Hamilton Pointe Health And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Newburgh, Indiana.
- Location
- 3800 Eli Place, Newburgh, Indiana 47630
- CMS Provider Number
- 155803
- Inspections on file
- 45
- Latest survey
- January 14, 2026
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Hamilton Pointe Health And Rehab during CMS and state inspections, most recent first.
Two residents received ongoing O2 therapy via nasal cannula without corresponding practitioner orders, despite documented use in vital signs, skilled notes, and NP progress notes, and one resident’s care plan specifying oxygen flow rates. One resident with COPD, pulmonary hypertension, and CHF was on O2 at varying flow rates over multiple days before any O2 orders appeared in the medical record, and another resident with COPD and CKD was started and titrated on O2 after low O2 sats and POA concerns, again without documented practitioner orders. Staff interviews confirmed that O2 requires a physician order and that orders typically define parameters, and the facility’s policy required O2 to be administered only under a physician’s order (except in emergencies) with weekly tubing changes.
A resident with multiple comorbidities had a surgical wound on the left foot, but clinical documentation repeatedly recorded the wound as being on the right foot due to an initial charting error by the wound nurse. This mistake was carried over in subsequent nursing notes and weekly skin observations, resulting in persistent inaccuracies in the resident's medical record. Staff interviews confirmed that documentation was often based on previous entries rather than direct assessment.
A medication cart was left unlocked and unattended with medications and a computer displaying a resident's clinical information visible. An LPN left the cart to respond to a possible emergency, contrary to facility policy requiring medications to be secured and resident privacy protected.
Staff did not use Enhanced Barrier Precautions during incontinence and wound care for a resident with a pressure ulcer, and a care plan for EBP was missing. Additionally, there were no physician orders in place for the care of a resident's colostomy, contrary to facility policy requiring such orders for ostomy care.
The facility did not notify the families of two residents after significant changes in their conditions, including a fall with mental status change and multiple seizure episodes. In both cases, required notifications to family, physician, or palliative care were not documented or made in a timely manner, despite facility policy and care plan requirements.
Two residents experienced accidents due to inadequate supervision and failure to follow care plan interventions, including one resident left unattended on a commode who suffered a fall and head injury, and another resident who fell from a mechanical lift when only one staff member was present during transfer, contrary to policy requiring two staff.
The facility failed to ensure proper infection control practices as staff members entered isolation rooms without appropriate PPE. Activity Staff, CNAs, and an RN were observed not following droplet precaution protocols, despite clear signage and available PPE. The facility had isolation rooms for Influenza A and RSV, with recent Norovirus cases affecting residents and staff.
The facility failed to maintain sanitary conditions in food service, with observations of improper glove use, bare hand contact with plates, and unsanitary kitchen conditions. Dietary aides did not follow proper procedures for changing gloves and handling food, leading to potential contamination. The facility's policies on food handling and cleaning were not adequately followed.
A facility failed to provide immediate physician orders for a newly admitted resident with multiple pressure wounds, including a stage IV ulcer. Despite the facility's policy requiring immediate care orders, no wound treatment orders were recorded until three days post-admission. Staff interviews confirmed that treatments should have been initiated upon admission, highlighting a lapse in adherence to care protocols.
Staff at the facility failed to respect resident privacy during care, as observed in multiple instances where staff entered rooms without knocking and did not ensure privacy during medical procedures. Despite having guidelines, the facility lacked a formal privacy policy, leading to a deficiency in maintaining residents' rights to privacy and dignity.
The facility failed to assess residents for their ability to self-administer medications, as observed in four cases where medications were found in residents' rooms without necessary assessments or orders. A resident with cognitive impairment had throat lozenges without an order, another had a nasal spray without verification of a current order, and a third had an inhaler and Tylenol without documentation. Additionally, a resident with diabetes had glucose shots without a self-administration evaluation, contrary to facility policy.
The facility failed to serve food at palatable temperatures, as evidenced by resident complaints and a test tray showing inadequate food temperatures. Residents reported meals were not hot, and a Resident Council meeting noted delays in food delivery. On one occasion, a test tray showed carrots at 116°F, below the required 135°F. The Dietary Manager confirmed the expected temperature range, and the facility's policy requires hot food to be served at a minimum of 135°F.
The facility was found to have unsanitary conditions in the kitchen and dining areas, with food items left open to air, expired, or improperly stored. Additionally, an employee failed to change gloves after handling trash during food preparation, violating the facility's glove usage policy.
The facility failed to ensure a sanitary environment and proper hand hygiene, leading to infection control deficiencies. Uncovered washbasins and toothbrushes were observed in residents' bathrooms, and staff did not sanitize hands when entering or exiting rooms with enhanced barrier precautions, contrary to facility policy.
The facility failed to maintain a pest-free environment, with gnats observed in various areas including resident rooms, offices, and the kitchen. A resident reported issues with gnats, and the ADON suggested they might have been stirred up by recent pipe flushing. The facility's pest control policy aims to provide a safe environment free of pests, but the presence of gnats indicates a failure to adhere to this policy.
The facility failed to accurately complete MDS assessments for two residents. One resident, with a malignant neoplasm, was incorrectly marked as not receiving opioids, despite records showing administration of such medications. Another resident, with a history of CVA, was inaccurately marked as not receiving antiplatelet medication, although it was administered. The MDS Coordinator acknowledged these errors.
The facility failed to adhere to physician orders for two residents, one with dementia and epilepsy and another with renal failure, regarding nutritional supplements and weight monitoring. Resident 55 experienced significant weight loss due to missed nutritional supplement administrations, while Resident S had numerous missing or incorrect weight entries, impacting their care plans.
A facility failed to adequately assess a resident before administering narcotic medication and did not have a person-centered care plan for narcotic use. The resident, who had asthma and atrial fibrillation, was receiving opioid pain medication without a care plan for monitoring side effects. A discrepancy in resuscitative measures was noted, as the care plan inaccurately indicated the resident was a full code. The resident's condition deteriorated, leading to a significant drop in oxygen saturation and inability to swallow medications. Emergency services were called, but CPR was not initiated as the resident stopped breathing.
Two residents experienced multiple falls due to the facility's failure to complete post-fall assessments and update care plans with new interventions. Despite being at risk for falls, one resident had incomplete neurological assessments after a fall, and another had no new interventions added to their care plan after falls.
Two residents in a LTC facility experienced inadequate pain management. One resident suffered an unintentional narcotic overdose due to improper monitoring and medication administration errors. Another resident's preference for non-pharmacological pain relief was not honored, as the facility did not provide a heating pad or alternative methods. The facility's policies on medication administration and monitoring were not effectively followed, leading to these deficiencies.
A facility was found to have a medication error rate of 12% during a survey. An LPN administered chewable tablets incorrectly and handled a medication patch without gloves for a resident with dementia. Another resident with diabetes received an insulin injection without proper technique, as the LPN did not keep the needle in the skin for the required time. These actions violated the facility's medication administration policies.
The facility failed to accurately document a glucometer reading for a resident and did not complete post-fall assessments for another resident. An LPN recorded a blood sugar reading that differed from the summary provided later. Additionally, a resident with hemiplegia experienced a fall, but the post-fall assessment was incomplete, lacking documentation for several shifts. The Regional Nurse Consultant confirmed the need for complete documentation as per policy.
The facility failed to post accurate daily staffing sheets for six out of seven days, omitting actual hours worked for various shifts by RNs, LPNs, and CNAs. The DON was unaware of the requirement to designate actual hours for half shifts, despite a policy mandating this information be posted daily.
Failure to Obtain Practitioner Orders for Oxygen Therapy and Equipment Management
Penalty
Summary
The deficiency involves the facility’s failure to obtain practitioner orders for oxygen therapy and to ensure appropriate oxygen therapy management for two residents receiving supplemental O2. For one resident with diagnoses including chronic pulmonary disease, pulmonary hypertension, acute diastolic congestive heart failure, and dependence on supplemental oxygen, the admission MDS was coded for oxygen therapy, and the care plan documented that the resident would receive oxygen at 2–3 L/min as ordered. Clinical documentation, including an admission/readmission evaluation, vital signs, daily skilled notes, and nurse practitioner progress notes, showed that this resident was receiving oxygen via nasal cannula on multiple dates in November at flow rates up to 4.5 L/min. However, a review of physician orders for November revealed no orders for oxygen therapy, even though the resident was documented as being on oxygen throughout that period. Oxygen orders, including continuous oxygen at 2 L/min via nasal cannula with titration as needed and weekly tubing changes, did not appear until December. For another resident with COPD and chronic kidney disease, surveyors observed the resident on oxygen via nasal cannula at 2.5 L/min and the resident reported being placed on oxygen upon readmission from the hospital. Progress notes documented that, following concerns from the resident’s POA about low O2 readings, staff initiated oxygen at 2 L/min and then increased it to 3 L/min when saturations remained in the high 80s to mid-90s, and daily skilled notes showed the resident on oxygen on multiple dates. A nurse practitioner note also documented the resident on 2 L of oxygen. Despite this, the record review did not identify corresponding practitioner orders for oxygen therapy. Staff interviews confirmed that residents are required to have physician orders for oxygen therapy and that orders typically specify oxygen parameters, and the facility’s oxygen administration policy stated that oxygen must be administered under a physician’s order except in emergencies, with tubing and delivery devices changed weekly and as needed.
Inaccurate Documentation of Wound Location in Resident Medical Record
Penalty
Summary
The facility failed to ensure accurate clinical records for a resident with a surgical wound. Specifically, documentation inconsistently recorded the location of the wound, with multiple entries indicating the wound was on the right plantar foot when it was actually on the left. This error originated from the initial wound note, where the wound nurse mistakenly charted the right foot instead of the left, and this incorrect information was subsequently carried over in ongoing documentation. Weekly skin observations and progress notes continued to reflect the incorrect wound location, and some weekly observations even failed to note the presence of a surgical wound. The resident involved had a complex medical history, including a displaced bimalleolar fracture of the left lower leg, diabetes, hemiplegia, lymphedema, morbid obesity, and chronic heart failure. The care plan and physician orders correctly referenced a surgical wound on the left foot, but nursing documentation and skin observation forms repeatedly listed the wound as being on the right foot. Interviews with staff confirmed that documentation was based on previous notes rather than direct observation, leading to persistent inaccuracies in the resident's clinical record.
Unsecured Medication Cart and Breach of Resident Privacy
Penalty
Summary
A medication cart on the 400 unit was observed to be left unlocked with a medication cup containing six pills on top, and a computer displaying a resident's picture and clinical record information. The cart was unattended for several minutes while the assigned LPN left the area to respond to a possible resident emergency on another unit. The LPN later confirmed that medications should not be left unattended and that the cart should have been locked before leaving. Facility policy requires all medications to be stored in locked compartments and for medications to be under the direct observation of the administering staff or locked during medication pass. The policy also mandates the protection of resident privacy during medication administration. The observed incident failed to meet these requirements, resulting in unsecured medications and a breach of resident privacy.
Failure to Follow Enhanced Barrier Precautions and Maintain Ostomy Care Orders
Penalty
Summary
Staff failed to follow Enhanced Barrier Precautions (EBP) for a resident with an unstageable pressure ulcer. During incontinence and wound care, two Qualified Medication Aides and a Wound Nurse did not don EBP supplies as required by physician orders and facility policy. The resident's clinical record also lacked a care plan related to EBP, despite an active order for EBP until the wound was healed. The Assistant Director of Nursing confirmed that EBP should have been used during these care activities. Additionally, for a resident with a colostomy, there were no physician orders in place for the care of the ostomy, as confirmed by review of the clinical record, Treatment Administration Record, and Electronic Medication Administration Record. The facility's policy requires licensed nurses to provide ostomy care under the orders of the attending physician, specifying the type of ostomy, frequency of pouch change, and type of equipment. This omission was acknowledged by nursing staff and was not in accordance with facility policy.
Failure to Notify Families of Changes in Resident Condition
Penalty
Summary
The facility failed to notify the families of two residents regarding significant changes in their conditions. For one resident with a history of falls and impaired balance, the family was not informed of a fall and subsequent mental status change until they visited and observed the change themselves. The resident's Power of Attorney confirmed that notification only occurred after the family discovered the incident, and the assigned nurse acknowledged that the family should have been contacted at the time of the fall but was not due to other tasks being prioritized. In another case, a resident with epilepsy and a seizure disorder experienced multiple seizures, but there was no documentation of family, physician, or palliative care notification following these events. The resident's care plan specifically required notification of palliative services with all changes in condition. The DON confirmed that staff are expected to monitor and notify the family and physician after a seizure, but this did not occur. The facility's policy also requires notification of the resident, physician, and family or legal representative when there is a change requiring such notification.
Failure to Prevent Accidents Due to Inadequate Supervision and Noncompliance with Care Plans
Penalty
Summary
The facility failed to ensure adequate safety measures and supervision were in place to prevent accidents for two of three residents reviewed. One resident, who had a history of cerebrovascular accident (CVA) with left hemiplegia, unsteady gait, and required substantial assistance with transfers and toileting, was left unattended on a commode despite care plan interventions specifying two-person assistance and not to be left alone. This resident experienced a fall in the bathroom after staff briefly exited the room to retrieve linens, resulting in a head injury, laceration, and subarachnoid hemorrhage that required hospitalization. Documentation and interviews revealed inconsistencies in staff awareness and implementation of updated care plans, particularly regarding the required level of assistance and supervision for this resident. Another resident, with diagnoses including mild cognitive impairment, history of falls, and reduced mobility, was being transferred using a mechanical lift by only one staff member, contrary to facility policy and manufacturer guidelines requiring two staff for such transfers. During the transfer, the mechanical lift struck the bed frame, causing the resident to fall out of the sling and onto the floor. Staff statements and interviews confirmed that only one CNA was present during the transfer, and the care plan for this resident required a mechanical lift with two-person assistance for all transfers. The facility's policies on safe handling, transfers, and fall prevention were not consistently followed, as evidenced by the incidents involving both residents. Staff interviews indicated a lack of awareness or adherence to updated care plans and required procedures, contributing to the accidents. These deficiencies resulted in significant harm to one resident and placed both residents at risk for injury.
Inadequate PPE Use in Isolation Rooms
Penalty
Summary
The facility failed to maintain proper infection control practices and ensure the use of Personal Protective Equipment (PPE) when entering isolation rooms on three observed halls. Multiple staff members, including Activity Staff 2, CNA 6, CNA 2, CNA 3, and RN 2, were observed entering rooms with droplet precaution signs without donning the required PPE. Specifically, Activity Staff 2 entered a room with droplet precautions without wearing any PPE and subsequently entered other non-isolation rooms. CNA 6 also entered a room under droplet precautions without PPE. CNA 2 donned PPE but failed to tie the gown at the neck, contrary to the facility's policy. CNA 3 and RN 2 entered a room with droplet precautions without any PPE, despite the presence of PPE and signage indicating the need for it. The Director of Nursing (DON) confirmed that the staff were expected to follow the droplet precaution signs posted on the isolation rooms. The facility had rooms on isolation for Influenza A and Respiratory Syncytial Virus (RSV), and Norovirus had recently affected some residents and staff. The facility's policies on infection prevention and control, transmission-based precautions, and PPE usage were provided, indicating the requirements for PPE use in such situations.
Sanitation Deficiencies in Food Service
Penalty
Summary
The facility failed to ensure food was served in a sanitary manner, as observed during two separate inspections of the kitchen and meal service. The kitchen floor was found to have debris along the walls, behind and under tables, equipment, racks, and in the dry pantry. Dietary Aide 2 was observed preparing salads without changing gloves after touching various surfaces and items, including a food scale and refrigerator handles, which could lead to contamination. Additionally, Dietary Aide 3 handled plates with bare fingers, and Dietary Aide 5 licked his fingers while organizing meal tickets, which were later sent with the plates of food to residents. Further observations revealed that Dietary Aide 4 touched plates with bare fingers where food was placed, and Dietary Aide 6 confirmed that gloves should be worn when touching food and changed after touching non-sterile surfaces. The facility's policies on food handling and kitchen cleaning were reviewed, indicating that employees should wash hands and change gloves after contact with non-sterile surfaces, and that cleaning tasks are assigned to specific positions. However, these policies were not adequately followed, leading to the cited deficiencies.
Failure to Provide Immediate Wound Care Orders for New Admission
Penalty
Summary
The facility failed to ensure that a newly admitted resident, identified as Resident B, received immediate physician orders for the treatment of pressure wounds upon admission. Resident B, who was admitted in June 2024, had multiple pressure wounds, including a stage IV pressure ulcer on the right buttock and unstageable pressure ulcers. Despite the presence of these wounds, there were no recorded orders for wound treatments from the date of admission until three days later. The facility's policy requires that a physician or other qualified healthcare professional provide written or verbal orders for a resident's immediate care upon admission, which was not adhered to in this case. Interviews with facility staff revealed that wound treatments should have been initiated upon admission, even if temporary, until a full assessment could be conducted by the facility's wound nurse. However, treatments were only clarified and initiated several days after admission. The facility's Director of Nursing provided the current admission orders policy, which mandates that essential care orders be in place consistent with the resident's condition upon admission. This deficiency was identified during a complaint investigation related to Resident B's care.
Failure to Ensure Resident Privacy During Care
Penalty
Summary
The facility failed to respect the privacy of residents during routine care and medical procedures, as observed in multiple instances. Staff members, including a Registered Nurse (RN), a Qualified Medication Aide (QMA), and a Licensed Practical Nurse (LPN), were seen entering residents' rooms without knocking or announcing themselves. This lack of privacy was noted in six random observations involving different residents. Additionally, during an insulin administration, the LPN did not close the door or draw the curtain, further compromising the resident's privacy. The Director of Nursing (DON) acknowledged the absence of a formal privacy policy, although a Nurse Aide Procedure check-off form was available, which instructed staff to knock and identify themselves before entering a resident's room and to maintain privacy by closing curtains, drapes, and doors. Despite these guidelines, the staff's actions did not align with the expected standards, leading to a deficiency in maintaining residents' rights to privacy and dignity.
Failure to Assess Residents for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that residents who self-administer medications were properly assessed for their ability to do so. This deficiency was observed in four residents who had medications in their rooms without the necessary assessments or orders. Resident 7, who had a moderate cognitive impairment and required assistance with daily activities, was found with throat lozenges in her room without an order or assessment for self-administration. The nurse acknowledged the presence of the medication but did not remove it, indicating a lack of adherence to the facility's policy. Similarly, Resident S, who had no cognitive impairment but required assistance with mobility and toileting, was found with a nasal spray in her room. The nurse was unsure if there was a current order for the nasal spray and left it in the room without verifying the necessary documentation. Resident 150, who also had no cognitive impairment, was found with an inhaler and unlabeled Tylenol in his room, again without the required self-administration order or assessment. The unit manager was uncertain about the policy for medications in resident rooms, highlighting a lack of clarity and enforcement of procedures. Resident 6, who was cognitively intact and had diabetes, was observed with glucose shots on her bedside table. Despite the need for these medications, there was no self-administration evaluation or order in her clinical record. The facility's policy required an interdisciplinary team assessment and documentation for self-administration, which was not followed in these cases. This oversight in ensuring proper assessments and orders for self-administration of medications led to the deficiency identified by the surveyors.
Failure to Serve Food at Palatable Temperatures
Penalty
Summary
The facility failed to ensure that food was served at palatable temperatures, as evidenced by multiple resident complaints and a test tray showing inadequate food temperatures. On several occasions, residents reported that their meals were not hot, with specific instances noted on 5/29/24 and 5/30/24. During a Resident Council meeting on 5/31/24, it was mentioned that food trays stayed in the hallways too long, causing the food to become cold. On 6/3/24, the process of serving lunch was observed, revealing delays between food preparation and delivery. The lunch cart was delivered to the 400 hall at 11:56 A.M. but was not immediately distributed, with staff beginning distribution at 12:01 P.M. A test tray obtained at 12:12 P.M. showed that the carrots were at 116°F, below the facility's policy requirement of at least 135°F for hot food. The Dietary Manager confirmed the expected temperature range for serving hot food, and the facility's Food Temperature Monitoring policy, revised in 12/22, was provided, indicating the requirement for hot food to be served at a minimum of 135°F.
Sanitation and Glove Usage Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen and dining areas, as observed during three separate kitchen inspections. In the reach-in freezer, items such as a slice of orange melon and small ice cream containers were left open to air, and in the walk-in freezer, french fries and a bag of mixed vegetables were similarly exposed. The walk-in refrigerator contained a broken egg, expired rice, and a boiled egg on the floor, along with other items like a bag of grapes and a container of boiled eggs in liquid that were open to air. Additionally, the dry pantry had packets of sugar, salt, and pepper on the floor, and the walk-in refrigerator had bacon on the floor and standing water by the shelves. In the main dining room's holding refrigerator, expired chocolate and fat-free milk containers were found, along with a whole milk container lacking a use-by date. The facility also failed to adhere to proper glove usage standards during food preparation. An employee was observed preparing pureed chicken without changing gloves after handling trash, which is against the facility's Glove Usage With Food Contact policy. The Dietary Manager acknowledged that staff were responsible for cleaning out the refrigerator daily, yet expired items were still present. The facility's policies on leftovers and glove usage were not followed, contributing to the unsanitary conditions observed during the survey.
Infection Control Deficiencies in Resident Care and Hand Hygiene
Penalty
Summary
The facility failed to maintain a safe, sanitary, and comfortable environment to prevent infection transmission, as evidenced by multiple observations of uncovered resident care items and inadequate hand hygiene practices. Specifically, uncovered washbasins were found on the floor in Resident 7's bathroom on two separate occasions, and an uncovered washbasin was observed in the sink of Resident 46's bathroom. Additionally, an uncovered toothbrush was noted on the back of the sink in Resident 20's bathroom, with staff indicating a lack of provided covers for these items. Furthermore, staff failed to adhere to hand hygiene protocols in rooms with enhanced barrier precautions. Qualified Medication Aide (QMA) 23 was observed entering and exiting Resident 37's room without sanitizing hands, despite a sign indicating the necessity of hand hygiene. Similarly, QMA 23 entered Resident D's room with a blood pressure machine and failed to perform hand hygiene before and after room entry. These actions were contrary to the facility's Enhanced Barrier Precautions policy, which mandates hand sanitization before entering and upon leaving rooms to prevent the transmission of multidrug-resistant organisms.
Facility Fails to Maintain Pest-Free Environment
Penalty
Summary
The facility failed to maintain an environment free of pests, as evidenced by multiple observations of gnats in various areas of the facility. During the survey, gnats were observed in a resident's room, the Nursing Manager's office, the ADON's office, the main dining room, the 300 hall nurse station, and the dry pantry in the kitchen. Resident 84 reported a problem with gnats in her room, which was confirmed by observation. The ADON suggested that the gnats might have been stirred up when the fire department flushed some pipes over the weekend. The facility's current pest control policy, dated 3/7/23, states that it is the policy of the facility to maintain an effective pest control program and provide a safe environment free of pests. However, the presence of gnats in multiple areas indicates a failure to adhere to this policy.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure accurate completion of the Minimum Data Set (MDS) Assessment for two residents, leading to discrepancies in their medical records. Resident 6, diagnosed with malignant neoplasm of the descending colon, was reported as cognitively intact and not receiving opioids during the 7-day lookback period of the MDS assessment dated 4/28/24. However, the Medication Administration Record (MAR) for April 2024 indicated that Resident 6 received oxycodone-acetaminophen multiple times and had a fentanyl patch applied on several occasions within the lookback period. The MDS Coordinator acknowledged that the MDS should have reflected the administration of opioids. Similarly, Resident 7, with a history of cerebrovascular accident (CVA) and moderate cognitive impairment, was inaccurately marked as not receiving antiplatelet medication in the MDS assessment dated 5/7/24. Despite this, the MAR for May 2024 showed that clopidogrel, an antiplatelet medication, was administered during the 7-day lookback period. The MDS Coordinator confirmed the error and noted the absence of a facility policy for MDS assessments, relying instead on the Resident Assessment Instrument (RAI) manual for guidance.
Failure to Follow Physician Orders for Nutrition and Weight Monitoring
Penalty
Summary
The facility failed to follow physician orders for two residents regarding their nutritional and weight management needs. Resident 55, who has diagnoses including dementia and epilepsy, was noted to have a significant unplanned weight loss of over 10% in six months. Despite physician orders for weekly weight monitoring and specific nutritional supplements, there were multiple instances where the nutritional supplements were not administered as ordered, with no documented reasons for these omissions. This lack of adherence to physician orders contributed to the resident's continued weight loss. Resident S, diagnosed with renal failure, had physician orders for daily weight monitoring, especially before dialysis, to manage potential weight fluctuations. However, the clinical record showed numerous missing weight entries over a two-month period, and some recorded weights were later crossed out without re-weighing or proper documentation. The Unit Manager indicated that weights were sometimes deleted if they seemed inconsistent, but there was no formal policy to guide this practice. This inconsistency in following physician orders and documenting weights could impact the resident's care and treatment plan.
Failure to Provide Adequate Assessment and Care Plan for Narcotic Use
Penalty
Summary
The facility failed to provide adequate care for Resident P by not conducting a thorough assessment prior to administering narcotic medication and not implementing a person-centered care plan for narcotic use. Resident P, who was cognitively intact and had diagnoses including asthma and atrial fibrillation, was receiving opioid pain medication. The clinical record lacked a care plan addressing the potential adverse side effects of narcotic pain medications. Additionally, there was a discrepancy in the care plan regarding resuscitative measures, as it inaccurately indicated the resident was a full code despite having a 'Do Not Resuscitate' order. On the day of the incident, Resident P was administered Norco multiple times, and later in the evening, the resident's oxygen saturation dropped significantly. Despite being alert and oriented earlier, Resident P was unable to rouse or swallow medications at bedtime. Emergency services were called, but CPR was not initiated as the resident stopped breathing. The LPN involved acknowledged the chaotic situation and the failure to update the electronic medication administration record to reflect that the resident did not take the medications. The facility also lacked a policy for monitoring adverse side effects of narcotic medications.
Failure to Update Care Plans and Complete Post-Fall Assessments
Penalty
Summary
The facility failed to ensure that post-fall assessments were completed and care plans were updated to prevent falls for two residents. Resident 40, who has a history of falls and moderate cognitive impairment, experienced seven falls over a period of time. Despite interventions being added to the care plan after each fall, such as providing a reacher, placing non-skid strips, and adding a cushion to the wheelchair, the resident continued to fall. Notably, after the seventh fall, neurological assessments were incomplete, indicating a lapse in following the facility's protocol for unwitnessed falls. Resident 83, who has hemiplegia and muscle weakness, was identified as being at high risk for falls. The resident experienced two unwitnessed falls while attempting to go to the bathroom. After the first fall, neurological assessments were conducted, but after the second fall, no neurological assessments were documented, and no new interventions were added to the care plan. This indicates a failure to adhere to the facility's policy of updating care plans with new interventions after each fall. The Director of Nursing acknowledged that neurological assessments should be completed per policy for unwitnessed falls or suspected head injuries and documented in the electronic medical record. However, the facility's failure to consistently perform and document these assessments, as well as update care plans with relevant interventions, contributed to the deficiency in providing adequate supervision and accident prevention for the residents.
Inadequate Pain Management and Monitoring in LTC Facility
Penalty
Summary
The facility failed to provide adequate pain management for two residents, resulting in significant deficiencies. Resident T, who suffered from arthritis and gout, was not properly monitored for side effects of narcotic pain medication, leading to an overdose. Despite receiving scheduled pain medications, Resident T experienced moderate pain and was not adequately monitored for narcotic side effects, as required by physician orders. The resident was hospitalized due to an unintentional narcotic overdose, which was resolved with Narcan administration. Additionally, there were discrepancies in the administration of Norco, with instances of incorrect dosages being given, either more or less than prescribed, without documented reasons. Resident 6, who had a history of malignant neoplasm of the descending colon, anxiety disorder, and depression, reported constant pain and expressed a preference for non-pharmacological pain relief methods, such as a heating pad, which she used at home. However, the facility did not honor her preference, citing safety concerns about heating devices in resident rooms. Although the resident was receiving opioid medications, her care plan included non-pharmacological approaches, which were not implemented. The facility's staff indicated that thermal therapy could be provided through therapy services, but there was no clear process for continuing such treatment after discharge from therapy. The facility's policies on medication administration and monitoring were not effectively followed, contributing to the deficiencies in pain management. The Director of Nursing acknowledged the lack of monitoring for narcotic side effects and the absence of a specific policy for following physician orders. Additionally, there was no policy for the use of heat as a non-pharmacological pain relief method, leading to confusion among staff about how to provide such interventions. These failures highlight the need for improved adherence to professional standards of practice and resident care plans to ensure effective pain management.
Medication Administration Errors Observed
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 12% error rate during a medication pass observation. Two residents were involved in the errors. For Resident 17, an LPN administered two chewable calcium carbonate tablets along with other medications in the same cup, which were meant to be chewed separately. Additionally, the LPN removed and applied a rivastigmine patch with bare hands, contrary to the facility's policy requiring gloves for such procedures. For Resident 6, the LPN administered an insulin injection without adhering to the proper technique. The LPN drew up 9 units of Admelog and injected it into the resident's abdomen without keeping the needle in the skin for the recommended duration to ensure absorption. This was against the facility's insulin administration policy, which specifies that the needle should remain in the skin for a count of five seconds. These actions were inconsistent with the facility's medication administration policies, contributing to the observed medication error rate.
Inaccurate Documentation of Glucometer Reading and Incomplete Post-Fall Assessments
Penalty
Summary
The facility failed to ensure accurate documentation for a resident's glucometer reading and post-fall assessments for another resident. During an observation, an LPN performed a glucose reading on a resident and recorded a reading of 177. However, the blood sugar summary provided later indicated a reading of 175 for the same time. This discrepancy highlights a failure in maintaining accurate medical records as confirmed by an RN who stated that blood sugar readings should be documented accurately. Additionally, the facility did not complete post-fall assessments for a resident who had a fall in the shower. The resident, who had diagnoses including hemiplegia and hemiparesis following a cerebral infarction, was dependent on assistance for activities of daily living. The post-fall assessment initiated on the day of the fall lacked documentation for several shifts, indicating incomplete charting. The Regional Nurse Consultant confirmed that all blanks should be filled on the fall assessment sheet, as per the facility's policy on documentation in medical records.
Deficiency in Daily Staffing Sheet Posting
Penalty
Summary
The facility failed to ensure that accurately completed staff sheets were posted daily for six out of seven days during the survey period. On multiple occasions, the posted staffing sheets, which were observed sitting on a table across from the nurse's station, lacked the designation of actual shift hours worked for various nursing staff, including RNs, LPNs, and CNAs. Specifically, the sheets did not include the actual hours worked for certain shifts, such as the 2 P.M. to 10 P.M. shift for LPNs and CNAs, and the 6 A.M. to 2 P.M. shift for RNs. This omission was noted on several dates, including 5/28, 5/29, 5/30, 5/31, 6/3, and 6/4. During an interview, the Director of Nursing (DON) indicated they were unaware of the requirement to designate the actual hours worked for half shifts on the staffing sheets. The facility's policy, revised in October 2022, mandates that the total number and actual hours worked by nursing personnel responsible for direct care be posted daily prior to each shift. Despite this policy, the facility did not comply with the requirement, leading to the noted deficiencies in the staffing sheets.
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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