Envive Of Evansville
Inspection history, citations, penalties and survey trends for this long-term care facility in Evansville, Indiana.
- Location
- 601 N Boeke Rd, Evansville, Indiana 47711
- CMS Provider Number
- 155716
- Inspections on file
- 40
- Latest survey
- March 16, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Envive Of Evansville during CMS and state inspections, most recent first.
The facility failed to maintain accurate documentation for residents, leading to discrepancies in fall risk assessments and dialysis records. A resident's fall history was inaccurately recorded, and blood pressure readings were documented incorrectly. Additionally, required dialysis assessments were missing or improperly documented, highlighting significant gaps in record-keeping practices.
A facility failed to update a care plan after a resident experienced a fall. The resident, who had diagnoses including cerebral infarction and repeated falls, required substantial assistance with daily activities. Despite being at risk for falls, the care plan was not revised following an unwitnessed fall. The facility's policy required the IDT to review falls and update care plans, but there was no documentation of such a meeting, and the Administrator could not confirm if it occurred.
A resident at high risk for falls experienced multiple falls due to inadequate implementation of fall prevention interventions. Despite updates to the care plan after each incident, the facility failed to ensure personal items were within reach, contributing to the falls. The facility's policy emphasized a resident-centered fall prevention plan, but repeated falls indicate a failure in adherence.
The facility failed to provide necessary assistance with ADLs for several residents, including assistance with meals and bathing. A resident with dementia was not assisted to the dining table in a timely manner, and meal intake was not documented. Other residents did not receive showers according to their care plans, and a resident with a broken arm was not assisted with personal hygiene. The DON confirmed that showers were charted, but there was no written policy on shower timing.
The facility failed to serve meals at appropriate temperatures, as residents reported receiving cold food and a test tray confirmed temperatures below the required level. A cheeseburger was served at 100.6°F and sweet potato fries at 87°F, contrary to the facility's policy of maintaining hot foods at or above 135°F.
The facility failed to document attempts to contact a resident's family for discharge arrangements, leading to a delay. Additionally, inconsistent documentation regarding a fall incident for another resident resulted in unclear details about the resident's injury and care needs.
The facility was found deficient in maintaining a sanitary environment, with surveyors observing strong odors of bowel movements and urine in various halls and an unattended trash cart emitting a similar odor. Additionally, the Pavilion dining room floor had a large puddle of fluid and debris. Despite the Housekeeping Supervisor's claim that odors were managed daily, these issues persisted, contradicting the facility's policy for maintaining pleasant, neutral scents.
A facility failed to provide a SNF-ABN to a resident after the end of Medicare skilled services. The resident was scheduled for discharge but remained in the facility due to family not picking her up. The Administrator confirmed the absence of a SNF-ABN, and the facility's policy did not address SNF-ABN requirements, highlighting a procedural gap in notifying residents of financial responsibilities post-Medicare coverage.
A resident with moderate cognitive impairment was discharged without proper documentation in their clinical record. The facility failed to record essential discharge details, such as the destination and date of discharge, despite having a policy requiring a discharge summary and post-discharge plan. This deficiency was confirmed through record review and staff interviews.
A facility failed to update the PASARR for a resident with complex mental health needs, including Wernicke's encephalopathy and multiple psychiatric disorders. The resident's PASARR was outdated, completed eight months prior to admission, and not reviewed upon admission despite policy requirements. This oversight led to a deficiency in providing necessary social services to meet the resident's mental and psychosocial needs.
A facility failed to develop a baseline care plan within 48 hours for a resident with chronic respiratory failure and a tracheostomy. The resident's clinical record lacked documentation for respiratory equipment use and Enhanced Barrier Precautions, despite ongoing physician orders and facility policy requirements.
A resident with a history of falls and mild cognitive impairment experienced an unwitnessed fall with injury, but the facility failed to update the care plan with a new intervention as required. The care plan, which included interventions for medication review and pain management, was not revised following the incident, as confirmed by the facility administrator.
The facility failed to follow physician orders for two residents. One resident, with renal failure and diabetes, did not receive the ordered compression stockings for edema management. Another resident, with dementia, did not have the required weight monitoring conducted. Interviews revealed a lack of documentation and no written policy to ensure adherence to physician orders.
A resident with severe cognitive impairment and limited mobility developed pressure ulcers due to the facility's failure to implement a physician-ordered pressure-reducing cushion and an individualized repositioning schedule. The facility also failed to document and communicate changes in the resident's skin condition, as required by their policy.
The facility failed to conduct proper post-fall assessments and update care plans for three residents, leading to deficiencies in fall prevention. A resident with Alzheimer's experienced a fall and returned from the hospital with a fracture, but the care plan was not updated. Another resident with dementia had multiple falls without proper assessments or notifications. A third resident's fall was not immediately assessed, and care plan updates were delayed. These issues highlight systemic deficiencies in managing fall risks.
A facility failed to provide proper respiratory care for a resident with a tracheostomy by not labeling oxygen and suction tubing, and not placing signs indicating oxygen use. The resident's clinical record lacked a baseline care plan for tracheostomy and oxygen use, despite having physician orders for oxygen administration. The DON confirmed the need for labeling and signage, as per the facility's policy.
A facility failed to follow physician orders for a resident requiring dialysis care, including not taking blood pressure from the left arm and conducting timely pre-dialysis assessments. Blood pressures were repeatedly taken from the left arm, and pre-dialysis assessments often contained outdated vitals. The facility lacked a written policy for following physician orders, and no policy for dialysis patient assessment was provided.
A facility failed to ensure a resident, admitted with renal failure and peripheral vascular disease, was assessed by a physician since admission. The resident, who required substantial assistance for daily activities, reported not being assessed by a physician, and a review of her clinical record confirmed this absence. The facility's policy on physician responsibilities was not followed.
The facility failed to ensure proper use of Enhanced Barrier Protocol (EBP), PPE, and hand hygiene for residents requiring wound and tracheostomy care. A resident with a tracheostomy did not have an EBP sign, and an LPN did not follow hand hygiene protocols. Two residents with wounds did not receive care with appropriate PPE, despite EBP signs being present. The facility's policies on EBP and hand hygiene were not adhered to during care activities.
A resident with dementia and other conditions was moved from a locked dementia unit to another hall without prior written notice, violating their rights. The resident expressed a preference for their previous room and did not receive the required notification. Facility policy mandates written notice before room changes, which was not followed.
A facility failed to promptly report an incident of resident-to-resident abuse involving a resident with a history of inappropriate sexual behavior. The incident, where a resident inappropriately touched another, was not reported to the State Agency for seven days and lacked detailed information. Staff interviews revealed a delay in reporting the incident to the Facility Administrator, contrary to the facility's policy.
A facility failed to ensure adequate supervision and assistance devices for a resident with a history of falls. Despite having a care plan with specific interventions, such as a fall mat and motion sensor, these were not consistently in place. Observations showed missing non-skid mats, and staff were unaware of the interventions required. The facility lacked a policy to ensure adherence to the care plan, contributing to the deficiency.
The facility failed to provide adequate supervision for an aggressive resident, resulting in a cognitively impaired resident being pushed to the floor and sustaining a right femur fracture that required hospitalization and surgical repair. The aggressive resident had a history of Alzheimer's and dementia with agitation, and had previously shown aggressive behavior towards staff but not other residents.
Documentation Deficiencies in Resident Records
Penalty
Summary
The facility failed to ensure complete and accurate documentation for several residents, leading to deficiencies in record-keeping. Resident M's clinical records showed discrepancies in fall risk assessments, with incorrect documentation of falls and cognitive status. Despite having multiple falls, the assessments inaccurately indicated no falls in the past three months and that the resident was alert and oriented, which was contradicted by other records showing severe cognitive impairment. Resident B's records revealed that blood pressure readings were incorrectly documented as being taken from the left arm, despite physician orders to avoid this due to renal failure. Additionally, there was a lack of pre and post-dialysis assessments on a specified date, which were required by physician orders. Similarly, Resident H's records lacked a post-dialysis assessment, and the documentation process was flawed as the Assistant Director of Nursing (ADON) signed off on assessments she did not perform, relying on information received by phone without proper documentation. Resident D's records also showed inconsistencies, with fall risk assessments inaccurately reflecting the resident's fall history and use of assistive devices. There was a lack of documentation for a fall that occurred, and the incident report was not integrated into the clinical record. The Director of Nursing acknowledged the need for re-education on documentation practices, as errors in documentation led to inaccurate assessments and incomplete records.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to update the care plan for a resident, identified as Resident D, after the resident experienced a fall. Resident D's clinical record indicated diagnoses including cerebral infarction, repeated falls, and muscle wasting and atrophy. The most recent Admission Minimum Data Set (MDS) Assessment showed that Resident D was cognitively intact and required substantial to maximal assistance with activities such as toileting and transferring. Despite being at risk for falls, as noted in a care plan initiated earlier, the care plan was not updated with new interventions following an unwitnessed fall on 3/10/25. The facility's policy required the Interdisciplinary Team (IDT) to meet the next clinical morning after a fall to review the incident and update the care plan with appropriate interventions. However, there was no documentation indicating that the IDT met to review Resident D's fall, and the care plan remained unchanged. The Administrator could not recall if the IDT had convened to address the fall, highlighting a lapse in the facility's adherence to its fall management policy.
Failure to Implement Effective Fall Prevention Interventions
Penalty
Summary
The facility failed to ensure that interventions were in place to prevent falls for a resident identified as being at risk for falls. The resident, who was cognitively intact and required substantial to maximal assistance with mobility and toileting, experienced five falls over a short period. Despite being assessed as low risk for falls initially, the resident's fall risk was later updated to high risk after multiple incidents. The care plan was updated with new interventions after each fall, except for the last incident, where no new intervention was added. Observations revealed that the resident's personal items were not within reach, which could have contributed to the falls. The Director of Nursing acknowledged the oversight and indicated that staff were re-educated on following fall interventions. The facility's policy on managing falls emphasized the need for a resident-centered fall prevention plan and the importance of monitoring and documenting the resident's response to interventions. However, the repeated falls and lack of timely updates to the care plan suggest a failure in implementing and adhering to these policies effectively.
Failure to Provide Assistance with ADLs for Multiple Residents
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADL) for seven out of eight residents reviewed. Resident L, who was moderately cognitively impaired, was observed sitting in a recliner and not assisted to the dining table until after other residents had finished eating. His meal intake was not documented for lunch or dinner on the observed day. Resident S, who required substantial assistance for bathing, reported not receiving showers according to the care plan, and records confirmed missed showers on specified days. Resident G, severely cognitively impaired, also did not receive showers on scheduled days. Resident U, who was cognitively intact and required supervision for bathing, did not receive showers as per her preference care plan. Similarly, Resident R, who required substantial to maximal assistance, did not receive showers on multiple scheduled days. Resident N, who required assistance due to chronic pain, also missed scheduled showers. An anonymous report indicated that Resident T, with mild to moderate cognitive impairment and a broken arm, was not receiving necessary assistance with personal hygiene, including showering and oral care. The Director of Nursing confirmed that showers were charted in the Point of Care system, but there was no written policy on the timing of showers. The facility's policy on meal assistance was provided, indicating that staff should help residents who require assistance with eating.
Failure to Serve Meals at Appropriate Temperatures
Penalty
Summary
The facility failed to ensure meals were served at a palatable temperature, as evidenced by observations and resident interviews. On multiple occasions, residents reported that their food was not served at the appropriate temperature, with hot foods being cold and cold foods not being adequately chilled. A test tray revealed that a cheeseburger was served at 100.6°F and sweet potato fries at 87°F, both below the required temperature for hot foods. Additionally, the cheeseburger was observed to be pink in the middle, despite being precooked. The facility's policy requires hot foods to be maintained at or above 135°F, which was not adhered to in this instance.
Incomplete Documentation for Discharge and Fall Incident
Penalty
Summary
The facility failed to ensure complete and accurate documentation for two residents, leading to deficiencies in their care. For Resident Z, the facility did not document attempts to contact the family regarding the resident's discharge from Medicare Part A. Although the Social Services Director left a voicemail for the family, there was no documentation of further attempts to reach them between January 15 and January 17, 2025. This lack of communication resulted in a delay in the resident's discharge, as the family was waiting for a call to set a discharge date. For Resident T, the facility's documentation was inconsistent regarding the details of an injury from a fall. The incident note indicated that the resident fell and complained of hip and neck pain, with bruising visible on the left arm. However, a nursing progress note documented bruising on the right arm. The Administrator later confirmed that it was not typical for the Social Services Director to decide on using a sling, and the progress note was inaccurately documented. This inconsistency in documentation failed to provide a clear and accurate account of the resident's condition and care needs.
Facility Fails to Maintain Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe and sanitary environment, as evidenced by multiple observations of unpleasant odors and unsanitary conditions. During seven random observations, surveyors noted strong odors consistent with bowel movements and urine in various areas, including the East Hall, 500-hall, and [NAME] Hall. Additionally, a rolling cart of trash emitting a bowel movement-like odor was left unattended in front of the East Hall nurses' station. The Pavilion dining room floor was observed with a large puddle of fluid and dirty debris. Despite the Housekeeping Supervisor's statement that managing odors was part of daily cleaning tasks and that odor-eliminating supplies were available, these issues persisted. The facility's Homelike Environment policy, effective August 2024, emphasized maintaining pleasant, neutral scents, which was not adhered to during the survey period.
Failure to Provide SNF-ABN to Resident Post-Medicare Coverage
Penalty
Summary
The facility failed to provide a Skilled Nursing Facility-Advanced Beneficiary Notice (SNF-ABN) to Resident Z after the end of Medicare skilled services. Resident Z began receiving Medicare Part A Skilled Services on December 4, 2024, with the last covered day being January 14, 2025. Although Resident Z was scheduled to be discharged home on January 15, 2025, the family did not pick her up, and she remained in the facility. The Administrator confirmed that a SNF-ABN was not issued to Resident Z, which is a requirement following the end of Medicare coverage. Upon review of Resident Z's clinical record, it was noted that the payer source changed from Medicare to private pay on January 15, 2025, and she was discharged from the facility on January 22, 2025. The facility's Notice of Medicare Non-Coverage (NOMNC) policy, revised on October 1, 2023, did not address the requirements for SNF-ABN forms. The Administrator acknowledged the absence of a policy for SNF-ABN forms and expected compliance with federal regulations, indicating a gap in the facility's procedures for notifying residents of their financial responsibilities post-Medicare coverage.
Failure to Document Resident Discharge
Penalty
Summary
The facility failed to document the discharge of a resident, identified as Resident 60, in the clinical record. Resident 60, who was moderately cognitively impaired and required substantial assistance for daily activities, was discharged with no anticipation of return. However, the clinical record lacked essential information regarding the discharge planning, including the destination of the resident, the date of discharge, and the documents sent with the resident. This oversight was identified during a review of the resident's clinical record and confirmed through an interview with the Admissions Director, who acknowledged the absence of discharge documentation. The facility's policy, titled Discharge Summary and Plan, mandates that a discharge summary and post-discharge plan be developed and documented for each resident. This includes an evaluation of the resident's discharge needs, a post-discharge plan, and a discharge summary, all of which should be reviewed with the resident and family at least 24 hours before discharge. Despite this policy, the facility did not adhere to these requirements for Resident 60, as evidenced by the lack of documentation in the clinical record and the inability of staff to provide the necessary discharge information.
Failure to Update PASARR for Resident with Complex Needs
Penalty
Summary
The facility failed to ensure that social services were provided to meet a resident's mental and psychosocial needs, specifically in relation to the Preadmission Screening and Resident Review (PASARR) process. The resident, who was admitted with multiple diagnoses including Wernicke's encephalopathy, alcohol use disorder, non-Alzheimer's dementia, seizures, anxiety, depression, and an unspecified psychiatric disorder, was found to have an outdated PASARR completed eight months prior to admission. The facility's policy required that all new admissions be screened for mental disorders, intellectual disorders, or related disorders per the Medicaid PASARR process, but this was not adhered to as the resident's diagnoses were updated after the PASARR was completed, and the Admissions Director did not review the PASARR upon admission to ensure it was current. The resident's clinical record indicated the use of multiple psychotropic medications and the presence of target behaviors such as psychosis, depression, and anxiety, which required monitoring and documentation. Despite these needs, the facility did not ensure that the PASARR was updated to reflect the resident's current condition and needs. The Administrator acknowledged that the PASARR should have been reviewed and updated upon admission, highlighting a lapse in the facility's adherence to its own admissions criteria policy. This oversight resulted in a deficiency related to the provision of necessary social services to address the resident's mental and psychosocial needs.
Failure to Develop Baseline Care Plan for Respiratory Care
Penalty
Summary
The facility failed to develop and complete a baseline care plan within 48 hours of admission for a resident requiring respiratory care. The resident, who was admitted with chronic respiratory failure with hypoxia and a tracheostomy, did not have a baseline care plan addressing the use of respiratory equipment, tracheostomy care, and Enhanced Barrier Precautions (EBP) to prevent the transmission of Multiple Drug-Resistant Organisms (MDROs). The absence of this care plan was identified during a review of the resident's clinical record, which showed ongoing physician orders for oxygen and humidifier changes, as well as the need for EBP due to the presence of a tracheostomy and PEG tube. Interviews with facility staff, including the Assistant Director of Nursing (ADON), revealed that the baseline care plan should have been based on the initial assessment completed by the admitting nurse. This assessment was supposed to include a physical evaluation and details on oxygen use, with the care plan initiated within 48 hours of admission. However, the clinical record lacked this essential documentation, which was confirmed by the facility's policy requiring a baseline care plan to be developed within the specified timeframe to meet the resident's immediate health and safety needs.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to update the care plan for a resident after a fall, which was identified during a review of the resident's clinical records and an interview with the facility's administrator. The resident, who was mildly cognitively impaired and required assistance with daily activities, had a history of falls and was at risk due to potential side effects of medications. Despite an unwitnessed fall with injury occurring on November 27, 2024, the care plan was not updated with a new intervention, as required by the facility's policy. The resident's care plan, which was initially developed in 2017 and revised in 2023, included interventions such as medication review, pain management, and ensuring a safe environment. However, after the fall, the clinical record did not document any new interventions being added to the care plan. The administrator confirmed that the care plan should have been updated with a new intervention following the fall, but this was not done, indicating a lapse in the facility's adherence to its care planning procedures.
Failure to Follow Physician Orders for Two Residents
Penalty
Summary
The facility failed to ensure physician orders were followed for two residents regarding their nutritional and medical care. For Resident 35, who was admitted with diagnoses including renal failure and diabetes mellitus, the physician had ordered the use of compression stockings to manage edema. However, during an observation, it was noted that the resident's lower extremities were swollen, and the resident reported that staff had not assisted in putting on the compression stockings as required. The clinical record confirmed the order for compression stockings, which was not adhered to by the staff. For Resident L, who was diagnosed with dementia and required substantial assistance from staff, the physician had ordered a weight check for monitoring purposes. Despite this order, the clinical record lacked documentation of any weight being recorded since the beginning of the month. Interviews with the Director of Nursing and the Administrator revealed that the ordered weights were not obtained, and there was no written policy in place to ensure physician orders were followed, although it was stated that the facility's policy was to follow such orders as written.
Failure to Prevent Pressure Ulcers in Resident
Penalty
Summary
The facility failed to prevent the development of pressure ulcers for Resident G, who was at risk due to severe cognitive impairment and required substantial assistance for daily activities. Despite a physician's order for a pressure-reducing cushion to be used in the resident's chair or wheelchair, observations revealed that Resident G was left sitting in a recliner without such a cushion, contributing to skin breakdown. The care plan for Resident G did not include an individualized repositioning schedule, which is crucial for preventing pressure ulcers in residents with limited mobility. Additionally, the facility did not adequately document or communicate changes in Resident G's skin condition. Progress notes indicated the presence of open wounds on Resident G's coccyx and bilateral buttocks, including two stage two wounds, yet there was no record of family or physician notification. Furthermore, skin observation tasks on multiple dates inaccurately documented no skin issues, highlighting a failure in monitoring and reporting Resident G's skin condition as per the facility's policy.
Deficiencies in Fall Management and Care Plan Updates
Penalty
Summary
The facility failed to ensure proper post-fall assessments, care plan updates, and interventions for three residents, leading to deficiencies in fall prevention and management. Resident W, diagnosed with Alzheimer's Disease, experienced a fall due to altered mental status and was sent to the ER, where a UTI was diagnosed. Despite returning with a new diagnosis of a femur fracture and an immobilizer, the care plan was not updated, and vital signs were not consistently monitored as required. The clinical record lacked documentation of the effectiveness of interventions and updates to the care plan after the resident's return from the hospital. Resident G, with a history of dementia and multiple falls, had several incidents where post-fall assessments were not conducted, and care plans were not updated with new interventions. The facility failed to document physician or family notifications for several falls, and the resident was not receiving therapy due to insurance issues. The lack of post-fall assessments and care plan updates for multiple falls indicates a systemic issue in managing fall risks for Resident G. Resident P, with Alzheimer's Disease and a history of a femur fracture, experienced a witnessed fall without immediate assessment or documentation. The care plan was updated with an intervention to apply anti-rollbacks to the wheelchair, but the initial assessment was delayed until later that night. The facility's failure to conduct timely assessments and update care plans after falls highlights deficiencies in their fall management protocols, as outlined in their policies.
Failure to Provide Proper Respiratory Care and Equipment Labeling
Penalty
Summary
The facility failed to provide respiratory care services in accordance with professional standards for a resident with chronic respiratory failure and a tracheostomy. Observations revealed that the resident's oxygen tubing, suction tubing, and oxygen concentrator were not labeled or dated, and there were no signs indicating oxygen use in the resident's room. Additionally, during tracheostomy care, the obturator for emergency use was not identified in the room. These deficiencies were noted during observations on two consecutive days. The resident's clinical record included diagnoses of chronic respiratory failure with hypoxia and a tracheostomy, with physician orders for oxygen administration and equipment changes. However, the clinical record lacked a baseline care plan for the tracheostomy and oxygen use. The Director of Nursing confirmed that the equipment should have been labeled and that a sign indicating oxygen use should have been placed on the door. The facility's Oxygen Administration policy, revised in August 2024, also required such signage.
Failure to Follow Dialysis Care Protocols
Penalty
Summary
The facility failed to adhere to physician orders and provide proper dialysis care for a resident with renal failure and peripheral vascular disease. The resident, who was cognitively intact and required substantial assistance for daily activities, had specific physician orders that included not obtaining blood pressure from the left arm and conducting pre- and post-dialysis assessments on designated days. However, the facility documented blood pressures taken from the left arm on multiple occasions, directly contradicting the physician's orders. Additionally, the facility did not consistently perform pre-dialysis assessments as required, with some assessments containing outdated vital signs from previous dates. Interviews with the Director of Nursing and the Administrator revealed that there was no written policy for following physician orders, although it was stated that the facility's policy was to follow them as written. A policy related to the assessment of dialysis patients was requested but not provided, indicating a lack of proper documentation and adherence to care protocols.
Failure to Conduct Physician Assessment for Resident
Penalty
Summary
The facility failed to ensure that a resident was assessed by a physician since admission, as required. Resident 35, who was admitted with diagnoses including renal failure and peripheral vascular disease, reported during an interview that she had not been assessed by a physician in the facility since her admission. A review of Resident 35's clinical record confirmed the absence of any physician assessments since admission. The facility's policy on the choice of attending physician, which outlines the responsibilities of participating in resident assessments and care planning, was not adhered to in this case.
Inadequate Use of PPE and Hand Hygiene in Resident Care
Penalty
Summary
The facility failed to ensure proper use of Enhanced Barrier Protocol (EBP), Personal Protective Equipment (PPE), and hand hygiene for residents requiring wound and tracheostomy care. Resident 277, diagnosed with chronic respiratory failure and a tracheostomy, did not have an EBP sign in their room. During tracheostomy care, an LPN did not wear a gown, failed to wash hands before donning gloves, and did not perform hand hygiene between glove changes. The Infection Preventionist confirmed that gloves should be changed between dirty and clean tasks, with handwashing in between. For Resident 18, who had peripheral vascular disease and ulcers, LPNs did not wear gowns during wound care despite an EBP sign indicating necessary precautions. The clinical record lacked orders and a care plan for EBP. Resident 13, with stage three pressure ulcers, had an EBP sign in the room, but LPNs did not wear gowns during dressing changes. The Director of Nursing stated that proper PPE, including gowns and gloves, should be worn for residents on EBP. The facility's policies on EBP and hand hygiene were not followed, as evidenced by the lack of proper PPE use and hand hygiene during care activities.
Failure to Provide Written Notice Before Room Change
Penalty
Summary
The facility failed to provide a resident with written notice prior to a room change, violating the resident's rights. Resident B, who had diagnoses including dementia with mood disturbance and agitation, anxiety, and major depressive disorder, was moved from a locked dementia unit to a different hall without prior or documented notification. The resident's most recent MDS assessment indicated no cognitive impairment, and physician orders specified that the resident may reside on a locked secured memory unit. Despite this, the resident was relocated, and all personal belongings and medications were moved to the new unit without prior written notice. During an interview, Resident B expressed that he did not receive notification before the room change and preferred his previous room. Social Service 4 confirmed that residents should be notified in writing prior to a room change using an intra-facility room change form, which should be documented in the resident's record. However, SS4 was not working on the day of the transfer and was unaware if the notification was provided. The facility's policy on room transfers, dated August 2024, mandates informing residents before moving them to a new room, which was not adhered to in this case.
Failure to Timely Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure that staff immediately reported an alleged incident of resident-to-resident abuse to the Facility Administrator and did not include all relevant information in the report. The incident involved Resident B, who was reported to have inappropriately touched Resident K. The incident was not reported to the State Agency until seven days after it occurred, and the report lacked details about all residents involved and a comprehensive description of the incident. Interviews revealed that staff members were aware of the incident but did not report it immediately as required by the facility's policy. Resident B had a history of dementia with mood disturbance and agitation, sexual dysfunction, and high-risk heterosexual behavior. The resident's care plan noted sexually inappropriate behaviors, and a psychiatry visit note indicated concerns about increased inappropriate sexual behaviors. Despite these documented concerns, the facility's response to the incident was delayed, and the reporting process was not followed according to the established guidelines. The facility's policy required immediate notification of the Executive Director and the State Department of Health, which was not adhered to in this case.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent falls for Resident K, who was reviewed for falls. Resident K had a history of Alzheimer's disease, dementia with psychotic disturbance, and repeated falls. The resident's care plan included interventions such as a fall mat at the bedside, a non-skid mat in front of the toilet, and a motion sensor while in bed. Despite these interventions, Resident K experienced four falls between August and September 2024, with one resulting in injury. Observations and interviews revealed that the interventions were not consistently in place. On October 22, 2024, a non-skid mat was not observed in front of the toilet in Resident K's room. Additionally, LPN 24 was unaware of Resident K's falls and the interventions in place, and QMA 43 was unsure about the presence of a non-skid mat or the functioning of the bed alarm. The facility's staff did not have a clear understanding of the interventions required for Resident K, and there was no policy in place to ensure adherence to the physician's orders and the resident's care plan. The facility's Falls and Fall Risk Managing Policy indicated that staff should implement a resident-centered fall prevention plan and that position-change alarms should not be the sole intervention to prevent falls. However, the lack of consistent implementation and monitoring of the interventions for Resident K contributed to the deficiency. The facility administrator acknowledged the absence of a policy to guide staff in following the physician's orders and the resident's plan of care.
Failure to Provide Adequate Supervision Leads to Resident Injury
Penalty
Summary
The facility failed to ensure adequate supervision for Resident C, an aggressive resident, which resulted in Resident B, a cognitively impaired resident, being pushed to the floor. This incident led to Resident B sustaining a right femur fracture that required hospitalization and surgical repair. Resident B reported that a man got mad, pushed her, and grabbed her hair. The clinical record review indicated that Resident B had a history of anxiety disorder and vascular dementia, and her mobility was generally independent with some assistance required for certain activities. On the night of the incident, Resident B was found on the floor with a large raised area on her head and complained of hip pain. She was transferred to the hospital for evaluation and treatment. Resident C, who had a history of Alzheimer's disease and unspecified dementia with agitation, had previously shown aggressive behavior towards staff but not towards other residents. On the night of the incident, Resident C entered Resident B's room and attacked her, leading to her fall and subsequent injuries. The facility's records indicated that Resident C had frequent episodes of anger and frustration, often refusing care and being verbally and physically aggressive towards staff. Despite these behaviors, there was no documentation of previous outbursts towards other residents. The facility's policy for unmanageable residents, which was last revised in April 2010, was reviewed but did not prevent the incident from occurring. The facility's failure to provide adequate supervision and ensure a safe environment for Resident B resulted in significant harm to her.
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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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