Hillside Manor Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Washington, Indiana.
- Location
- 1109 E National Highway, Washington, Indiana 47501
- CMS Provider Number
- 155708
- Inspections on file
- 30
- Latest survey
- March 24, 2026
- Citations (last 12 mo.)
- 31 (1 serious)
Citation history
Health deficiencies cited at Hillside Manor Nursing Home during CMS and state inspections, most recent first.
Surveyors found multiple food safety and sanitation deficiencies, including an unclean, discolored backsplash with dried splatterings behind a three-compartment sink, uncovered cookie dough stored open to air in a freezer, and improper utensil handling when the DM repeatedly rested chicken-serving tongs against a sanitizing towel between uses during meal service. A live roach was observed on an outlet near the three-compartment sink, despite the DM stating she had not seen live roaches and that pest control visits routinely. Kitchen staff reported that food should be covered in the freezer and that staff are responsible for ongoing and end-of-shift cleaning, while facility policy required food service areas to be kept clean, sanitary, and protected from pests, with the food services manager responsible for scheduling regular cleaning.
A resident with a history of exit-seeking and psychiatric diagnoses eloped by climbing a gazebo and jumping a courtyard wall while unsupervised, despite prior incidents and documented risks. The resident was found by law enforcement after leaving the property, and staff had not updated the care plan or implemented additional interventions following previous escape attempts.
Surveyors identified multiple environmental and sanitation deficiencies, including warped and cracked flooring in a dining room, uncovered transport of clean linens, dust and rust on overhead vents, and a shared shower room with broken tiles, unclean conditions, and a swarm of gnats and flies. A resident reported ongoing maintenance issues, and facility policy requirements for cleanliness and safe linen handling were not met.
A resident with multiple psychiatric diagnoses did not receive several doses of a prescribed antipsychotic medication after a change in their routine medications, due to the facility's inability to obtain the medication from the pharmacy. Staff documented the medication as unavailable on multiple occasions, and interviews confirmed ongoing difficulties in securing the medication, despite facility policy requiring follow-up with the pharmacy and use of emergency drug kits.
The facility did not ensure a safe and comfortable environment, as water temperatures in a resident room and shower room reached 140°F, far above policy limits. Air temperatures in a dining room were recorded as high as 89°F during meals and activities, with residents observed fanning themselves and no fans in use. Multiple areas, including resident rooms and the dining room, had damaged flooring, water leaks, and ceiling damage due to malfunctioning AC units, resulting in wet and uneven floors.
The facility's assessment was found to be incomplete and inaccurate, lacking a staffing plan, specific training topics, transportation details, and communication plans for residents and staff with communication barriers. The Administrator was unaware that the assessment could include detailed facility-specific information and relied on a template updated annually without a specific policy in place.
The facility did not designate a certified Infection Preventionist (IP) for its infection prevention and control program. An LPN, acting as the IP, lacked specialized training and could only dedicate limited time to the role. The facility also lacked a policy or job description for the IP position.
A facility enforced a policy to crush all narcotic medications without resident input or specific physician orders, affecting 10 residents. This decision, made by the Administrator, Medical Director, and DON, was based on concerns about potential misuse of medications. Resident 5, experiencing severe pain, refused her medication due to the unpleasant taste of crushed pills, leading to its discontinuation. The facility lacked a formal narcotic administration policy and did not inform residents of the change beforehand.
The facility failed to ensure accurate MDS assessments for five residents, resulting in discrepancies in documenting medication administration. Residents with various diagnoses were not recorded as taking prescribed antiplatelet, diuretic, or oxygen therapies. The DON was unaware that aspirin is an antiplatelet medication, contributing to the inaccuracies.
The facility failed to develop comprehensive care plans for residents on medications such as antipsychotics, antidepressants, and diuretics. A resident with a history of substance abuse and on antipsychotic medication lacked a care plan. Another resident with COPD and on oxygen also lacked care plans for their medications. The DON acknowledged the absence of care plans and indicated that updates were done quarterly, but care plans were expected for each medication.
The facility failed to provide adequate respiratory care for several residents, including maintaining clean oxygen equipment and ensuring proper documentation of oxygen orders. Residents were observed with dusty filters and undated tubing, and there was confusion about equipment ownership and maintenance responsibilities.
The facility failed to obtain necessary physician orders for medications and oxygen for several residents. A resident with diabetes received insulin without a current order, and three residents lacked current oxygen orders due to a pharmacy change. The facility's pharmacy policy was not followed, leading to these deficiencies.
The facility failed to ensure proper labeling and storage of medications, with several instances of medications lacking open dates and incomplete refrigerator temperature logs. Observations included inhalers, eye drops, and other medications without open dates, and missing temperature records in the medication storage room. The DON confirmed the requirement for open dates on multidose medications and daily temperature logging, but the facility lacked a specific policy for open dates.
The facility failed to meet professional standards in food handling and kitchen sanitation. Staff did not wear proper hairnets or footwear, and food items were unlabeled. The dishwasher was not monitored for safe sanitation, with temperatures below the required minimum and no chemical checks documented. Handwashing protocols were not followed, and scoops were left in containers. The facility's policies on dishwashing, food storage, hairnet use, and thermometer sanitation were not adhered to.
The facility failed to ensure a sanitary environment, with staff not changing gloves between tasks, not sanitizing hands, and not implementing Enhanced Barrier Precautions for residents with wounds and catheters. Clean clothing was transported improperly, and ice was handled inappropriately, indicating a lack of adherence to infection control protocols.
The facility failed to ensure a safe, sanitary, and homelike environment, with issues such as brown substances around toilets, rusted fixtures, chipped doors, and missing tiles in communal restrooms and shower rooms. A couch had peeled fabric, and a courtyard door had a gap. The Maintenance Supervisor, also the Housekeeping Supervisor, was unaware of some issues and indicated a lack of formal policies and documentation for maintenance and cleaning tasks.
The facility failed to maintain an effective pest control program, as evidenced by the presence of insects and rodents in the downstairs dry storage room. Sticky pads were found full of insects and a dead mouse, with a live mouse also observed. The pest control company had visited recently but reported no concerns, despite ongoing issues with mice. The facility's policy required the building to be kept free of pests, but this was not achieved.
A facility failed to assess the clinical appropriateness of self-administration of medications for a resident with COPD and asthma. An Albuterol inhaler was found in the resident's room without an order to keep it at the bedside or a self-administration assessment. The resident was cognitively intact, but the facility did not follow its policy requiring an assessment by an interdisciplinary team.
The facility failed to update comprehensive care plans for three residents. A resident's care plan did not include bed rails as a fall intervention, another resident's care plan listed an outdated antidepressant, and a third resident's care plan was not revised after an antianxiety medication was discontinued. The DON acknowledged these oversights, noting that she was the only staff member able to update care plans in the electronic health record.
A resident at risk for pressure ulcers developed multiple stage two and a stage three pressure injury due to the facility's failure to provide effective care and documentation. Despite the resident's reports of pain and the presence of wounds, staff were unaware of the injuries, and there were inconsistencies in treatment records. The facility did not adhere to its pressure ulcer program policy, leading to inadequate assessments and care plans.
The facility failed to supervise and manage vaping devices among residents, leading to safety hazards. Two residents were found with vapes despite policies requiring storage at the nurse's station. Resident 15, with a history of substance abuse, had vapes on his bedside table, and staff did not address this. Resident 24, with cognitive impairment, was observed holding vapes, and staff failed to intervene. Staff interviews revealed inconsistencies in handling and documenting vaping incidents, and the facility's smoking policy was unclear.
The facility failed to maintain complete and accurate clinical documentation for two residents. One resident's records lacked details about an incident involving THC use and subsequent hospitalization, while another resident had an undated Band-Aid with no documented reason. Staff interviews revealed uncertainty and incomplete records, highlighting deficiencies in documentation practices.
The facility failed to provide adequate staff training for managing residents with substance abuse and PTSD. A resident with a history of substance abuse lacked a care plan for overdose risk, and staff were not trained on Narcan use. Another resident with PTSD had specific needs that were not addressed due to insufficient staff training.
A resident with severe cognitive impairment and documented behaviors eloped from the facility unwitnessed due to insufficient behavioral health care. The resident's care plan was not updated, and the incident was not documented in progress notes. The facility's behavior management program policy was not followed, and the resident's behavioral tracking log was missing.
The facility failed to maintain accurate records for two residents. One resident's elopement incident and behaviors were not documented, and another resident's wound treatment orders were not updated or recorded properly. Staff interviews confirmed the lack of proper documentation.
Food Storage, Sanitation, and Pest Control Deficiencies in Kitchen
Penalty
Summary
Surveyors identified that the facility failed to store and handle food in accordance with food safety standards during two kitchen observations. During one observation, the backsplash behind the three-compartment sink appeared unclean, discolored, and had several dried splatterings. In a downstairs standing freezer, surveyors found an open bag of individual cookie dough balls exposed to air. Kitchen Staff 4 later stated that food should be covered when stored in the freezer and that staff are responsible for cleaning during their shifts and performing a full kitchen cleaning at the end of each shift. In a separate observation during meal service, the Dietary Manager used a pair of tongs to plate chicken and repeatedly set the tongs down on a tabletop so that the serving end rested against a cleaning towel that had been dipped in sanitizing solution, then used the same tongs to plate the next piece of chicken. Additionally, a live roach was observed on an outlet near the three-compartment sink. The Dietary Manager reported not having seen any live roaches in the kitchen and indicated that pest control visits the facility routinely. The facility’s written sanitization policy required that food service areas be kept clean, sanitary, and protected from rodents, roaches, flies, and other insects, and assigned the food services manager responsibility for scheduling regular cleaning of kitchen and dining areas.
Failure to Prevent Elopement of Resident with Exit-Seeking Behaviors
Penalty
Summary
The facility failed to provide adequate supervision and prevent accident hazards for a resident with a known history of exit-seeking and elopement behaviors. The resident, who had diagnoses including anxiety, depression, unspecified psychosis, schizophrenia, and pedophilia, was assessed as having moderately impaired cognitive skills and required supervision for mobility and transfers. Despite a care plan identifying the resident as at risk for elopement and documenting previous incidents of exit-seeking, interventions such as personal safety alarms or devices were not implemented. The resident had previously exhibited exit-seeking behaviors, including climbing over a courtyard wall when frightened by EMTs and moving furniture to facilitate escape attempts. On the evening of the incident, the resident climbed a gazebo in the facility's walled courtyard, jumped over the 66-inch wall, and left the property. The event occurred while the nurse was occupied assisting EMS with another resident, leaving the at-risk resident unsupervised. The resident was located approximately 0.6 miles from the facility, hiding behind an air conditioning unit near a busy intersection, and attempted to flee from law enforcement before being apprehended. The facility's records and staff interviews confirmed that the resident had previously used the same method to attempt elopement and that staff were aware of the resident's behaviors and triggers, such as being frightened by EMS presence. The facility's policy required that residents identified as at risk for wandering or elopement have care plans with appropriate interventions to maintain safety. However, the resident's care plan and supervision were not updated in response to repeated exit-seeking behaviors and prior incidents. Staff interviews indicated that elopement risk assessments and care plan updates were not consistently performed when the resident exhibited increased exit-seeking behavior, contributing to the failure to prevent the elopement event.
Removal Plan
- Completed audits of clinical records for residents at risk for exit-seeking behavior or elopement.
- Removed the Gazebo from the courtyard.
- Removed a tree in the courtyard.
- Secured patio furniture.
- Equipped all exit doors with Wander-guard key pad.
- Provided in-service training to staff on the elopement exit seeking policy.
- Monitoring changes in residents' behavior.
Environmental and Sanitation Deficiencies in Resident Areas
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's environment, including a lack of maintenance and cleanliness in key resident areas. In the North Unit dining room, the flooring was found to be uneven, warped, and cracked, with a towel placed under an in-wall air conditioning unit. Clean linens were transported through the South Unit in an open laundry basket, exposing them to potential contamination. Overhead air vents in both the North Unit hall and the shared shower room were noted to have a significant build-up of dust, and one vent appeared rusted. The shared shower room in the middle hall, used by residents from both the North and South Units, had three broken floor tiles near the base of the commode, which itself appeared unclean. A small swarm of gnats and flies was observed around the commode, indicating unsanitary conditions. During an interview, a resident reported that the shower room required maintenance and that the maintenance staff could not keep up with the facility's needs. Facility policy requires the environment to be safe, functional, sanitary, and comfortable, and for clean linens to be transported in a manner that prevents contamination, but these standards were not met in the areas observed.
Failure to Provide Ordered Routine Medication Due to Pharmacy Service Issues
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of a resident who required routine physician-prescribed medication. Following a change in the resident's medication regimen, the facility did not obtain the ordered medication, Geodon 40 mg, resulting in multiple missed doses over several days. Documentation in the Medication Administration Record and nurse's progress notes repeatedly indicated that the medication was unavailable or not in stock on specific dates. The resident's diagnoses included anxiety, depression, unspecified psychosis, schizophrenia, and pedophilia, and the resident was noted to have moderately impaired cognitive skills and was rarely to never understood. Interviews with staff revealed ongoing difficulties in obtaining the medication from the pharmacy, attributed in part to the resident's payor source. Nursing staff reported that when a routine medication was unavailable, they were expected to check the emergency drug kit, document missed doses, and notify the physician. Despite these procedures, the resident did not receive the prescribed medication as ordered, and the facility's policy required contacting the pharmacy and using after-hours emergency numbers if necessary. The deficiency was identified through record review and staff interviews, confirming that the facility did not ensure the resident received all ordered medications.
Failure to Maintain Safe, Sanitary, and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, sanitary, and homelike environment in several areas, as evidenced by observations and interviews. In one resident room and one shower room, water temperatures were found to be excessively high, reaching 140 degrees Fahrenheit, which exceeds the facility's policy limit of 120 degrees Fahrenheit. The Maintenance Director confirmed that these temperatures were too high and indicated that adjustments would be made. Additionally, a resident reported a lack of hot water in their restroom and shower room, further highlighting inconsistencies in water temperature regulation. In the North Unit dining room, air temperatures were consistently recorded as excessively high, with the thermostat indicating temperatures between 85 and 89 degrees Fahrenheit during meal times and activities. Residents were observed fanning themselves, and staff confirmed that the dining room became uncomfortably hot during a recent heat wave. No fans were in use to mitigate the heat, and the air conditioning unit was not functioning adequately. The Maintenance Director reported that the AC unit had frozen and required servicing, and an external HVAC company was scheduled to address the issue. Multiple areas of the facility were found to be in disrepair. In one resident room, a ceiling tile was damaged and stained due to a leaking AC unit, with an air vent and duct hanging from the ceiling. The same room had a hole and soft spot in the floor, and the closet floor was patched with plywood. Another resident room had broken flooring near the doorway. The North Unit dining room had a leaking AC unit, resulting in a wet, uneven, and soft floor, with water seeping through cracks. These conditions were confirmed by the Maintenance Director, who attributed the damage to previous incidents and ongoing maintenance issues.
Incomplete Facility Assessment Lacks Critical Details
Penalty
Summary
The facility failed to ensure a complete and accurate facility assessment that was based on the resident population and the identification of resources needed to provide necessary care and services. During the survey, it was found that the facility assessment form, revised on January 17, 2024, listed facility personnel but lacked a staffing plan to ensure sufficient staff were available to meet resident needs. The form also omitted training topics and competencies specific to the facility, transportation information including the use of a facility van, Enhanced Barrier Precautions, resident equipment, use of oxygen therapy, pharmacy information, and the facility's plan for communication with residents and staff who have communication barriers. The Administrator indicated that she was unaware that the facility assessment could include specific detailed information about the facility. She mentioned that a template was used to fill out the current facility assessment, which was updated annually, and that there was no facility policy in place, but regulation guidelines were followed to complete the assessment.
Lack of Certified Infection Preventionist in Facility
Penalty
Summary
The facility failed to ensure the designation of a certified Infection Preventionist (IP) responsible for the infection prevention and control program. The current IP, an LPN, indicated that she did not have any specialized training or certification for the role and was only able to dedicate approximately 3-4 hours per week to the infection control program. Additionally, the facility's Administrator, through the Activity Director, confirmed that there was no policy or job description for the Infection Preventionist, and the role was simply assigned to someone without formal designation or training.
Facility's Blanket Policy on Crushing Narcotics Violates Resident Rights
Penalty
Summary
The facility failed to uphold residents' rights to participate in the development and implementation of their person-centered care plans by enforcing a blanket policy to crush all narcotic medications without resident input or obtaining specific physician orders. This policy affected 10 out of 32 residents reviewed for narcotic use. The decision to crush narcotics was made by the facility's Administrator, Medical Director, and Director of Nursing (DON) due to concerns about residents potentially hoarding or trading pills. However, this decision was implemented without consulting the residents or considering individual needs, leading to some residents, like Resident 5, refusing their medication due to the unpleasant taste of crushed pills. Resident 5, who suffered from severe pain, had her narcotic medication discontinued because she refused to take it in crushed form. Despite her complaints and the absence of any suspicion of her hoarding or selling narcotics, the facility continued with the policy. The facility did not have a formal narcotic administration policy, and the residents were not informed of the change prior to its implementation. The facility's actions were based on unverified concerns about residents' misuse of medications, and the policy was enforced without proper documentation or physician orders for each affected resident.
Inaccurate MDS Assessments for Medication Administration
Penalty
Summary
The facility failed to ensure accurate Minimum Data Set (MDS) assessments for five residents, leading to discrepancies in the documentation of medication administration. Resident 16, who had diagnoses including COPD, anemia, and atrial fibrillation, was not recorded as taking antiplatelet medication or using oxygen, despite physician orders for aspirin and oxygen therapy. Similarly, Resident 28, with diagnoses of cerebral infarction, anemia, and heart failure, was not documented as using antiplatelet or diuretic medications, although physician orders indicated daily aspirin and furosemide. Resident 25, diagnosed with schizophrenia, renal insufficiency, and thyroid disorder, was not marked as taking antiplatelet medication, despite an order for daily aspirin. Resident 7, with diabetes mellitus, depression, and cancer, was also not recorded as taking antiplatelet medication, although there was an order for daily aspirin. The Director of Nursing was unaware that aspirin is an antiplatelet medication, indicating a lack of knowledge that contributed to the inaccurate MDS assessments.
Failure to Implement Comprehensive Care Plans for Residents on Medications
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for six residents who were on various medications, including antipsychotics, antidepressants, antianxiety, diuretics, and oxygen. The deficiency was identified through observation, interviews, and record reviews. For instance, Resident 15, who had a history of substance abuse and was taking antipsychotic medication, did not have a care plan addressing these issues. The Director of Nursing (DON) acknowledged that care plans should have been in place but indicated that she was the only staff member capable of entering care plans into the electronic health record. Resident 16, who had diagnoses including COPD, anemia, and atrial fibrillation, was on medications such as antiplatelets, anticoagulants, and diuretics, and required oxygen. However, the clinical record lacked care plans for these medications and oxygen use. Similarly, Resident 28, with diagnoses of cerebral infarction, anemia, and heart failure, was taking antidepressants, antiplatelets, and diuretics, but did not have corresponding care plans. The DON confirmed that care plans should have been implemented for these medications and treatments. Other residents, such as Resident 7, Resident 25, and Resident 6, also lacked appropriate care plans for their prescribed medications, including antidepressants, antiplatelets, antipsychotics, and diuretics. The DON indicated that care plans were updated quarterly and with the MDS, but acknowledged the expectation for care plans to be in place for each specific medication administered to residents. The facility's care planning policy, dated May 2013, required comprehensive care plans for each resident, which were not adhered to in these cases.
Failure to Provide Adequate Respiratory Care
Penalty
Summary
The facility failed to provide necessary respiratory care and services in accordance with professional standards for several residents. Resident 6's oxygen tank was observed with debris, and the filter was caked with dust. Despite having a care plan that included oxygen as an intervention, Resident 6's clinical record lacked a current order for oxygen. The resident was using oxygen at night due to a sleep study, but there was no documentation or order in the clinical record to support this. Resident 5 was observed using an oxygen concentrator without a filter, and the tubing was undated. The resident's clinical records indicated diagnoses of COPD, emphysema, and asthma, but lacked orders to change the oxygen tubing and clean the filter. The care plan did not include interventions for changing the tubing or cleaning the filter. There was confusion about the ownership and maintenance of the oxygen concentrator, with conflicting information from the DON, the resident, and the Administrator. Resident 23 was observed with undated oxygen tubing and a dust-covered filter on the oxygen concentrator. The resident's clinical records indicated a diagnosis of COPD with acute exacerbation, but lacked orders to change the tubing and clean the filter. Similarly, Resident 14 was observed with a dust-covered filter on the oxygen concentrator and lacked a current physician order for oxygen. The facility's respiratory therapy policy required changing the oxygen cannula and tubing every seven days and washing the filters weekly, but these actions were not documented or consistently performed.
Deficiency in Obtaining Physician Orders for Medications and Oxygen
Penalty
Summary
The facility failed to ensure that all physician's orders were obtained from the pharmacy for certain residents, leading to deficiencies in medication administration and respiratory care. Specifically, Resident 2, who has a severe cognitive impairment and diabetes mellitus, did not have a current physician order for Tresiba Flextouch insulin, despite receiving it daily as indicated in the August blood sugar log. This oversight was confirmed by RN 5 and the Director of Nursing (DON), who provided evidence of the insulin administration without a corresponding physician order. Additionally, the facility did not have current physician orders for oxygen for Residents 14, 5, and 23. Resident 14, who has a mild cognitive impairment and uses oxygen, was observed with oxygen administered via nasal cannula, but lacked a current order for it. The DON explained that a change in pharmacy at the beginning of August resulted in the failure to transfer oxygen orders from the previous pharmacy to the current one. The facility's pharmacy policy requires maintaining a medication profile for each resident, but this was not adhered to, contributing to the deficiency.
Medication Storage Deficiencies
Penalty
Summary
The facility failed to maintain safe and secure storage of medications, as observed in two medication carts and one medication storage room. During the review of the Back Hall Medication Cart, several medications were found without open dates, including an Albuterol Sulfate inhaler, Breyna inhaler, and allergy relief nasal spray. Additionally, a ferrous sulfate pill was found in a medication cup without identification, and a Trelegy Ellipta inhaler was observed with an open date of 5/21/24. Another Trelegy Ellipta inhaler had a tag to discard after six weeks but lacked an open date. Furthermore, Neo/Poly/HC otic drops, which should have been discarded after 8/22/24, were still present in the drawer. In the Back Hall Medication Storage Room, the medication refrigerator temperature log was incomplete, with missing entries for several days in August 2024. The Front Hall Medication Cart also had medications without open dates, such as Polymyxin B TMP eye drops and artificial tears. A Ventolin inhaler was found with an open date of 6/30/23 and an expiration date of 6/30/24. The Director of Nursing confirmed that multidose medications should have open dates, and the medication refrigerator temperature should be logged daily. The facility's Medication Storage Policy, dated 5/2013, requires daily monitoring of refrigerator temperatures, but there was no specific policy for open dates on multidose medications, although it was their practice to do so.
Deficiencies in Kitchen Sanitation and Food Handling
Penalty
Summary
The facility failed to adhere to professional standards in food storage, preparation, distribution, and service, as observed in the kitchen. Staff members did not wear hairnets that adequately covered all their hair, and inappropriate footwear was noted. Additionally, food items were not properly labeled, and the dishwasher was not monitored daily for safe sanitation. Observations revealed that the dishwasher's temperature was below the required minimum, and there was no documentation of chemical checks. Staff members also did not wash their hands for the appropriate length of time, and scoops were left in containers, which is against the facility's policies. During the inspection, it was noted that the kitchen lacked soap in the handwashing sink, and the Dietary Manager and Kitchen Staff 1 did not wear hairnets that fully covered their hair. The freezer and refrigerator contained opened and unlabeled food items, and there was stagnant water in the freezer room. The dishwasher was not properly checked for chemical levels, and the staff was unaware of the correct procedures for ensuring sanitation. Interviews with the Dietary Manager and Maintenance Supervisor revealed a lack of training and knowledge regarding the dishwasher's operation and chemical monitoring. Further observations showed that the ice scoop was left uncovered on a dusty machine, and staff members did not follow proper handwashing protocols. The Dietary Manager used a washcloth to clean a thermometer probe, which was not in line with the facility's policy. The facility's policies on dishwashing machine use, food receiving and storage, hairnet use, and thermometer sanitation were not followed, leading to the deficiencies noted during the survey.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain a safe, sanitary, and comfortable environment, leading to the potential transmission of infections. Observations revealed that staff did not change gloves between dirty and clean tasks, nor did they sanitize their hands between glove changes. In one instance, a resident was not completely cleaned during incontinence care, and fecal matter was transferred onto the resident's back and clean sheet. Additionally, staff did not offer residents the opportunity to wash their hands after toileting, which is a basic hygiene practice. The facility also failed to implement Enhanced Barrier Precautions (EBP) for residents with wounds, urinary catheters, and a stoma. The Director of Nursing was unaware of any residents on EBP, and the Infection Preventionist did not know what EBP was. This lack of knowledge and implementation of EBP could contribute to the spread of infections among vulnerable residents. Furthermore, clean clothing was not handled properly, as staff transported it uncovered and against their uniforms, risking contamination. Ice was also transported inappropriately in a trash bag, which was then used to serve residents. These practices indicate a lack of adherence to infection control protocols, potentially compromising resident safety and health.
Facility Fails to Maintain Safe and Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe, sanitary, and homelike environment in several areas, including a communal restroom and three shower rooms. Observations revealed various issues such as a brown substance around the bottom of toilets, rusted toilet paper holders, chipped doors, and missing tiles in the shower rooms. Additionally, there were gnats on the floor, spiderwebs on the ceiling, and soiled grout. These deficiencies were consistently observed over multiple days, indicating a lack of timely maintenance and cleaning. Further observations included a couch in a common area with peeled fabric and a courtyard door with a three-quarter inch gap, which the Maintenance Supervisor was unaware of and unable to fix immediately. The Maintenance Supervisor, who also served as the Housekeeping Supervisor, indicated there were no formal policies for maintenance or housekeeping, and tasks were not documented. Despite daily walkthroughs and a cleaning schedule, the facility failed to address these issues promptly, leading to the observed deficiencies.
Pest Control Deficiency in Storage Room
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by observations made in the downstairs dry storage room. On two separate occasions, a sticky pad intended for catching insects and rodents was found full of insects, with a dead mouse attached to it. Additionally, a live mouse was observed stuck to the sticky pad, and flying insects, both dead and alive, were present in the area. The refrigerator door in the storage room was not properly closed, which may have contributed to the presence of flying insects. The facility's pest control contract indicated that the pest control company was scheduled to visit monthly, with additional visits in January, to monitor for specific pests such as spiders, mice, and German cockroaches. Despite this arrangement, the facility had ongoing issues with mice, which the Administrator was not aware of until notified. The pest control company had visited approximately two weeks prior and reported no concerns. The facility's Pest Control Policy, dated January 2024, stated that the building should be kept free of insects and rodents, with maintenance services assisting as necessary.
Failure to Assess Self-Administration of Medications
Penalty
Summary
The facility failed to determine the clinical appropriateness of self-administration of medications for a resident. An Albuterol inhaler was found in the room of a resident diagnosed with chronic obstructive pulmonary disease (COPD) and asthma, without an order to keep it at the bedside or a self-administration assessment. The resident was cognitively intact according to the most recent Minimum Data Set (MDS) assessment. The physician's order for the inhaler did not specify that it should be kept at the bedside, and the clinical record lacked a self-administration assessment. The facility's policy required an interdisciplinary team to assess each resident's cognitive and physical abilities to determine if self-administration of medications was safe and clinically appropriate, but this was not done for the resident in question.
Failure to Update Comprehensive Care Plans
Penalty
Summary
The facility failed to ensure that comprehensive care plans were reviewed and revised for three residents. For Resident 2, the care plan was not updated to include the use of bed rails as a fall intervention, despite the resident being observed with a bed rail in use and having a severe cognitive impairment requiring extensive assistance. The Director of Nursing (DON) acknowledged that the care plan should have included the bed rail intervention. Resident 16's care plan was outdated, as it still listed Lexapro as the antidepressant medication, even though the resident was currently prescribed venlafaxine. The DON admitted to not updating care plans with specific medication names due to potential changes. Similarly, Resident 15's care plan was not revised to reflect the discontinuation of Klonopin, an antianxiety medication, and the current use of Hydroxyzine, which is not classified as an antianxiety medication. The DON was the only staff member capable of updating care plans in the electronic health record, which contributed to the oversight.
Failure to Prevent and Manage Pressure Injuries
Penalty
Summary
The facility failed to provide effective services to prevent the development of pressure injuries for a resident who was admitted without any pressure ulcers but was identified as being at risk. The resident, who had a history of cerebral infarction, anemia, and heart failure, required extensive assistance with mobility and was incontinent of bowel. Despite being at risk, the resident developed multiple stage two pressure injuries and a stage three pressure injury over time. The facility's records showed inconsistencies and omissions in documenting the resident's skin condition and wound treatments. Observations revealed that the resident had been experiencing pain in the buttocks for several weeks, which he had reported to the staff. However, the clinical records lacked specific care plans for the actual pressure ulcers, and there were missing entries for wound treatments in August. The facility's staff, including the DON and LPN, were unaware of the resident's wounds until they were observed during incontinence care. The staff failed to perform hand hygiene before and after providing care, and there was a lack of timely notification and documentation of new wounds. The facility's pressure ulcer program policy required comprehensive assessments and individual care plans for residents at risk, but these were not adequately implemented for the resident. The DON indicated that risk assessments would only be updated with significant health changes, and the resident's record lacked updated care plans for the new wounds. The facility's failure to adhere to its policy and ensure proper wound care and documentation contributed to the development and worsening of the resident's pressure injuries.
Inadequate Supervision and Management of Vaping Devices
Penalty
Summary
The facility failed to ensure adequate supervision and management of vaping devices among residents, leading to potential safety hazards. During observations, two residents were found with vapes in their possession, despite facility policies requiring these devices to be stored at the nurse's station and used only in designated smoking areas. Resident 15, who has a history of substance abuse, was observed with vapes on his bedside table, and staff members, including a Qualified Medication Aide and the Dietary Manager, did not address the presence of these devices. The resident's clinical record lacked a care plan addressing his history of substance abuse and risk of overdose, and there was no documentation of a previous incident where the resident allegedly smoked a THC-containing vape, resulting in a change of condition and hospitalization. Resident 24, who has moderate cognitive impairment and requires extensive assistance, was observed holding vapes on multiple occasions. Despite a behavior care plan indicating the need to remind the resident to return vaping materials to staff, the resident was seen with vapes in his possession, and staff did not intervene. An anonymous resident reported that vaping and smoking occurred in the building, affecting their allergies. A Registered Nurse acknowledged that some residents, including Resident 24, were reluctant to return vapes to staff, and there was confusion among staff about the facility's policy on vapes. Interviews with facility staff, including the Director of Nursing and the Social Services Director, revealed inconsistencies in the handling and documentation of vaping incidents. The facility's smoking policy, dated October 2021, did not require a smoking evaluation for e-cigarette use, and vapes were to be kept at the nurse's station. However, staff were unclear about the policy, and there was a lack of documentation regarding incidents involving vapes. The Administrator admitted to wanting to change the policy but had not done so, contributing to the ongoing issue of residents possessing and using vapes within the facility.
Incomplete Clinical Documentation for Two Residents
Penalty
Summary
The facility failed to ensure complete and accurate clinical record documentation for two residents. For Resident 15, the clinical record lacked documentation related to an incident where the resident allegedly smoked a vape containing THC, leading to a change in condition and hospitalization. The Administrator and DON were unsure of the exact details and dates, and the clinical record did not reflect the incident accurately. The resident admitted to smoking a vape from a local gas station, which led to unconsciousness and hospitalization. However, the Administrator later clarified that the hospitalization was due to sepsis from a fall, not the THC incident, indicating a lack of accurate documentation. For Resident 23, the facility failed to document the reason for a Band-Aid on the resident's left lower arm. The resident was observed with multiple bruises and an undated Band-Aid, but the clinical records and physician orders did not provide any information about a dressing or skin issue. Interviews with staff, including a QMA and LPN, revealed that they were unaware of the reason for the Band-Aid, and the nursing notes lacked documentation. The DON acknowledged that dressings should be dated, but there was no indication of a wound when the Band-Aid was removed, highlighting incomplete documentation.
Deficiency in Staff Training for Substance Abuse and PTSD
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for staff, which led to deficiencies in care for residents with specific needs. Resident 15, who had a history of substance abuse, was not provided with a care plan addressing the risk of overdose. Despite being prescribed Norco, a narcotic pain medication, there was no plan in place to manage the resident's substance abuse history. Additionally, staff were not trained on the use of Narcan, a medication used to treat narcotic overdoses, as evidenced by an LPN's uncertainty about its location and administration. Resident 24, diagnosed with PTSD, was also affected by the lack of staff training. The resident expressed that knocking on the door was a trigger, yet there was no indication that staff were trained to accommodate this need. The Director of Nursing confirmed the absence of specific in-services for PTSD, substance abuse, or Narcan administration, relying instead on common nurse knowledge. The facility lacked a policy for required in-services, contributing to the deficiency in addressing the residents' needs.
Failure to Provide Sufficient Behavioral Health Care Leading to Resident Elopement
Penalty
Summary
The facility failed to provide sufficient behavioral health care for a resident with documented behaviors, resulting in the resident eloping from the facility unwitnessed. The resident, who had severe cognitive impairment and used a wheelchair for mobilization, was upset about not being able to obtain cigarettes and exited the facility courtyard through an unlocked gate. The incident was not documented in the resident's progress notes, and the resident's care plan was not updated following the elopement. Additionally, the resident's behavioral tracking log was missing from their record, and the facility's behavior management program policy was not followed. The resident's diagnoses included undifferentiated schizophrenia, acquired absence of the right leg below the knee, partial traumatic amputation of the left midfoot, and nicotine dependence. Despite having a care plan that included interventions for behavior problems, the facility did not provide additional monitoring or services during the behavioral episode. The resident's physician orders included Lorazepam for agitation, but the medication was not administered during the month of the incident. Interviews with staff revealed that the resident had not previously attempted to elope and was not considered exit-seeking prior to the incident.
Failure to Maintain Accurate Resident Records
Penalty
Summary
The facility failed to maintain complete and accurate records for two residents. For Resident B, there was no documentation of an elopement incident, the behaviors leading up to it, or any monitoring following the event. Resident B's diagnoses included undifferentiated schizophrenia, acquired absence of the right leg below the knee, partial traumatic amputation of the left midfoot, and nicotine dependence. Despite an incident where Resident B exited the facility to buy cigarettes, no records reflected this occurrence or the resident's behavior before and after the event. For Resident C, the facility did not update wound treatment orders in the resident's record, nor did they document wound treatment changes as required. Resident C, diagnosed with quadriplegia, overactive bladder, and neurogenic bowel, had specific wound care orders that were not consistently followed or recorded. The treatment administration record showed incomplete documentation, and interviews with staff confirmed that updates from the wound care center were not properly recorded in the resident's records. The DON acknowledged that maintaining accurate records is part of the nurse's job description, but there was no specific policy for documentation.
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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