Chateau Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Fort Wayne, Indiana.
- Location
- 6006 Brandy Chase Cove, Fort Wayne, Indiana 46815
- CMS Provider Number
- 155249
- Inspections on file
- 47
- Latest survey
- February 18, 2026
- Citations (last 12 mo.)
- 42
Citation history
Health deficiencies cited at Chateau Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
The facility failed to follow ordered pressure ulcer treatments for two residents with chronic pressure injuries. One resident with paraplegia and an unstageable ischial/buttock wound had NP orders for calcium alginate with Santyl three times daily, and later wound clinic orders for specific dressings to the buttock and sacrum, but the TAR showed only once-daily Santyl-based treatments and no implementation of the wound clinic’s regimen. Another resident with a stage 4 sacral pressure injury and osteomyelitis had wound clinic orders for Endoform AM with a bordered superabsorber dressing every other day, yet the TAR documented ongoing use of collagen with silver and daily Vashe-soaked gauze instead. Leadership interviews confirmed that wound NP and wound clinic orders were supposed to be followed as written and placed on the TAR, but staff did not update and carry out the treatments as ordered.
A resident with paraplegia and an Indiana pouch required straight catheterization every 4 hours, with staff instructed to offer assistance, especially at night, and to document urine output and monitor for UTI signs. On one day, scheduled catheterizations were not completed at two time points, no urine output was recorded, and there was no documentation explaining the missed catheterizations. Later that day, the resident was noted to be lethargic with a distended, painful abdomen, staff were unable to catheterize the pouch, and the resident was sent to the ER, where 2 liters of urine with mucus and blood were drained and labs showed leukocytosis, acute kidney injury, urinary retention, and hyponatremia. The DON reported being unaware that catheterizations had not been done or documented, despite a facility policy requiring monitoring of residents with Indiana pouches and reassessment of self-care ability with changes in condition.
A resident with end stage renal disease, chronic pain, and diabetes experienced significant changes in condition, including refusal of dialysis and medications, altered mental status, and suspected alcohol use. Staff failed to document these events and did not notify the physician or dialysis team as required by facility policy, resulting in a lack of timely medical intervention.
A resident with dementia and other comorbidities developed significant pressure injuries, including an unstageable coccyx wound and black wounds on both heels, after the facility failed to update care plans, document wound progression, and implement individualized interventions despite changes in mobility and incontinence. Wound care recommendations were not consistently incorporated, and the extent of the wounds was not communicated to the receiving facility or family at discharge.
The facility was found deficient in maintaining cleanliness in ceiling return air ducts, with three out of ten vents observed to have gray, feathery debris. The vents were located in Hall 100, including the memory unit and near the nurse's station. The Administrator confirmed that the vents should be debris-free, but the facility's Deep Clean List did not include cleaning instructions for these intakes.
A facility failed to conduct a comprehensive assessment and implement non-pharmacological approaches before reducing a resident's antipsychotic medication. The resident, with a history of dementia and behavioral disturbances, experienced increased agitation and aggression following the medication reduction, leading to a fall and hip fracture. The facility did not document non-pharmaceutical interventions or obtain family consent for the medication change.
The facility failed to ensure their registered dietician was licensed in Indiana, as required for providing dietary services. The dietician, hired in June 2024, was licensed in other states but not in Indiana. This deficiency was identified during a review of employee records and confirmed by the Indiana Professional Licensing Agency's website, which mandates state licensure for dieticians.
A facility failed to record and communicate fall interventions for a resident with Alzheimer's and other conditions, leading to multiple undocumented falls. Despite a history of falls and risk factors, interventions were inconsistently documented, and care plans were outdated and inaccessible to staff, contributing to inadequate supervision and fall prevention.
The facility failed to clean a shared glucometer between uses for three residents, leading to a breach in infection control practices. An LPN used the glucometer for multiple residents without disinfecting it, contrary to facility policy. The residents involved had serious health conditions, including diabetes and renal disease. The facility's policy requires cleaning the glucometer with a disinfectant wipe before and after each use, which was not followed.
A resident with multiple medical conditions was found to have a significant area of missing floor paneling near their bed. Staff, including RNs and CNAs, were unaware of the damage until it was observed, and maintenance was not informed prior. The facility uses an application for reporting maintenance issues, but the damage was not reported through this system.
Failure to Follow Ordered Pressure Ulcer Treatments for Two Residents
Penalty
Summary
The facility failed to provide pressure ulcer treatments as ordered for two residents with pressure injuries. For one resident with paraplegia and chronic pressure-related wounds, an in-house wound NP documented an unstageable left ischial wound measuring 20 cm x 16 cm x 1 cm with specific orders to clean the wound, apply calcium alginate with Santyl to the wound base, and secure with a bordered dressing three times per day. The January Treatment Administration Record (TAR) showed that from the beginning of the month through multiple days, Santyl was applied only once daily to a left buttock wound and the left ischium was treated once per day with Santyl and calcium alginate, rather than three times per day as ordered. A subsequent wound clinic note documented two wounds (left buttock and sacrum) with new treatment orders for each, but the TAR continued to reflect the prior regimen and did not show that the wound clinic’s specific dressing orders were implemented. Later NP documentation again referenced only a sacral wound with the same measurements as the earlier ischial wound, and an LPN clarified that the measured area included the left buttock, indicating inconsistency between documentation and ordered treatments. For another resident with a chronic stage 4 sacral pressure injury and osteomyelitis of the coccyx, a wound clinic note ordered cleansing with baby soap and water, followed by application of Endoform AM and coverage with a bordered superabsorber dressing, with dressing changes every other day. Manufacturer information described Endoform AM as an antimicrobial dressing for acute and chronic wounds that can remain in place for several days and is to be changed per physician order. However, the January TAR showed that throughout the month the resident’s sacral wound was treated instead with collagen with silver placed in the wound bed three times weekly, along with daily Vashe-soaked gauze and bordered gauze, with collagen applied first and Vashe gauze over it. The TAR did not reflect implementation of the wound clinic’s Endoform AM orders. In interviews, the ADON and DON confirmed that wound care orders from either the in-house wound NP or the wound clinic were to be followed as written and placed on the TAR, and the Administrator acknowledged that staff had missed changing the wound treatments as ordered, contrary to the facility’s wound care policy requiring wound care to be done as ordered by the physician.
Failure to Monitor and Assist With Indiana Pouch Catheterization Leading to Acute Illness
Penalty
Summary
The deficiency involves the facility’s failure to ensure necessary assessment, monitoring, and assistance with catheterization for a resident with an Indiana pouch, resulting in hospitalization for sepsis. The resident had diagnoses including paraplegia, an Indiana pouch (continent urinary reservoir), pressure-related wounds, and chronic pain syndrome treated with routine pain medications. Her care plan indicated she required some assistance with ADLs due to paraplegia, muscle wasting, and intermittent catheterization, and specified that straight catheterization of the Indiana pouch was to occur every 4 hours. Although the resident was considered competent to self-catheterize, the care plan and physician orders directed staff to offer assistance with catheterization every 4 hours, especially at night, document urine output, and observe for signs and symptoms of UTI. On the date in question, the Treatment Administration Record showed that scheduled catheterizations at 8:00 a.m. and 12:00 p.m. were not completed and no urine output was recorded. The nurse’s initials and notation to refer to progress notes were present, but there were no corresponding progress notes during that time frame explaining why catheterization was not done or why there was no output. Later that afternoon, a progress note documented that the resident had been lethargic during the day, and when the nurse went to change dressings, the resident’s abdomen was observed to be distended and painful. The nurse attempted to assist the resident with catheterizing the pouch but was unsuccessful, and the on-call NP was notified with orders to send the resident to the ER for mental status change, distended abdomen, inability to catheterize, and wound changes. Hospital records documented that the resident reported abdominal pain beginning around lunchtime and decreased appetite over the preceding days. She stated she self-catheterized her Indiana pouch but had not obtained any urine that day and had been unable to remove urine since the previous night. Examination revealed a distended abdomen, and after gentle dilation of the urostomy, a catheter was placed and 2 liters of urine with large amounts of mucus and blood were drained from the pouch. Laboratory results showed a markedly elevated WBC, positive urine for blood, WBCs, and bacteria, low sodium, and elevated creatinine, and she was admitted for leukocytosis, acute kidney injury, urinary retention, and hyponatremia. The DON later indicated she was not aware that catheterizations had not been performed or documented earlier that day, and acknowledged there should have been documentation in the TAR or progress notes explaining why catheterization was not done. The facility’s Indiana pouch management policy required assessment of the resident’s ability to perform self-care with any change in condition and nursing monitoring for changes in continence and signs of infection or complications.
Failure to Notify Physician and Dialysis Team of Resident's Change in Condition and Refusal of Treatment
Penalty
Summary
The facility failed to ensure timely and appropriate notification of a resident's physician and dialysis team regarding significant changes in the resident's condition and refusal of treatment. The resident in question had end stage renal disease requiring dialysis, chronic pain managed with opioids, and diabetes, and was noted to have moderately impaired cognition. On multiple occasions, staff observed the resident to be out of sorts, smelling of alcohol, refusing dialysis, and refusing medications, but there was a lack of documentation and communication with the medical team regarding these changes. Specifically, after the resident was noted to smell of alcohol, an order was obtained for a drug and alcohol screen, but the resident refused the test. This refusal was not documented in the medical record, nor was the nurse practitioner or dialysis team notified of the refusal. Additionally, when the resident refused dialysis and medications and exhibited altered consciousness, there was no documentation of nursing assessment or notification to the medical team about the held medications or the resident's ongoing condition. The nephrologist confirmed that neither she nor her staff were informed of the resident's possible intoxication or altered mental status prior to the next dialysis session. Facility policy required immediate notification of physicians for acute problems or significant changes in resident status, with appropriate assessment and documentation. However, the facility did not follow these guidelines, as evidenced by the lack of timely communication and documentation regarding the resident's refusal of treatment, changes in condition, and the holding of medications. This deficiency was identified through interviews, record reviews, and policy examination.
Failure to Assess, Document, and Intervene for Pressure Ulcers
Penalty
Summary
A resident with a history of dementia, major depressive disorder, and chronic obstructive pulmonary disease was admitted to the facility from an inpatient psychiatric hospital. Upon admission, the resident was assessed as not being at risk for pressure ulcers and had no current skin impairments. However, over the course of her stay, the resident developed significant skin issues, including large blisters on both heels and eventually a pressure injury to the coccyx. Despite changes in her mobility, increased incontinence, and the development of pressure injuries, the care plan was not updated to reflect these changes or to include new interventions as recommended by wound care specialists and as indicated by skin assessments. The facility failed to consistently document and assess the resident's wounds. Although wound care consultations and recommendations were made, such as the use of heel protectors, barrier creams, and turning protocols, these were not always incorporated into the care plan or consistently documented in the medical record. There was also a lack of detailed wound measurements and descriptions, particularly regarding the coccyx wound, and no evidence that the wound nurse practitioner was notified of the open area on the coccyx. Orders for wound treatments were given, but staff interviews revealed confusion about the presence and treatment of the coccyx wound, and the wound was not properly tracked or communicated. Upon discharge to another facility, the resident was found to have an extensive, unstageable pressure injury to the coccyx with foul odor and slough, as well as black wounds on both heels. The receiving facility and the resident's family were unaware of the extent of the wounds prior to transfer. Documentation from the sending facility did not accurately reflect the resident's wound status at discharge, and there was no indication that the care plan had been updated to address the new and worsening wounds. The lack of timely assessment, documentation, and individualized interventions led to the worsening of the resident's pressure injuries.
Facility Fails to Maintain Clean Ceiling Air Ducts
Penalty
Summary
The facility failed to maintain cleanliness in the ceiling return air ducts, as observed during an environmental tour. Specifically, three out of ten vents were found to have gray, feathery debris. These vents were located on Hall 100 south of the dining room, on the memory unit, and by the nurse's station. During an interview, the Administrator acknowledged that the ceiling air intake vents should be free of debris. However, a review of the facility's undated Deep Clean List revealed that it did not include instructions for cleaning the ceiling air intakes. This deficiency was related to a complaint identified as IN00448990.
Failure to Implement Comprehensive Assessment Before Medication Reduction
Penalty
Summary
The facility failed to ensure a comprehensive assessment and evaluation, along with non-pharmacological approaches, were identified and implemented before decreasing a resident's antipsychotic medication. Resident B, who had a history of dementia with behavioral disturbances, anxiety disorder, and severe malnutrition, was admitted to the facility with a fractured left ankle and was on Zyprexa for psychosis. Despite the psychiatric physician's recommendation to continue Zyprexa, the facility's interdisciplinary team decided to reduce the medication without proper documentation of non-pharmaceutical interventions or family consent. On the day following the medication reduction, Resident B exhibited agitation and aggressive behavior, which led to an incident where she threw silverware at staff and subsequently fell, resulting in a right hip fracture. The facility's records lacked documentation of delusions or other behaviors that would justify the reduction of Zyprexa. Furthermore, there was no evidence that the resident's family was informed or agreed to the medication change, nor was there a comprehensive treatment plan in place to address her behavioral symptoms. The facility's policy on medication management and psychotropic agents was not adhered to, as there was no comprehensive regimen review or appropriate gradual dose reduction assessment. The psychiatric NP involved in the decision to reduce the medication did not have access to the resident's hospital records and had not evaluated the resident before the medication change. This lack of communication and documentation contributed to the resident's adverse event and subsequent hospitalization.
Dietician Licensing Deficiency
Penalty
Summary
The facility failed to ensure that their registered dietician was licensed in the state of Indiana, which is a requirement for providing dietary services. The review of employee records revealed that the registered dietician, hired on June 1, 2024, did not possess an Indiana license. Instead, the dietician was licensed in North Carolina, South Carolina, and Florida. This oversight was identified during a record review and interview process conducted on August 18 and 19, 2024. The Indiana Professional Licensing Agency's website confirmed that, effective July 1, 2019, dieticians must be licensed through the Medical Licensing Board of Indiana. Despite this requirement, no Indiana license was found for the dietician in question. The facility's policy, dated November 2021, also stipulated that a qualified dietician must be licensed in the state where services are performed. The administrator acknowledged the federal regulation requiring state licensure for dieticians, yet no Indiana license was provided for the dietician by the time of the survey exit.
Failure to Record and Communicate Fall Interventions
Penalty
Summary
The facility failed to ensure that fall interventions were recorded and communicated for a resident with Alzheimer's disease, major depressive disorder, and unilateral primary osteoarthritis of the right hip. The resident's record indicated a history of falls and various risk factors, including disorientation, incontinence, decreased muscular coordination, and medication side effects. Despite multiple falls occurring between May and August, interventions were inconsistently documented and communicated. For instance, after a fall on May 18, no interventions were recorded, and subsequent falls on June 23 and July 5 also lacked detailed descriptions or interventions. The care plan and Kardex were not updated promptly, and staff were unaware of the current interventions due to outdated care plan documentation. During an observation and interview, it was revealed that the care instructions for residents were outdated and not easily accessible to staff. The care plan book contained information for residents no longer residing in the unit, and the current care plan for the resident in question was missing. The facility's policy required that new interventions be implemented immediately after a fall and communicated to staff, but this was not consistently done. The lack of updated and accessible care plans contributed to the failure in providing adequate supervision and fall prevention for the resident.
Failure to Clean Shared Glucometer Between Uses
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices by not cleaning a shared glucometer between uses for three residents. During a medication pass observation, an LPN used a glucometer to check the blood glucose level of a resident without cleaning it before or after use. The glucometer was then returned to the medicine cart and used for other residents without disinfection. The LPN admitted to not cleaning the device, mistakenly believing another employee had done so. The facility's policy requires glucometers to be cleaned with a disinfectant wipe for a specified duration before and after each use to prevent cross-contamination. The residents involved in this deficiency included individuals with type 2 diabetes and other serious health conditions such as chronic kidney disease, end-stage renal disease, and heart failure. The residents' mental status varied, with some being cognitively impaired and others intact. The facility's policy and the administrator confirmed the requirement for cleaning the glucometer to prevent cross-contamination, but this was not adhered to during the observed medication pass.
Failure to Maintain Safe Flooring for Resident
Penalty
Summary
The facility failed to ensure that the flooring panels were complete and intact for one of the residents reviewed. During an observation, a significant area of floor paneling was found missing in front of the heating unit and near the end of the resident's bed. A loose floor panel was lying across a portion of the uncovered area. The resident involved had multiple medical conditions, including multiple sclerosis, unspecified dementia, and type 2 diabetes mellitus, and was cognitively impaired with a Basic Interview for Mental Status (BIMS) score of 4. Staff members, including a registered nurse and certified nurse aides, were unaware of the floor damage until it was pointed out during the observation. The maintenance staff also indicated that this was the first time they were informed of the issue. The facility's administrator stated that floor damage should be reported through the facility maintenance system immediately upon discovery. However, there was no record of the damage being reported prior to the observation, and the facility's current method of communication regarding maintenance issues was through an application called tells, as indicated in the Point Click Care Dashboard.
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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