Countryside Meadows
Inspection history, citations, penalties and survey trends for this long-term care facility in Avon, Indiana.
- Location
- 762 N Dan Jones Rd, Avon, Indiana 46123
- CMS Provider Number
- 155792
- Inspections on file
- 42
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Countryside Meadows during CMS and state inspections, most recent first.
A resident with a chronic stage 3 pressure ulcer on the mid upper back, identified in the medical record and care plan as requiring enhanced barrier precautions (EBP) due to MDRO risk, received a dressing change from two LPNs who wore masks and gloves but did not don gowns despite posted EBP signage and an active EBP order. The resident’s care plan and the facility’s EBP policy required gown and glove use for high-contact care activities, including wound care for chronic wounds, yet the LPN performing the dressing change stated she believed the resident had been removed from EBP because the wound was small, resulting in noncompliance with the infection prevention and control program.
A resident with dementia and a history of falls sustained a severe leg laceration requiring sutures after being transferred to bed with a bedframe missing protective end-caps, exposing jagged metal. Observations and interviews revealed that multiple beds in the facility lacked these safety caps, and there was no policy or routine monitoring in place to address such hazards. The resident had prior skin injuries, but the facility did not identify or mitigate the environmental risk before the incident.
A resident with chronic UTIs and a nephrostomy tube was not provided timely incontinence and perineal care, as staff failed to respond to requests for assistance for several hours, resulting in the resident remaining in soiled linens and a saturated brief. Documentation showed incontinence care was not provided every two hours as required by policy and care plan, and staff interviews revealed confusion about the resident's nephrostomy tube care orders.
The facility failed to ensure call lights were within reach for four residents, leading to a deficiency. A resident with right-sided hemiplegia and another with dementia were observed with call lights out of reach, despite care plans requiring accessibility to prevent falls. Two other residents, one with heart failure and another with schizophrenia, also had call lights out of reach, contrary to their care plans. This oversight resulted in a deficiency noted by surveyors.
The facility failed to ensure proper labeling and dating of medications across three medication carts. Observations revealed expired medications and those lacking open dates or prescription labels, affecting several residents. This non-compliance with facility policy indicates a systemic issue in medication management.
A resident with Down's Syndrome and Alzheimer's dementia experienced a fall resulting in a femur fracture and subsequent decline in condition. Despite ongoing pain and changes in behavior, the facility failed to notify the physician or NP of these changes, as required by their policy.
A resident's MDS inaccurately reported her medication regimen, failing to document her use of antiplatelet medication despite her care plan indicating a risk for bleeding and bruising. The Regional Director of Clinical Services confirmed the resident was on Plavix during the observation period, highlighting a discrepancy in the MDS documentation.
A facility failed to implement a care plan for the use of Seroquel, an antipsychotic medication, for a resident with multiple mental health diagnoses, including bipolar disorder. The resident's medical record lacked a care plan addressing the medication's use, and the DON had no additional information regarding this omission. The facility's policy requires a comprehensive care plan for each resident, including physician's orders.
Two residents experienced delays in treatment and pain management after falls in a LTC facility. One resident with dementia and intellectual disability had a femur fracture that was not promptly diagnosed or treated, while another resident with cognitive impairments experienced a delay in x-ray and physician notification after a knee fracture. Both cases highlight deficiencies in assessing and managing changes in condition and pain.
The facility failed to prevent medication mismanagement and implement fall prevention measures. A resident had unsupervised medications in their room without a self-medication assessment, contrary to policy. Another resident, at risk for falls, lacked care-planned interventions like brake extenders and colored tape on wheelchair brakes, as confirmed by the DON.
A facility failed to implement a pharmacy recommendation for a resident with GERD, who was supposed to switch from omeprazole to famotidine 20 mg daily. Despite the physician's acceptance of the recommendation, the facility did not initiate famotidine and instead started Tums as needed. The DON confirmed the oversight, and the facility's policy did not cover pharmacy recommendations and new order changes.
A resident with a suprapubic catheter developed urosepsis and acute kidney failure due to the facility's failure to promptly collect and review lab specimens for a suspected urinary tract infection. Despite symptoms like increased confusion and back pain, there was no documentation of physician notification. STAT labs were delayed, and the NP waited for culture results before treatment, leading to the resident's death.
A facility failed to ensure a resident's treatments aligned with the legal guardian's wishes. Despite the guardian's request for the resident to remain a full code, the resident's son, not the legal guardian, was allowed to sign a DNR form, changing the resident's code status to DNR with comfort measures. This unauthorized change occurred after the NP discussed the resident's declining condition with the guardian, who had not consented to the change.
A facility failed to notify a resident's family about a significant change in his condition due to an acute UTI, leading to urosepsis and acute kidney injury. The family was only informed on the day of the resident's death, despite the facility's policy requiring timely communication of such changes. The resident had a history of infections and multiple diagnoses, including Alzheimer's and the use of a suprapubic catheter.
A facility failed to update the care plan for a resident with skin breakdown. The resident, with a history of stroke, Parkinson's, and diabetes, had a skin event resulting in breakdown on the coccyx. Despite a care plan identifying risk factors, it was not updated after the event. The DON noted care plans should be updated after seven days, but this was not done. Facility policy requires periodic review and revision of care plans, which was not followed.
A facility failed to involve a resident's legal guardian in care decisions, leading to unauthorized changes in the resident's treatment plan. The resident's son, not the legal guardian, was misled into signing a DNR form, and the resident's care was shifted to palliative without the guardian's consent. The guardian was not informed of these changes until a care plan meeting was requested due to a serious medical condition.
A facility failed to document glucometer readings for a resident with diabetes, cerebral infarction, and Parkinson's disease. The resident's MAR for June and July showed missing blood sugar results on multiple occasions, despite a physician's order for regular monitoring. The DON admitted that the facility had stopped running reports to identify documentation omissions. The facility's policy required documentation of blood glucose results on the monitoring tool or MAR.
A resident with severe cognitive impairment and requiring substantial assistance with ADLs was observed multiple times with long, untrimmed fingernails and dark debris underneath. Despite the care plan indicating the need for staff assistance with personal hygiene, nail care was not completed. The resident's family member also reported having to clean the nails during visits. The DON confirmed the nails were too long and dirty, and the CNA admitted to forgetting to complete the nail care.
The facility failed to follow the NPO diet order for a resident with multiple serious medical conditions, leading to the resident being given solid food and experiencing an adverse event. The care plan was not correctly updated or followed, and the facility did not provide a policy for care plans.
The facility failed to prevent a significant medication error by not following the manufacturer's administration guidelines for a resident's chemotherapy medication, Rezlidhia. The medication was to be given on an empty stomach, 12 hours apart, but was administered at inconsistent times and not always on an empty stomach. The error was acknowledged by the LPN and DON after the resident's mother brought it to their attention.
A resident on gastric tube feedings with an NPO order was given a sandwich by a CNA who did not provide a dietary ticket. The resident consumed some of the sandwich, believing he was cleared to eat. The facility did not provide a dietary policy.
Failure to Use Required Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program by not using required enhanced barrier precautions (EBP) during wound care for a resident with a chronic pressure ulcer. During an observed dressing change to a mid-back wound, two LPNs wore masks and gloves but did not don gowns, despite a sign above the resident’s bed indicating EBP was required. One LPN assisted with positioning the resident on her side while the other completed the dressing change, both without gowns. When interviewed, the LPN performing the dressing change stated she believed the resident had been removed from EBP because the wound was small and did not explain why the EBP sign remained posted. Record review showed that the resident’s electronic medical record banner indicated EBP was required, and wound documentation identified a pressure ulcer on the mid upper back first noted on 1/23/26. The care plan initiated on that date documented impaired skin integrity related to the pressure ulcer, with interventions including observation for signs and symptoms of infection. A separate care plan, last reviewed and revised on 1/28/26, stated the resident was at risk of transferring or becoming colonized with an MDRO and required EBP due to a chronic wound needing a dressing, with interventions to identify the need for EBP through signage and the medical record and to wear gown and gloves prior to high-contact care. A physician’s order directed daily dressing changes to the mid upper back wound, which was assessed on 3/9/26 as a stage 3 pressure ulcer with a granulation tissue bed. The facility’s EBP policy required gown and glove use for high-contact care activities, including wound care for chronic wounds such as pressure ulcers, and allowed discontinuation of EBP only when a wound placed on EBP had healed.
Failure to Maintain Safe Bedframe Results in Resident Injury
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards, resulting in a resident sustaining a significant injury. During a transfer from wheelchair to bed, a resident's leg was caught on a jagged, uncapped metal edge of the bedframe, causing an 18 cm by 5 cm avulsion skin tear that required six sutures. At the time of the incident, both protective end-caps on the bedframe were missing, exposing rough metal edges. Observations confirmed that the mattress cover above the uncapped area was also torn, indicating the hazard had been present for some time. Interviews with staff and the resident's family revealed that the missing end-caps were not an isolated issue; several other beds in the facility were also found to be missing the same protective pieces during subsequent safety checks. The Maintenance Director and Assistant confirmed that the end-caps were replaced only after the injury occurred, and there was no ongoing plan for regular monitoring of bed safety at the time of the incident. The facility lacked a specific policy addressing environmental hazards, and the existing maintenance policy only required semi-annual checks, which did not include routine inspection for missing bedframe end-caps. The injured resident had a history of dementia, repeated falls, and skin tears, and resided in a secured memory care unit. Previous care plans and progress notes indicated ongoing issues with skin injuries, but lacked documentation on the causes or follow-up for these incidents. Despite care plan interventions to keep the environment free from hazards and observe for potential causes of skin trauma, the hazardous condition of the bedframe was not identified or addressed prior to the resident's injury.
Failure to Provide Timely Incontinence and Perineal Care for Resident with Nephrostomy Tube
Penalty
Summary
A resident with chronic urinary tract infections (UTIs), a nephrostomy tube, and a history of breast cancer with metastasis was not provided with appropriate and timely incontinence and perineal care. Observations revealed that the resident was left in bed with soiled linens and a saturated brief for several hours after requesting assistance, resulting in visible distress and discomfort. The resident reported using the call light at 8:00 a.m. to be changed, but staff did not respond until after 12:22 p.m., at which time the resident was found tearful and in pain. The room had a strong ammonia odor, and the resident's nephrostomy tube dressing was observed to be several days old. Review of the resident's medical record indicated that she was incontinent two to three times daily throughout the month, but documentation showed that incontinence care was only provided two to three times per day, rather than the every two hours as required by facility policy and the resident's care plan. The care plan specifically called for assistance with incontinence care and for staff to check and change the resident every two hours and as needed. There was no documentation of the resident refusing care or exhibiting behaviors that would prevent staff from providing timely incontinence care. Interviews with facility staff revealed confusion and inconsistency regarding the resident's nephrostomy tube orders and care. The DON and Unit Manager provided conflicting information about the status and care requirements for the nephrostomy tube, and there was a lack of clarity about whether the tube was dislodged or functioning. The facility's policy required residents who are totally incontinent to be checked and changed every two hours, but this was not consistently followed for this resident.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for four residents, leading to a deficiency in accommodating the needs and preferences of these residents. Resident 25, who had a history of right-sided hemiplegia, atrial fibrillation, and other conditions, was observed with her call light out of reach. Her care plan, which included interventions to keep her call light within reach due to her risk of falls, was not followed. Similarly, Resident 52, diagnosed with dementia, cerebral ischemia, and other conditions, was found with her call light not in reach. Her care plan also emphasized the importance of keeping her call light accessible to mitigate her fall risk, which was not adhered to during the observation. Resident 72 and Resident 50 were also observed with their call lights out of reach. Resident 72 had a history of heart failure, COPD, and diabetes, with a care plan that included keeping his call light in reach to prevent falls. Resident 50, with diagnoses including paranoid schizophrenia and diabetes, had a care plan that required his call light to be within reach due to his fall risk. The facility's failure to follow these care plans resulted in the deficiency noted by the surveyors.
Medication Labeling and Dating Deficiencies
Penalty
Summary
The facility failed to ensure that medications were properly labeled and dated, as observed during a review of three medication carts. The surveyors found several instances of non-compliance with labeling and dating protocols. For example, the tuberculin serum on the 500 back hall medication cart was opened and expired without proper labeling. Additionally, medications for several residents, including latanoprost, budesonide-formoterol, and breyna, were found without open dates or proper labeling. These observations indicate a lack of adherence to the facility's policy, which requires staff to record the date opened on medication containers when the medication has a shortened expiration date once opened. Further observations on the 500 front and 100 front medication carts revealed additional deficiencies. Medications such as lispro insulin, fluticasone spray, and dorzolamide-timolol drops were either expired or lacked prescription labels and open dates. The facility's policy, as provided by the Executive Director, emphasizes the importance of recording open dates to ensure medications are not retained longer than recommended. The failure to comply with these guidelines was evident in the findings, highlighting a systemic issue in medication management within the facility.
Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to notify the physician of a resident's change in condition following a fall, which resulted in breakthrough pain and a decline in the resident's ability to perform activities of daily living. The resident, who had Down's Syndrome and Alzheimer's dementia, experienced a fall that led to a femur fracture requiring surgery. Post-surgery, the resident was unable to walk and had to use a wheelchair. Despite these significant changes, there was no documentation that the nurse practitioner (NP) or physician was informed of the resident's ongoing pain and limping, as well as his refusal to stand or transfer to the toilet. The resident's medical records indicated several instances where the resident exhibited changes in behavior and physical condition, such as hostility, resistance to care, and refusal to stand due to knee pain. These changes were documented in nursing progress notes and occupational therapy summaries, but there was a lack of communication to the medical team about these issues. The facility's policy required that all changes in a resident's condition be communicated to the physician and family, but this was not adhered to in the case of this resident.
Inaccurate MDS Documentation for Resident's Medication
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) for a resident, identified as Resident 61, who was reviewed for MDS accuracy. Resident 61 was admitted with diagnoses including paroxysmal atrial fibrillation, long-term use of antithrombotic/antiplatelet medications, and dementia. Her medication orders included aspirin, an antiplatelet, prescribed for her atrial fibrillation. However, the MDS inaccurately indicated that she was not on an antiplatelet medication during the observation period. The care plan for Resident 61, dated prior to the MDS assessment, noted her risk for bleeding and bruising due to antiplatelet use, with a goal to avoid adverse effects. Despite this, the MDS did not reflect her antiplatelet medication use. During an interview, the Regional Director of Clinical Services confirmed that Resident 61 was on Plavix, another antiplatelet, for a period within the observation timeframe. This discrepancy between the resident's actual medication regimen and the MDS documentation led to the identified deficiency.
Failure to Implement Care Plan for Antipsychotic Medication
Penalty
Summary
The facility failed to implement a care plan for the use of Seroquel, an antipsychotic medication, for a resident diagnosed with dementia, anxiety, major depressive disorder, and bipolar disorder. During a record review, it was found that the resident's medical record did not include a care plan addressing the use of Seroquel for managing bipolar disorder. An interview with the Director of Nursing revealed that there was no additional information to provide regarding the absence of a care plan. The facility's policy on comprehensive care plans, which was provided by the DON, states that each resident should have an interdisciplinary comprehensive person-centered care plan, including physician's orders as part of the comprehensive plan of care.
Delayed Treatment and Pain Management Deficiencies
Penalty
Summary
The facility failed to adequately assess and manage the condition of a resident with dementia and intellectual disability, leading to a delay in treatment after a fall. The resident, who had Down's Syndrome and Alzheimer's dementia, experienced a fall resulting in a femur fracture. Despite exhibiting signs of pain and a decline in condition, the facility did not promptly notify the physician or adjust the care plan to address the resident's needs. The resident's pain was not effectively managed, and there was a lack of timely communication with the medical team, resulting in a delayed diagnosis and treatment of the fracture. Another resident, with a history of falls and cognitive impairments, also experienced a delay in treatment after a fall. The resident was found on the floor with no initial complaints of pain, but later exhibited signs of pain and swelling in the knee. Despite receiving pain medication, the resident's condition was not promptly reassessed, and there was a delay in obtaining an x-ray and notifying the physician of the fracture. The resident was eventually sent to the emergency department for further evaluation and treatment, but the delay in response contributed to prolonged discomfort and potential complications. Both cases highlight deficiencies in the facility's response to changes in resident conditions, particularly in assessing and managing pain and communicating with medical professionals. The lack of timely intervention and inadequate documentation of changes in condition and pain management contributed to delays in treatment and potential harm to the residents.
Medication Mismanagement and Fall Prevention Lapses
Penalty
Summary
The facility failed to ensure that medications were not left unsupervised in a resident's room, as observed with Resident 49. During an observation, it was noted that Resident 49, who was under transmission-based precautions, had a clear plastic cup with approximately eight pills inside, which he identified as his morning medications. The resident's record lacked a self-medication administration assessment, and the Director of Nursing confirmed that medications should not have been left at the bedside, as per the facility's policy on medication administration. Additionally, the facility did not implement fall prevention interventions for Resident 37, who had a history of falls and was at risk due to various factors including decreased mobility and cognitive issues. The care plan for Resident 37 included interventions such as brake extenders and bright colored tape on her wheelchair brakes, which were not present during an observation. The Director of Nursing acknowledged that these interventions should have been in place, as outlined in the facility's comprehensive care plan policy.
Failure to Implement Pharmacy Recommendation for GERD Medication
Penalty
Summary
The facility failed to implement a pharmacy recommendation for a resident diagnosed with dementia, insomnia, major depression, and gastroesophageal reflux disease (GERD). A pharmacy recommendation was made to reevaluate the continued need for omeprazole and to initiate famotidine 20 mg once daily, with the end goal of discontinuation. The physician accepted this recommendation and left instructions to implement it as written. However, the facility did not initiate the new order for famotidine and instead started Tums as needed (PRN). During an interview, the Director of Nursing (DON) confirmed that famotidine was never initiated. Additionally, the facility's policy on General Dose Preparation and Medication Administration did not address pharmacy recommendations and new order changes.
Failure to Timely Address UTI Symptoms Leads to Resident's Death
Penalty
Summary
The facility failed to ensure timely collection and review of lab specimens for a resident with an indwelling urinary catheter, leading to a delay in treatment and the development of urosepsis, acute kidney failure, and systemic inflammatory response syndrome (SIRS), resulting in the resident's death. Resident F, who had a history of cerebral infarction, Alzheimer's disease, and required a suprapubic catheter due to neurogenic bladder, exhibited symptoms of a urinary tract infection, including increased confusion, back pain, and purulent drainage around the catheter. Despite these symptoms, there was no documentation that the physician was notified of the resident's worsening condition. The Nurse Practitioner (NP) ordered STAT labs, but the facility did not have a policy for lab services, resulting in a delay in the collection and processing of the urine sample. The lab did not pick up the sample until the next morning, and the results indicating infection were not reviewed promptly. Over the holiday weekend, the NP received the urinalysis results but chose to wait for the culture and sensitivity results before initiating treatment, despite the resident's history of frequent infections. Throughout the weekend, there was a lack of documentation of vital signs and assessment of the resident's condition, including the suprapubic catheter site. The resident's condition continued to deteriorate, with signs of infection and elevated BUN and creatinine levels. The facility's failure to follow up on critical lab results and provide timely intervention contributed to the resident's decline and eventual death.
Unauthorized Change in Resident's Code Status
Penalty
Summary
The facility failed to honor the resident's right to have treatments and services provided in accordance with the guardian's wishes. Resident E, who had diagnoses including Parkinson's disease, Alzheimer's disease, peripheral vascular disease, and atherosclerosis, was under the care of a legal guardian who had the authority to make medical decisions. Despite this, the facility allowed Resident E's son, who was not the legal guardian, to sign a Do-Not-Resuscitate (DNR) form and change the resident's code status from full code to DNR with comfort measures. This change was made without the consent of the legal guardian, who had explicitly requested that Resident E remain a full code. The incident occurred after the nurse practitioner (NP) discussed Resident E's declining condition with the guardian, who requested that her brother visit Resident E before making any decisions about changing the code status. However, during a care plan meeting, the guardian was informed that her brother had already signed the DNR form, which she had not authorized. The NP's progress notes indicated that the son was presented with the DNR form under the assumption that it was already approved by the guardian, leading to confusion and unauthorized changes to Resident E's treatment plan. This resulted in the resident being placed on palliative care with orders for morphine and lorazepam, contrary to the guardian's wishes.
Failure to Notify Family of Resident's Acute Condition Change
Penalty
Summary
The facility failed to notify the family or representative of a resident, identified as Resident F, about a significant change in his condition due to an acute urinary tract infection (UTI) that led to urosepsis-associated acute kidney injury/failure and a systemic inflammatory response. This deficiency was identified during an interview and record review, where it was revealed that Resident F's family was only informed of his condition on the day he passed away. The family was unaware of the infection and the severity of his condition until the facility contacted them to confirm his Do-Not-Resuscitate (DNR) orders and inquire if they wanted him sent to the hospital. By the time the family arrived, Resident F was in critical condition, and he passed away shortly after their arrival. Resident F had a history of infections and was a long-term care resident with multiple diagnoses, including a history of cerebral infarction, Alzheimer's disease, and the use of a suprapubic catheter due to neuromuscular dysfunction of the bladder. Despite the facility's policy requiring timely communication of changes in a resident's condition to the family and physician, there was no documentation indicating that Resident F's family was notified of his acute change in condition until the day of his death. The facility's policy outlined the need for immediate notification in life-threatening situations, but this protocol was not followed in Resident F's case.
Failure to Update Care Plan for Skin Breakdown
Penalty
Summary
The facility failed to update the care plan for a resident with skin breakdown. Resident D, who had a history of cerebral infarction, Parkinson's disease, and diabetes mellitus, experienced a skin event on 7/17/24, resulting in skin breakdown on the coccyx measuring 1.0 cm x 1.0 cm x 1.0 cm. Despite having a care plan dated 6/14/24 that identified the resident as at risk for skin breakdown due to decreased mobility, incontinence, and other factors, the care plan was not updated following the skin event. The Director of Nursing Services indicated that care plans should be updated after seven days, but this was not done in Resident D's case. The facility's policy requires care plan problems, goals, and interventions to be reviewed and revised periodically and after each MDS assessment, which was not adhered to in this instance.
Failure to Involve Legal Guardian in Care Decisions
Penalty
Summary
The facility failed to ensure that a resident's legal guardian was involved in and agreed to changes in the resident's plan of care and treatment. Resident E, who had a legal guardian, experienced a decline in condition, which was communicated to the guardian by a Nurse Practitioner (NP). The NP suggested changing the resident's code status from Full Code to Do-Not-Resuscitate (DNR), but the guardian requested time for her brother to visit the resident before making a decision. Despite this, the facility proceeded with changes without the guardian's consent. The guardian's brother visited Resident E and found him alert and able to eat and drink with assistance. The family requested staff assistance with meals, but the guardian was not informed of any further developments until she was notified of a serious condition involving Resident E's toe. The NP had already placed a referral for a vascular surgeon and ordered a doppler ultrasound. The guardian found the delay in medical attention unacceptable and requested a care plan meeting, during which she discovered that her brother had been asked to sign a DNR form and that Resident E's care had been changed to palliative care without her knowledge. Resident E's son, who was not the legal guardian, was under the impression that the DNR form was already approved by the guardian. The facility's records showed that the son signed the DNR form, and the resident's treatment plan was altered to focus on comfort measures. The guardian was not informed of these changes, and the facility failed to ensure that the legal guardian's authority was respected in making significant decisions about Resident E's care.
Failure to Document Blood Sugar Results for a Resident
Penalty
Summary
The facility failed to document the results of glucometer readings for one of the three residents reviewed for quality of care, identified as Resident D. Resident D had diagnoses including cerebral infarction, Parkinson's disease, and diabetes mellitus, with a physician's order to check blood sugar every six hours and notify the physician if results were below 70 or above 400. However, the Medication Administration Record (MAR) for June and July 2024 showed missing documentation of blood sugar results on several dates and times. During an interview, the Director of Nursing Services acknowledged that the facility had stopped running reports to identify omissions from the previous day. The facility's policy on blood glucose monitoring, dated February 2015, required documentation of blood glucose results on the capillary blood glucose monitoring tool or the MAR.
Failure to Provide Adequate Nail Care to a Resident
Penalty
Summary
The facility failed to provide adequate nail care to a dependent resident, identified as Resident D, who was observed multiple times with long, untrimmed fingernails and dark debris underneath them. This was noted on several occasions while the resident was lying in bed watching television. The resident's family member also reported having to trim and clean the resident's nails during visits due to the presence of dark debris. The Director of Nursing (DON) confirmed the resident's nails were too long and dirty, indicating that staff should have addressed this during routine care and bathing. Resident D, who was admitted with diagnoses including dementia, hemiplegia, hemiparesis, and aphasia, required substantial assistance with activities of daily living (ADLs). The resident's care plan indicated the need for staff assistance with personal hygiene tasks. Despite this, a Certified Nursing Aide (CNA) reported that the resident withdrew her hand during an attempt to perform nail care and that the CNA forgot to return to complete the task. The facility's policy required a comprehensive care plan to promote the resident's highest level of functioning, which was not adhered to in this instance.
Failure to Follow NPO Diet Order for Resident
Penalty
Summary
The facility failed to accurately promote continuity of care and communication within Resident C's care plan, leading to a significant safety issue. Despite having a physician's order for nothing by mouth (NPO) due to a history of food aspiration and other serious medical conditions, Resident C was given a meal tray containing solid food on Christmas Eve. The resident consumed the meal, which led to an adverse event where food had to be removed from his mouth by the nursing staff. This incident was confirmed by the resident's responsible party and the resident himself, who indicated he thought he had graduated from speech therapy but had not. The medical record review revealed that Resident C had multiple diagnoses, including food in the respiratory tract, pneumonitis due to inhalation of food and vomit, malignant neoplasm of the brain, COPD, type 2 diabetes mellitus, and epilepsy. The care plan, dated 12/22/2023, indicated an NPO diet with enteral feeding, yet the resident was still given solid food. Interviews with the Director of Nurses (DON), Executive Director (ED), and RN 5 confirmed that the care plan was not correctly updated or followed, leading to the resident receiving inappropriate food. The facility did not provide a policy for care plans, and the care plan for the resident was acknowledged to be incorrect by RN 5.
Failure to Follow Chemotherapy Medication Administration Guidelines
Penalty
Summary
The facility failed to prevent a significant medication error by not following the manufacturer's administration guidelines for a resident's chemotherapy medication, Rezlidhia. The resident's responsible party indicated that the facility was not administering the medication correctly, despite providing special instructions. The medication was to be given on an empty stomach, 12 hours apart, but the facility administered it at inconsistent times and not always on an empty stomach. The Licensed Practical Nurse (LPN) and Director of Nurses (DON) acknowledged the error and confirmed that the medication administration times were changed only after the resident's mother brought it to their attention. The resident had multiple diagnoses, including malignant neoplasm of the brain, chronic obstructive pulmonary disease (COPD), type 2 diabetes mellitus, and epilepsy. The medication administration record (MAR) showed that the medication was administered at varying times, conflicting with the prescribed schedule. The DON admitted that they did not obtain an order to administer the medication 12 hours apart on an empty stomach, as required by the manufacturer's guidelines. The facility's policy and procedure manual also emphasized the importance of following manufacturer medication administration guidelines, which was not adhered to in this case.
Failure to Implement NPO Order for Resident
Penalty
Summary
The facility failed to implement a nothing by mouth (NPO) order for a resident with dietary restrictions, leading to the resident being given oral intake. Resident C, who was on gastric tube feedings and had a sign indicating no solid foods or regular liquids unless given by a speech therapist, was given a sandwich on a meal tray. The resident consumed some of the sandwich, believing he had been cleared to eat since he received the tray. A nurse later removed the food from his mouth, and a chest x-ray was obtained with no negative outcomes indicated. The incident occurred when a certified nurse aide (CNA) obtained a meal tray for the resident from the dietary department without providing a tray ticket, claiming it was lost. The CNA gave the resident the meal because he requested it. The Executive Director confirmed that the kitchen staff should not deliver a tray without a dietary ticket or nurse approval. Dietary Cook 4 also stated that trays are not served without a dietary ticket and that residents on NPO status do not receive meal trays. The facility did not provide a dietary policy.
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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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