Crown Point Health Campus
Inspection history, citations, penalties and survey trends for this long-term care facility in Crown Point, Indiana.
- Location
- 6685 East 117th Avenue, Crown Point, Indiana 46307
- CMS Provider Number
- 155637
- Inspections on file
- 40
- Latest survey
- March 23, 2026
- Citations (last 12 mo.)
- 19 (1 serious)
Citation history
Health deficiencies cited at Crown Point Health Campus during CMS and state inspections, most recent first.
The deficiency involves failures to follow infection prevention and control practices, including incorrect isolation signage and practices for a resident on contact isolation for Group A streptococcal infection, improper PPE use by a contracted phlebotomist under enhanced barrier precautions, and an RN’s repeated use of a shared BP cuff on three residents on enhanced barrier precautions without cleaning or disinfection between uses. These actions conflicted with posted enhanced barrier precautions instructions and the facility’s Infection Prevention and Control Program policy requiring proper handling and reprocessing of reusable equipment shared among residents.
Surveyors found that the facility did not maintain a clean and sanitary environment in the main kitchen and on two resident units. In the kitchen, a portable fan placed on a garbage can near a handwashing sink was covered with dirt and dried food, the adjacent garbage can had dried food and debris on its lid and sides, and there was visible dirt and debris along baseboards, in front of the oven, and on PVC pipes under a food prep counter. On the units, a microwave in the Memory Care Unit pantry had dried food buildup, and a refrigerator on Independence Hall had dried juice spillage on its shelves. The DFM and DON acknowledged these areas required cleaning.
A resident with COPD had a Breo Ellipta inhaler and Salonpas patches stored on the overbed table and was self-administering medications without a corresponding physician’s order authorizing self-administration. The care plan referenced self-administration of inhalers, and a self-administration assessment noted the resident wanted to self-administer some medications stored in the room, but the specific medications were not identified and no self-administration order was obtained. The resident’s inhaler had only a standard administration order, there was no order for the Salonpas patches the resident brought in, and the medications were not secured at bedside as outlined in facility policy.
A resident with dementia and a documented history of wandering and elopement risk had a care plan and physician’s order for a Wanderguard device on the right ankle with checks each shift, but the quarterly MDS assessment inaccurately coded that no wander/elopement alarm was used. This discrepancy between the resident’s care plan, physician’s orders, and the MDS assessment reflects a failure to ensure an accurate comprehensive MDS assessment.
The facility failed to follow care plan interventions requiring documentation of food intake and urinary catheter output for multiple residents. A resident with dementia, dysphagia, and protein-calorie malnutrition, who was dependent on staff for eating and on a mechanically altered diet, had multiple meals with no recorded intake despite a care plan directing staff to document consumption at every meal. Two residents with indwelling catheters, including one with vascular dementia and neurogenic bladder and another with obstructive and reflux uropathy and a suprapubic catheter, had care plans requiring intake and output or output every shift, yet urinary output was not documented on numerous shifts and for one resident was absent for an entire 30-day period. Facility leadership acknowledged that output should have been documented each shift and that one care plan intervention should have been discontinued.
A resident with Charcot-Marie-Tooth disease, cognitively intact but dependent on staff for toileting hygiene, reported not receiving routine incontinence care and being left in a wet brief for extended periods. Record review showed multiple day, evening, and night shifts with no documented incontinence care in CNA bladder elimination tasks, despite the care plan indicating assistance with ADLs and the DON’s expectation that incontinence care be documented at least once per shift. This reflects a failure to ensure and document required ADL and incontinence care for a dependent resident.
Surveyors found that a resident with vascular dementia, CHF, and bilateral lower extremity edema was repeatedly observed without ordered tubi grip compression wraps, even though the care plan and TAR documented their use and the resident required assistance with dressing. In a separate case, another resident with cholecystitis and severe cognitive impairment was observed in bed with a biliary drain lying on the mattress, but the record contained no physician’s orders for the biliary drain or its care, despite the resident’s dependence for basic activities.
A resident with a history of rectal cancer, severe cognitive impairment, and a colostomy had care plan interventions and physician orders directing staff to monitor the ostomy, empty the pouch, and change it as needed each shift, as well as to monitor the peri-stoma area. While the MAR/TAR reflected that the pouch was checked every shift, the record contained no documentation that the colostomy pouch was fully changed or that stoma care was performed. During interviews, the DON could not state how often stoma care and complete bag changes occurred, and the Administrator noted the resident used a one-piece pouch system. This lack of documented full pouch changes and stoma care conflicted with facility policy requiring regular pouch changes and skin care around the stoma.
A resident with a G-tube received an initial 30 cc water flush that an LPN pushed into the tube with a syringe plunger instead of allowing it to flow by gravity, although the subsequent medication and remaining flush were given by gravity. In an interview, the LPN admitted she sometimes pushed flushes in and was unsure of facility policy. The DON acknowledged that the written policy did not specify that flushes must be administered by gravity, while an external clinical resource described that feeding tube flushes should be allowed to flow by gravity.
Surveyors found that clinical records were incomplete and inaccurate for two residents. A resident with Alzheimer's disease and dysphagia, ordered a pureed diet with nectar thickened liquids and specific assistive devices, was served soup with chunks and repeatedly given thickened juice in a clear plastic cup instead of the ordered Provale cup, while the DON acknowledged the diet and device orders had not been updated to reflect a speech therapy discharge summary. Another resident with severe cognitive impairment, cholecystitis, and a UTI had physician orders and treatment records indicating the presence of an indwelling urinary catheter with catheter care every shift, but observations and the DON's confirmation showed no catheter was present, even though staff continued to document catheter care.
A resident with multiple diagnoses was prescribed melatonin for insomnia, but the facility did not notify the resident's Responsible Party or family about the new medication order, as confirmed by record review and staff interview.
A deficiency was cited due to the facility not ensuring an area was free from accident hazards and not providing adequate supervision to prevent accidents. The report highlights that the environment did not meet required safety standards.
Several residents did not receive necessary care and services, including missed wound treatments, incomplete blood glucose monitoring, and undocumented insulin administration. Inaccurate elopement risk assessments were also identified, with staff failing to review relevant documentation. These deficiencies were found through observation, record review, and staff interviews.
A resident with dementia and bipolar disorder alleged physical and sexual abuse, but the incident was not promptly reported to the Administrator, IDOH, physician, responsible party, or law enforcement as required by facility policy. An LPN attributed the allegation to the resident's mental state and failed to initiate immediate reporting and investigation procedures.
A resident with a gastrostomy tube and severe cognitive impairment did not receive tube feeding according to the physician's prescribed schedule and flow rate. Observations and record review showed inconsistencies in the timing and administration of the feeding, with documentation not matching the ordered schedule.
A resident with a PICC line did not have physician's orders for line flushes, dressing changes, or other care, and the dressing was not changed weekly as required. Nursing documentation was inconsistent, with gaps in recording flushes and assessments, and the care plan interventions for PICC line care were not consistently followed or documented.
Medications and biologicals were left unsupervised and accessible on top of two medication carts in hallways while LPNs were away from the carts, with residents present in the area. The medications included antibiotics, wound care products, and various oral medications, all labeled for specific residents. Staff acknowledged that these medications were not stored in their proper locations.
The facility failed to maintain complete and accurate medical records for two residents. One resident with dementia was involved in an elopement incident that was not properly documented by the assigned LPN, and the only note present was written later by the DON, who did not witness the event. For another resident with osteomyelitis, there was a discrepancy between the physician's order for antibiotics and the documentation, with nursing notes indicating continued administration after the medication had been discontinued and no supporting physician orders. These actions resulted in incomplete and inaccurate medical records.
Staff failed to perform required hand hygiene during medication administration, including after contact with residents and before preparing or administering medications. LPNs were observed not using hand sanitizer or washing hands at key points, such as after leaving a resident's room, before donning gloves, and before applying a pain patch, contrary to facility policy.
A resident with diabetes and other conditions did not receive prescribed long-acting insulin for two evenings due to a pharmacy refill issue. Although staff contacted the pharmacy and attempted to notify the on-call NP, there was no documentation that the physician or the resident was informed about the missed doses, resulting in a failure to provide required notifications.
A resident with severe cognitive impairment and total dependence on staff for ADLs did not have incontinence care documented on multiple shifts, despite care plan interventions requiring such care. The facility's policy required appropriate services for incontinence, but documentation was missing for several dates and shifts.
A resident with neuropathy and arthritis was prescribed guaifenesin ER 600 mg every 12 hours for seven days to treat a cough, but only received 9 out of 14 ordered doses. The MAR showed multiple missed administrations, and the IDON confirmed the medication was not given as prescribed, contrary to facility policy.
Two residents with significant weight loss did not consistently receive prescribed nutritional supplements or have their meal intake properly documented. One resident did not receive a required Mighty Shake supplement at lunch, and another had multiple undocumented meals despite care plans and facility policy requiring monitoring and documentation. Staff confirmed these lapses during interviews.
A resident with multiple diagnoses did not receive several scheduled doses of prescribed cephalexin and guaifenesin due to pharmacy delivery issues, transcription errors, and lack of follow-up on insurance authorization. Documentation and interviews revealed missed doses, confusion about medication sources, and failure to ensure medications were available and administered as ordered.
The facility failed to document COVID-19 vaccine education and administration for four residents. Medical records lacked evidence of education on vaccine benefits and risks, and reasons for non-administration were not documented. The Infection Preventionist did not periodically offer vaccines beyond admission, and the facility faced challenges in setting up a vaccination clinic.
The facility failed to assess and obtain physician orders for two residents self-administering medications. One resident was left with a medicine cup of pills without proper assessment or orders, while another had unauthorized medications on her nightstand. The DON noted that a resident's companion brought medications without a physician's order.
The facility failed to implement comprehensive care plans for two residents experiencing significant weight loss. One resident, cognitively intact, lost 24% of their weight over six months without a care plan addressing the issue. Another resident, cognitively impaired, experienced significant weight loss over 180 days, with no care plan in place despite dietary assessments noting the loss. The DON confirmed the absence of appropriate care plans.
A facility failed to update the care plan for a resident with cerebral palsy, mild intellectual disabilities, and hemiplegia following a stroke. The resident was observed with a contracted left hand, and the care plan included interventions for ambulation and range of motion. However, no restorative therapy was documented for the last 30 days, and the Director of Nursing confirmed that restorative therapy had not been provided since September 2024. The care plan was not revised to reflect this change, resulting in a deficiency.
The facility failed to follow physician's orders for skin condition treatments for two residents. One resident had a sore on her chest that was not assessed or treated promptly, while another resident with chronic ulcers did not receive prescribed treatments on multiple occasions. The Wound Nurse was unaware of the first resident's condition until informed by the resident, and there were no progress notes for the second resident's treatment refusals.
The facility failed to conduct weekly wound assessments and update treatment orders for two residents with pressure ulcers. A resident with severe cognitive impairment had a stage 4 pressure ulcer that was not assessed weekly as required. Another resident received incorrect treatment due to an outdated physician's order in the medical record.
A facility failed to implement a prescribed palmar guard and resting hand splint for a resident with a right hand contracture. Observations showed the resident's hand clenched against her chest, and a CNA was unaware of the need for a palm protector. The resident's OT plan recommended these devices to reduce pain and prevent joint deformity. Interviews revealed a lack of communication and implementation of the splinting schedule, leading to the deficiency.
A resident with Alzheimer's and a history of falls was observed in a wheelchair without anti-tippers, despite a care plan requiring them. Staff mistakenly placed the resident in a roommate's wheelchair lacking these safety features, leading to a deficiency in fall precautions.
A facility failed to monitor and document urinary output for a resident with an indwelling catheter, as required by physician orders. The resident, who had a history of UTIs and other urinary issues, had several instances of low urinary output that were not reported to the physician. Documentation was missing for multiple shifts, and the physician was not notified when output was less than 300 ml, as mandated.
The facility failed to monitor and document the nutritional intake and weight of three residents, leading to significant weight loss. A resident experienced a 24% weight loss over six months with missing weekly weight records. Another resident had significant weight loss without a care plan, and supplements were not properly documented. A third resident had missing documentation for meals and fluid intake over a 30-day period.
A facility failed to document the administration of tube feedings for a resident with a g-tube, leading to a deficiency. The resident, who was severely cognitively impaired and receiving hospice care, experienced significant weight loss. Despite recommendations to increase tube feeding duration, records showed missed feedings on several occasions. The DON indicated the nurse forgot to sign off on the administration.
The facility failed to ensure correct oxygen flow rates and monitoring for two residents. One resident had an oxygen flow rate set higher than the physician's order, while another had inconsistent settings and lacked recent oxygen saturation monitoring. These discrepancies were confirmed by nursing staff.
The facility failed to ensure timely delivery and accurate dispensing of medications for two residents. One resident experienced a delay in receiving prescribed cream for a rash, while another continued to receive a discontinued medication due to a pharmacy error. The DON confirmed that medications should be received within 24 hours, but delays and errors in pharmacy communication led to these deficiencies.
A facility failed to document attempts of non-pharmacological interventions before administering Norco to a resident with chronic pain due to spinal stenosis. Despite having a care plan that included various non-drug interventions, the resident's medication records showed multiple administrations of Norco without prior attempts of these methods. The Director of Nursing confirmed the lack of documentation for non-pharmacological interventions.
A resident with severe cognitive impairment and total dependence on staff for ADLs did not have incontinence care consistently documented over a 30-day period, despite care plan interventions requiring such care. The resident's POA reported finding the resident in a wet brief on multiple occasions, and facility records showed missing documentation across several shifts. The DON was unable to provide additional information regarding these lapses.
Staff failed to follow infection control protocols for two residents, including not wearing required PPE during g-tube medication administration for a resident under Enhanced Barrier Precautions, and not maintaining contact isolation signage for a resident with candida auris. These lapses resulted in noncompliance with infection prevention guidelines.
The facility failed to ensure a controlled substance was double locked in the Grace Point medication room. A clear tackle box containing Dronabinol pills was found unlocked inside an unlocked refrigerator. An LPN admitted the key to the box was lost, and the Assistant Director of Nursing confirmed the box should always be locked. Facility policy mandates controlled substances be stored in a locked container, separate from non-controlled medications.
A resident with Alzheimer's and congestive heart failure had abnormal lab results that were not promptly communicated to the physician or family. The oversight was due to a nurse's absence and failure to enter lab orders into the EHR, leading to a delay in reporting critical lab values.
The facility failed to provide necessary care for two residents, including lack of orders for a neck collar, delayed treatment for critical lab results, and improper medication administration. A resident with a neck collar had no monitoring instructions, while another experienced a delay in hospital transfer due to critical hemoglobin levels. Additionally, medications were not administered as ordered, and a new skin condition was not properly documented or reported.
A resident who had neck surgery experienced a delay in receiving a scheduled cervical spine x-ray, which was ordered by the physician on 12/10/24 but not completed until 12/16/24. The Director of Nursing was unsure why the order was delayed, and there was no documentation explaining the delay. The facility's policy requires diagnostic tests to be scheduled according to physician orders.
A resident with Alzheimer's disease had their privacy breached when an RN used a personal cell phone to photograph bruising without consent. The DON instructed the RN to take the photos, which were sent to the DON's personal phone, violating facility policy that prohibits such actions without proper authorization.
A resident with Alzheimer's disease was found with significant bruising on the left arm and breast, but the facility failed to immediately report the injury to the Administrator/Abuse Coordinator and the Indiana Department of Health. The resident's care plan required assistance for transfers, but staff interviews revealed confusion and inconsistencies in reporting the incident. The facility's investigation was incomplete, and the required protocols for reporting injuries of unknown origin were not followed.
A resident requiring oxygen therapy did not receive care consistent with physician orders due to a malfunctioning concentrator and staff inaction. The resident's oxygen saturation was low, and staff were unfamiliar with using available oxygen cylinders. The facility's policy to provide oxygen as ordered was not followed.
The facility failed to ensure proper infection control practices, including the sanitization of glucometers and oximeters used on multiple residents. Additionally, staff were not adequately educated on Enhanced Barrier Precautions (EBP), leading to improper use of PPE. Observations revealed that staff did not sanitize equipment between uses and were unaware of EBP requirements, potentially affecting numerous residents.
A resident with Alzheimer's and a gastrostomy tube experienced a mechanical malfunction that prevented the administration of medications and water flushes. Despite multiple staff attempts to resolve the issue, the physician and family were not notified until several hours later, contrary to facility policy. The resident was eventually sent to the hospital for intervention.
The facility failed to provide scheduled bathing for two residents dependent on staff for ADLs. One resident with Alzheimer's and another with vascular dementia missed multiple scheduled showers, as documentation was either left blank or marked non-applicable. The Unit Manager confirmed the requirement for twice-weekly bathing, which was not consistently met.
Failure to Implement Isolation Precautions and Clean Shared Equipment
Penalty
Summary
The deficiency involves failures in implementing appropriate infection prevention and control measures, including incorrect isolation precautions, improper use of personal protective equipment (PPE), and lack of cleaning of shared medical equipment. One resident with diagnoses including cholecystitis and urinary tract infection was readmitted after a hospital stay and had a physician’s order dated 3/13/26 for contact isolation due to a Group A streptococcal blood culture, specifying a contact sign outside the room, gown and gloves for high-contact care, and a face shield for tasks with splash or spray risk. However, surveyors observed that this resident’s room displayed an enhanced barrier precautions sign instead of a contact isolation sign, and the DON acknowledged awareness of the contact isolation order while the resident remained on enhanced barrier precautions. Surveyors also observed a contracted phlebotomist wearing a face mask and blue protective gown enter a room posted with an enhanced barrier precautions sign, then exit and approach another resident in a common area and enter another room without changing the gown and mask, contrary to the posted instructions that gowns and gloves must not be worn for care of more than one person. In a separate observation, an RN obtained a reusable blood pressure cuff from the top of a medication cart and used it sequentially on three different residents who were all on enhanced barrier precautions, returning the cuff to the cart after each use without cleaning or disinfecting it before or after use. The facility’s Infection Prevention and Control Program policy stated that cleaning and disinfection policies must address handling of equipment shared among residents, including blood pressure cuffs, and that reusable medical devices must be cleaned and reprocessed appropriately prior to use on another resident.
Failure to Maintain Clean Kitchen and Unit Appliances
Penalty
Summary
Surveyors identified that the facility failed to maintain a clean and well‑kept kitchen and unit pantries, resulting in environmental sanitation deficiencies in the main kitchen, Memory Care Unit, and Independence Hall. During a kitchen sanitation tour with the Dietary Food Manager, a portable fan placed on top of a garbage can next to the handwashing sink was found with an accumulation of dirt and dried food spillage. The white garbage can next to the same handwashing sink had dried food spillage and debris on the lid and sides. Dirt and debris were observed along the baseboards underneath the food preparation counter, as well as on the floor in front of the oven. Additionally, dried food spillage was noted on white PVC pipes located underneath the food preparation counter, and the DFM acknowledged these areas needed cleaning. Further observations on resident units showed that the microwave in the Memory Care Unit pantry contained an accumulation of dried food spillage, and the refrigerator on Independence Hall had dried juice spillage on its shelves. During interview, the Director of Nursing acknowledged that the microwave and refrigerator required cleaning. These findings reflect the facility’s failure to keep the kitchen and certain unit appliances clean and in good repair as required by 410 IAC 16.2-3.1-19(f).
Failure to Complete Self-Administration Assessment and Obtain Orders for Bedside Medications
Penalty
Summary
Surveyors observed that a resident had an unopened box of Salonpas medicated pain relief patches and a Breo Ellipta inhaler stored on the overbed table in the resident’s room on multiple occasions. The resident, who had diagnoses including COPD and was admitted earlier in the month, was seen in the room with these medications present, and the inhaler remained at bedside even when the resident was not in the room. The resident’s care plan indicated there was a physician’s order for self-administration of inhalers, and a self-administration of medication assessment documented that the resident wished to self-administer some medications that would be stored in the room, but the specific medications were not identified. Record review showed a physician’s order for fluticasone-salmeterol 100/25 mcg inhaler to be administered as one puff twice daily, but there was no physician’s order authorizing the resident to self-administer this inhaler. There was also no physician’s order for the Salonpas patches, which the resident had brought into the facility. The self-administration assessment did not specify which medications the resident was permitted to self-administer, and the medications were not stored in a lockbox or locked drawer as referenced in facility policy. During interview, facility leadership acknowledged that the care plan referenced self-administration of the inhaler, but this was not reflected in the physician’s orders or the medication assessment, and that the Salonpas patches had been found without orders and removed from the room.
Inaccurate MDS Assessment of Wander/Elopement Alarm Use
Penalty
Summary
The deficiency involves the facility’s failure to ensure an accurate MDS comprehensive assessment for a resident with dementia and a documented history of wandering and elopement risk. Record review showed that the resident’s care plan, revised on 6/13/25, identified the resident as an elopement risk/wanderer related to dementia and included an intervention to check a Wanderguard device on the right ankle for placement and function. A physician’s order dated 12/4/25 also directed that a Wanderguard be applied to the resident’s right ankle and that its placement be checked each shift. Despite these orders and care plan interventions, the quarterly MDS assessment dated 12/18/25 documented that a wander/elopement alarm was not used, with the Wander/elopement alarm item coded as 0 (not used) for this resident. During an interview, the Administrator acknowledged the issue by indicating that an MDS modification was going to be submitted, confirming that the original MDS did not accurately reflect the resident’s use of a Wanderguard alarm.
Failure to Implement Care Plan Documentation for Nutrition and Catheter Output
Penalty
Summary
Surveyors identified that the facility did not implement existing care plan interventions for monitoring and documenting nutritional intake and urinary catheter output. One resident with Alzheimer's disease, dysphagia, and protein-calorie malnutrition had a care plan directing staff to monitor and record meal consumption at every meal due to a history of weight loss and dependence on staff for eating. However, food intake documentation was missing for multiple meals on several dates, including no dinner intake recorded on specific days and no breakfast and lunch intake recorded on others. The DON stated the resident’s food consumption was supposed to be documented after each meal. Two residents with indwelling urinary catheters also had care plans requiring intake and output monitoring and documentation each shift, but staff failed to document urinary output as directed. One resident with vascular dementia and neurogenic bladder had a Foley catheter with orders and a care plan intervention to monitor and document intake and output per facility policy, yet there were multiple shifts across day, evening, and night with no urinary output recorded. Another resident with obstructive and reflux uropathy, neuromuscular bladder dysfunction, and a suprapubic catheter had a care plan intervention to record urinary output every shift, but there was no documented urinary output for the prior 30 days. The DON and Nurse Consultant confirmed that output should have been documented every shift for one resident and that the care plan intervention for the other should have been discontinued, indicating the care plans were not accurately implemented or updated.
Failure to Ensure and Document Incontinence Care for Dependent Resident
Penalty
Summary
Surveyors identified a deficiency in the provision and documentation of ADL care when a dependent resident did not have documented incontinence care on multiple shifts. The resident, who had Charcot-Marie-Tooth disease and was care planned as needing assistance with ADLs, including one-staff assist for bathing and a preference for bed baths, was assessed on the Quarterly MDS as cognitively intact and dependent on staff for toileting hygiene. During an interview, the resident reported not receiving routine incontinence care and being left in a wet brief for long periods of time. Review of CNA bladder elimination task documentation showed no recorded incontinence care on specified day, evening, and night shifts, despite the DON’s stated expectation that staff document incontinence care at least once per shift, three times daily, as required by 410 IAC 16.2-3.1-38(a)(3). The missing documentation dates included several day shifts, evening shifts, and night shifts over a span of weeks, indicating that incontinence care was either not provided or not recorded for this dependent resident on those occasions. The deficiency centers on the facility’s failure to ensure that ADL and incontinence care were consistently provided and documented for a resident who relied entirely on staff for toileting hygiene.
Failure to Follow Compression Wrap Orders and Lack of Biliary Drain Orders
Penalty
Summary
Surveyors found that one resident with vascular dementia, congestive heart failure, and bilateral lower extremity edema did not receive ordered compression treatment. Observation on multiple occasions showed the resident seated in a wheelchair and later in a chair in her room without tubi grips on either leg, despite a physician’s order dated 2/12/26 directing tubi grips to be applied every morning and removed at bedtime for bilateral lower extremity edema. The resident’s care plan, dated 2/13/26, included tubi grips as an intervention for edema, and the MDS indicated she was cognitively impaired and required partial to moderate assistance with dressing. The March 2026 TAR, however, showed the tubi grips as signed out as applied on the days they were observed not to be in use. Surveyors also identified a failure to obtain and implement physician’s orders for a biliary drain for another resident. This resident, who had diagnoses including cholecystitis and a UTI and had been readmitted from the hospital on 3/13/26, was observed lying in bed with a biliary drain on the mattress next to her. Record review showed no physician’s orders for the biliary drain or for care of the drain, despite the presence of the device. The resident’s significant change MDS indicated severe cognitive impairment and dependence for toileting, bed mobility, and eating, yet there was no documented medical direction for management or monitoring of the biliary drain.
Failure to Document and Provide Complete Colostomy Pouch Changes and Stoma Care
Penalty
Summary
The deficiency involves a failure to provide and document appropriate colostomy care and services for a resident with a history of rectal, rectosigmoid, and anal cancer who had undergone an abdominoperineal resection and had a colostomy. The resident was severely cognitively impaired and had both an indwelling catheter and an ostomy. The care plan, revised on 6/18/24, directed staff to monitor and record bowel movements by emptying the ostomy pouch, monitor and record the peri-stoma condition, and provide and maintain appropriate ostomy supplies. A physician’s order dated 2/26/26 required staff to check the colostomy pouch every shift for patency and, if full, to empty or change it every shift and as needed. The March 2026 MAR/TAR showed that the colostomy pouch was monitored every shift as ordered. However, the clinical record lacked documentation that the colostomy pouch was ever fully changed or that stoma care was provided, despite the resident’s ongoing need for ostomy management. During interviews, the DON was unable to provide information about the frequency of stoma care and complete bag changes, and the Administrator stated that the resident’s colostomy pouch was a one-piece system, with no separate wafer or pieces to change. The facility’s own policy on colostomy, urostomy, or ileostomy care required regular changing of the pouching system to avoid leaks and skin irritation, limiting removal to no more than once a day unless there was a problem, and cleaning and drying the skin around the stoma. The absence of documentation of full pouch changes and stoma care, in the context of these orders and policies, constituted the identified deficiency.
Improper Administration of G-Tube Flushes Not Performed by Gravity
Penalty
Summary
The deficiency involves the administration of G-tube flushes not being performed by gravity as required for a resident receiving enteral medications. During a medication pass, an LPN prepared a crushed pill for a resident with a gastrostomy tube, entered the room, performed hand hygiene, donned a gown and gloves, placed the tube feeding on hold, and checked for residual. She then drew up 30 cc of tap water into a syringe, opened the G-tube, inserted the syringe directly into the tube, and pushed the 30 cc of water into the tube using the plunger instead of allowing it to flow by gravity. The same nurse then diluted the medication in 30 cc of water and administered the medication and remaining flush by gravity. In a subsequent interview, the LPN acknowledged that she had not administered the initial G-tube flush by gravity and stated that while she always administered medications by gravity, she sometimes pushed flushes in and was unsure of the facility’s policy. The DON was informed that the G-tube flush had not been administered by gravity and stated that the facility’s policy did not specify that flushes must be given by gravity. The facility’s written policy addressed flushing the feeding tube with 30 cc of water or as ordered after verifying placement and residual, and an external article from Ohio State University Medical Center specified that water should be allowed to flow into the feeding tube by gravity when flushing.
Incomplete and Inaccurate Clinical Records for Diet Orders and Catheter Care
Penalty
Summary
The deficiency involves incomplete and inaccurate clinical records related to diet orders and assistive devices for one resident and urinary catheter care documentation for another resident. One resident with Alzheimer's disease and dysphagia had an MDS indicating a mechanically altered diet and a physician's order for a pureed diet with nectar thickened liquids, along with use of a scoop plate and Provale cup. Despite this, the resident was served chicken and rice soup containing chunks of carrots and chicken, which a CNA removed after realizing the resident was on a pureed diet. The resident was repeatedly observed receiving thickened juice in a clear plastic cup rather than the ordered Provale cup. The DON later indicated that a speech therapy discharge summary allowed mechanical soft pleasure feeds and acknowledged that the resident's diet and Provale cup orders needed to be updated, and that the Provale cup could not be used with thickened liquids. The deficiency also includes inaccurate documentation of urinary catheter care for another resident. This resident, with diagnoses including cholecystitis and a UTI, had severe cognitive impairment and was dependent for toileting, bed mobility, and eating. A physician's order on readmission from the hospital indicated the resident had a urinary catheter with catheter care every shift, and the March Treatment Administration Record showed catheter care documented on multiple days. However, observations showed no urinary catheter present; the DON confirmed there was no catheter and stated it must have been removed while the resident was in the hospital. The Administrator was informed that staff had been documenting catheter care when no catheter was present, and no additional information was provided.
Failure to Notify Responsible Party of New Medication Order
Penalty
Summary
The facility failed to notify a resident's Responsible Party or family member regarding a new medication order. Specifically, a resident with diagnoses including osteomyelitis and schizophrenia reported difficulty sleeping, and a Nurse Practitioner subsequently ordered melatonin to be administered nightly for insomnia. Record review showed no documentation that the Responsible Party or family was informed of this new medication order. During an interview, the Regional Nurse Consultant confirmed that the notification had not occurred.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to the risk of accidents for residents. Specific actions or inactions by staff or details about the residents involved are not provided in the report.
Failure to Provide Necessary Care and Complete Required Assessments
Penalty
Summary
The facility failed to provide necessary care and services to several residents, as evidenced by incomplete treatments, lack of required assessments, and failure to follow physician orders. For one resident with multiple surgical wounds and complex medical needs, the facility did not complete a comprehensive admission assessment as required by policy, and wound care treatments were missed on specific dates. Additionally, blood glucose monitoring orders were not clarified or carried out, and the orders were not properly transcribed onto the Medication Administration Record, resulting in the monitoring not being performed. Another resident with dementia and psychiatric diagnoses was not accurately assessed for elopement risk. Despite multiple documented behaviors indicating confusion, exit-seeking, and attempts to leave the facility, the Elopement Risk Assessment was completed inaccurately, with key risk factors marked as absent. The Social Service Director responsible for the assessment did not review relevant nursing notes prior to completing the assessment, leading to an underestimation of the resident's elopement risk. For two additional residents with diabetes, insulin administration was not documented as given on several occasions, and corresponding blood glucose checks were also missing. The Medication Administration Records for these residents showed multiple instances where insulin doses were not signed out, and no explanation was provided by facility staff for these omissions. These failures affected residents with significant medical conditions, including diabetes, dementia, and other chronic illnesses, and were identified through record review, observation, and staff interviews.
Failure to Timely Report and Investigate Abuse Allegation
Penalty
Summary
The facility failed to develop and implement policies and procedures to ensure the timely reporting of a reasonable suspicion of a crime, specifically regarding an allegation of physical and sexual abuse made by a resident diagnosed with dementia, bipolar disorder with current manic episodes and psychotic features, and unsteadiness on her feet. The resident, who had recently been admitted, voiced the allegation to staff, but the incident was not immediately reported to the Administrator, Indiana Department of Health (IDOH), the resident's previous facility, physician, responsible party, or local law enforcement. The LPN involved believed the allegation was related to the resident's mental state and did not report it as required. The facility's abuse policy required immediate reporting and investigation of any abuse allegations, but this was not followed in this case.
Failure to Administer Tube Feeding per Physician Orders
Penalty
Summary
A deficiency was identified when a resident with a gastrostomy tube and severe cognitive impairment did not receive tube feeding according to the physician's prescribed schedule and flow rate. Observations revealed that the resident's liquid tube feeding was not infusing at one point, and at another time, it was infusing at the ordered rate of 60 cc/hr. The resident's care plan and physician's orders specified that the tube feeding should be administered at 60 cc/hr for 18 hours, with feeding turned off at 8:00 a.m. and resumed at 2:00 p.m. However, documentation on the Medication Administration Record showed inconsistencies with the timing and administration of the feeding, indicating it was checked off as done at 5:30 p.m., which did not align with the prescribed schedule.
Failure to Ensure Proper PICC Line Care and Documentation
Penalty
Summary
The facility failed to ensure proper care and monitoring of a peripherally inserted central catheter (PICC) line for a resident with multiple diagnoses, including osteomyelitis, stroke, and post-surgical wound care. Observations revealed that the PICC line dressing was not changed weekly as required, with the dressing date indicating it had not been changed for ten days. Additionally, there were no physician's orders for PICC line flushes, dressing changes, or other aspects of PICC care. Review of the resident's medical record and medication administration records showed a lack of documented instructions for these essential PICC line care procedures. Nursing progress notes inconsistently documented PICC line flushes and assessments, with several gaps in documentation and no consistent evidence that the line was flushed or assessed according to the care plan. The care plan indicated the site should be assessed during infusions and at least every shift when not in use, and that the line should be flushed with normal saline and heparin, but these interventions were not consistently documented. Facility policy required regular flushing and dressing changes every five to seven days, but these standards were not met for this resident.
Medications Left Unsecured on Medication Carts
Penalty
Summary
Surveyors observed that medications and biologicals were not properly stored on two medication carts. On one occasion, several medications, including a bottle of amoxicillin, two bottles of Nystatin, a tube of wound paste, and a tube of cooling gel, all labeled for specific residents, were left unsupervised and accessible on top of a medication cart in the hallway while the assigned LPN was in a resident's room. The LPN stated that these medications belonged in the treatment cart, which was located at the end of the hallway, and not on her medication cart. In a separate instance, another LPN left medication cards containing pantoprazole, carvedilol, digoxin, acetaminophen, and ferrosol on top of a medication cart while she left to check for an out-of-stock medication, with at least one resident present in the hallway at the time. The Nurse Consultant acknowledged awareness of the medication storage concern but did not provide further information.
Incomplete and Inaccurate Medical Record Documentation for Two Residents
Penalty
Summary
The facility failed to ensure complete and accurate medical record documentation for two residents. For one resident with dementia and other psychiatric diagnoses, there was no nursing progress note documenting an elopement incident in which the resident left the building undetected and was returned by a community member. The LPN assigned to the resident during the incident reported being instructed not to document the event, and the only note present was written later by the DON, who had not witnessed the incident. The documentation did not reflect the actual sequence of events or the resident's condition during the elopement, and there was inconsistency among staff regarding instructions for documentation. For another resident with osteomyelitis and a history of stroke and pressure ulcers, there was a discrepancy between the physician's order for antibiotic administration and the documentation in the medical record. The order specified the antibiotic was to be given until a certain date, but the medication administration record showed the last dose was given a day earlier, while nursing notes incorrectly indicated the antibiotic was still being administered after it had been discontinued. There were no additional physician orders to continue the antibiotic, and the DON was unable to provide clarification for the documentation inconsistencies.
Failure to Follow Hand Hygiene Protocols During Medication Pass
Penalty
Summary
The facility failed to ensure proper infection control practices were followed during medication administration, specifically regarding hand hygiene. Observations revealed that one LPN did not perform hand hygiene after leaving one resident's room before preparing medication for another resident, nor before donning gloves to enter the next resident's room. The same LPN also failed to perform hand hygiene at multiple points during another medication pass, including after checking a resident's blood pressure, before preparing medication, and prior to applying a pain patch. Another LPN was observed not performing hand hygiene before entering a resident's room to administer medication after retrieving a medication from the medication room. Interviews with the staff indicated a lack of awareness regarding the need for hand hygiene at specific points during the medication pass process. The facility's current hand hygiene policy requires hand hygiene before and after direct contact with a resident's skin and after glove removal. The observed failures to follow these procedures were confirmed by both direct observation and staff interviews.
Failure to Notify Physician and Resident of Unavailable Insulin
Penalty
Summary
A resident with diagnoses including type 2 diabetes mellitus, atrial fibrillation, and multiple sclerosis did not receive prescribed doses of long-acting insulin (Lantus) on two consecutive evenings. The resident, who was cognitively intact, reported not receiving the medication and not being given an explanation. Documentation showed that the insulin was unavailable due to a pharmacy refill issue and was not present in the emergency drug kit. The Medication Administration Record and electronic notes indicated the medication was not administered, but there was no documentation that the physician or the resident had been notified of the unavailability. Interviews with facility staff confirmed that the nurse on duty had contacted the pharmacy and attempted to notify the on-call Nurse Practitioner via text message, but there was no documentation to support that the physician or the resident had been formally informed about the missed doses. Progress notes for the relevant dates also lacked evidence of such notifications. This failure to notify both the physician and the resident of the medication's unavailability constituted the deficiency.
Failure to Document Incontinence Care for Dependent Resident
Penalty
Summary
The facility failed to document incontinence care for a resident who was dependent on staff for activities of daily living (ADLs). The resident had diagnoses including dementia, hemiplegia, and hemiparesis following a stroke, and was assessed as severely cognitively impaired, totally dependent on staff for toileting and transfers, and frequently incontinent of bladder and always incontinent of bowel. The care plan required staff to provide incontinence care and scheduled toileting or voiding. However, review of CNA documentation from 3/17/25 to 4/7/25 revealed multiple shifts where incontinence care was not documented, specifically on several dates and shifts across the review period. The facility's policy required appropriate treatment and services for residents who are incontinent to maintain bladder function and prevent complications.
Medication Not Administered as Ordered
Penalty
Summary
A resident with diagnoses including neuropathy and arthritis had a physician's order for guaifenesin extended release 600 mg to be administered every 12 hours for seven days to treat a cough, totaling 14 doses. Review of the Medication Administration Record (MAR) showed that the medication was not administered as ordered on several occasions, with the resident receiving only 9 of the 14 prescribed doses. The Interim Director of Nursing confirmed that the medication had not been given according to the physician's order. Facility policy required medications to be administered as prescribed.
Failure to Provide Prescribed Supplements and Document Nutritional Intake for Residents with Weight Loss
Penalty
Summary
The facility failed to provide prescribed nutritional supplements and to document meal intake for residents experiencing weight loss. For one resident with diagnoses including dementia and protein-calorie malnutrition, observations showed that a prescribed Mighty Shake supplement was not provided with lunch, and both a CNA and an LPN confirmed the supplement was not given. The resident had a documented weight loss over several months and required setup assistance for eating. Physician orders and care plans specified the need for the supplement and fluid restrictions, but these were not followed during the observed meal. Another resident, who was severely cognitively impaired, dependent on staff for all activities of daily living, and receiving hospice care, also experienced significant weight loss. The care plan required monitoring and recording of food intake at each meal. However, review of documentation revealed multiple instances where meal intake was not recorded, specifically missing lunch and dinner entries on several dates. The facility's own policy required staff to ensure residents received correct diets and supplements and to monitor and document meal and supplement consumption, but this was not consistently done.
Failure to Provide Timely Pharmaceutical Services and Medication Administration
Penalty
Summary
The facility failed to provide routine medications in a timely manner for a resident with diagnoses including neuropathy, arthritis, and a recent urinary tract infection. After being readmitted from the hospital, the resident had physician orders for cephalexin (an antibiotic) and guaifenesin (a cough suppressant). Documentation showed that several doses of cephalexin were not administered as ordered due to issues such as a power outage, lack of medication in the Emergency Drug Kit (EDK), and insurance authorization delays. The Medication Administration Record (MAR) and progress notes indicated missed doses, and interviews revealed confusion regarding the source of administered doses and transcription errors indicating another pharmacy would supply the medication. The facility pharmacy had not communicated insurance coverage issues, and staff did not follow up with the pharmacy regarding the missing medication or authorization. Similarly, guaifenesin was not administered as ordered for several scheduled doses because it was not delivered from the pharmacy and was not available in the EDK. Progress notes documented the unavailability of the medication, and interviews confirmed transcription errors and uncertainty about the source of one administered dose. Facility policy required medication orders to be entered and sent to the pharmacy, but the process was not followed correctly, resulting in the resident not receiving prescribed medications as ordered.
Failure to Document COVID-19 Vaccine Education and Administration
Penalty
Summary
The facility failed to ensure proper documentation and education regarding COVID-19 vaccinations for four out of five residents reviewed. Specifically, the medical records of Residents 53, B, 201, and 300 lacked documentation that education on the benefits and potential risks of the COVID-19 vaccine was provided to the residents or their representatives. Additionally, there was no documentation explaining why the vaccine was not administered to these residents. The records indicated that Resident 53 had not been offered or administered the vaccine since September 2022, and Resident B had not been offered or administered the vaccine since February 2022. Residents 201 and 300 had no documentation of the vaccine being offered or administered at all. Interviews with the Infection Preventionist (IP) and the Director of Nursing revealed that the facility had not been proactive in offering COVID-19 vaccinations beyond the time of admission. The IP admitted to not periodically asking long-term residents if they were interested in receiving the vaccine and was unaware of the need to do so. The facility faced challenges in obtaining the vaccine from their pharmacy and had difficulties setting up a vaccination clinic with the county health department. The facility's policy required that COVID-19 vaccinations be offered per CDC and FDA guidelines, with education provided prior to administration, but these procedures were not followed as documented in the residents' medical records.
Failure to Assess and Authorize Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that residents were properly assessed and had a physician's order to self-administer medications. During an observation, a resident was seen with a medicine cup containing several pills on her overbed table, and she expressed uncertainty about taking them. A nurse admitted to leaving the medications with the resident, acknowledging it was inappropriate. The resident's records lacked a self-medication administration assessment and a physician's order for self-administration. In another instance, a resident had a tube of antibiotic ointment and loperamide tablets on her nightstand, which were not removed by the RN. The resident's records did not contain a self-medication assessment, a physician's order for self-administration, or orders for the medications present. The Director of Nursing later indicated that the resident's companion had brought the medications and was informed that all medications required a physician's order.
Failure to Implement Care Plans for Significant Weight Loss
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for residents experiencing significant weight loss. Resident 75, who was cognitively intact and dependent on staff for toileting and bed mobility, experienced a 24% weight loss over six months. Despite a dietary note indicating significant weight loss and difficulty with chewing and holding cups, no care plan was established to address these issues. The Director of Nursing confirmed the absence of a care plan related to the resident's weight loss. Similarly, Resident 85, who was cognitively impaired, experienced significant weight loss over a period of 180 days. Although the resident's care plan was updated to include a regular diet and supplements, it did not address the significant weight loss. The Culinary Nutritional Assessments documented the ongoing weight loss, yet no specific care plan was in place to manage this condition. The Director of Nursing acknowledged that a care plan should have been implemented for the resident's weight loss.
Failure to Update Care Plan for Resident with Cerebral Palsy
Penalty
Summary
The facility failed to update the care plan for a resident, leading to a deficiency in care. The resident, who has cerebral palsy, mild intellectual disabilities, and hemiplegia and hemiparesis following a stroke, was observed in a wheelchair with a contracted left hand. The resident's care plan, dated August 2024, included interventions for ambulation and maintaining range of motion, but there was no documentation of restorative therapy for the last 30 days reviewed. The Director of Nursing confirmed that the facility had not provided restorative therapy since September 2024, and the care plan should have been updated to reflect this change. The resident's Quarterly Minimum Data Set assessment indicated moderate cognitive impairment and functional limitations in the range of motion on one side of the upper extremities. Despite these needs, the care plan was not revised to address the lack of restorative therapy, and no recommendations for splinting devices were made. This oversight resulted in a failure to ensure the care plan was current and reflective of the resident's needs, as required by regulations.
Failure to Follow Physician's Orders for Skin Condition Treatments
Penalty
Summary
The facility failed to ensure physician's orders were followed for non-pressure skin condition treatments and monitoring for two residents. Resident 1 had a sore area on her right upper chest, which she reported to staff, but it was not assessed or treated until several days later. The Wound Nurse was unaware of the condition until the resident informed her, leading to a delay in assessment and treatment. The resident's record did not reflect any skin concerns prior to this, and the Director of Nursing did not provide further information on the follow-up. Resident 16 had multiple non-pressure chronic ulcers and required specific treatments as per physician's orders. However, the Treatment Administration Records indicated that these treatments were not completed on several occasions. The Wound Nurse noted that the resident frequently refused treatments, but there were no corresponding progress notes for these refusals. The Director of Nursing had no additional information to provide. The facility's policy required new wounds to be assessed and documented upon observation, which was not adhered to in these cases.
Failure to Conduct Weekly Wound Assessments and Update Treatment Orders
Penalty
Summary
The facility failed to ensure proper care and treatment for residents with pressure ulcers, as evidenced by incomplete weekly wound assessments and outdated physician's treatment orders. Resident D, who has severe cognitive impairment and a history of pressure ulcers, was observed with a healing stage 4 pressure ulcer on the left heel. Despite the facility's policy requiring weekly wound assessments, the Wound Nurse did not perform these assessments, citing the presence of only a scab. The Director of Nursing confirmed that weekly assessments should have been conducted. Resident 4, who has moderate cognitive impairment and a stage 4 pressure ulcer, received treatment that did not align with the physician's updated orders. The Wound Nurse applied a different treatment than prescribed, as the physician's order had not been updated in the medical record. The nurse acknowledged the oversight and indicated that the order had been changed a couple of weeks prior but was not reflected in the records until recently.
Failure to Implement Prescribed Splinting for Resident with Hand Contracture
Penalty
Summary
The facility failed to ensure that a prescribed palmar guard and resting hand splint were in place for a resident with a right hand contracture. During multiple observations, the resident was seen with her right hand clenched against her chest, indicating that the prescribed devices were not being used. A CNA reported that she was unaware of the need for a palm protector and had never used one for the resident. The resident's medical record indicated a diagnosis of Alzheimer's disease with late onset, generalized muscle weakness, and stiffness, and an OT plan recommended the use of a palmar guard and resting hand splint to reduce pain and prevent joint deformity. Interviews with facility staff revealed a lack of communication and implementation regarding the resident's splinting schedule. The PT indicated that nursing staff were educated on the splinting schedule, which was to be followed daily except during bathing and exercise. However, the Assistant Director of Nursing mentioned that there was no splint order in place for the resident, and there was confusion about whether the splint order was to be discontinued due to the resident's hand tightness. This lack of coordination and adherence to the prescribed treatment plan led to the deficiency in care for the resident's range of motion needs.
Failure to Implement Fall Precautions for Resident
Penalty
Summary
The facility failed to ensure fall precautions were in place for a resident with a history of falls. Resident 34, who has Alzheimer's Disease, hypertension, and depression, was observed multiple times seated in a wheelchair without anti-rollback bars or anti-tippers, despite being at risk for falls. The resident's Quarterly Minimum Data Set (MDS) assessment indicated cognitive impairment and a history of two or more falls with minor injury since the prior assessment. The resident was dependent on staff for transfers, and a care plan intervention dated 11/9/24 required the application of front and rear anti-tippers to the wheelchair. The deficiency was identified when it was discovered that staff had been mistakenly placing Resident 34 in his roommate's wheelchair, which lacked the necessary anti-tippers. This error occurred despite a care plan note indicating that anti-tippers were added to the resident's wheelchair following a fall on 11/9/24. The Director of Nursing confirmed that the resident was now in the correct wheelchair, but the oversight in ensuring the resident's safety measures were consistently applied led to the deficiency.
Failure to Monitor and Report Low Urinary Output
Penalty
Summary
The facility failed to ensure proper monitoring and documentation of urinary output for a resident with an indwelling urinary catheter. The resident, who was severely cognitively impaired and had a history of urinary tract infections, urethral stricture, and obstructive and reflux uropathy, had a physician's order to monitor Foley catheter output every shift and notify the physician if the output was less than 300 milliliters. However, the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for February 2025 showed that the Foley output was not documented on several shifts, and there were multiple instances where the output was less than 300 milliliters without any documentation of the physician being contacted. The specific dates and shifts where the output was not documented include the 1st shift on 2/4/25, the 2nd shift on 2/1, 2/2, and 2/9/25, and the 3rd shift on 2/1 and 2/11/25. Additionally, the output was less than 300 milliliters on several shifts, including the 1st shift on 2/2, 2/9, 2/10, and 2/16/25, the 2nd shift on 2/3, 2/6, 2/8, 2/10, 2/11, and 2/17/25, and the 3rd shift on 2/5, 2/6, and 2/9/25. Despite these occurrences, there was no evidence that the physician was notified as required by the care plan and physician orders.
Failure to Monitor and Document Nutritional Intake and Weight Loss
Penalty
Summary
The facility failed to adequately monitor and document the nutritional intake and weight of three residents, leading to significant weight loss. Resident 75 experienced a 24% weight loss over six months, with missing weekly weight records despite a physician's order to monitor weekly weights. The Medication Administration Record (MAR) showed several instances where weights were not recorded, and the Director of Nursing confirmed the absence of additional weight records. Resident 85, who was cognitively impaired, had a significant weight loss without a care plan addressing this issue. Although supplements were ordered to address the weight loss, the MAR only showed check marks for administration without documenting the amount consumed. Similarly, Resident C, who was severely cognitively impaired and dependent on staff for all activities of daily living, had missing documentation for meals and fluid intake over a 30-day period. The Director of Nursing acknowledged the lack of documentation and had no further information to provide.
Failure to Document Tube Feeding Administration
Penalty
Summary
The facility failed to provide proper care for a resident with a gastrostomy tube (g-tube) as per professional standards. The deficiency was identified through a lack of documentation of tube feeding administration for a resident with a history of weight loss. The resident, who was severely cognitively impaired and receiving hospice care, had a g-tube due to dysphagia following a stroke. The care plan indicated the resident was at risk for dehydration related to g-tube use, and interventions included administering all tube feedings and fluids via g-tube per order. Despite these interventions, the facility did not document the administration of tube feedings on several occasions. The resident's dietary records showed significant weight loss, prompting a recommendation to increase the duration of tube feeding. However, the February 2025 Medication and Treatment Administration Records indicated that the tube feeding was not administered on specific days. During an interview, the Director of Nursing acknowledged that the nurse had forgotten to sign off on the tube feeding administration, indicating a lapse in following the prescribed care plan and documentation procedures.
Failure to Ensure Correct Oxygen Flow Rates and Monitoring
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents, resulting in incorrect oxygen flow rates and inadequate monitoring of oxygen levels. Resident 75 was observed with an oxygen flow rate set between 2.5 and 3 liters per minute, contrary to the physician's order of 2 liters per minute. This discrepancy was noted during observations on two separate occasions, and the error was confirmed by a nurse who adjusted the flow rate to the correct setting. Similarly, Resident 74 was observed with an oxygen concentrator set at 2.5 liters and later at 4 liters, despite a physician's order specifying 2 liters as needed for hypoxia. The resident's oxygen saturation levels had not been checked since a previous assessment, which recorded a saturation of 98% on room air. The Assistant Director of Nursing confirmed the incorrect settings and acknowledged the lack of recent oxygen saturation monitoring.
Medication Delivery and Dispensing Failures
Penalty
Summary
The facility failed to ensure timely delivery and accurate dispensing of medications for two residents. Resident 32 experienced an itching rash and was prescribed triamcinolone cream, which was not received until three days after the order was placed. Despite the pharmacy receiving the order and sending it out via delivery service, the medication was delayed, causing distress to the resident. The Director of Nursing (DON) confirmed that medications should be received within 24 hours, but the resident did not receive the cream until three days later. For Resident 77, there was an issue with the continued delivery of a discontinued medication, Sertraline. Despite the medication being discontinued on the same day it was ordered, it continued to be delivered weekly due to a pharmacy error. The LPN had informed the pharmacy multiple times to stop sending the medication and had placed a note on the medication cart to prevent its administration. The DON confirmed that the pharmacy was interfaced with the facility and should have received the discontinuation order, but a pharmacy staff member mistakenly reordered the medication, leading to its continued delivery.
Failure to Attempt Non-Pharmacological Interventions Before Administering Narcotics
Penalty
Summary
The facility failed to ensure that non-pharmacological interventions were attempted before administering narcotic pain medication to a resident. The resident, who was cognitively intact and dependent on staff for toileting and bed mobility, suffered from chronic pain due to spinal stenosis. Despite having a pain care plan that included various non-pharmacological interventions such as positioning, relaxation therapy, and heat application, the facility did not document any attempts to use these methods before administering Norco, an opioid pain medication. The resident's medication administration records for January and February 2025 showed that Norco was administered multiple times without any documentation of non-pharmacological interventions being attempted first. This lack of documentation was confirmed during an interview with the Director of Nursing, who acknowledged that there was no evidence of non-pharmacological interventions being tried prior to the administration of the narcotic medication.
Failure to Document Incontinence Care for Dependent Resident
Penalty
Summary
A deficiency was identified when the facility failed to document incontinence care for a resident who was fully dependent on staff for all activities of daily living (ADLs). The resident, who had diagnoses including Alzheimer's disease and dementia, was severely cognitively impaired, always incontinent of bowel and bladder, and received hospice care. According to the care plan, the resident required staff assistance for all ADLs and was to receive incontinence care with each episode. The resident's Power of Attorney reported multiple instances of finding the resident in a soaking wet brief, indicating lapses in care. A review of the CNA task documentation for incontinence care over a 30-day period revealed multiple shifts where care was not documented, including several dates across all three shifts. During an interview, the Director of Nursing was unable to provide further information regarding the missing documentation. This deficiency was identified during a complaint investigation.
Failure to Implement and Maintain Infection Control Precautions
Penalty
Summary
The facility failed to implement proper infection prevention and control measures in two separate instances. In the first instance, an LPN was observed administering medication via g-tube to a resident who had a sign on the door indicating Enhanced Barrier Precautions, which required the use of gloves and a gown for high-contact activities such as feeding tube care. The LPN only wore gloves and did not don a gown during the procedure, despite the signage and the nature of the care activity. The LPN stated that the resident was no longer on isolation, even though the sign was still posted on the door. In the second instance, a resident with diagnoses including dementia, colon and breast cancer, and traumatic brain injury was on contact isolation due to candida auris. Observations over several days showed that the resident's room had an isolation bin but lacked any signage indicating contact isolation precautions. The Infection Preventionist confirmed that the resident was on contact isolation and believed the sign had been removed by the family. These lapses demonstrate a failure to ensure infection control guidelines were consistently in place and followed.
Controlled Substance Storage Deficiency
Penalty
Summary
The facility failed to ensure that a controlled substance was double locked at all times in one of the medication rooms, specifically at Grace Point. During an observation, it was found that a clear tackle box inside an unlocked refrigerator was not locked, and it contained two medication cards of Dronabinol (Marinol) pills, a Schedule III medication. An LPN indicated that the key to the clear box was lost, and the box should have been locked. The Assistant Director of Nursing confirmed that the box should be locked at all times and mentioned the intention to locate the key to ensure proper storage. The facility's policy requires controlled substances to be stored in a locked container, separate from non-controlled medications, and to remain locked except when accessed with a key or access code.
Failure to Notify Physician of Abnormal Lab Results
Penalty
Summary
The facility failed to notify a resident's physician and responsible party in a timely manner regarding abnormal laboratory results for a resident with multiple health conditions, including Alzheimer's disease, dementia, and congestive heart failure. The resident was severely cognitively impaired and dependent on staff for all activities of daily living. Abnormal laboratory results were reported on multiple occasions, including low red blood cell count, hemoglobin, and hematocrit levels, as well as a positive stool occult blood test. Despite these findings, there were no notes indicating that the physician or family representative was notified of these results. The deficiency was attributed to a lapse in communication and documentation processes within the facility. A nurse on duty who was responsible for entering lab orders into the Electronic Health Record (EHR) had to leave the facility due to COVID-19, resulting in the lab draw order not being entered into the system. Consequently, the Director of Nursing (DON) did not receive notifications of completed labs when running daily reports. This oversight occurred over a weekend, and the abnormal laboratory values were not reported to the physician until several days later, which was not in accordance with the facility's policy on diagnostic testing services.
Deficiencies in Resident Care and Medication Administration
Penalty
Summary
The facility failed to provide necessary care and services for Resident M, who had undergone neck surgery and was observed wearing a soft neck collar. Despite the presence of the collar, there were no physician orders or monitoring instructions for its use or for checking the skin underneath. The Director of Nursing was informed of the lack of orders and monitoring, but no further information was provided. Resident F experienced a delay in treatment following critical laboratory results. The resident, who had a history of anemia and other medical conditions, was found to have critical hemoglobin levels. Although the lab results were communicated to the facility, the nurse did not act promptly, resulting in a delay in sending the resident to the hospital. The Director of Nursing later discovered the oversight and arranged for the resident's transfer to the hospital. Additionally, Resident F did not receive medications as ordered, and there was a lack of assessment and monitoring for a new skin condition. The medication lansoprazole was not administered as prescribed due to a delay in delivery, and the MAR inaccurately reflected administration. Furthermore, a new skin condition was identified but not documented or reported to the Wound Care Nurse, contrary to facility policy. The Director of Nursing was unaware of the physician's lab orders, leading to missed laboratory tests.
Delayed X-ray Completion for Post-Surgery Resident
Penalty
Summary
The facility failed to ensure that an x-ray was completed in a timely manner as ordered by the physician for Resident M, who was one of the three residents reviewed for a change in condition. Resident M, who had undergone neck surgery, was observed wearing a soft neck collar. Her family indicated that a neck x-ray was supposed to be done the previous week to compare with a prior x-ray, but it was delayed until the current week without a clear reason for the delay. The record review revealed that a new order for a cervical spine x-ray was received on 12/10/24, but the x-ray was not completed until 12/16/24. The Director of Nursing confirmed the delay and was unsure why the orders were not placed until 12/16/24. The x-ray was considered non-emergent, and the facility's policy indicated that diagnostic tests should be scheduled in accordance with the physician's orders. There was no documentation explaining the delay in completing the x-ray.
Privacy Breach Due to Unauthorized Photography
Penalty
Summary
The facility failed to ensure the privacy of a cognitively impaired resident, identified as Resident B, by allowing a registered nurse (RN 2) to use her personal cell phone to take pictures of the resident's bruising without the approval of the resident's Responsible Party. Resident B, who has a diagnosis of Alzheimer's disease and a moderately impaired cognitive status, was found with bruising on the left breast and left upper arm, as well as a slightly swollen left ankle. The resident was unable to recall how the bruises occurred and complained of pain with ankle movement. The incident was reported by RN 1, who observed the bruising and was instructed by the Director of Nursing (DON) to take photographs, which were then sent to the DON's personal cell phone. This action was against the facility's policy, as outlined in the Employee Handbook, which prohibits the use of cell phone cameras or any cameras in resident areas or for capturing photos of residents. The facility's policy also required consent for photographs, which was not obtained in this case, as the existing consent was only for marketing purposes.
Failure to Report and Investigate Injury of Unknown Source
Penalty
Summary
The facility failed to immediately report an injury of unknown source involving a resident to the Administrator/Abuse Coordinator and the Indiana Department of Health (IDOH). The incident involved a resident with Alzheimer's disease who was observed with significant bruising on the left arm and breast. The bruising was first noted by a CNA during care, but the cause of the injury was unknown, and the resident could not recall how it occurred. Despite the facility's policy requiring immediate reporting of such incidents, the bruising was not reported to the IDOH until much later. The resident's care plan required assistance for activities of daily living, including transfers with two staff members and a mechanical lift. However, there was confusion among staff regarding who had cared for the resident during the time the bruising was first observed. Interviews with various CNAs revealed inconsistencies in reporting and communication, with some staff members assuming others had already reported the bruising. The initial nurse who observed the bruising did not measure it, contrary to the facility's policy, and the Director of Nursing (DON) later admitted to forgetting about photographs taken of the bruising. The facility's investigation into the incident was incomplete, with interviews conducted but not documented. Staff interviews did not reveal any reports of the resident falling, and there were rumors of the resident being dropped during a transfer. The facility's abuse policy required immediate notification of the Abuse Coordinator and IDOH for injuries of unknown origin, but this protocol was not followed. The failure to report and thoroughly investigate the injury led to a deficiency citation related to the complaint.
Failure to Provide Adequate Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care to a resident who required oxygen therapy, as per the physician's orders. During an observation, it was noted that the resident's oxygen concentrator was alarming, and the device displayed a wrench symbol, indicating a malfunction. The oxygen concentrator was set at less than 0.5 liters per minute, contrary to the physician's order of 2 liters per minute. Despite the alarm, the LPN initially prioritized administering medications and did not immediately address the malfunctioning concentrator. The resident's oxygen saturation was recorded at 83%, indicating inadequate oxygenation. Further investigation revealed that the staff was unsure of the meaning of the alarm and did not have immediate access to a functioning concentrator. Although there were oxygen cylinders available, they were not utilized promptly due to unfamiliarity. The resident's condition included a diagnosis of pneumonia, and the care plan required medications to be administered as ordered. The facility's policy stated that oxygen should be provided as ordered by the attending physician, which was not adhered to in this instance.
Infection Control and EBP Deficiencies
Penalty
Summary
The facility failed to maintain a safe and sanitary environment, which could potentially lead to the transmission of communicable diseases and infections. Specifically, the facility did not ensure that glucometers used for multiple residents were sanitized before and after each use. An RN was observed conducting blood sugar tests without sanitizing the glucometer after each resident, contrary to the facility's policy. Additionally, an oximeter used on multiple residents was not sanitized after use, as observed with an LPN who failed to clean the equipment after checking a resident's oxygen saturation levels. Furthermore, the facility did not adequately educate staff on Enhanced Barrier Precautions (EBP) and failed to ensure that staff were aware of which residents required EBP. There were no signs indicating EBP on residents' doors, and staff members, including CNAs and an LPN, were observed providing care without the appropriate Personal Protective Equipment (PPE). Interviews with staff revealed a lack of understanding and training regarding EBP, with the Unit Manager/Infection Control Nurse and the Assistant Director of Nursing acknowledging the absence of EBP training since their employment began.
Failure to Timely Notify Physician and Family of G-Tube Malfunction
Penalty
Summary
The facility failed to notify a resident's physician and responsible party in a timely manner regarding a gastrostomy tube mechanical malfunction that required hospital intervention. This deficiency involved a resident with Alzheimer's disease, a gastrostomy, and iron deficiency anemia, who relied on a feeding tube for nutrition and fluids. On the day of the incident, the resident's liquid tube feeding was observed to be infusing, but later turned off. An LPN was unable to administer the resident's morning medications and water flush due to an inability to separate the feeding tube line from the g-tube. Despite attempts by multiple staff members, including the ADON and Unit Manager/Infection Control Nurse, the issue persisted, and the resident's medications and flushes were not administered as scheduled. The physician and family were not notified of the malfunction until several hours after the issue was identified. The LPN attempted to contact the physician for an order to transfer the resident to the hospital, but the notification was delayed until after 2:30 p.m., and the family was informed only when they arrived at the facility later in the afternoon. The facility's policy required timely notification of the physician and responsible party in the event of a change in status or need to alter treatment, which was not adhered to in this case. The resident was eventually sent to the hospital for the g-tube to be changed and returned to the facility.
Failure to Provide Scheduled Bathing for Dependent Residents
Penalty
Summary
The facility failed to ensure that residents who were dependent on staff for activities of daily living (ADLs) received the required bathing or showers at least twice a week. Resident B, diagnosed with Alzheimer's disease, a gastrostomy tube, and iron deficiency anemia, was noted to have a self-care performance deficit and was dependent on staff for ADLs. Despite being scheduled for showers on Mondays and Thursdays, documentation revealed that Resident B did not receive the required bathing on several occasions, with forms either left blank or marked as non-applicable. Similarly, Resident H, who had vascular dementia and was totally dependent on staff for bathing, did not receive the scheduled showers on multiple occasions. The care plan indicated that Resident H required assistance with ADLs and was scheduled for showers on Wednesdays and Saturdays. However, documentation showed missed bathing sessions, with forms marked as non-applicable or left blank. The Unit Manager/Infection Control Nurse confirmed that residents were supposed to receive bathing twice a week and as needed, but this was not consistently documented or provided.
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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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