Castleton Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Indianapolis, Indiana.
- Location
- 7630 E 86th St, Indianapolis, Indiana 46256
- CMS Provider Number
- 155245
- Inspections on file
- 35
- Latest survey
- March 6, 2026
- Citations (last 12 mo.)
- 42
Citation history
Health deficiencies cited at Castleton Health Care Center during CMS and state inspections, most recent first.
The deficiency involves missing and improperly handled narcotic pain medications affecting three residents. A cognitively intact resident with chronic pain had 40 tablets of oxycodone/APAP 10/325 mg delivered per pharmacy records, but none were signed out on the controlled drug record and the tablets were missing from the locked cart, with conflicting staff statements about who removed them. A cognitively impaired resident with paraplegia and other conditions had PRN oxycodone/APAP 5/325 mg ordered, yet an LPN documented removing two tablets under one prescription number and two more under a second prescription number at the same time, despite being aware the order had been changed. Another resident with dementia and epilepsy had hydrocodone/APAP 5/325 mg ordered as one tablet QID, but the same LPN signed out two tablets at once, and the physician confirmed there was no one-time order for an extra dose. These events show failures to safeguard residents’ medications and to accurately document controlled substance administration.
The facility failed to timely and completely report two allegations of misappropriation of narcotic pain medications. In one case, a QMA discovered that a resident’s oxycodone 10 mg/325 mg supply was short when the pharmacy reported it was too early for a refill and that 40 tablets should still be on hand; the QMA reported that the DON had removed the medication from the cart earlier in the shift. In another case, a controlled drug reconciliation at shift start revealed a discrepancy that was reported to the ADON and Administrator. For both incidents, the reportable incident forms omitted the names of the resident and staff involved, and the Administrator later acknowledged that required information and time frames for reporting to the state health department were not met, despite a facility policy requiring prompt and thorough reporting and investigation of abuse allegations.
A resident with multiple diagnoses, including traumatic brain injury, acute respiratory failure, cannabis dependence, and alcohol dependence, was discharged with medications and belongings but without a comprehensive person-centered discharge care plan in the clinical record. An LPN acknowledged that a discharge care plan should have been in place and provided to the resident at discharge. Review of the facility’s current “Transfer and Discharge” policy showed it requires a comprehensive person-centered discharge care plan for residents, yet no such plan was documented for this resident, resulting in a cited deficiency.
The facility did not ensure complete reconciliation and documentation of controlled medications upon delivery for three residents. For one resident receiving oxycodone/acetaminophen 10/325 mg, both the pharmacy delivery slip and the controlled drug record were missing required entries such as who received the medication, the delivery date/time, starting balance, and check-in information. For another resident with paraplegia, diabetes, and anxiety, narcotic administration records for oxycodone/acetaminophen 5/325 mg lacked documentation of who checked in the medications, the date, and the starting balance. For a third resident with dementia, epilepsy, and cognitive communication deficit, the controlled drug record for hydrocodone/acetaminophen 5/325 mg was missing the "checked in by" and date fields. An LPN confirmed that nurses should fully complete these records in accordance with facility policy requiring verification of deliveries and signing with name, date, and time.
Residents experienced disrespectful treatment, delayed responses to call lights, and lack of privacy due to staff actions such as turning off call lights without providing care, speaking rudely, using earbuds or phones during care, and discussing personal care needs loudly in hallways. Some residents waited up to two hours for assistance, and one was left exposed without a privacy curtain. These issues were more frequent during evening, night, and weekend shifts, and persisted despite being reported to management.
Two residents did not receive timely assistance with ADLs, including shaving and toileting. One resident with hemiplegia was not shaved as required by his care plan, and another resident with cerebral palsy waited an extended period for toileting care despite using his call light and being able to communicate his needs. Staff were unaware of the care needed, and records did not document required hygiene tasks.
Multiple residents reported that staff were rude, dismissive, and rough during care, often using cell phones while providing assistance, ignoring call lights for extended periods, and speaking in a demeaning manner. Some residents were left in soiled briefs, denied food or beverage requests, and felt treated like children, contrary to facility policies requiring respectful and dignified care.
A resident with significant mobility and cognitive impairments was repeatedly found unable to reach her call light, which was tied to the bed rail and hanging near the floor. Despite staff being present in the room and delivering meals, the call light was not placed within her reach, forcing her to use a stick to attract attention. This failure to ensure the call device was accessible was contrary to the facility's policy and the resident's care plan.
Two residents did not receive timely assistance with nail care and facial hair grooming, despite care plans and facility policies requiring these services as part of ADLs. One resident had long, dirty nails that were not trimmed on multiple documented occasions, while another resident with a self-care deficit was left with unkempt facial hair for weeks despite repeated requests for shaving.
Two residents with chronic pain did not receive timely or properly documented pain management, including missing care plans, delayed administration of PRN pain medications, and lack of required documentation such as pain assessments, vital signs, and non-pharmacological interventions, as required by physician orders and facility policy.
Surveyors observed dirty floors with unknown black substance spills in a unit, and all residents reviewed reported environmental concerns. Multiple interviews and Resident Council minutes documented ongoing housekeeping issues, especially on weekends, with unclear cleaning responsibilities between CNAs and housekeeping staff. The facility's policy requires a clean environment, but this standard was not met.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
A resident with moderate cognitive impairment had $80 reported missing after being given to a previous BOM for safekeeping. The current BOM was unaware of the funds' location, and the incident was not documented in grievance records. The allegation was raised in a meeting with the BOM, Ombudsman, and Social Services Director, but was not reported to the state agency within the required timeframe, as the ED was on vacation and unaware of the situation. This failure to promptly report the suspected misappropriation of resident property resulted in a deficiency.
The facility did not provide pharmaceutical services to meet residents' needs and failed to employ or obtain the services of a licensed pharmacist, as required.
The facility did not complete timely post-fall assessments for a resident with cognitive impairment and heart failure, failed to document or follow physician orders for wound care and insulin administration for two residents with diabetes, and did not consistently record blood sugar readings or notify physicians when insulin was withheld, as required by policy.
A resident with cognitive impairment and multiple diagnoses exhibited confusion and restlessness, prompting a STAT order for CBC and CMP from the on-call provider. Despite the order, the laboratory tests were never drawn, and no results were present in the clinical record, indicating a failure to provide timely laboratory services as required by facility policy.
A resident with dementia and a history of repeated falls experienced an unwitnessed fall from a wheelchair, which was documented in a risk management incident report but not in the clinical record. Required notifications to the physician and responsible party were also not documented in the medical record, contrary to facility policy. The DON confirmed that best practice was not followed in this instance.
A resident with multiple medical conditions was prescribed oxycodone-acetaminophen for pain, and a shipment of 60 tablets was delivered by pharmacy. The medication was received by an RN and handed to another RN to be placed in the medication cart, but there was no documentation or record of it being added. Subsequent counts and searches revealed the medication and its record sheet were missing, and video footage confirmed the handoff but not the final disposition. The resident did not miss any doses, but the facility failed to follow required procedures for handling and securing controlled substances.
The facility's kitchen was found to have several deficiencies, including cracked flooring, improper dishwasher temperatures, and unlabeled food items. Personal drinks were also stored inappropriately. The dietary aide did not monitor dishwasher temperatures, and the Registered Dietitian confirmed issues with labeling and storage practices.
The facility did not effectively implement an antibiotic stewardship program, failing to track and monitor antibiotic usage among residents. The DON provided a binder missing monthly tracking data from January to May 2024, and subsequent months lacked details on infection types and resident locations. A change in corporate ownership in March 2024 led to documentation gaps, and the DON's tracking from June 2024 was incomplete.
A resident with type 1 diabetes mellitus did not receive properly administered insulin due to an LPN's failure to prime the insulin flex pen before injection. The LPN admitted to forgetting this crucial step, which is necessary to ensure the pen functions correctly and delivers the accurate dosage. Manufacturer instructions emphasize the importance of priming to avoid incorrect insulin delivery.
A resident with dementia, stroke, and major depressive disorder was admitted to a facility without a timely individualized behavior plan. Despite physician orders to monitor behaviors, the facility failed to document and address the resident's behavioral needs, including verbal aggression and mood swings. Delays in psychiatric evaluation and inconsistent documentation contributed to the deficiency.
A facility failed to monitor a resident's blood pressure before administering midodrine, a medication for low blood pressure, despite a physician's order to withhold the drug if systolic blood pressure was above 110. The medication was given without recording necessary blood pressure readings, as confirmed by the Regional Nurse Consultant, contrary to the facility's medication administration policy.
A facility failed to implement enhanced barrier precautions during a wound dressing change for a resident with a diabetic ulcer. The DON and an LPN did not use gowns, which are part of the required PPE, during the procedure. A misunderstanding about the duration of enhanced barrier precautions contributed to this deficiency.
Misappropriation and Improper Handling of Controlled Pain Medications
Penalty
Summary
The deficiency involves failure to protect residents from misappropriation of controlled pain medications and improper handling and documentation of narcotics. Resident B, who had diagnoses including ankylosing spondylitis and muscle weakness and was documented as cognitively intact, reported that staff told him his pain medication was missing. His physician’s order authorized oxycodone/acetaminophen 10/325 mg, one tablet orally every six hours for pain. Pharmacy records showed that 40 tablets of this medication were delivered for him, and the controlled drug record reflected a starting balance of 40 tablets with no doses signed out as administered. A facility investigation included conflicting staff statements: one QMA stated the DON removed Resident B’s oxycodone/acetaminophen from the locked cart, while the DON stated she removed several medications from carts but none for Resident B and did not know what happened to his medication. The pharmacy indicated Resident B should have had 40 tablets available in the locked cart, but they were missing. The deficiency also includes improper documentation and handling of controlled substances for Resident C. Resident C had diagnoses including paraplegia, diabetes, and anxiety and was documented as cognitively impaired. A physician’s order authorized oxycodone/acetaminophen 5/325 mg, two tablets every eight hours as needed for pain. On a narcotic administration record, an LPN initialed that she removed two oxycodone/acetaminophen 5/325 mg tablets for Resident C under one prescription number at a specific time, and also documented removal of two additional oxycodone/acetaminophen 5/325 mg tablets for Resident C under a different prescription number at the same time. A handwritten statement indicated the LPN had been made aware that Resident C’s physician’s order for oxycodone/acetaminophen 5/325 mg had been changed, yet the records still showed these removals and administrations. For Resident D, who had diagnoses including dementia, epilepsy, and cognitive communication deficit, a physician’s order authorized hydrocodone/acetaminophen 5/325 mg, one tablet orally four times daily for pain. The controlled drug record showed that the same LPN signed out two hydrocodone/acetaminophen 5/325 mg tablets for Resident D at a specific time, exceeding the ordered single-tablet dose. An undated written statement from the attending physician confirmed that no one-time order had been given to administer an extra tablet of hydrocodone/acetaminophen 5/325 mg on that date. The facility’s abuse prevention policy stated that each resident has the right to be free from misappropriation, yet the documented missing narcotics and unexplained extra doses for multiple residents demonstrate failures in protecting residents’ property and in accurate narcotic documentation and handling.
Failure to Timely and Completely Report Alleged Misappropriation of Narcotic Medications
Penalty
Summary
The facility failed to timely and completely report two separate allegations of misappropriation of residents' narcotic pain medications. In the first incident, a facility reportable incident form dated 1/23/26 at 1:15 p.m. was provided, but the sections for the resident involved and the staff involved were left blank. Eight days after the initial allegation was reported to the Administrator, the brief description was completed, documenting that on 1/23/26 at 1:25 p.m. a QMA reported calling the pharmacy for a refill of a resident's oxycodone 10 mg/325 mg, and the pharmacy indicated it was too early to refill and that the resident should have had 40 tablets at the facility. The QMA reported that the DON had removed the medication from the medication cart earlier in the shift. The type of injury was documented as not applicable, and the immediate action taken section indicated the DON was suspended pending investigation. The follow-up section, dated 2/5/26, stated the facility was unable to substantiate the allegation of misappropriation. In the second incident, a facility reportable incident form dated 2/17/26 at 10:45 p.m. was also missing the names of the resident involved and the staff involved. The brief description, dated 2/18/26, indicated that during routine controlled drug reconciliation at the beginning of a shift, a discrepancy was identified and immediately reported to the ADON and the Administrator. The follow-up section, dated 3/5/26, indicated that the investigation had been completed and referenced personnel action, a complete audit of the medication cart, staff education, and ongoing audits. During an interview, the Administrator acknowledged that the staff and residents' names should have been included in each initial report, that misappropriation incidents should have been reported to the state health department within 24 hours, and that follow-ups should have been reported within five days of the incident. The facility’s Abuse Prevention and Prohibition Program policy stated that the facility promptly and thoroughly reports and investigates allegations of abuse.
Failure to Provide Person-Centered Discharge Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered discharge care plan for one resident. Resident F, whose diagnoses included traumatic brain injury, acute respiratory failure, cannabis dependence, and alcohol dependence, was reviewed on 3/4/26, and the clinical record showed a progress note dated 2/10/26 documenting that the resident was discharged with medications and belongings. However, the clinical record lacked any person-centered discharge care plan, and there was no evidence that such a plan had been created or provided to the resident at discharge. During an interview, an LPN confirmed that the resident should have had a person-centered discharge care plan in place and that a copy should have been given to the resident upon discharge. The Administrator provided the facility’s current “Transfer and Discharge” policy, dated 6/2020, which stated that residents will have a comprehensive person-centered discharge care plan. The absence of such a plan in Resident F’s record, despite the documented discharge and the facility’s policy requirement, formed the basis of the deficiency cited under 410 IAC 16.2-3.1-35(a) related to Intake 2743057.
Incomplete Reconciliation and Documentation of Controlled Medications
Penalty
Summary
The facility failed to ensure controlled medications were accurately reconciled during delivery and properly documented on pharmacy delivery slips and controlled drug records for three residents. For one resident, a pharmacy delivery slip dated 1/8/26 showed that 40 tablets of oxycodone/acetaminophen 10/325 mg were delivered, but the spaces for "Received By," "Delivery Date/Time," and "Print Name" were left blank. The corresponding Controlled Drug Record for the same prescription and date also lacked entries for the starting balance, the nurse who checked in the medication, and the date, and no tablets were signed out as administered on that record. For a second resident with diagnoses including paraplegia, diabetes, and anxiety, a Narcotic Administration Record covering a period from late January to mid-February for oxycodone/acetaminophen 5/325 mg showed that the spaces for "Checked in By" and "Date" were left blank. A subsequent Narcotic Administration Record for a new prescription of the same medication also had the "Starting Balance" field left blank. For a third resident with dementia, epilepsy, and cognitive communication deficit, a Controlled Drug Record for hydrocodone/acetaminophen 5/325 mg similarly lacked entries for "Checked in By" and "Date." During interview, an LPN stated that the pharmacy delivery slips and controlled drug records for these residents should have been completed in full by the nurse receiving the medications, and the facility’s policy required checking the delivery manifest at the time of delivery and signing with name, date, and time if correct.
Failure to Maintain Resident Dignity, Timely Care, and Privacy
Penalty
Summary
Multiple residents experienced a lack of dignity and respect due to staff actions and inactions, as evidenced by resident council meeting notes, direct observations, and interviews. Residents reported that staff would enter rooms, turn off call lights without providing the requested care, and leave without returning, resulting in residents waiting one to two hours for assistance. Staff were also described as speaking disrespectfully, being rude, and using earbuds or phones while providing care. Additionally, staff were overheard discussing residents' personal care needs loudly in hallways, including using residents' names and making derogatory comments about care tasks they did not want to perform. These issues were reported to occur more frequently during evening, night, and weekend shifts. Direct observations confirmed that call lights for two residents remained unanswered for extended periods, with one resident waiting approximately 30 minutes before staff entered the room and another waiting nearly two hours to be cleaned up. One resident was found with his pants down and without a privacy curtain available, indicating a lack of bodily privacy. Another resident reported waiting an hour and a half after her call light was answered before being assisted to bed, resulting in discomfort. Staff were observed engaging in personal conversations and not prioritizing resident care needs, while some staff were unaware of residents' care requirements during their assigned shifts. Resident council meeting minutes from several dates documented ongoing concerns about untimely call light responses, staff being distracted by phones and earbuds, and unkind or disrespectful behavior. Residents also reported that their concerns had been brought to management but remained unresolved. Facility policies reviewed by surveyors emphasized the importance of dignity, respect, privacy, and timely assistance, but these standards were not consistently upheld for the residents involved.
Failure to Provide Timely ADL Care and Personal Hygiene
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL) for two residents. One resident with hemiplegia and a history of stroke required total staff assistance for self-care and preferred bed baths. The care plan specified that the resident should be shaved on shower days. However, observations on multiple occasions showed the resident with long facial hair, and the resident reported that staff did not offer to shave him. Bathing records confirmed that shaving was not documented on several bed bath days, and the Executive Director was unable to explain why shaving was not provided as required by the care plan and facility policy. Another resident with cerebral palsy and depression, who had moderately impaired cognitive ability but could communicate his needs, was observed with his call light on for an extended period. The resident was found lying in bed with his pants down, waiting to be cleaned up, and reported waiting for two hours for assistance. The assigned CNA was not aware of the resident's need for care until informed during the observation. The Executive Nurse Consultant confirmed that call lights should be answered promptly and care provided in a timely manner. These findings demonstrate a failure to provide timely and appropriate ADL care, including personal hygiene and toileting assistance.
Failure to Maintain Resident Dignity and Respect
Penalty
Summary
The facility failed to ensure that residents were treated with dignity and respect, as evidenced by multiple reports from residents and observations during interviews and record reviews. Several cognitively intact residents reported that Certified Nurse Aides (CNAs) and other staff were rude, sarcastic, and dismissive, often using their cell phones during care and speaking to residents in a demeaning manner. One resident described being transferred with a mechanical lift while the CNA was on a speakerphone call, and another reported that staff would call him out of his name and refuse to assist with food requests. Residents also described staff as rough during care, particularly when moving residents with physical limitations, causing both physical and emotional discomfort. Residents further reported significant delays in response to call lights, with some stating that their calls for assistance went unanswered for extended periods, sometimes overnight. During a resident council meeting, multiple residents expressed that staff treated them like children, pushed them to their rooms, and ignored their needs. The council also noted that staff often spoke in a commanding tone and failed to address residents by their preferred names, contributing to a sense of being dismissed and forgotten. Additional concerns included staff limiting access to beverages such as coffee, ignoring residents' requests, and leaving residents in soiled briefs for prolonged periods. Interviews with both residents and staff confirmed that these practices were ongoing, with staff admitting that residents would not receive certain items during specific shifts. The facility's own policies require staff to treat residents with dignity, respect, and kindness, and prohibit demeaning practices, but these standards were not upheld in the care provided to the residents identified in the report.
Call Light Not Accessible to Resident with Mobility Impairments
Penalty
Summary
A deficiency was identified when a resident with multiple diagnoses, including chronic obstructive pulmonary disease, chronic kidney disease, heart failure, and arthritis, was found to have her call light out of reach on two separate occasions. The resident, who was moderately cognitively impaired and had significant mobility limitations, was observed lying in bed with her call light cord tied around the right side rail, hanging eight inches from the floor. She was unable to reach the call light and instead used a wooden stick to hit the bedside table or side rail to get staff attention. The resident reported that staff had been in her room earlier but did not adjust the call light to be within her reach, and she frequently could not access it when needed. Further observations confirmed that the call light remained out of reach even after her lunch was delivered, and staff did not ensure it was accessible. The facility's policy requires that call lights be within reach of residents and never placed on the floor or bedside stand. The deficiency was based on the failure of staff to ensure the call light was accessible to the resident, as required by both her care plan and facility policy.
Failure to Provide Timely Nail and Facial Hair Care for Residents
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for two residents, specifically in the areas of nail care and facial hair grooming. For one resident with heart failure and moderate cognitive impairment, observations revealed long nails with a black substance underneath, and the resident expressed a desire to have them trimmed. Review of bathing sheets showed multiple instances where nail care was not documented as provided, despite the care plan specifying that nail care should occur on bath days and as needed. The Assistant Director of Nursing confirmed that nail care should have been provided on those days. Another resident, diagnosed with Parkinson's disease and a history of fractures, also with moderate cognitive impairment, was observed with long, unkempt facial hair. The resident reported having requested to be shaved for several weeks without the request being fulfilled. Documentation indicated the last shave occurred several days prior to the observation, and the resident confirmed that shaving was only recently provided after repeated requests. Facility policies require that residents be cared for in a manner that promotes dignity and includes regular shaving as part of personal hygiene.
Failure to Ensure Timely and Documented Pain Management for Residents
Penalty
Summary
The facility failed to provide safe and appropriate pain management for two residents with chronic pain and complex medical histories. For one resident with chronic pain, polyosteoarthritis, COPD, chronic kidney disease, and heart failure, there was no care plan in place to address her pain. Although physician orders specified the use of tramadol as needed, with requirements for pain assessment before and after administration, documentation of pain scale results, vital signs, and non-pharmacological interventions, these were not completed. Medication administration records showed tramadol was given on two occasions, but the corresponding treatment records and progress notes lacked required documentation, including vital signs and non-pharmacological interventions. The effect of the medication was also not documented in one instance. For another resident with diagnoses including cancer, right femur fracture, peripheral vascular disease, inguinal hernia, and spinal stenosis, the care plan included goals and interventions for pain management, such as anticipating pain needs and encouraging non-pharmacological methods. However, the resident reported significant delays in receiving as-needed pain medication, particularly at night, with one instance where he waited several hours after requesting medication. Physician orders required pain assessments, documentation of pain scale, vital signs, and non-pharmacological interventions before and after PRN medication administration, but these were not documented in the treatment records or progress notes for multiple administrations. Interviews with the DON confirmed that vital signs were supposed to be obtained and documented when residents complained of pain, but this was not consistently done. The facility's pain management policy required timely interventions and documentation of both pharmacological and non-pharmacological measures, but the records reviewed did not reflect compliance with these requirements for the residents involved.
Failure to Maintain Clean and Safe Environment Due to Inadequate Housekeeping
Penalty
Summary
The facility failed to maintain clean floors in one of five units, affecting all 14 residents reviewed for environmental conditions. Observations on multiple occasions revealed dirt and spillage of an unknown black substance on the floors near the nurse's station and in the Shoreline hallway. Resident interviews and Resident Council meeting minutes documented ongoing concerns about inadequate housekeeping, particularly on weekends, with reports of rooms and bathrooms not being cleaned and food trays left in rooms. Residents and their representatives described the facility as dirty, and staff interviews confirmed that there had been recent problems with housekeeping coverage. Documentation from Resident Council meetings indicated that both residents and staff were unclear about cleaning responsibilities, with CNAs and housekeeping staff each indicating it was the other's duty. The facility's policy requires a safe, clean, and comfortable environment, but observations and interviews demonstrated that this standard was not met during the survey period. The deficiency was cited in relation to a specific complaint.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Timely Report Allegation of Missing Resident Funds
Penalty
Summary
The facility failed to timely report an allegation of missing funds for a resident with a cognitive communication deficit and moderate cognitive impairment. The resident's representative reported bringing $80 into the facility and giving it to the previous Business Office Manager (BOM) to be placed in a safe. Later, when the representative inquired about the funds, the current BOM was unaware of the money's location, and the resident was not listed in the facility's grievance records for missing items or funds. During a meeting with the current BOM, the resident's representative, the Ombudsman, and the Social Services Director, the allegation of missing funds was raised, and the BOM indicated she notified the Executive Director (ED) afterward. However, the ED was on vacation at the time of the meeting and could not confirm being notified of the missing funds. The ED stated that if she had been made aware, she would have reported the incident to the Department of Health. The facility's policy requires reporting allegations of misappropriation of resident property within 24 hours of forming a suspicion, but the incident was not reported in a timely manner as required. The missing funds were later located, but the initial failure to report the allegation constituted a deficiency.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated by regulations. No additional details regarding specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Perform Timely Post-Fall Assessments and Adhere to Physician Orders for Diabetic Care
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, resident preferences, and goals for multiple residents. For one resident with encephalopathy and heart failure, there were two documented falls within a short period. Despite policy requiring a post-fall assessment and investigation within 24 hours, the clinical record did not contain evidence of such assessments after either fall. The Director of Nursing confirmed that the required fall risk evaluations were not completed, and there was a lack of documentation in the medical record regarding the falls and subsequent assessments. Another resident with diabetes, a foot ulcer, repeated falls, and dementia did not have updated or consistent physician orders for wound care, despite podiatry notes indicating changes in wound treatment. The Medication Administration Record (MAR) showed that wound care was provided inconsistently with the orders, and there was no documentation of a physician's order for weekly dressing changes at podiatry visits. Additionally, this resident did not receive insulin on several occasions due to blood sugar readings, but there was no documentation that the physician was notified as required. Blood sugar checks were also incompletely documented, with only one daily reading recorded despite orders for checks before meals and at bedtime. A third resident with diabetes had physician orders for blood sugar checks and insulin administration every six hours. However, the MAR lacked documentation of blood sugar readings and insulin administration on multiple occasions. The facility's policy required that vital signs and test results be recorded prior to medication administration and that any held medications be documented with reasons. The Director of Nursing confirmed that the required documentation was missing for these instances.
Failure to Obtain STAT Laboratory Tests for Resident with Altered Mental Status
Penalty
Summary
The facility failed to provide timely laboratory services for one resident who was reviewed following a fall. The resident, who had diagnoses including encephalopathy and heart failure and was noted to be cognitively impaired, exhibited confusion and restlessness. Nursing staff received new STAT orders from the on-call Nurse Practitioner/Physician for a complete blood count (CBC) and complete metabolic panel (CMP) due to altered mental status. Despite these orders, the laboratory tests were never drawn, and the clinical record did not contain results for the ordered tests. The facility's policy requires coordination and timely provision of laboratory services as ordered by a provider, but this was not followed in this instance.
Failure to Document Resident Fall and Required Notifications in Clinical Record
Penalty
Summary
The facility failed to ensure that a resident's fall, as well as the notifications to the physician and responsible party, were properly documented in the clinical record. The resident involved had diagnoses including diabetes with foot ulcer, repeated falls, and dementia, and was assessed as severely cognitively impaired, requiring substantial assistance with daily activities. Although a fall incident report was completed and maintained in risk management, this documentation was not included in the resident's clinical record. The incident report detailed that the resident fell forward out of a wheelchair while reaching for a dropped fork, with no injuries noted, and that the family and DON were notified. However, there was no documentation in the clinical record on the day of the fall regarding the incident or the notifications made. A subsequent health status note referenced the fall but was written the day after the event, based on information from the unit manager. The facility's policy required documentation of the fall, notification of the physician and responsible party, completion of an incident report, and detailed progress notes in the medical record, including the resident's condition every shift for 72 hours. The DON acknowledged that it was best practice to document falls in the clinical record and that risk management notes were sometimes copied into progress notes, but this was not done in this case.
Failure to Secure and Document Receipt of Controlled Medication
Penalty
Summary
The facility failed to ensure the secure handling and storage of a resident's controlled medication, specifically 60 tablets of oxycodone-acetaminophen, which were delivered by the pharmacy. The medication was received by a registered nurse (RN 2), who handed both the narcotic record sheet and the medication to another nurse (RN 1) to be placed in the medication cart. However, there was no documentation or record that the medication was added to the cart, and subsequent counts by staff revealed that the medication and its record sheet were missing. Multiple staff statements and interviews confirmed that the medication was not observed in the cart during shift changes, and a thorough search of all medication carts and the medication supply room failed to locate the missing narcotics. Video surveillance footage showed RN 2 handing the medication and record sheet to RN 1, who placed them in a folder or envelope on top of the medication cart, but the footage did not show what happened to the items afterward. RN 1 did not return to work the following day and was unresponsive to attempts to obtain a statement regarding the missing medication. The resident for whom the medication was intended had diagnoses including stroke, heart disease, and kidney disease, and was prescribed oxycodone-acetaminophen for pain management. Despite the missing medication, the resident did not report pain or missed doses, as there was still a supply available. The incident was reported to the appropriate authorities, and the facility's policy required controlled substances to be stored under double lock and properly documented upon receipt, which was not followed in this case.
Kitchen Sanitation and Food Storage Deficiencies
Penalty
Summary
The facility failed to maintain a clean and properly functioning kitchen environment, which had the potential to affect 52 of 53 residents consuming food from the kitchen. During an observation, the kitchen was found to have cracked and broken flooring tiles in the dishwasher and dry storage areas, and a yellow substance was observed dripping down the walls behind the dishwasher and oven. The dishwasher was not reaching the required rinse cycle temperature of 180 degrees Fahrenheit, as indicated by the manufacturer's guidelines, and the dishwasher log lacked recorded temperatures for several meal periods. Additionally, food items in the refrigerators were not labeled or dated, and personal drinks were improperly stored in the walk-in refrigerator. The dietary aide responsible for operating the dishwasher admitted to not monitoring the temperature gauges during its operation. The Registered Dietitian confirmed that the rinse cycle gauge was broken and acknowledged the need for all food items to be labeled and dated, as well as the prohibition of storing personal drinks in the walk-in refrigerators. The facility's policies on cleaning schedules, dish machine temperature recording, and food storage were not adhered to, contributing to the deficiencies observed during the survey.
Failure to Implement Effective Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program, which is crucial for tracking and monitoring antibiotic usage among residents. The deficiency was identified when the Director of Nursing (DON) provided an antibiotic stewardship binder that lacked monthly tracking data from January 2024 through May 2024. Additionally, the tracking sheets for June, July, and August 2024 did not include essential information such as the type of infection or the location of residents with infections within the facility. This oversight had the potential to affect all 53 residents residing in the facility. During an interview, the Regional Nurse Consultant (RNC) revealed that the facility had undergone a change in corporate ownership in March 2024, which resulted in a lack of documentation for the first three months of the year. The previous corporation's staff had been responsible for tracking and monitoring antibiotic usage, but this process was not continued effectively after the transition. The DON began tracking antibiotic usage in June 2024 but failed to document critical details such as the type of infection and the location of infected residents, which are necessary for a comprehensive antibiotic stewardship program.
Failure to Prime Insulin Pen Before Administration
Penalty
Summary
The facility failed to ensure proper administration of insulin for a resident with type 1 diabetes mellitus. During an observation of medication administration, an LPN was seen preparing and administering 8 units of Humulin N insulin using an insulin flex pen without priming it first. The priming step is crucial as it removes air from the needle and cartridge, ensuring the pen functions correctly and delivers the accurate dosage of insulin. The LPN admitted to normally priming the pen with two units of insulin but forgot to do so on this occasion. The manufacturer's instructions for the Humulin N Pen, retrieved from the manufacturer's website, clearly state the necessity of priming the pen before each injection. The instructions detail the steps required to prime the pen, which include selecting 2 units, holding the pen with the needle pointing up, and ensuring insulin is visible at the needle tip. Failure to prime the pen can result in administering too much or too little insulin, which was not observed in this instance, as the LPN did not follow the priming procedure.
Failure to Implement Timely Behavior Plan for Resident
Penalty
Summary
The facility failed to timely develop and implement an individualized behavior plan of care for a resident, identified as Resident 15, who was reviewed for behaviors. Resident 15 was admitted to the facility from a psychiatric hospital with diagnoses including dementia, stroke, aphasia, and major depressive disorder with psychotic symptoms. Despite a physician's order to monitor and document targeted behaviors and interventions, the clinical record lacked a care plan addressing the resident's aphasia and specific interventions for behaviors. The resident exhibited various behaviors such as yelling, verbal aggression, and emotional lability, which were not adequately documented or addressed in the care plan. Throughout the resident's stay, there were multiple instances of behavioral episodes, including yelling at staff, becoming upset during interactions, and displaying mood swings. These behaviors were noted in progress and behavior notes, but the facility's documentation was inconsistent, and the Nurse Administration Record did not contain documentation of behaviors, interventions, or outcomes. The resident's care plan was not updated to reflect his behavioral needs until a month after admission, and there was a delay in psychiatric evaluation due to miscommunication and scheduling issues. Interviews with facility staff revealed that the resident's mood was labile, and there was a lack of timely psychiatric intervention. The Social Services Director and Regional Nurse Consultant acknowledged the resident's behavioral issues and the need for a psychiatric evaluation, which was delayed. The facility's Behavior Management policy emphasized the importance of identifying residents with behavioral risks and developing effective management programs, which was not adequately followed in this case.
Failure to Monitor Blood Pressure Before Administering Midodrine
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications, specifically concerning the administration of midodrine for a resident with hypertension. The physician's order required that midodrine be withheld if the resident's systolic blood pressure exceeded 110. However, from the beginning of September until mid-September, the medication was administered without recording the necessary blood pressure readings prior to administration. This oversight was confirmed during an interview with the Regional Nurse Consultant, who acknowledged that staff should have been obtaining blood pressure readings before administering the medication. The facility's medication administration policy also emphasized the need to check vital signs before medication administration.
Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to implement enhanced barrier precautions during a wound dressing change for Resident 25, who was observed to have a diabetic ulcer on the right ankle. The care plan indicated that the resident was under enhanced barrier precautions due to a wound, and a physician's order specified the wound care procedure. During an observation of the wound dressing change, the Director of Nursing (DON) and a Licensed Practical Nurse (LPN) performed hand hygiene and donned gloves but did not use any other personal protective equipment (PPE) such as gowns, which are part of the enhanced barrier precautions. An interview with the Regional Nurse Consultant revealed a misunderstanding among the facility staff regarding the duration for maintaining enhanced barrier precautions. The staff believed that once the infection in Resident 25's wound was resolved, the precautions could be discontinued. This misunderstanding led to the failure in implementing the necessary infection control measures as outlined in the facility's infection control policy, which aims to prevent the transmission of disease and infection.
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Surveyors observed that dietary staff repeatedly worked in kitchen and meal service areas with uncovered facial hair, despite facility policy and state sanitation requirements mandating effective hair restraints. Two dietary aides with short beards or mustaches were seen walking through food preparation areas, taking food temperatures, handling food, and plating meals at steamtables in dining rooms without any facial hair coverings, while the current policy required all hair, including facial hair, to be restrained to prevent contamination.
The facility failed to consistently provide and document required bed-hold policy notices when several residents were transferred to the hospital. In multiple cases, residents with dementia, psychotic disorders, COPD, chronic respiratory failure, altered mental status, and cerebral infarction were sent out for acute changes in condition, and while transfer notes reflected physician and family notifications, they lacked documentation that the bed-hold policy was discussed with the resident or responsible party. Notices of Transfer or Discharge often indicated a copy of the bed-hold policy was sent with the resident, but the records did not show signed and dated acknowledgment by the resident or appropriate representative, including in situations where a resident had moderate cognitive impairment, short-term memory issues, or a documented need for a proxy and a financial POA authorizing an agent for health care decisions.
Surveyors found that the facility failed to provide trauma‑informed and culturally competent care by not incorporating two residents’ extensive trauma histories and specific behavioral triggers into their care plans. One resident with documented homelessness, polysubstance abuse, severe accidents with multiple fractures, viral encephalitis with coma, physical and sexual abuse, loss of family contact, and a past suicide attempt had multiple behavior‑focused care plans that referenced identifying triggers but listed none and did not mention their physical, sexual, medical, or psychosocial trauma. Another resident with TBI from being struck by a truck, an 11‑month coma, long‑term state hospital residence, alleged shooting of a parent, and diagnoses including intermittent explosive disorder and borderline personality disorder had a PASRR identifying a specific trigger and notes of inappropriate sexual behavior, yet their care plans omitted these traumatic events, the identified trigger, and the sexual behavior. Staff interviews confirmed that residents were screened for trauma, but the trauma histories and triggers were not reflected in the individualized plans of care.
A resident with schizophrenia, post‑stroke hemiparesis, and mild cognitive impairment expressed feeling down and wanting to kill himself, but staff did not document asking about a specific plan, did not notify the physician or psychiatric NP as expected, and did not develop or update a care plan addressing depression or suicidal ideation. The SSD documented offering support and initiating 15‑minute checks once, but there was no further follow‑up or documentation of interventions after subsequent suicidal statements made in a care plan meeting with the resident’s father. The DON and Administrator reported that facility policy requires immediate notification of key staff, assessment for a plan and means of self‑harm, and thorough documentation, which were not carried out or reflected in the medical record for this resident.
A resident with schizophrenia, post-stroke hemiparesis, and mild cognitive impairment verbalized suicidal ideation, but the care plan did not address depression or suicidal thoughts, and required assessments and services were not accurately or timely documented. An SSD note recorded the resident saying he wanted to kill himself and referenced 15‑minute checks and a care plan update, yet the active care plan lacked depression/suicidal ideation interventions. Multiple late-entry Social Services notes were later added, describing follow-up visits and the resident denying suicidal ideation, but the SSD later reported she did not typically ask about a suicide plan and did not personally provide individual follow-up visits as described. These practices conflicted with the facility’s policy requiring factual, first-hand, and timely documentation of assessments and services.
A resident was observed with an Albuterol inhaler on an overbed table and later reported keeping the inhaler in a nightstand drawer, with no staff present during these observations. Record review showed the resident had no cognitive impairment on the admission MDS but lacked any documented self-medication administration assessment. The DON acknowledged that the required assessment had not been completed, despite facility policy requiring staff and the practitioner to evaluate each resident’s mental and physical abilities before allowing self-administration of medications.
Surveyors found that the facility submitted inaccurate direct care staffing data to CMS through the PBJ system over multiple days in a quarter. CASPER reports showed apparent gaps in 24-hour licensed nurse coverage, low weekend staffing, and a 1-star staffing rating, while internal staffing sheets documented that licensed nurses were present and the facility was fully staffed on those days. The Administrator reported that the discrepancies were due to PBJ data entry errors, despite a facility policy requiring all PBJ entries to be accurate, auditable, and verifiable against payroll, invoices, or contracts.
Surveyors found that the facility did not provide or document required written transfer/discharge notices and bed-hold policy information for four residents who were sent to the hospital, including individuals with conditions such as dementia, CHF, chronic respiratory failure, and CKD. In each case, progress notes showed that the resident was transferred for acute issues, but the clinical records lacked evidence that written notices were given to the residents or their representatives, and in one case lacked documentation that required information was sent to the receiving provider. Facility leadership, including the ADON, DON, and Administrator, acknowledged that the records did not contain the required documentation, despite a written policy requiring such notices and information exchange.
A resident with Alzheimer’s disease and depression, previously on an antidepressant, exhibited intermittent refusals of medications and care, occasional yelling at staff, and reports of unusual perceptions, such as believing men were in or near her room. Nursing notes over several months documented these refusals and complaints but did not show that the behaviors were evaluated or recorded as dangerous, non-redirectable, or causing significant distress, nor did they document specific non-pharmacological interventions attempted or their outcomes. Despite this, a psychiatric NP later added new diagnoses of schizoaffective disorder, borderline personality disorder, and delusional disorder and ordered an antipsychotic (Seroquel) without a comprehensive evaluation in the record to support these diagnoses. The facility’s psychotropic medication policy, which requires identification and documentation of target behaviors, use of nonpharmacological interventions, and ongoing behavior monitoring, was not followed for this resident.
The facility failed to keep PASARR Level I screenings accurate and current for three residents when new mental health diagnoses and psychoactive medications were initiated. One resident’s PASARR omitted a PTSD diagnosis and an added antidepressant, despite documentation of PTSD on the MDS and care plan and a physician order for Pristiq. Another resident’s PASARR listed only depression and dementia, even after additional diagnoses such as borderline personality disorder, delusional disorder, and schizoaffective disorder were added and an antipsychotic (quetiapine) was ordered, with the MDS later reflecting psychotic disorder, schizophrenia, and depression with antipsychotic and antidepressant use. A third resident’s PASARR did not include a depression diagnosis or newly ordered escitalopram and lorazepam, although the admission MDS documented depression with antianxiety and antidepressant use. These omissions occurred despite facility policy requiring a new Level I review after significant mental status changes, including new mental health diagnoses or new psychotropic medications.
Uncovered Facial Hair During Food Preparation and Meal Service
Penalty
Summary
The deficiency involves the facility’s failure to ensure that food was served in a sanitary and safe manner in accordance with professional standards and facility policy during multiple kitchen and meal service observations. During an initial kitchen observation, two dietary aides were seen walking through the kitchen food preparation area with uncovered facial hair. One aide had facial hair above and below the lip and along the jaw line, approximately one-fourth inch in length, and the other had a mustache of similar length; neither used any facial hair covering. These observations occurred while staff were present in the kitchen area where food was stored and prepared. During subsequent observations on the same day, the same two dietary aides were again observed with uncovered facial hair while directly involved in meal preparation and service. One aide walked through the kitchen while the noon meal was being prepared and placed into a transport cart for service in the south dining room, and later was observed plating the noon meal at the steamtable in that dining room, still without a facial hair covering. The other aide walked through the kitchen while the noon meal was being prepared and placed into the steamtable for the north dining room, took food temperatures, assisted with plating meals at the steamtable, and retrieved food items and supplies from the kitchen, all while having an uncovered mustache approximately one-fourth inch in length. The Dietary Manager stated that staff hair was to be covered when in the kitchen and during meal service, and the facility’s written policy and the cited Indiana Food Establishment Sanitation Requirements both required effective hair restraints, including for facial hair, to prevent contamination of food, equipment, and utensils.
Failure to Provide and Document Bed-Hold Policy at Time of Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure that required bed-hold policy information was provided and documented for four residents transferred to the hospital. For a resident with dementia, psychotic disorder, and autistic disorder who had a BIMS score of 0 indicating severe cognitive impairment, progress notes documented physician notification and guardian notification when the resident was sent to the hospital, but there was no documentation that the bed-hold policy was provided to the responsible party. A Notice of Transfer or Discharge later indicated a copy of the bed-hold policy was sent with the resident. Another resident with COPD and chronic respiratory failure, cognitively intact with a BIMS score of 13, experienced a decline in condition and was transferred to the hospital by ambulance; progress notes documented family notification but did not document any discussion of the bed-hold policy, although a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident. A third resident with altered mental status and cerebral infarction, with a BIMS score of 10 indicating moderate cognitive impairment and documented short-term memory impairment, experienced changes in condition and was transferred to the hospital. Progress notes stated the resident was their own responsible party and that no other notification was completed, and transfer documentation did not include the bed-hold policy, although an untimed Notice of Transfer or Discharge indicated a copy of the bed-hold policy was signed by the resident. A financial power of attorney document in the record showed the resident had designated an agent to act in consent or refusal of health care. For a fourth resident with dementia and osteomyelitis, transfer documentation and a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident, and the transfer form noted the resident required a proxy for decision making. The facility’s policy required that at the time of transfer to a hospital, written notice specifying the duration of the bed-hold policy and information on return to the next available bed be provided, and that a signed and dated copy of the bed-hold notice given to the resident or representative be kept in the resident file, which was not consistently documented for these residents.
Failure to Integrate Trauma Histories and Behavioral Triggers Into Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to identify and incorporate residents’ trauma histories and specific behavioral triggers into their care plans, despite documented histories of significant trauma and behavioral health issues. For one resident, extensive social service and progress notes documented homelessness, polysubstance abuse, major depressive and anxiety disorders, chronic pain, a history of severe car accidents with multiple fractures, viral encephalitis resulting in a three‑month coma, loss of child custody, multiple divorces, physical abuse by a spouse, the death of a fiancé who was struck by a car while in a wheelchair, lack of family contact, and a past suicide attempt by Valium overdose. Additional documentation noted a history of rape by a brother at age eight and prior placement under direct supervision and 15‑minute checks related to suicidal ideation. Despite these documented traumatic events and behavioral health concerns, the resident’s care plans did not identify a history of physical trauma, sexual trauma, homelessness, substance abuse, medical trauma, or attempted suicide. For this same resident, the MDS showed no cognitive deficit and identified behaviors such as verbal aggression and rejection of care, along with diagnoses including seizure disorder, depression, chronic pain syndrome, homelessness, and anxiety disorder. Multiple care plans addressed behaviors such as drug‑seeking, pretending to have seizures for attention or medication, making false allegations, verbal aggression when unable to smoke, and a desire for intimate relationships with consenting male residents. These care plans referenced goals such as effective coping skills, seeking staff support, and compliance with the smoking policy, and they called for identification and reduction of behavioral triggers. However, none of these care plans actually listed any specific triggers. The care plan addressing the resident’s right to consensual intimate relationships focused on assessment and education regarding consent but did not integrate the resident’s extensive trauma history. Staff interviews indicated the resident had displayed sexual behaviors since admission, including an incident where the resident expressed anger at another resident for not buying a soda after engaging in sexual acts. A second resident with a documented history of traumatic brain injury (TBI), dementia, seizure disorder, borderline personality disorder, anxiety, intermittent explosive disorder, tobacco use, and other behavioral/emotional disorders was also affected by the same deficiency. Social history and progress notes documented that this resident sustained a TBI after being hit by a semi‑truck while riding a bicycle at age 18, resulting in an 11‑month coma, followed by 13 years in a state hospital and subsequent residence in a group home. Additional documentation indicated the resident allegedly shot their father at age 26 after being sworn at and had a PASRR identifying TBI, intermittent explosive disorder, and borderline personality disorder, with a specific trigger of hearing the name of the current U.S. President. Progress notes also described inappropriate sexual behavior toward staff, including touching themselves intimately during personal care and refusing to stop when redirected. Despite this, the resident’s care plans, which addressed explosive disorder and history of altercations, risk for decreased psychosocial well‑being, and refusal to bathe or shower, did not list any specific behavioral triggers, did not reference the traumatic events such as being hit by a truck or shooting their father, and did not document the inappropriate sexual behavior. The Administrator and Social Service Director acknowledged that residents were to be screened for trauma and that trauma responses and PTSD should be added to care plans, but the specific trauma histories and triggers for these two residents were not incorporated into their plans of care.
Failure to Assess and Care Plan for Resident Suicidal Ideation
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess, investigate, and care plan for a resident’s suicidal ideation in accordance with its own policy and staff expectations. The resident had diagnoses including schizophrenia, cerebral edema, and hemiparesis/hemiplegia following a cerebral infarction, and a current MDS showed mild cognitive impairment (BIMS score 12). A progress note documented that the resident told the Social Services Director (SSD) he was feeling down and wanted to kill himself; the SSD offered assistance, activities, and initiated 15‑minute checks, and the note stated the care plan was updated. However, the note did not indicate that the SSD asked whether the resident had a plan to kill himself, and there were no additional notes regarding suicidal ideation or follow‑up. Review of the current care plan showed no problem, goal, or interventions addressing depression or suicidal ideation, and progress notes over the following month contained no documentation of physician notification related to the suicidal statement. Further record and interview evidence showed that the care plan conference summary did not document interventions for suicidal ideation, and the SSD acknowledged she did not normally ask residents expressing suicidal ideation if they had a plan. The SSD reported that the resident had admission paperwork mentioning suicidal ideation related to depression after a stroke and that the resident again vocalized suicidal ideation during a care plan meeting with his father, after which emotional support was offered and the father took the resident out on a leave of absence; no further visits or follow‑up were done. The DON stated that, upon notification of suicidal verbalization, staff should assess the resident, ask if there is a plan, remove potential means of self‑harm, immediately notify the psychiatric NP, and document the occurrence, and that a detailed progress note and updated care plan were expected but not present for this resident. The Administrator similarly stated that staff should ask about a plan, document interventions, notify the physician and family, and update the care plan, and indicated the resident should have had a care plan addressing depression with suicidal ideation. The facility’s written policy required immediate notification of the DON, SSD, and physician, an interview including asking about a plan and assessing mood and means for self‑harm, and thorough documentation of mood, behavior, and all actions taken, which were not reflected in the resident’s record.
Incomplete and Inaccurate Documentation of Suicidal Ideation and Follow-Up
Penalty
Summary
The facility failed to ensure accurate, complete, and timely documentation of assessments and services for a resident who verbalized suicidal ideation. Resident 6, who had schizophrenia, cerebral edema, and right-sided hemiparesis/hemiplegia following a cerebral infarction, had a BIMS score of 12 indicating mild cognitive impairment. The resident’s admission paperwork mentioned suicidal ideation related to depression after a stroke, and a Social Services note on 3/11/2026 documented that the resident was feeling down and said he wanted to kill himself. The Social Services Director (SSD) documented that she talked with the resident, coordinated with Activities, advised the resident to contact SSD or nursing if he wanted to talk, and that the resident was scheduled for 15-minute checks and the care plan was updated. However, the current care plan initiated on 2/26/2026 did not address depression or suicidal ideation. Multiple Social Services progress notes were later entered as late entries in April, with effective dates in March, stating that the resident had no plan and no longer had suicidal ideation, that he felt much better after 1:1 time, and that he continued his daily routine and therapy. These late entries described follow-up visits and reassessments of suicidal ideation on several consecutive days, but in interviews the SSD stated she did not normally ask residents about having a plan when they verbalized suicidal ideation and did not recall any other occurrences beyond the initial event. She further indicated she did not personally provide individual follow-up visits with this resident regarding suicidal ideation, despite the late-entry notes describing such visits. The DON acknowledged that late entries had been added to address concern about suicidal verbalization, and the Administrator stated that upon suicidal statements staff should ask about a plan, notify the physician and family, and update the care plan, and that this resident should have had a care plan addressing depression with suicidal ideation. The facility’s documentation policy required factual, first-hand, timely documentation, which was not followed in this case.
Failure to Complete Required Self-Administration Assessment for Inhaler Kept at Bedside
Penalty
Summary
Surveyors identified that a resident was allowed to keep and access an Albuterol inhaler without the facility completing the required self-administration medication assessment. During an initial tour, the resident was observed sitting in a wheelchair with a handheld Albuterol inhaler on the overbed table and no staff present in the room or hallway. On a subsequent observation, the resident again was in a wheelchair and reported that the Albuterol inhaler was stored in the top drawer of the nightstand, where it was found. Review of the clinical record showed an admission MDS indicating no cognitive impairment, but there was no documentation of a self-medication administration assessment. In an interview, the DON confirmed that the resident did not have the required self-medication assessment, despite the facility’s policy stating that staff and the practitioner must assess each resident’s mental and physical abilities to determine whether self-administering medications is clinically appropriate. This failure to complete and document a self-administration medication assessment for a resident who had an Albuterol inhaler kept at bedside constituted noncompliance with the facility’s own policy and with 410 IAC 16.2-3.1-11(a).
Inaccurate PBJ Staffing Data Submission to CMS
Penalty
Summary
The deficiency involves the facility’s failure to electronically submit complete and accurate direct care staffing information to CMS through the Payroll-Based Journal (PBJ) system for 22 days in a fiscal quarter. A CASPER report review on 4/6/26 showed that, according to PBJ data, the facility did not have licensed nursing coverage 24 hours per day on multiple specific dates across three months, had low weekend staffing, and held a 1-star staffing rating. However, review of the facility’s internal staffing sheets for that quarter indicated the facility was fully staffed and had licensed nurse coverage on all of the dates in question. During an interview, the Administrator stated that the PBJ information must have contained data entry errors, as she had verified licensed staff coverage on the timesheets. The facility’s PBJ policy in effect stated that all staffing data entered into the PBJ system would be auditable and verifiable through payroll, invoices, or contracts, but the submitted PBJ data did not accurately reflect the facility’s actual licensed nurse staffing as documented on internal records. No specific residents or clinical conditions were mentioned in the report, and the deficiency centers solely on inaccurate staffing data submission rather than direct resident care events.
Failure to Provide and Document Required Transfer/Discharge and Bed-Hold Notices
Penalty
Summary
The deficiency involves the facility’s failure to provide and document required written notices of transfer/discharge and bed-hold policies, as well as required information to receiving providers, for four residents who were transferred or discharged to the hospital. For a resident with generalized anxiety disorder, major depressive disorder, and dementia, progress notes showed that the resident was sent to the hospital via 911 for chest pain, lower back pain, and shortness of breath and later returned to the facility, but the clinical record lacked documentation that a written Notice of Transfer/Discharge and the bed-hold policy were provided to the resident or representative, and lacked documentation that required information was conveyed to the receiving facility. The ADON and the Administrator both confirmed there was no documentation that these written notices were provided. For a resident with congestive heart failure and muscle weakness who was sent to the emergency room for painful urination and bloody urine, the clinical record lacked documentation that a Notice of Transfer/Discharge or bed-hold policy was given to the resident or representative, which the DON confirmed. Another resident with chronic respiratory failure and diabetes was discharged to the hospital for respiratory failure, and a resident with chronic kidney disease and dementia was discharged to the hospital, but in both cases there was no documentation that a written notice of transfer/discharge or bed-hold policy was provided to the residents or their representatives. Review of the facility’s Transfer and Discharge policy, dated 1/15/26, showed that the policy required the facility to provide written transfer/discharge notices and bed-hold information to residents and representatives and to provide specified information to receiving providers, but the records for these four residents did not contain the required documentation.
Failure to Document Target Behaviors and Non-Pharmacological Interventions Before Initiating Antipsychotic
Penalty
Summary
The deficiency involves the facility’s failure to document how a resident’s behaviors presented danger or distress to self or others, and failure to document non-pharmacological interventions attempted prior to initiating an antipsychotic medication. Resident 6 had documented diagnoses of Alzheimer’s disease, depression, and severe cognitive impairment, and was receiving sertraline for depression. A PASSAR identified only depression and dementia, and the admission MDS listed Alzheimer’s disease and depression as active diagnoses. Over several months, nursing progress notes documented that the resident intermittently reported unusual perceptions, such as believing there were men causing trouble, a man in her room, or a man wanting to marry her and yelling through the walls, but there was no documentation that these episodes caused danger to the resident or others or that they resulted in unmanageable distress. From late April through mid-July, nursing notes primarily described the resident’s frequent refusals of evening and morning medications, blood sugar checks, blood pressure checks, insulin administration, hygiene care, and showers. Staff documented that the resident sometimes yelled at staff, said “Get out!”, was visibly upset by a room move, was leery of staff and asked to see name badges, and became upset about a pillow under her head until it was removed, after which she calmed down. The notes also recorded instances where the resident believed housekeeping had not cleaned her room or that she had not received medications when she had. However, there were no progress notes or assessments indicating that these behaviors were evaluated as dangerous, non-redirectable, or causing significant distress or functional impairment, and no detailed behavior monitoring logs were present as required by facility policy. On a psychiatric NP visit for initial psychotropic medication management, new mental health diagnoses of schizoaffective disorder, borderline personality disorder, and delusional disorder were added, and Seroquel 25 mg, an antipsychotic, was ordered. The clinical record did not contain a comprehensive evaluation to support these new diagnoses, and there was no documentation of target behaviors meeting the facility’s policy criteria for psychotropic use, such as behaviors representing danger to self or others, causing distress and impairment in functional abilities, or clearly attributable to psychosis or mania. The resident’s representative reported that the resident had no prior history of mental health disorders or psychiatric hospitalization and was unaware of the new diagnoses. The facility’s own psychotropic medication policy required identification and documentation of specific target behaviors, use and documentation of nonpharmacological interventions, and ongoing monitoring of behaviors and interventions, which were not reflected in the record for this resident.
Failure to Update PASARR Screens for New Mental Health Diagnoses and Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that Preadmission Screening and Resident Review (PASARR) Level I screenings were accurate and updated when new mental health diagnoses and psychoactive medications were initiated for multiple residents. For one resident with dementia, anxiety, depression, and post-traumatic stress disorder (PTSD), the PASARR completed on admission listed anxiety, depression, and dementia with sertraline and quetiapine, but did not include the PTSD diagnosis or the antidepressant Pristiq, despite the admission MDS and care plan documenting PTSD and a subsequent physician’s order for Pristiq. For another resident with Alzheimer’s disease, borderline personality disorder, delusional disorder, schizoaffective disorder, and depression, the PASARR only reflected depression and dementia with sertraline, even though additional mental health diagnoses were added later and an antipsychotic (quetiapine) was ordered for borderline personality disorder, and the quarterly MDS documented psychotic disorder, schizophrenia, and depression with antipsychotic and antidepressant use. A third resident had diagnoses including Alzheimer’s disease, depression, anxiety disorder, irritability and anger, and nonrheumatic aortic valve stenosis. The PASARR for this resident listed dementia and anxiety with Risperdal but omitted the diagnosis of depression and the medications escitalopram and lorazepam, although physician’s orders were in place for escitalopram for depression and lorazepam for anxiety, and the admission MDS documented depression with antianxiety and antidepressant use. Interviews with the Assistant Director of Nursing confirmed that new Level I PASARR screens should have been completed when new mental health diagnoses and psychoactive medications were added, and that the PASARR for one resident, completed prior to arrival, should have included all mental health diagnoses and medications. The facility’s own policy required notification of the state mental health authority within 14 days after a significant change in mental condition and specified that a new Level I screen is required for new mental health diagnoses or newly prescribed psychotropic medications, which was not followed in these cases.
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