not incorporated into their plans of care.
Failure to Assess and Care Plan for Resident Suicidal Ideation
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess, investigate, and care plan for a resident’s suicidal ideation in accordance with its own policy and staff expectations. The resident had diagnoses including schizophrenia, cerebral edema, and hemiparesis/hemiplegia following a cerebral infarction, and a current MDS showed mild cognitive impairment (BIMS score 12). A progress note documented that the resident told the Social Services Director (SSD) he was feeling down and wanted to kill himself; the SSD offered assistance, activities, and initiated 15‑minute checks, and the note stated the care plan was updated. However, the note did not indicate that the SSD asked whether the resident had a plan to kill himself, and there were no additional notes regarding suicidal ideation or follow‑up. Review of the current care plan showed no problem, goal, or interventions addressing depression or suicidal ideation, and progress notes over the following month contained no documentation of physician notification related to the suicidal statement. Further record and interview evidence showed that the care plan conference summary did not document interventions for suicidal ideation, and the SSD acknowledged she did not normally ask residents expressing suicidal ideation if they had a plan. The SSD reported that the resident had admission paperwork mentioning suicidal ideation related to depression after a stroke and that the resident again vocalized suicidal ideation during a care plan meeting with his father, after which emotional support was offered and the father took the resident out on a leave of absence; no further visits or follow‑up were done. The DON stated that, upon notification of suicidal verbalization, staff should assess the resident, ask if there is a plan, remove potential means of self‑harm, immediately notify the psychiatric NP, and document the occurrence, and that a detailed progress note and updated care plan were expected but not present for this resident. The Administrator similarly stated that staff should ask about a plan, document interventions, notify the physician and family, and update the care plan, and indicated the resident should have had a care plan addressing depression with suicidal ideation. The facility’s written policy required immediate notification of the DON, SSD, and physician, an interview including asking about a plan and assessing mood and means for self‑harm, and thorough documentation of mood, behavior, and all actions taken, which were not reflected in the resident’s record.
Incomplete and Inaccurate Documentation of Suicidal Ideation and Follow-Up
Penalty
Summary
The facility failed to ensure accurate, complete, and timely documentation of assessments and services for a resident who verbalized suicidal ideation. Resident 6, who had schizophrenia, cerebral edema, and right-sided hemiparesis/hemiplegia following a cerebral infarction, had a BIMS score of 12 indicating mild cognitive impairment. The resident’s admission paperwork mentioned suicidal ideation related to depression after a stroke, and a Social Services note on 3/11/2026 documented that the resident was feeling down and said he wanted to kill himself. The Social Services Director (SSD) documented that she talked with the resident, coordinated with Activities, advised the resident to contact SSD or nursing if he wanted to talk, and that the resident was scheduled for 15-minute checks and the care plan was updated. However, the current care plan initiated on 2/26/2026 did not address depression or suicidal ideation. Multiple Social Services progress notes were later entered as late entries in April, with effective dates in March, stating that the resident had no plan and no longer had suicidal ideation, that he felt much better after 1:1 time, and that he continued his daily routine and therapy. These late entries described follow-up visits and reassessments of suicidal ideation on several consecutive days, but in interviews the SSD stated she did not normally ask residents about having a plan when they verbalized suicidal ideation and did not recall any other occurrences beyond the initial event. She further indicated she did not personally provide individual follow-up visits with this resident regarding suicidal ideation, despite the late-entry notes describing such visits. The DON acknowledged that late entries had been added to address concern about suicidal verbalization, and the Administrator stated that upon suicidal statements staff should ask about a plan, notify the physician and family, and update the care plan, and that this resident should have had a care plan addressing depression with suicidal ideation. The facility’s documentation policy required factual, first-hand, timely documentation, which was not followed in this case.
Failure to Complete Required Self-Administration Assessment for Inhaler Kept at Bedside
Penalty
Summary
Surveyors identified that a resident was allowed to keep and access an Albuterol inhaler without the facility completing the required self-administration medication assessment. During an initial tour, the resident was observed sitting in a wheelchair with a handheld Albuterol inhaler on the overbed table and no staff present in the room or hallway. On a subsequent observation, the resident again was in a wheelchair and reported that the Albuterol inhaler was stored in the top drawer of the nightstand, where it was found. Review of the clinical record showed an admission MDS indicating no cognitive impairment, but there was no documentation of a self-medication administration assessment. In an interview, the DON confirmed that the resident did not have the required self-medication assessment, despite the facility’s policy stating that staff and the practitioner must assess each resident’s mental and physical abilities to determine whether self-administering medications is clinically appropriate. This failure to complete and document a self-administration medication assessment for a resident who had an Albuterol inhaler kept at bedside constituted noncompliance with the facility’s own policy and with 410 IAC 16.2-3.1-11(a).
Inaccurate PBJ Staffing Data Submission to CMS
Penalty
Summary
The deficiency involves the facility’s failure to electronically submit complete and accurate direct care staffing information to CMS through the Payroll-Based Journal (PBJ) system for 22 days in a fiscal quarter. A CASPER report review on 4/6/26 showed that, according to PBJ data, the facility did not have licensed nursing coverage 24 hours per day on multiple specific dates across three months, had low weekend staffing, and held a 1-star staffing rating. However, review of the facility’s internal staffing sheets for that quarter indicated the facility was fully staffed and had licensed nurse coverage on all of the dates in question. During an interview, the Administrator stated that the PBJ information must have contained data entry errors, as she had verified licensed staff coverage on the timesheets. The facility’s PBJ policy in effect stated that all staffing data entered into the PBJ system would be auditable and verifiable through payroll, invoices, or contracts, but the submitted PBJ data did not accurately reflect the facility’s actual licensed nurse staffing as documented on internal records. No specific residents or clinical conditions were mentioned in the report, and the deficiency centers solely on inaccurate staffing data submission rather than direct resident care events.
Failure to Provide and Document Required Transfer/Discharge and Bed-Hold Notices
Penalty
Summary
The deficiency involves the facility’s failure to provide and document required written notices of transfer/discharge and bed-hold policies, as well as required information to receiving providers, for four residents who were transferred or discharged to the hospital. For a resident with generalized anxiety disorder, major depressive disorder, and dementia, progress notes showed that the resident was sent to the hospital via 911 for chest pain, lower back pain, and shortness of breath and later returned to the facility, but the clinical record lacked documentation that a written Notice of Transfer/Discharge and the bed-hold policy were provided to the resident or representative, and lacked documentation that required information was conveyed to the receiving facility. The ADON and the Administrator both confirmed there was no documentation that these written notices were provided. For a resident with congestive heart failure and muscle weakness who was sent to the emergency room for painful urination and bloody urine, the clinical record lacked documentation that a Notice of Transfer/Discharge or bed-hold policy was given to the resident or representative, which the DON confirmed. Another resident with chronic respiratory failure and diabetes was discharged to the hospital for respiratory failure, and a resident with chronic kidney disease and dementia was discharged to the hospital, but in both cases there was no documentation that a written notice of transfer/discharge or bed-hold policy was provided to the residents or their representatives. Review of the facility’s Transfer and Discharge policy, dated 1/15/26, showed that the policy required the facility to provide written transfer/discharge notices and bed-hold information to residents and representatives and to provide specified information to receiving providers, but the records for these four residents did not contain the required documentation.
Failure to Document Target Behaviors and Non-Pharmacological Interventions Before Initiating Antipsychotic
Penalty
Summary
The deficiency involves the facility’s failure to document how a resident’s behaviors presented danger or distress to self or others, and failure to document non-pharmacological interventions attempted prior to initiating an antipsychotic medication. Resident 6 had documented diagnoses of Alzheimer’s disease, depression, and severe cognitive impairment, and was receiving sertraline for depression. A PASSAR identified only depression and dementia, and the admission MDS listed Alzheimer’s disease and depression as active diagnoses. Over several months, nursing progress notes documented that the resident intermittently reported unusual perceptions, such as believing there were men causing trouble, a man in her room, or a man wanting to marry her and yelling through the walls, but there was no documentation that these episodes caused danger to the resident or others or that they resulted in unmanageable distress. From late April through mid-July, nursing notes primarily described the resident’s frequent refusals of evening and morning medications, blood sugar checks, blood pressure checks, insulin administration, hygiene care, and showers. Staff documented that the resident sometimes yelled at staff, said “Get out!”, was visibly upset by a room move, was leery of staff and asked to see name badges, and became upset about a pillow under her head until it was removed, after which she calmed down. The notes also recorded instances where the resident believed housekeeping had not cleaned her room or that she had not received medications when she had. However, there were no progress notes or assessments indicating that these behaviors were evaluated as dangerous, non-redirectable, or causing significant distress or functional impairment, and no detailed behavior monitoring logs were present as required by facility policy. On a psychiatric NP visit for initial psychotropic medication management, new mental health diagnoses of schizoaffective disorder, borderline personality disorder, and delusional disorder were added, and Seroquel 25 mg, an antipsychotic, was ordered. The clinical record did not contain a comprehensive evaluation to support these new diagnoses, and there was no documentation of target behaviors meeting the facility’s policy criteria for psychotropic use, such as behaviors representing danger to self or others, causing distress and impairment in functional abilities, or clearly attributable to psychosis or mania. The resident’s representative reported that the resident had no prior history of mental health disorders or psychiatric hospitalization and was unaware of the new diagnoses. The facility’s own psychotropic medication policy required identification and documentation of specific target behaviors, use and documentation of nonpharmacological interventions, and ongoing monitoring of behaviors and interventions, which were not reflected in the record for this resident.
Failure to Update PASARR Screens for New Mental Health Diagnoses and Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that Preadmission Screening and Resident Review (PASARR) Level I screenings were accurate and updated when new mental health diagnoses and psychoactive medications were initiated for multiple residents. For one resident with dementia, anxiety, depression, and post-traumatic stress disorder (PTSD), the PASARR completed on admission listed anxiety, depression, and dementia with sertraline and quetiapine, but did not include the PTSD diagnosis or the antidepressant Pristiq, despite the admission MDS and care plan documenting PTSD and a subsequent physician’s order for Pristiq. For another resident with Alzheimer’s disease, borderline personality disorder, delusional disorder, schizoaffective disorder, and depression, the PASARR only reflected depression and dementia with sertraline, even though additional mental health diagnoses were added later and an antipsychotic (quetiapine) was ordered for borderline personality disorder, and the quarterly MDS documented psychotic disorder, schizophrenia, and depression with antipsychotic and antidepressant use. A third resident had diagnoses including Alzheimer’s disease, depression, anxiety disorder, irritability and anger, and nonrheumatic aortic valve stenosis. The PASARR for this resident listed dementia and anxiety with Risperdal but omitted the diagnosis of depression and the medications escitalopram and lorazepam, although physician’s orders were in place for escitalopram for depression and lorazepam for anxiety, and the admission MDS documented depression with antianxiety and antidepressant use. Interviews with the Assistant Director of Nursing confirmed that new Level I PASARR screens should have been completed when new mental health diagnoses and psychoactive medications were added, and that the PASARR for one resident, completed prior to arrival, should have included all mental health diagnoses and medications. The facility’s own policy required notification of the state mental health authority within 14 days after a significant change in mental condition and specified that a new Level I screen is required for new mental health diagnoses or newly prescribed psychotropic medications, which was not followed in these cases.
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