Greencroft Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Goshen, Indiana.
- Location
- 1225 Greencroft Dr, Goshen, Indiana 46527
- CMS Provider Number
- 155205
- Inspections on file
- 35
- Latest survey
- December 23, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Greencroft Healthcare during CMS and state inspections, most recent first.
A resident with a history of falls and multiple neurological diagnoses experienced repeated falls resulting in serious injuries after staff failed to consistently implement and update care plan interventions, such as keeping a walker within reach and applying non-skid socks. The care plan was not updated after each fall, interventions were inconsistently applied in different facility areas, and there was no documentation of intervention refusals.
A resident dependent on staff for bathing, with multiple medical conditions, did not receive scheduled showers as required. Documentation was missing for several scheduled shower dates, and there was no record of showers being offered or refusals being documented, despite facility policy and care plan interventions requiring such care.
A resident with multiple chronic conditions did not receive weekly wound assessments as ordered by the physician, and required documentation of skin checks and wound re-evaluations was missing on several occasions. Despite ongoing treatment for a partial thickness skin tear, facility records lacked evidence of consistent assessment and documentation in accordance with both physician orders and facility policy.
A resident admitted for respite care under hospice received morphine, Lomotil, and Tums as routine medications instead of PRN, due to incorrect order entry by the admitting nurse. The resident, who had no symptoms requiring these medications, subsequently developed nausea and vomiting, necessitating additional treatment.
Surveyors identified that residents were not aware of where to find the Ombudsman and state agency contact information or a copy of resident rights. The required postings were placed in locations that were not easily visible or accessible, especially for residents using wheelchairs, and residents reported not knowing where this information was posted.
A resident with severe cognitive impairment and anxiety was administered lorazepam for restlessness without documented notification or education to the resident's representative about the risks and benefits of psychotropic medication use, as required by facility policy. Staff interviews and record review confirmed the absence of this required communication.
A resident with a suprapubic catheter and severe cognitive impairment was repeatedly observed with an uncovered urinary drainage bag visible to anyone entering the room and from the hallway. Staff interviews confirmed that a dignity cover should have been used, but it was not in place. The facility's policy and care plan did not address the use of dignity covers, resulting in a failure to honor the resident's right to dignity.
A resident with severe cognitive impairment and anxiety received PRN lorazepam on multiple occasions beyond the 14-day limit without required physician documentation or justification for continued use. Staff interviews and facility policy confirmed the 14-day restriction, but the necessary documentation for extending the medication was not present in the medical record.
The facility did not complete or retain required transfer documentation for two residents sent to the hospital, including missing bed hold forms, clinical status prior to transfer, reasons for transfer, and recent diagnostic/lab results. The DON confirmed that only medication lists, POA information, and verbal reports were provided, with no comprehensive transfer documentation or checklist available.
The facility did not develop individualized care plans for two residents: one with a new pressure area that was not properly documented or addressed in the care plan, and another who repeatedly refused assistance with facial hair removal, with these refusals not reflected in the care plan. Staff interviews confirmed that required procedures and documentation were not followed for these care issues.
A nurse administered omeprazole to a resident after the resident had eaten most of his lunch, contrary to manufacturer guidelines and facility policy, which require the medication to be given before meals. The resident had a diagnosis of GERD and a physician's order for daily omeprazole at noon, but the timing of administration did not align with recommended practice.
A resident with significant risk factors for skin breakdown developed a stage II pressure ulcer after staff failed to consistently implement care plan interventions, including regular repositioning, timely skin assessments, and use of appropriate pressure-reducing devices. Documentation did not reflect the presence of the wound until after it was observed, and no treatment order or incident report was initiated as required by facility policy.
A resident with multiple medical conditions was observed repeatedly smoking unsupervised on facility grounds, extinguishing cigarettes on his wheelchair, and storing smoking materials unsecured in his room. Staff were unclear about the resident's supervision needs and disposal of cigarette butts, and a required safe smoking assessment was not completed until after these events, contrary to facility policy.
A resident with severe cognitive impairment, dysphagia, and significant weight loss was not provided with the individualized meal interventions outlined in her care plan, such as serving small portions in bowls and avoiding overwhelming plates. Despite staff awareness and policy requirements, observations showed the resident continued to receive full plates of food, and the necessary interventions to promote meal consumption were not consistently implemented.
A resident with a feeding tube and multiple complex diagnoses did not consistently receive the physician-ordered water flushes before and after tube feedings. Documentation in the MAR showed that water flush amounts varied from the prescribed 120 mL, with some entries above or below the order and incorrect daily totals. The care plan and facility policy required adherence to these orders, but the correct hydration was not provided or accurately documented.
A resident with multiple chronic conditions, including COPD, was found to have a nebulizer mask and tubing that were not dated, bagged, or cleaned, and were left dirty on the bedside table over several days. Staff confirmed this did not follow facility policy, which requires respiratory equipment to be cleaned, bagged, and dated after use.
A resident with end stage renal disease and a left bicep dialysis fistula did not receive daily or shift-based monitoring and documentation of the access site as required by physician orders, the care plan, and facility policy. Nursing staff only assessed the site on dialysis days, omitting required checks on non-dialysis days.
Staff failed to ensure medications and biologicals were properly labeled, stored, and disposed of. A resident's nystatin powder was left unattended in a bathroom, and multiple opened medications on various carts and in medication rooms were not dated when opened. Expired items, such as povidone iodine swabs and probe covers, were also found and had not been discarded. Staff acknowledged these lapses during interviews.
A resident with a suprapubic catheter and pressure ulcer, who was severely cognitively impaired and on hospice, did not receive enhanced barrier precautions as required during high-contact care activities. Two CNAs provided incontinent care without wearing gowns, despite physician orders and facility policy mandating the use of PPE for such residents.
The facility failed to consistently assess and log hot food temperatures, affecting all 155 residents in nursing care. Food was prepared in the main kitchen and delivered to unit serveries, but concerns were raised about food not being warm enough. A resident reported being served cold food, affecting their appetite, and several residents confirmed this issue. The Interim Dietary Manager admitted to inconsistent documentation of food temperatures, violating the facility's policy.
A resident with a history of falls was not promptly reported to their family after a fall incident. Despite notifying the physician, the facility failed to inform the family until weeks later, contrary to their policy on change notifications.
A resident with severe cognitive impairment and dependent on others for transfers was injured during a transfer using a mechanical stand lift. The CNA conducted the transfer alone, without the required second staff member, contrary to the facility's policy. The resident fell, sustaining multiple injuries, including a subdural hematoma, and later passed away. The incident was reported to the state health department, revealing non-compliance with the facility's transfer protocol.
A resident's rights were violated when a staff member took and posted a photo of the resident with her breast exposed on social media without consent. The resident, who was cognitively intact, was photographed by an employee who admitted to not seeking permission. The incident was reported by a CNA, leading to an investigation and the employee's suspension. The facility's policy on resident rights and confidentiality was not followed, resulting in this violation.
A facility failed to create a person-centered care plan for a resident with a contracted left hand requiring a splint. The care plan lacked strategies for addressing the resident's refusal to wear the splint, despite the resident's severe cognitive impairment and dependency on staff for daily activities. The DON confirmed the omission, which was contrary to the facility's policy on comprehensive care plans.
A facility failed to update a care plan for a resident regarding the use of a CPAP machine. The resident, with interstitial lung disease and atrial fibrillation, had a care plan that did not mention the CPAP machine, despite being at risk for respiratory distress. An LPN confirmed the omission, and the facility's policy requires care plans to be reviewed and revised by the interdisciplinary team.
A facility failed to ensure physician orders were in place for a resident using a CPAP machine. Observations revealed the CPAP mask and tubing were improperly stored, and the resident reported inconsistent use of distilled water and cleaning of the equipment. Staff confirmed the absence of necessary orders, and facility policies regarding medication orders and CPAP cleaning were not adhered to.
A facility failed to provide proper G-tube care for a resident with multiple diagnoses, including functional quadriplegia and cerebral palsy. An LPN did not return 60 mL of gastric residuals to the resident, contrary to facility policy and professional standards. Interviews with staff confirmed that residuals should be returned before administering tube feedings.
A resident's CPAP equipment was improperly stored and maintained, leading to a deficiency in respiratory care. The mask and tubing were left hanging over the headboard, and the distilled water container was open and undated on the bathroom floor. The resident confirmed the equipment was not cleaned or stored properly, and there were no physician's orders or care plan for the CPAP machine. An LPN indicated the equipment should have been stored in a dated plastic bag and cleaned according to facility policy.
The facility failed to document pre and post-dialysis assessments for two residents requiring dialysis. One resident had missing documentation for a specific date, while another had multiple instances of missing post-dialysis assessments and vitals. Interviews with staff confirmed the expectation for these assessments to be completed and recorded, yet the documentation was absent, indicating non-compliance with facility policy.
A resident with type 2 diabetes was mistakenly given another resident's insulin pen, which he used before realizing the error. The incident occurred when a nurse mixed up the insulin pens after being interrupted. The resident, capable of self-administering medication, had previously been given the wrong pen but had not injected it before. The facility's policy requires verification of medication with the MAR, which was not followed in this case.
The facility failed to label medications with open dates on three medication carts and did not separate treatments and inhalers from oral medications. Additionally, food items were improperly stored in a medication refrigerator. Interviews with staff confirmed these practices were against facility policies.
A facility failed to obtain a declination form for a resident who refused the pneumococcal vaccine. The resident's record lacked documentation of a signed declination form, which was confirmed by the IP Nurse during an interview. The deficiency was identified during a record review.
Failure to Implement and Update Fall Prevention Interventions
Penalty
Summary
The facility failed to follow the plan of care for a resident with a known history of falls, resulting in multiple incidents where the resident fell and sustained serious injuries. The resident had diagnoses including dementia, traumatic subarachnoid hemorrhage, conversion disorder with seizures, and other neurological and psychiatric conditions. Assessments indicated the resident required a walker for ambulation and needed staff assistance or supervision while moving or walking. The care plan specified that staff should keep the walker within the resident's reach and apply non-skid socks at bedtime. However, documentation showed that these interventions were not consistently implemented, and there was no record of the resident refusing these interventions. Following a fall on 10/10, the care plan was not updated with new preventative interventions until several days later, despite the resident not using the walker at the time of the fall. Another fall occurred on 10/16, again with the resident not using the walker and not wearing non-skid socks, and no new interventions were added to the care plan. Additional falls occurred in the following weeks, including a significant incident in the dining room where the resident got up without assistance or a walker, fell, and suffered a seizure. The care plan intervention to keep the walker within reach was not applied in the dining room, and staff moved the walker out of reach due to concerns it might be a tripping hazard for others. Interviews with facility leadership revealed a lack of awareness regarding the need to update the care plan after each fall and uncertainty about the application of interventions in different facility areas. The facility did not have a policy for following care plan interventions at the time, and documentation of intervention refusals was lacking. The failure to implement and update fall prevention interventions as required by the care plan led to repeated falls and ultimately resulted in the resident sustaining multiple traumatic injuries, including hemorrhages and a skull fracture.
Failure to Provide Scheduled Showers and Document Care for Dependent Resident
Penalty
Summary
A dependent resident with diagnoses including displaced fracture of cervical vertebra, Lewy Bodies dementia, Parkinson's disease, and right foot drop did not receive scheduled showers as required. The resident was assessed as having intact cognition but was dependent on staff for showering. Record review showed missing documentation for scheduled showers on multiple dates, and there was no evidence that the resident was offered showers or that refusals were documented on those dates. The resident's care plan indicated a self-care deficit related to bathing, with interventions for staff assistance with activities of daily living. During interviews, the resident could not recall the last time a shower was provided, and the DON confirmed the absence of documentation for the required showers or refusals. Facility policy required staff to provide care and services for bathing and other activities of daily living, but this was not followed as documented in the resident's records.
Failure to Document and Perform Weekly Wound Assessments as Ordered
Penalty
Summary
The facility failed to provide wound care as directed by the physician for a resident with multiple diagnoses, including peripheral neuropathy, type 2 diabetes, chronic kidney disease, and a history of stroke. The resident had a physician's order for weekly skin checks, including a head-to-toe assessment and re-evaluation of any existing skin concerns every week. Despite this order, documentation showed that weekly re-evaluations of a partial thickness skin tear on the right buttock were not completed or documented on several specified dates. The Treatment Administration Record indicated the order was signed off, but there was no associated documentation of the required assessments. Further review of the resident's skin evaluations over several weeks indicated no change in the wound's size or condition, and the wound continued to be treated with zinc oxide. When the resident requested a skin assessment, the nurse examined the area and notified the Nurse Practitioner, who ordered new topical treatments. However, there was no documentation of a skin assessment on the date of this request. Facility policy required weekly skin assessments and documentation, including detailed wound descriptions, but interviews with facility leadership confirmed a lack of documentation regarding the required weekly skin check re-evaluations for the resident's wound.
Significant Medication Error Due to Incorrect Order Entry
Penalty
Summary
A deficiency occurred when a resident admitted for respite care under hospice services received several medications as routine doses rather than as needed (PRN), contrary to the physician's orders. The resident's orders included morphine, Lomotil, and Tums, all intended to be administered PRN for specific symptoms such as shortness of breath, severe pain, diarrhea, or gastroenteritis. However, due to an error by the admitting nurse, these medications were entered into the electronic medical system as scheduled routine medications. As a result, the resident received morphine and Lomotil at scheduled times despite not exhibiting symptoms that warranted their use, such as pain, shortness of breath, or diarrhea. Documentation confirmed that the resident was not experiencing these symptoms at the time the medications were administered. Following the administration of these medications, the resident experienced adverse effects, including nausea and vomiting, which required the administration of Zofran to manage the symptoms. Interviews with facility staff and the hospice nurse confirmed that the medication orders had been incorrectly entered and administered, and the error was identified after the resident developed side effects. The facility's policy required medications to be administered according to the prescriber's orders, which was not followed in this instance, resulting in a significant medication error.
Failure to Ensure Accessible Posting of Resident Rights and Ombudsman Contact Information
Penalty
Summary
Surveyors found that the facility failed to ensure residents were informed of the location of the Ombudsman and other state agencies' contact information, as well as where a copy of resident rights was posted. During a resident/surveyor meeting, all residents present reported being unaware of where to find this information. Observation revealed that the resident rights poster was placed on a wall in a lounge area past the receptionist desk, with a small desk beneath it that obstructed visibility for residents using wheelchairs. Additionally, the Ombudsman and other required contact numbers were found on a shelf in the same lounge area, but not in a clearly accessible or visible location. The Administrator confirmed that while families could access the information and residents received a handbook at admission, the postings were not readily accessible to all residents as required by facility policy.
Failure to Inform Resident Representative of Psychotropic Medication Risks
Penalty
Summary
The facility failed to ensure that a resident with severe cognitive impairment and diagnoses including anxiety disorder and major depressive disorder was fully informed of treatment and medication changes. A review of the resident's record showed that the resident was receiving lorazepam as needed for restlessness, as ordered by a physician. The care plan documented the use of anti-anxiety medication and included interventions such as assessing anxiety levels and administering medication per physician orders. However, there was no documentation that the resident or their representative had been notified or educated about the risks and benefits of psychotropic medication use, as required by facility policy. Interviews with staff confirmed that the resident was receiving lorazepam, but the DON was unable to locate any record of notification to the resident's representative regarding the risks associated with psychotropic medication. The facility's policy specifically states that residents and/or their representatives must be educated on the risks and benefits of psychotropic drug use, as well as alternative treatments. This lack of documentation and communication led to the deficiency cited during the survey.
Failure to Provide Dignity Cover for Urinary Drainage Bag
Penalty
Summary
A deficiency was identified when the facility failed to provide a dignity cover for a urinary drainage bag for a resident with a suprapubic catheter. The resident, who had severe cognitive impairment, a history of urinary retention, an unstageable pressure ulcer, and was receiving hospice services, was observed on multiple occasions lying in bed with the urinary drainage bag visible and uncovered. The bag was seen by anyone entering the room and was even visible from the hallway. Interviews confirmed that staff were aware a dignity cover should have been used, but it was not in place during the observations. Record review showed that the resident had a physician's order for catheter care, including the use of a leg bag when out of bed and a urinary drainage bag when in bed. The care plan included interventions for catheter management but did not specifically address the use of a dignity cover. The facility's policy on indwelling catheter use did not mention dignity covers for resident comfort. The lack of a dignity cover for the urinary drainage bag resulted in a failure to honor the resident's right to be treated with respect and dignity.
Failure to Limit PRN Psychotropic Medication Without Required Documentation
Penalty
Summary
The facility failed to limit the use of an as-needed (PRN) psychotropic medication, specifically lorazepam, to a 14-day duration without the required documentation for continued use for one resident. The resident, who had diagnoses including anxiety disorder and major depressive disorder and was noted to have severe cognitive impairment, received lorazepam on multiple occasions beyond the 14-day PRN limit. The medical record did not contain documentation from the prescribing practitioner justifying the continued use of lorazepam beyond the initial 14-day period, nor was there evidence of monitoring or rationale for the extended use in psychiatric progress notes. The care plan for the resident indicated the use of anti-anxiety medication related to his diagnoses, with interventions to assess anxiety and administer medication per physician order. However, interviews with staff confirmed that PRN psychotropic medications are limited to 14 days unless otherwise documented, and the facility's policy required physician documentation for any extension. Despite this, the resident continued to receive lorazepam without the necessary documentation or justification for its ongoing use.
Failure to Provide Required Transfer Documentation for Hospitalized Residents
Penalty
Summary
The facility failed to ensure that required transfer and resident clinical information was completed for two residents who were transferred to the hospital. For one resident with multiple diagnoses including heart failure, depression, arthritis, diabetes, and septicemia, the documentation lacked copies of the bed hold form, the resident's clinical status prior to transfer, the reason for transfer, and the most recent diagnostic and lab tests. Although some information such as a Notice of Transfer or Discharge form and medication lists were provided, there was no comprehensive transfer documentation or checklist available, and the Director of Nursing confirmed that she could not provide these documents. Similarly, for another resident with diagnoses including malnutrition, atrial valve disorder, cancer, and heart failure, the record did not contain the required transfer documentation. The facility was unable to provide the bed hold form, clinical status prior to transfer, reason for transfer, or recent diagnostic and lab results. The Director of Nursing indicated that only a list of medications, POA information, and a verbal report to the hospital were provided, and no transfer checklist or policy regarding discharge/transfers was available at the time of the survey.
Failure to Develop Person-Centered Care Plans for Skin Integrity and Personal Care Refusals
Penalty
Summary
The facility failed to develop person-centered care plans for two residents regarding a new pressure area and refusal of facial hair removal. For one resident with multiple diagnoses including chronic kidney disease, hemiplegia, and venous insufficiency, staff observed an open area on the left inner buttock cheek. Although the resident had existing care plans addressing skin integrity and mobility, there was no documentation of a skin incident, no treatment order, and no care plan specifically addressing the new open area. Staff interviews confirmed that the required procedures for new skin issues, such as incident reporting, physician notification, and care plan initiation, were not followed. For another resident with diagnoses including malnutrition, anxiety, and depression, staff and the resident confirmed repeated refusals of assistance with facial hair removal. The care plan noted a potential self-care deficit and refusal of showers but did not document the resident's specific refusals regarding facial hair care. Staff interviews indicated that refusals were documented in the electronic medical record but not reflected in the care plan, contrary to facility policy. The unit manager confirmed that such refusals should have been included in the care plan documentation.
Failure to Administer Omeprazole According to Manufacturer Guidelines
Penalty
Summary
A deficiency occurred when a nurse administered omeprazole 20 mg delayed release capsule to a resident after the resident had already eaten most of his lunch, rather than before a meal as recommended by the manufacturer. The resident, who had a diagnosis of gastro-esophageal reflux disease, had a physician's order to receive omeprazole daily at noon. The facility's policy required medications to be administered according to manufacturer specifications, which for omeprazole includes administration before meals. The pharmacist and medication information sheet both confirmed that omeprazole should be given prior to meals, but this was not followed during the observed medication pass.
Failure to Prevent and Treat Pressure Ulcer in At-Risk Resident
Penalty
Summary
A resident with multiple comorbidities, including chronic kidney disease, hemiplegia, venous insufficiency, and frail skin, was identified as being at risk for pressure ulcers based on Braden Scale assessments. Despite care plans outlining the need for daily skin observation, frequent position changes, and the use of pressure-reducing devices, the resident developed an open area on the left inner buttock cheek, approximately half an inch in diameter with red tissue at the center. This area was observed without a dressing, and staff interviews revealed that the resident often remained in his wheelchair for extended periods, with limited assistance from staff in repositioning or transferring him. Documentation and assessments failed to identify or address the new skin issue in a timely manner. Weekly skin checks and shower sheets did not document the open area prior to its discovery, and skin evaluation forms repeatedly marked preventative interventions as "not applicable" or "inapplicable." When the open area was finally assessed by a nurse, it was noted that no skin incident report or treatment order had been initiated, and the required notifications and care plan updates had not been completed as per facility policy. Further observations revealed that the resident's wheelchair cushion was nearly flat, and staff were unsure if it was an appropriate pressure-reducing device. The resident reported significant discomfort and stated that staff rarely assisted with repositioning, despite his requests. The facility's policy required thorough assessment, timely intervention, and the use of pressure-redistributing surfaces for residents at risk, but these measures were not consistently implemented, resulting in the development of a stage II pressure ulcer.
Failure to Ensure Safe Smoking Practices and Supervision
Penalty
Summary
The facility failed to ensure a safe environment related to smoking for a resident with diagnoses including polyneuropathy, glaucoma, diabetes mellitus type 2, and nicotine dependence, who was cognitively intact and used a motorized wheelchair. Multiple observations showed the resident leaving the building independently to smoke, smoking on facility grounds, extinguishing cigarettes on his wheelchair, and storing cigarettes and a lighter unsecured in his room. The resident also disposed of cigarette butts in his room trash can and kept smoked butts in his hand. Despite a physician's order requiring education on smoking risks and secure storage of smoking materials, these measures were not consistently implemented. A review of records revealed that a safe smoking assessment was not completed or signed by the resident until after several of these incidents. The care plan indicated the resident was to use nicotine safely in designated areas and was encouraged to store smoking materials securely, but the resident declined these interventions. Staff interviews confirmed uncertainty about the resident's compliance with smoking policies, supervision needs, and disposal of cigarette butts. The facility's policy required assessment and supervision for residents who smoke, as well as secure storage and designated smoking areas, but these procedures were not followed for this resident.
Failure to Implement Nutrition Interventions for At-Risk Resident
Penalty
Summary
The facility failed to implement identified interventions to promote adequate meal consumption for a resident with significant nutritional risk. The resident had diagnoses including cerebral infarction, dysphagia, and left-sided hemiplegia, and was assessed as having severe cognitive impairment and requiring mechanically altered foods. Over several months, the resident experienced notable weight loss, with a 6.55% loss in one month, 13.42% in three months, and 15.31% over several months. The care plan specified interventions such as serving half portions of one food in a bowl at a time, providing encouragement and assistance during meals, and avoiding overwhelming the resident with large plates of food. A nursing note also documented that the resident appeared overwhelmed by plates of food and recommended serving one item at a time in a bowl. Despite these documented interventions, multiple observations showed the resident being served full plates of food with multiple items at once, both in the dining room and in her room. Staff interviews confirmed awareness that the resident should receive small portions in individual bowls, but this was not consistently practiced. The facility's policy required that weight loss interventions be addressed in the care plan and implemented, but the interventions were not followed as outlined, contributing to the resident's continued weight loss.
Failure to Administer Physician-Ordered Hydration for Tube Feeding
Penalty
Summary
The facility failed to follow and administer physician-ordered hydration for a resident with a feeding tube. The resident, who had diagnoses including functional quadriplegia, adult failure to thrive, and protein-calorie malnutrition, was assessed as having moderate cognitive impairment and required tube feeding for nutritional support. Physician orders specified that the feeding tube should be flushed with 120 mL of water before and after each Jevity feeding, totaling 240 mL per feeding. However, review of the Medication Administration Record (MAR) for the month showed that the water flushes provided were inconsistent with the physician's orders, with amounts both below and above the prescribed volume, and the daily totals were incorrect. The resident's care plan indicated the need for tube feeding and specified interventions such as providing 120 mL of water before and after each feeding and monitoring for dehydration. During an interview, an LPN confirmed that the resident should have received the specified water flushes and that the amounts were documented in the MAR. Despite this, the MAR lacked documentation of the correct amount of water flushes and accurate daily totals. The facility's policy required adherence to clinical standards and physician orders for feeding tube care, including hydration, but these were not followed as documented.
Failure to Maintain Sanitary Storage of Respiratory Equipment
Penalty
Summary
A deficiency was identified regarding the improper storage and sanitation of respiratory equipment for a resident requiring respiratory care. Over the course of several days, observations revealed that the resident's nebulizer mask and tubing were not dated or stored in a bag as required. The equipment, which was visibly dirty with white specs of dried debris, was repeatedly found lying on the bedside table rather than being properly cleaned and stored. These observations were made on three separate occasions, indicating a persistent failure to follow proper procedures for respiratory equipment maintenance. The resident involved had multiple diagnoses, including diabetes, depression, dementia, anxiety, and chronic obstructive pulmonary disease, and had a physician's order for nebulizer treatments as needed. However, there were no specific physician orders regarding the frequency of changing the nebulizer mask or tubing. Facility staff confirmed during interviews that the nebulizer mask should have been bagged and dated when not in use, in accordance with the facility's policy, which requires cleaning and bagging after each use and weekly changes of the equipment and storage bag.
Failure to Perform and Document Daily Dialysis Fistula Checks
Penalty
Summary
The facility failed to provide daily monitoring and documentation of a dialysis fistula site for a resident with end stage renal disease who required hemodialysis three times per week. The resident's care plan and physician's orders specified that the dialysis access site, located in the left bicep, should be assessed, observed, and documented for care and complications. However, a review of the interdisciplinary notes and treatment/medication administration records revealed no documentation of daily or shift-based fistula site assessments. Interviews with nursing staff confirmed that the fistula access site was only monitored on dialysis days, and no assessments were completed on non-dialysis days. The facility's own policy required that the dialysis access site be checked before and after dialysis treatments and every shift for patency by auscultation for a bruit and palpation of a thrill. This lack of daily monitoring and documentation constituted a failure to follow both professional standards of practice and the facility's policy for residents receiving hemodialysis.
Failure to Properly Label, Store, and Dispose of Medications and Biologicals
Penalty
Summary
Facility staff failed to ensure that drugs and biologicals were properly labeled, stored, and disposed of according to professional standards and facility policy. During multiple observations, medications such as nystatin powder were found left unattended in a resident's bathroom, rather than being secured in a locked compartment. The nystatin bottle was specifically labeled for use on a resident with multiple diagnoses, including hypertension, hemiplegia, anxiety, depression, and renal insufficiency, and was observed on the bathroom counter on consecutive days. The Households Unit manager confirmed that the medication should not have been left in the resident's room. Further observations revealed that several medication carts and medication rooms contained multiple opened bottles of medications and supplements, such as polyethylene glycol, meclizine, risiquad, Centrum Silver, gas relief chews, omega 3 capsules, Breo Ellipta inhaler, and flaxseed oil, none of which were dated when opened. Additionally, expired items, including povidone iodine swabs and probe covers, were found in medication rooms and had not been disposed of as required. Staff interviewed during these observations acknowledged that medications should have been dated when opened and that expired items should have been discarded.
Failure to Implement Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for a resident with a suprapubic catheter and a pressure ulcer, as required by physician orders and facility policy. The resident had a history of severe cognitive impairment, an indwelling urinary catheter, an unstageable pressure ulcer, and was receiving hospice services. Both the care plan and physician's order specified the need for EBP, including the use of gowns and gloves during high-contact care activities such as changing briefs or providing incontinent care. Despite these documented requirements, two CNAs were observed providing incontinent care to the resident without wearing gowns. One CNA acknowledged during an interview that EBP was required and that personal protective equipment (PPE) should have been used during the care. Facility policy, provided by the DON, clearly outlined the necessity of making gowns and gloves available and using them during high-contact care activities for residents with indwelling medical devices or wounds.
Failure to Consistently Log Food Temperatures
Penalty
Summary
The facility failed to ensure that hot food temperatures were consistently assessed and logged in the main kitchen, which had the potential to affect all 155 residents in nursing care. Interviews and record reviews revealed that food was prepared in the main kitchen and delivered to unit servery kitchens, where it was held in steam tables. The Dietary Team Lead acknowledged hearing concerns about food not being served warm enough. Resident B reported being served cold food multiple times, which affected their appetite and led to refusals to eat. During a Resident Council meeting, several residents confirmed that hot food was sometimes served cold. The Interim Dietary Manager admitted that the kitchen had not been consistently documenting food temperatures before serving meals to the nursing units, as required by the facility's policy. A review of the Kitchen Food Temp Log sheets from August 11, 2024, to September 15, 2024, showed numerous days with no recorded food temperatures. The facility's policy, dated March 1, 2022, mandates daily recording of food temperatures to ensure proper serving temperatures, with hot foods held at 135 degrees Fahrenheit or greater and cold foods at or below 41 degrees Fahrenheit. This deficiency was related to a specific complaint, IN00442353.
Failure to Notify Family After Resident Fall
Penalty
Summary
The facility failed to notify a resident's responsible party in a timely manner following a fall incident. Resident C, who has a history of repeated falls and is at high risk for falls, experienced a fall on 8/23/24. The incident occurred when a CNA found Resident C on the floor in front of her recliner, with no injuries or pain reported. Although the physician was notified shortly after the fall, the resident's family was not informed until nearly a month later, on 9/19/24, when the Director of Nursing acknowledged the oversight and apologized. The facility's policy on Notification of Changes, dated 1/23/24, mandates prompt notification of the resident's family or legal representative in the event of a change requiring notification. However, in this instance, the policy was not followed, as there was no documentation of family notification on the incident form. This deficiency was identified during a complaint investigation, highlighting a lapse in communication and adherence to established protocols.
Failure to Provide Safe Transfer Assistance Results in Resident Injury
Penalty
Summary
The facility failed to ensure safe transfer assistance for a resident, resulting in a significant injury. The resident, who had severe cognitive impairment and was dependent on others for transfers, was being moved by a Certified Nurses Aide (CNA) using a mechanical stand lift without the required assistance of a second staff member. The resident's care plan specified that two staff members were needed for transfers using the lift, but the CNA proceeded alone, contrary to the facility's policy. During the transfer, the CNA placed the resident on the bed at an angle and removed the sling. As the CNA moved the lift away, the resident reached out, causing her to fall to the floor. The fall resulted in multiple injuries, including lacerations and a subdural hematoma, which required emergency medical attention and hospitalization. The resident was later readmitted to the facility under hospice care and subsequently passed away. The incident was reported to the Indiana State Department of Health, and an investigation revealed that the CNA was aware of the transfer requirements but did not seek assistance. The facility's policy mandated that mechanical lift transfers be conducted by two team members at all times, a protocol that was not followed in this case, leading to the resident's fall and subsequent injuries.
Violation of Resident's Rights Due to Unauthorized Photograph
Penalty
Summary
The facility failed to respect the rights of a resident, identified as Resident F, by allowing a staff member to take and post a photograph of the resident on social media without consent. Resident F, who was cognitively intact and required moderate assistance for most activities of daily living, was photographed with her breast exposed by Employee 3. The incident was reported by a Certified Nursing Assistant (CNA) who observed the photo on social media and informed the administration. The investigation revealed that Employee 3 took the photograph without Resident F's knowledge or permission and posted it on Snapchat. The employee admitted to not asking for permission and acknowledged that it was disrespectful. The photo was seen by other employees, who reported it to the nurse. The facility's Human Resources Handbook, which Employee 3 had signed, explicitly prohibited such actions, emphasizing the importance of treating residents with respect and maintaining confidentiality. The incident was reported to the Indiana State Department of Health, and the facility's administration took immediate action by notifying the resident's family, suspending Employee 3, and initiating an investigation. The facility's policy on resident rights, which mandates that all staff be educated on respecting residents' dignity and confidentiality, was not adhered to in this case, leading to the violation of Resident F's rights.
Failure to Develop Person-Centered Care Plan for Splint Use
Penalty
Summary
The facility failed to develop a person-centered care plan for a resident with a contracted left hand who required the use of a splint. During an observation, it was noted that the resident's left hand was contracted, and a splint was present on the table next to her bed. The resident confirmed that she usually wore the splint during the day. A review of the resident's records revealed a diagnosis of cerebrovascular accident with hemiplegia, severely impaired cognition, and dependency on staff for daily activities. The care plan, dated several months prior, included interventions for applying the splint but lacked any strategies for addressing the resident's refusal to wear it. The Director of Nursing (DON) confirmed that the care plan did not include interventions for when the resident refused the splint or methods to encourage its use. The facility's policy on comprehensive care plans indicated that all care assessment areas triggered by the Minimum Data Set (MDS) should be considered in developing the plan of care, including factors identified by the interdisciplinary team or in accordance with the resident's preferences. However, the care plan for this resident did not address these aspects, leading to the deficiency.
Failure to Update Care Plan for CPAP Machine Use
Penalty
Summary
The facility failed to update the care plan for a resident regarding the use of a Continuous Positive Airway Pressure (CPAP) machine. The resident, who was admitted with diagnoses including interstitial lung disease and atrial fibrillation, had a care plan dated February 12, 2024, which indicated a risk for respiratory distress related to allergies, cough, and COVID. However, the interventions in the care plan did not mention the use of a CPAP machine. During an interview, an LPN acknowledged that the care plan should have included the CPAP machine and its settings. The facility's policy on comprehensive care plans, revised on January 29, 2024, requires that care plans be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment.
Lack of Physician Orders for CPAP Machine
Penalty
Summary
The facility failed to ensure that physician orders were in place for a resident using a Continuous Positive Airway Pressure (CPAP) machine. During an observation, the CPAP mask and tubing were found hanging over the headboard, and a container of distilled water was on the bathroom floor without an open date. The resident indicated that the mask and tubing had never been placed in a plastic bag, the tubing had not been cleaned, and the water was not always put in the machine, leading to instances where the machine was run without water. A record review revealed that there were no physician's orders for the CPAP machine settings or for the cleaning of the equipment. Interviews with staff confirmed the absence of orders for the CPAP machine settings and the cleaning/storage of the equipment. The facility's policies, including the Medication Order Policy and the CPAP/BIPAP Cleaning Policy, were reviewed. These policies outlined the requirements for medication orders and the cleaning of CPAP equipment, including the use of distilled or sterile water and specific cleaning procedures. However, these policies were not followed, resulting in the deficiency.
Improper G-Tube Care and Residual Management
Penalty
Summary
The facility failed to provide proper care for a resident with a G-tube, as observed during a G-tube feeding procedure. An LPN checked the gastric residuals of the resident and extracted 60 mL of gastric contents, which she left in a graduated cylinder on the bedside table. After administering the prescribed tube feeding and flushing the tubing with water, the LPN did not return the gastric residuals to the resident, as required by the facility's policy and professional standards. The LPN was unsure whether to return the residuals and intended to discard them, which was contrary to the facility's policy. Interviews with other staff members, including another LPN and the Director of Nursing, confirmed that the facility's policy required gastric residuals to be returned to the resident through the G-tube before administering the tube feed. The resident involved had multiple diagnoses, including functional quadriplegia, adult failure to thrive, cerebral palsy, and major depressive disorder, and had a physician's order for G-tube feeding and residual checks. The facility's policy on checking gastric residuals clearly stated that contents should be replaced via the enteral tube, up to 500 mL or as per the physician's order.
Improper Storage and Maintenance of CPAP Equipment
Penalty
Summary
The facility failed to ensure proper storage and maintenance of CPAP equipment for a resident, leading to a deficiency in respiratory care. During observations, it was noted that the CPAP mask and tubing were improperly stored over the headboard, and the distilled water container was left open on the bathroom floor without a date. The resident confirmed that the mask and tubing were never placed in a plastic bag, the tubing was not cleaned, and the water was sometimes not added to the machine. Additionally, there were no physician's orders or a care plan regarding the use of the CPAP machine for the resident, who had diagnoses including interstitial lung disease and atrial fibrillation. An interview with an LPN revealed that the CPAP mask should have been stored in a dated plastic bag when not in use, and the distilled water should have been marked with an opened date and stored properly. The facility's policy, which aligns with CDC guidelines, requires daily cleaning of the CPAP equipment and proper storage to prevent infection. However, these procedures were not followed, as evidenced by the observations and interviews conducted during the survey.
Failure to Document Dialysis Assessments
Penalty
Summary
The facility failed to provide ongoing assessment and monitoring for complications for two residents who required dialysis services. Resident 354, diagnosed with end-stage renal disease and dependent on renal dialysis, had missing documentation for Pre and Post Dialysis Evaluations on one occasion. The facility's electronic charting system required these evaluations to be completed and placed in the resident's dialysis book, but the documentation for 5/24 was absent. An interview with RN 7 confirmed the lack of documentation and indicated that the evaluations should have been completed. Similarly, Resident 88, with diagnoses including chronic kidney disease stage 5 and type 2 diabetes, had multiple instances where post-dialysis assessments and vitals were not recorded in the dialysis binder. The facility's policy required pre- and post-dialysis weights, vital signs, and access site assessments to be documented. Interviews with the DON and LPNs confirmed the expectation for these assessments to be completed and recorded, yet the documentation was missing for several dates. This lack of documentation indicates a failure to adhere to the facility's policy and professional standards of practice.
Significant Medication Error: Incorrect Insulin Pen Administered
Penalty
Summary
The facility failed to prevent a significant medication error involving a resident who was given an incorrect insulin pen. The incident involved a resident who self-administered 40 units of insulin using a Basaglar Kwik Pen. On the day of the incident, the resident was mistakenly given another resident's insulin pen, which he used before realizing the error. This was not the first time the resident had been given the wrong insulin pen, but it was the first time he injected himself with it. The resident's medical history includes type 2 diabetes, chronic kidney disease stage 3, benign prostatic hyperplasia, and dysphagia. The resident's cognition was intact, and he was assessed as capable of self-administering his medication. The error occurred when a nurse, after being interrupted, mixed up the insulin pens upon returning to the medication cart. The nurse failed to adhere to the facility's policy of verifying the medication source with the Medication Administration Record (MAR) to ensure the correct resident, medication, dose, route, and time. The facility's policy mandates that medications should only be administered upon a signed order from an authorized prescriber and documented accordingly. The incident was reported to the physician, and the resident's wife was informed. The resident refused blood work ordered by the physician to check for HIV and hepatitis.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to properly label medications with an open date on three out of five medication carts observed. Specific instances included an opened bottle of Fiberwell gummies, Peg 3350 Powder, Reguloid, and antacid chew for various residents without an open date on [NAME] Vesta cart 2. Similar issues were observed on [NAME] cart 1 and [NAME] cart 2, where opened bottles of Tums, brimonidine eye drops, Peg 3350 powder, and liquid protein were found without open dates. Interviews with QMAs and LPNs confirmed that these medications should have been dated when opened, as per the facility's policy on labeling medications and biologicals. Additionally, the facility failed to ensure that treatments and inhalers were separated from oral medications. On [NAME] unit cart 2, a tube of Aquaphor and capsaicin cream was stored with oral medications, and on [NAME] Vesta unit cart 1, an inhaler was found in the same drawer as oral medications. Furthermore, the medication room refrigerator on the Lea Unit contained food items, which should not have been stored there according to the facility's policy on medication storage. Interviews with LPNs confirmed these storage practices were not in compliance with the facility's policies.
Failure to Obtain Vaccine Declination Form
Penalty
Summary
The facility failed to obtain a declination form for a resident who refused the pneumococcal vaccine. During a record review on May 31, 2024, it was found that Resident 101 had refused the pneumococcal vaccine on October 10, 2023. However, the resident's record did not contain the necessary documentation showing that a declination form was signed by the resident or their representative. In an interview conducted on the same day, the Infection Preventionist (IP) Nurse confirmed that there was no signed declination form for the pneumococcal vaccine for Resident 101, acknowledging that such a form should have been obtained.
Latest citations in Indiana
Surveyors observed that dietary staff repeatedly worked in kitchen and meal service areas with uncovered facial hair, despite facility policy and state sanitation requirements mandating effective hair restraints. Two dietary aides with short beards or mustaches were seen walking through food preparation areas, taking food temperatures, handling food, and plating meals at steamtables in dining rooms without any facial hair coverings, while the current policy required all hair, including facial hair, to be restrained to prevent contamination.
The facility failed to consistently provide and document required bed-hold policy notices when several residents were transferred to the hospital. In multiple cases, residents with dementia, psychotic disorders, COPD, chronic respiratory failure, altered mental status, and cerebral infarction were sent out for acute changes in condition, and while transfer notes reflected physician and family notifications, they lacked documentation that the bed-hold policy was discussed with the resident or responsible party. Notices of Transfer or Discharge often indicated a copy of the bed-hold policy was sent with the resident, but the records did not show signed and dated acknowledgment by the resident or appropriate representative, including in situations where a resident had moderate cognitive impairment, short-term memory issues, or a documented need for a proxy and a financial POA authorizing an agent for health care decisions.
Surveyors found that the facility failed to provide trauma‑informed and culturally competent care by not incorporating two residents’ extensive trauma histories and specific behavioral triggers into their care plans. One resident with documented homelessness, polysubstance abuse, severe accidents with multiple fractures, viral encephalitis with coma, physical and sexual abuse, loss of family contact, and a past suicide attempt had multiple behavior‑focused care plans that referenced identifying triggers but listed none and did not mention their physical, sexual, medical, or psychosocial trauma. Another resident with TBI from being struck by a truck, an 11‑month coma, long‑term state hospital residence, alleged shooting of a parent, and diagnoses including intermittent explosive disorder and borderline personality disorder had a PASRR identifying a specific trigger and notes of inappropriate sexual behavior, yet their care plans omitted these traumatic events, the identified trigger, and the sexual behavior. Staff interviews confirmed that residents were screened for trauma, but the trauma histories and triggers were not reflected in the individualized plans of care.
A resident with schizophrenia, post‑stroke hemiparesis, and mild cognitive impairment expressed feeling down and wanting to kill himself, but staff did not document asking about a specific plan, did not notify the physician or psychiatric NP as expected, and did not develop or update a care plan addressing depression or suicidal ideation. The SSD documented offering support and initiating 15‑minute checks once, but there was no further follow‑up or documentation of interventions after subsequent suicidal statements made in a care plan meeting with the resident’s father. The DON and Administrator reported that facility policy requires immediate notification of key staff, assessment for a plan and means of self‑harm, and thorough documentation, which were not carried out or reflected in the medical record for this resident.
A resident with schizophrenia, post-stroke hemiparesis, and mild cognitive impairment verbalized suicidal ideation, but the care plan did not address depression or suicidal thoughts, and required assessments and services were not accurately or timely documented. An SSD note recorded the resident saying he wanted to kill himself and referenced 15‑minute checks and a care plan update, yet the active care plan lacked depression/suicidal ideation interventions. Multiple late-entry Social Services notes were later added, describing follow-up visits and the resident denying suicidal ideation, but the SSD later reported she did not typically ask about a suicide plan and did not personally provide individual follow-up visits as described. These practices conflicted with the facility’s policy requiring factual, first-hand, and timely documentation of assessments and services.
A resident was observed with an Albuterol inhaler on an overbed table and later reported keeping the inhaler in a nightstand drawer, with no staff present during these observations. Record review showed the resident had no cognitive impairment on the admission MDS but lacked any documented self-medication administration assessment. The DON acknowledged that the required assessment had not been completed, despite facility policy requiring staff and the practitioner to evaluate each resident’s mental and physical abilities before allowing self-administration of medications.
Surveyors found that the facility submitted inaccurate direct care staffing data to CMS through the PBJ system over multiple days in a quarter. CASPER reports showed apparent gaps in 24-hour licensed nurse coverage, low weekend staffing, and a 1-star staffing rating, while internal staffing sheets documented that licensed nurses were present and the facility was fully staffed on those days. The Administrator reported that the discrepancies were due to PBJ data entry errors, despite a facility policy requiring all PBJ entries to be accurate, auditable, and verifiable against payroll, invoices, or contracts.
Surveyors found that the facility did not provide or document required written transfer/discharge notices and bed-hold policy information for four residents who were sent to the hospital, including individuals with conditions such as dementia, CHF, chronic respiratory failure, and CKD. In each case, progress notes showed that the resident was transferred for acute issues, but the clinical records lacked evidence that written notices were given to the residents or their representatives, and in one case lacked documentation that required information was sent to the receiving provider. Facility leadership, including the ADON, DON, and Administrator, acknowledged that the records did not contain the required documentation, despite a written policy requiring such notices and information exchange.
A resident with Alzheimer’s disease and depression, previously on an antidepressant, exhibited intermittent refusals of medications and care, occasional yelling at staff, and reports of unusual perceptions, such as believing men were in or near her room. Nursing notes over several months documented these refusals and complaints but did not show that the behaviors were evaluated or recorded as dangerous, non-redirectable, or causing significant distress, nor did they document specific non-pharmacological interventions attempted or their outcomes. Despite this, a psychiatric NP later added new diagnoses of schizoaffective disorder, borderline personality disorder, and delusional disorder and ordered an antipsychotic (Seroquel) without a comprehensive evaluation in the record to support these diagnoses. The facility’s psychotropic medication policy, which requires identification and documentation of target behaviors, use of nonpharmacological interventions, and ongoing behavior monitoring, was not followed for this resident.
The facility failed to keep PASARR Level I screenings accurate and current for three residents when new mental health diagnoses and psychoactive medications were initiated. One resident’s PASARR omitted a PTSD diagnosis and an added antidepressant, despite documentation of PTSD on the MDS and care plan and a physician order for Pristiq. Another resident’s PASARR listed only depression and dementia, even after additional diagnoses such as borderline personality disorder, delusional disorder, and schizoaffective disorder were added and an antipsychotic (quetiapine) was ordered, with the MDS later reflecting psychotic disorder, schizophrenia, and depression with antipsychotic and antidepressant use. A third resident’s PASARR did not include a depression diagnosis or newly ordered escitalopram and lorazepam, although the admission MDS documented depression with antianxiety and antidepressant use. These omissions occurred despite facility policy requiring a new Level I review after significant mental status changes, including new mental health diagnoses or new psychotropic medications.
Uncovered Facial Hair During Food Preparation and Meal Service
Penalty
Summary
The deficiency involves the facility’s failure to ensure that food was served in a sanitary and safe manner in accordance with professional standards and facility policy during multiple kitchen and meal service observations. During an initial kitchen observation, two dietary aides were seen walking through the kitchen food preparation area with uncovered facial hair. One aide had facial hair above and below the lip and along the jaw line, approximately one-fourth inch in length, and the other had a mustache of similar length; neither used any facial hair covering. These observations occurred while staff were present in the kitchen area where food was stored and prepared. During subsequent observations on the same day, the same two dietary aides were again observed with uncovered facial hair while directly involved in meal preparation and service. One aide walked through the kitchen while the noon meal was being prepared and placed into a transport cart for service in the south dining room, and later was observed plating the noon meal at the steamtable in that dining room, still without a facial hair covering. The other aide walked through the kitchen while the noon meal was being prepared and placed into the steamtable for the north dining room, took food temperatures, assisted with plating meals at the steamtable, and retrieved food items and supplies from the kitchen, all while having an uncovered mustache approximately one-fourth inch in length. The Dietary Manager stated that staff hair was to be covered when in the kitchen and during meal service, and the facility’s written policy and the cited Indiana Food Establishment Sanitation Requirements both required effective hair restraints, including for facial hair, to prevent contamination of food, equipment, and utensils.
Failure to Provide and Document Bed-Hold Policy at Time of Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure that required bed-hold policy information was provided and documented for four residents transferred to the hospital. For a resident with dementia, psychotic disorder, and autistic disorder who had a BIMS score of 0 indicating severe cognitive impairment, progress notes documented physician notification and guardian notification when the resident was sent to the hospital, but there was no documentation that the bed-hold policy was provided to the responsible party. A Notice of Transfer or Discharge later indicated a copy of the bed-hold policy was sent with the resident. Another resident with COPD and chronic respiratory failure, cognitively intact with a BIMS score of 13, experienced a decline in condition and was transferred to the hospital by ambulance; progress notes documented family notification but did not document any discussion of the bed-hold policy, although a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident. A third resident with altered mental status and cerebral infarction, with a BIMS score of 10 indicating moderate cognitive impairment and documented short-term memory impairment, experienced changes in condition and was transferred to the hospital. Progress notes stated the resident was their own responsible party and that no other notification was completed, and transfer documentation did not include the bed-hold policy, although an untimed Notice of Transfer or Discharge indicated a copy of the bed-hold policy was signed by the resident. A financial power of attorney document in the record showed the resident had designated an agent to act in consent or refusal of health care. For a fourth resident with dementia and osteomyelitis, transfer documentation and a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident, and the transfer form noted the resident required a proxy for decision making. The facility’s policy required that at the time of transfer to a hospital, written notice specifying the duration of the bed-hold policy and information on return to the next available bed be provided, and that a signed and dated copy of the bed-hold notice given to the resident or representative be kept in the resident file, which was not consistently documented for these residents.
Failure to Integrate Trauma Histories and Behavioral Triggers Into Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to identify and incorporate residents’ trauma histories and specific behavioral triggers into their care plans, despite documented histories of significant trauma and behavioral health issues. For one resident, extensive social service and progress notes documented homelessness, polysubstance abuse, major depressive and anxiety disorders, chronic pain, a history of severe car accidents with multiple fractures, viral encephalitis resulting in a three‑month coma, loss of child custody, multiple divorces, physical abuse by a spouse, the death of a fiancé who was struck by a car while in a wheelchair, lack of family contact, and a past suicide attempt by Valium overdose. Additional documentation noted a history of rape by a brother at age eight and prior placement under direct supervision and 15‑minute checks related to suicidal ideation. Despite these documented traumatic events and behavioral health concerns, the resident’s care plans did not identify a history of physical trauma, sexual trauma, homelessness, substance abuse, medical trauma, or attempted suicide. For this same resident, the MDS showed no cognitive deficit and identified behaviors such as verbal aggression and rejection of care, along with diagnoses including seizure disorder, depression, chronic pain syndrome, homelessness, and anxiety disorder. Multiple care plans addressed behaviors such as drug‑seeking, pretending to have seizures for attention or medication, making false allegations, verbal aggression when unable to smoke, and a desire for intimate relationships with consenting male residents. These care plans referenced goals such as effective coping skills, seeking staff support, and compliance with the smoking policy, and they called for identification and reduction of behavioral triggers. However, none of these care plans actually listed any specific triggers. The care plan addressing the resident’s right to consensual intimate relationships focused on assessment and education regarding consent but did not integrate the resident’s extensive trauma history. Staff interviews indicated the resident had displayed sexual behaviors since admission, including an incident where the resident expressed anger at another resident for not buying a soda after engaging in sexual acts. A second resident with a documented history of traumatic brain injury (TBI), dementia, seizure disorder, borderline personality disorder, anxiety, intermittent explosive disorder, tobacco use, and other behavioral/emotional disorders was also affected by the same deficiency. Social history and progress notes documented that this resident sustained a TBI after being hit by a semi‑truck while riding a bicycle at age 18, resulting in an 11‑month coma, followed by 13 years in a state hospital and subsequent residence in a group home. Additional documentation indicated the resident allegedly shot their father at age 26 after being sworn at and had a PASRR identifying TBI, intermittent explosive disorder, and borderline personality disorder, with a specific trigger of hearing the name of the current U.S. President. Progress notes also described inappropriate sexual behavior toward staff, including touching themselves intimately during personal care and refusing to stop when redirected. Despite this, the resident’s care plans, which addressed explosive disorder and history of altercations, risk for decreased psychosocial well‑being, and refusal to bathe or shower, did not list any specific behavioral triggers, did not reference the traumatic events such as being hit by a truck or shooting their father, and did not document the inappropriate sexual behavior. The Administrator and Social Service Director acknowledged that residents were to be screened for trauma and that trauma responses and PTSD should be added to care plans, but the specific trauma histories and triggers for these two residents were not incorporated into their plans of care.
Failure to Assess and Care Plan for Resident Suicidal Ideation
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess, investigate, and care plan for a resident’s suicidal ideation in accordance with its own policy and staff expectations. The resident had diagnoses including schizophrenia, cerebral edema, and hemiparesis/hemiplegia following a cerebral infarction, and a current MDS showed mild cognitive impairment (BIMS score 12). A progress note documented that the resident told the Social Services Director (SSD) he was feeling down and wanted to kill himself; the SSD offered assistance, activities, and initiated 15‑minute checks, and the note stated the care plan was updated. However, the note did not indicate that the SSD asked whether the resident had a plan to kill himself, and there were no additional notes regarding suicidal ideation or follow‑up. Review of the current care plan showed no problem, goal, or interventions addressing depression or suicidal ideation, and progress notes over the following month contained no documentation of physician notification related to the suicidal statement. Further record and interview evidence showed that the care plan conference summary did not document interventions for suicidal ideation, and the SSD acknowledged she did not normally ask residents expressing suicidal ideation if they had a plan. The SSD reported that the resident had admission paperwork mentioning suicidal ideation related to depression after a stroke and that the resident again vocalized suicidal ideation during a care plan meeting with his father, after which emotional support was offered and the father took the resident out on a leave of absence; no further visits or follow‑up were done. The DON stated that, upon notification of suicidal verbalization, staff should assess the resident, ask if there is a plan, remove potential means of self‑harm, immediately notify the psychiatric NP, and document the occurrence, and that a detailed progress note and updated care plan were expected but not present for this resident. The Administrator similarly stated that staff should ask about a plan, document interventions, notify the physician and family, and update the care plan, and indicated the resident should have had a care plan addressing depression with suicidal ideation. The facility’s written policy required immediate notification of the DON, SSD, and physician, an interview including asking about a plan and assessing mood and means for self‑harm, and thorough documentation of mood, behavior, and all actions taken, which were not reflected in the resident’s record.
Incomplete and Inaccurate Documentation of Suicidal Ideation and Follow-Up
Penalty
Summary
The facility failed to ensure accurate, complete, and timely documentation of assessments and services for a resident who verbalized suicidal ideation. Resident 6, who had schizophrenia, cerebral edema, and right-sided hemiparesis/hemiplegia following a cerebral infarction, had a BIMS score of 12 indicating mild cognitive impairment. The resident’s admission paperwork mentioned suicidal ideation related to depression after a stroke, and a Social Services note on 3/11/2026 documented that the resident was feeling down and said he wanted to kill himself. The Social Services Director (SSD) documented that she talked with the resident, coordinated with Activities, advised the resident to contact SSD or nursing if he wanted to talk, and that the resident was scheduled for 15-minute checks and the care plan was updated. However, the current care plan initiated on 2/26/2026 did not address depression or suicidal ideation. Multiple Social Services progress notes were later entered as late entries in April, with effective dates in March, stating that the resident had no plan and no longer had suicidal ideation, that he felt much better after 1:1 time, and that he continued his daily routine and therapy. These late entries described follow-up visits and reassessments of suicidal ideation on several consecutive days, but in interviews the SSD stated she did not normally ask residents about having a plan when they verbalized suicidal ideation and did not recall any other occurrences beyond the initial event. She further indicated she did not personally provide individual follow-up visits with this resident regarding suicidal ideation, despite the late-entry notes describing such visits. The DON acknowledged that late entries had been added to address concern about suicidal verbalization, and the Administrator stated that upon suicidal statements staff should ask about a plan, notify the physician and family, and update the care plan, and that this resident should have had a care plan addressing depression with suicidal ideation. The facility’s documentation policy required factual, first-hand, timely documentation, which was not followed in this case.
Failure to Complete Required Self-Administration Assessment for Inhaler Kept at Bedside
Penalty
Summary
Surveyors identified that a resident was allowed to keep and access an Albuterol inhaler without the facility completing the required self-administration medication assessment. During an initial tour, the resident was observed sitting in a wheelchair with a handheld Albuterol inhaler on the overbed table and no staff present in the room or hallway. On a subsequent observation, the resident again was in a wheelchair and reported that the Albuterol inhaler was stored in the top drawer of the nightstand, where it was found. Review of the clinical record showed an admission MDS indicating no cognitive impairment, but there was no documentation of a self-medication administration assessment. In an interview, the DON confirmed that the resident did not have the required self-medication assessment, despite the facility’s policy stating that staff and the practitioner must assess each resident’s mental and physical abilities to determine whether self-administering medications is clinically appropriate. This failure to complete and document a self-administration medication assessment for a resident who had an Albuterol inhaler kept at bedside constituted noncompliance with the facility’s own policy and with 410 IAC 16.2-3.1-11(a).
Inaccurate PBJ Staffing Data Submission to CMS
Penalty
Summary
The deficiency involves the facility’s failure to electronically submit complete and accurate direct care staffing information to CMS through the Payroll-Based Journal (PBJ) system for 22 days in a fiscal quarter. A CASPER report review on 4/6/26 showed that, according to PBJ data, the facility did not have licensed nursing coverage 24 hours per day on multiple specific dates across three months, had low weekend staffing, and held a 1-star staffing rating. However, review of the facility’s internal staffing sheets for that quarter indicated the facility was fully staffed and had licensed nurse coverage on all of the dates in question. During an interview, the Administrator stated that the PBJ information must have contained data entry errors, as she had verified licensed staff coverage on the timesheets. The facility’s PBJ policy in effect stated that all staffing data entered into the PBJ system would be auditable and verifiable through payroll, invoices, or contracts, but the submitted PBJ data did not accurately reflect the facility’s actual licensed nurse staffing as documented on internal records. No specific residents or clinical conditions were mentioned in the report, and the deficiency centers solely on inaccurate staffing data submission rather than direct resident care events.
Failure to Provide and Document Required Transfer/Discharge and Bed-Hold Notices
Penalty
Summary
The deficiency involves the facility’s failure to provide and document required written notices of transfer/discharge and bed-hold policies, as well as required information to receiving providers, for four residents who were transferred or discharged to the hospital. For a resident with generalized anxiety disorder, major depressive disorder, and dementia, progress notes showed that the resident was sent to the hospital via 911 for chest pain, lower back pain, and shortness of breath and later returned to the facility, but the clinical record lacked documentation that a written Notice of Transfer/Discharge and the bed-hold policy were provided to the resident or representative, and lacked documentation that required information was conveyed to the receiving facility. The ADON and the Administrator both confirmed there was no documentation that these written notices were provided. For a resident with congestive heart failure and muscle weakness who was sent to the emergency room for painful urination and bloody urine, the clinical record lacked documentation that a Notice of Transfer/Discharge or bed-hold policy was given to the resident or representative, which the DON confirmed. Another resident with chronic respiratory failure and diabetes was discharged to the hospital for respiratory failure, and a resident with chronic kidney disease and dementia was discharged to the hospital, but in both cases there was no documentation that a written notice of transfer/discharge or bed-hold policy was provided to the residents or their representatives. Review of the facility’s Transfer and Discharge policy, dated 1/15/26, showed that the policy required the facility to provide written transfer/discharge notices and bed-hold information to residents and representatives and to provide specified information to receiving providers, but the records for these four residents did not contain the required documentation.
Failure to Document Target Behaviors and Non-Pharmacological Interventions Before Initiating Antipsychotic
Penalty
Summary
The deficiency involves the facility’s failure to document how a resident’s behaviors presented danger or distress to self or others, and failure to document non-pharmacological interventions attempted prior to initiating an antipsychotic medication. Resident 6 had documented diagnoses of Alzheimer’s disease, depression, and severe cognitive impairment, and was receiving sertraline for depression. A PASSAR identified only depression and dementia, and the admission MDS listed Alzheimer’s disease and depression as active diagnoses. Over several months, nursing progress notes documented that the resident intermittently reported unusual perceptions, such as believing there were men causing trouble, a man in her room, or a man wanting to marry her and yelling through the walls, but there was no documentation that these episodes caused danger to the resident or others or that they resulted in unmanageable distress. From late April through mid-July, nursing notes primarily described the resident’s frequent refusals of evening and morning medications, blood sugar checks, blood pressure checks, insulin administration, hygiene care, and showers. Staff documented that the resident sometimes yelled at staff, said “Get out!”, was visibly upset by a room move, was leery of staff and asked to see name badges, and became upset about a pillow under her head until it was removed, after which she calmed down. The notes also recorded instances where the resident believed housekeeping had not cleaned her room or that she had not received medications when she had. However, there were no progress notes or assessments indicating that these behaviors were evaluated as dangerous, non-redirectable, or causing significant distress or functional impairment, and no detailed behavior monitoring logs were present as required by facility policy. On a psychiatric NP visit for initial psychotropic medication management, new mental health diagnoses of schizoaffective disorder, borderline personality disorder, and delusional disorder were added, and Seroquel 25 mg, an antipsychotic, was ordered. The clinical record did not contain a comprehensive evaluation to support these new diagnoses, and there was no documentation of target behaviors meeting the facility’s policy criteria for psychotropic use, such as behaviors representing danger to self or others, causing distress and impairment in functional abilities, or clearly attributable to psychosis or mania. The resident’s representative reported that the resident had no prior history of mental health disorders or psychiatric hospitalization and was unaware of the new diagnoses. The facility’s own psychotropic medication policy required identification and documentation of specific target behaviors, use and documentation of nonpharmacological interventions, and ongoing monitoring of behaviors and interventions, which were not reflected in the record for this resident.
Failure to Update PASARR Screens for New Mental Health Diagnoses and Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that Preadmission Screening and Resident Review (PASARR) Level I screenings were accurate and updated when new mental health diagnoses and psychoactive medications were initiated for multiple residents. For one resident with dementia, anxiety, depression, and post-traumatic stress disorder (PTSD), the PASARR completed on admission listed anxiety, depression, and dementia with sertraline and quetiapine, but did not include the PTSD diagnosis or the antidepressant Pristiq, despite the admission MDS and care plan documenting PTSD and a subsequent physician’s order for Pristiq. For another resident with Alzheimer’s disease, borderline personality disorder, delusional disorder, schizoaffective disorder, and depression, the PASARR only reflected depression and dementia with sertraline, even though additional mental health diagnoses were added later and an antipsychotic (quetiapine) was ordered for borderline personality disorder, and the quarterly MDS documented psychotic disorder, schizophrenia, and depression with antipsychotic and antidepressant use. A third resident had diagnoses including Alzheimer’s disease, depression, anxiety disorder, irritability and anger, and nonrheumatic aortic valve stenosis. The PASARR for this resident listed dementia and anxiety with Risperdal but omitted the diagnosis of depression and the medications escitalopram and lorazepam, although physician’s orders were in place for escitalopram for depression and lorazepam for anxiety, and the admission MDS documented depression with antianxiety and antidepressant use. Interviews with the Assistant Director of Nursing confirmed that new Level I PASARR screens should have been completed when new mental health diagnoses and psychoactive medications were added, and that the PASARR for one resident, completed prior to arrival, should have included all mental health diagnoses and medications. The facility’s own policy required notification of the state mental health authority within 14 days after a significant change in mental condition and specified that a new Level I screen is required for new mental health diagnoses or newly prescribed psychotropic medications, which was not followed in these cases.
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