Holy Cross Rehabilitation And Wellness
Inspection history, citations, penalties and survey trends for this long-term care facility in South Bend, Indiana.
- Location
- 17475 Dugdale Dr, South Bend, Indiana 46635
- CMS Provider Number
- 155506
- Inspections on file
- 26
- Latest survey
- March 13, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Holy Cross Rehabilitation And Wellness during CMS and state inspections, most recent first.
Two residents with non-pressure wounds did not receive wound care according to physician orders, and treatments were not accurately documented. One resident with a surgical scrotal/perineal wound had an order for NPWT, but the DON removed the existing dressing, unsuccessfully attempted to apply a wound vac, did not obtain a new order, and instead used wet-to-dry packing and adaptic without updating the physician’s orders, and the TAR lacked a signed-out treatment for the ordered date. Another resident with a left plantar foot ulcer had a detailed physician order for iodoform packing, betadine-soaked gauze, dry 4x4, kerlix, and ace wrap; however, the TAR showed the treatment as completed while an RN later removed a foam dressing applied the same day and stated it was the wrong dressing, confirming the ordered regimen was not followed despite being signed out as done.
A resident with a non-pressure ulcer on the left foot, along with heart failure and anemia, underwent a wound dressing change during which an RN contaminated gloves by rummaging through dresser drawers for tape and then resumed handling the Kerlix dressing without performing hand hygiene or changing gloves. The RN also demonstrated uncertainty about whether a gown was required to re-enter the room and apply tape for a resident on Enhanced Barrier Precautions, reflecting a lack of understanding of appropriate PPE use during wound care.
Multiple residents with significant care needs experienced prolonged call light wait times, sometimes exceeding two hours, resulting in soiled conditions and emotional distress. Staff often failed to respond promptly or turned off call lights without providing assistance, and grievances about these delays were not consistently resolved or documented. The facility lacked a clear policy or monitoring system for timely call light response, and staff education did not specifically address this issue.
The facility did not resolve ongoing concerns from the Resident Council about long call light response times, with multiple residents reporting continued delays and documented instances of call lights going unanswered for over an hour. Despite awareness of the issue and repeated interventions, including staff education and monitoring, the problem persisted and residents continued to experience significant wait times.
A resident with multiple diagnoses was discharged, but the Discharge MDS assessment was not completed and submitted until 122 days later. The DON confirmed the delay and noted the absence of a facility-specific policy for MDS completion, relying instead on the RAI manual.
Two residents did not have comprehensive care plans addressing their specific clinical needs. One resident with cognitive impairment and chronic conditions received multiple medications for constipation without a care plan for bowel management. Another resident with a G-tube developed abdominal blisters from tubing friction, but no care plan was in place to address skin integrity or G-tube care. Nursing staff confirmed the absence of these care plans and indicated reliance on general nursing standards rather than specific facility policies.
A resident with a G-tube developed multiple blisters on the abdomen due to friction from the tubing. An LPN observed the blisters and attributed them to the tubing being too long, but there was no documentation of provider notification, treatment orders, or an updated care plan. The CCC was verbally informed but did not follow up, and the DON confirmed that no care plan was created after the initial blister.
A resident with bipolar disorder was prescribed an antipsychotic medication, but the required AIMS assessments to monitor for side effects were not completed as recommended by the pharmacy and outlined in the care plan. Staff interviews revealed confusion about the monitoring process and a lack of a written policy regarding the frequency of AIMS assessments.
A kitchen sink was found leaking and with a faucet that could not be turned off, and the issue was not properly communicated or addressed by staff. The Dietary Manager believed Maintenance was aware and waiting for a part, but the Maintenance Director had not received a work order and was unaware of the problem. The Registered Dietician was also unaware of the issue, despite regular rounds. Facility policies assign responsibility for kitchen maintenance and monitoring to the Director of Dining Services and the Registered Dietitian.
Staff failed to follow enhanced barrier precautions for two residents requiring isolation due to indwelling medical devices. In one case, a CNA entered a resident's room and assisted with a transfer without wearing a gown or mask, and in another, an LPN performed a gastrostomy tube flush while only wearing gloves. Both residents had physician orders and care plans indicating the need for EBP, but staff did not adhere to facility policy.
Surveyors found that water faucets in four rooms were either leaking, missing, or could not be turned off, with one resident reporting the issue had persisted for some time despite being reported. The Maintenance Director stated that repairs were delayed due to waiting for parts and a tool, and no documentation of maintenance actions was provided. The facility lacked a policy for building maintenance.
A resident with impaired cognition and a history of cerebrovascular accident and osteoporosis was injured after being transferred by a CNA without the required assistance of a second staff member, as specified in the care plan. The incident resulted in a non-displaced fracture of the resident's right tibia and fibula, leading to hospital admission. The facility lacked a policy on following care plans, and the CNA did not provide a reason for the incorrect transfer.
The facility failed to maintain appropriate food temperatures for meal trays on St. Paul's Unit, affecting 21 residents. A resident reported consistently receiving cold meals, and an observation confirmed that food temperatures were below the required serving level. The Dietary Project Manager acknowledged the issue and initiated reheating of all meal trays.
The facility was found to have multiple sanitation and food storage deficiencies. Ice scoops were improperly stored, and various food items were expired or undated. A Sous Chef prepared food without a hair restraint, and a CNA assisted a resident with bare hands, indicating a lack of clear hygiene guidance. Additionally, food brought in by outside sources was improperly labeled and stored, with staff food found in resident refrigerators, violating facility policies.
A resident with a history of partial foot amputation and diabetes was hospitalized for pneumonia, but the facility failed to provide the required notice of transfer/discharge or bed hold policy. The DON confirmed the lack of documentation and absence of a policy for hospital transfers, although a checklist was available.
A facility failed to create a person-centered care plan for a resident with major depressive disorder, chronic obstructive pulmonary disease, and heart failure. The care plan noted mood and behavior concerns but lacked specific interventions for the resident's triggers. The Assistant Director of Nursing confirmed the absence of person-centered interventions, and the DON stated there was no policy for such care plans.
The facility failed to revise care plans and hold quarterly care conferences for two residents. One resident had inconsistent application of a prescribed splint, and their family had not been invited to a care conference for over a year. Another resident's family reported a similar lack of care conferences. The DON confirmed these deficiencies, and the facility could not provide relevant policies during the survey.
Two residents in an LTC facility did not receive adequate assistance with ADLs, leading to deficiencies in personal hygiene and care. One resident, dependent on staff for hygiene, had long and dirty fingernails over several days, with infrequent bed baths documented. Another resident, requiring extensive assistance, was not shaved regularly and reported not being turned every two hours, as needed. The DON acknowledged gaps in care provision and the absence of specific policies for turning and repositioning.
A resident with a history of cardiovascular accident and limited range of motion did not receive the prescribed left hand splint as ordered. Observations showed the splint was often not applied, despite physician orders to use it upon rising. Staff interviews revealed inconsistencies in following these orders, with an LPN admitting to delayed application due to workload. The facility lacked a policy for splints or braces, contributing to the deficiency.
The facility failed to label medications in the med cart according to professional standards. An LPN found a bottle of milk of magnesia without a pharmacy label or resident identification in the cart. The facility's policy requires medications with missing labels to be destroyed and reordered.
The facility failed to follow infection control standards for two residents. An RN did not wash hands before donning gloves for a blood glucose check, and an LPN did not wear a gown during a wound dressing change for a resident under Enhanced Barrier Precautions. The LPN cited the unavailability of PPE as the reason for non-compliance, and the facility lacked a specific policy on dressing changes.
Failure to Follow and Document Physician-Ordered Wound Treatments
Penalty
Summary
The deficiency involves the facility’s failure to provide wound treatment and care according to physician orders for residents with non-pressure related skin conditions. Resident B, who had diagnoses including diabetes, atrial fibrillation, hypertension, and GERD, was cognitively intact and admitted with a surgical wound to the scrotal and perineal area. A care plan dated 2/5/26 identified an alteration in skin integrity and directed staff to provide treatments as ordered and monitor for infection. A physician’s order dated 2/5/26 specified application of a NPWT (wound vac) dressing with white foam to the scrotal/perineal area, to be changed every 48–72 hours. The TAR did not show the wound order signed out for 2/5/26. The DON reported that the resident arrived from the hospital with a wet-to-dry dressing after the hospital had removed the wound vac, and that she removed this dressing and attempted multiple times to apply the wound vac without success. She stated she did not obtain a new physician order when the wound vac could not be applied and instead packed the wound with wet-to-dry gauze and placed an adaptic dressing over it, deviating from the existing order. The deficiency also includes failure to follow and accurately document wound treatment orders for Resident C, who had diagnoses including a non-pressure ulcer of the left foot, heart failure, anemia, and restless leg syndrome, and was documented as alert and oriented with normal cognitive status. A care plan dated 3/10/26 identified alteration in skin integrity to the left foot with approaches to complete treatments as ordered and observe for infection. A physician’s order dated 3/11/26, to begin 3/12/26, directed that the left plantar foot wound be treated with iodoform packing strip to the wound bed, betadine-soaked gauze, a dry 4x4, kerlix wrap, and an ace bandage. The TAR indicated this ordered treatment was signed out as completed on 3/12/26. However, during an observed wound treatment on 3/13/26, an RN removed a foam dressing dated 3/12/26 and stated that it was the wrong dressing on the wound, indicating that the treatment documented as completed on the TAR did not match the physician’s ordered regimen. The DON acknowledged understanding of the concern regarding the wound treatment and the signed-out treatment that was not followed.
Inadequate Infection Control During Wound Care and Unclear PPE Use Under Enhanced Barrier Precautions
Penalty
Summary
The deficiency involves a failure to implement infection prevention and control guidelines during a wound dressing change and a lack of staff understanding of required PPE for a resident on Enhanced Barrier Precautions. During an observed wound treatment for Resident C, an RN removed the existing foam dressing from the resident’s left foot, left the room to clarify treatment orders, and later returned with an NP who assessed the wound and provided new verbal orders to cleanse with betadine, apply a 4x4 gauze, and wrap with Kerlix. After cleansing the wound with a betadine-soaked pad and covering it with clean gauze, the RN began to unroll the Kerlix but realized there was no tape available. The RN then set the Kerlix roll down and rummaged through the resident’s side dresser drawers with gloved hands in search of tape, then returned to the Kerlix roll and resumed dressing the wound without performing hand hygiene or changing gloves after touching the dresser drawers. The deficiency also includes the RN’s uncertainty regarding appropriate PPE use for a resident requiring Enhanced Barrier Precautions. After completing the Kerlix wrap and doffing PPE to search for tape, the RN later appeared at the resident’s doorway and questioned whether applying tape was “gown worthy,” indicating he was unsure if a gown was required to re-enter and apply tape to the dressing. Resident C’s record showed diagnoses including a non-pressure ulcer of the left foot, heart failure, anemia, and restless leg syndrome, with a care plan addressing alteration in skin integrity of the left foot and directing staff to complete treatments as ordered and observe for signs and symptoms of infection. During an interview, the DON acknowledged understanding the concern that the nurse should have changed gloves after searching for tape in the resident’s dresser drawers.
Failure to Address Resident Grievances and Excessive Call Light Wait Times
Penalty
Summary
The facility failed to adequately address resident grievances regarding excessive call light wait times for all 18 residents reviewed. Multiple residents reported waiting extended periods, ranging from 15 minutes to over two hours, for assistance after activating their call lights. Several residents described being left in soiled conditions, experiencing humiliation, discomfort, and emotional distress as a result. Interviews revealed that staff sometimes turned off call lights without providing the requested assistance, and residents felt their complaints were either ignored or not resolved. The facility's call light system was operational, but there were no visual indicators outside resident rooms or at the nurse's station, relying solely on a beeper system for staff notification. The DON and ADON confirmed that call light audits and monitoring, which had been implemented after a previous survey, were discontinued after a certain date with no explanation or documentation for the cessation. There was no specific facility policy or defined expectation for timely call light response, and staff education did not specifically address prompt call light answering. The ADON was unable to articulate a standard for reasonable response time, and the facility's in-service records did not include targeted training on this issue. Review of resident care plans and grievance records showed that many residents required substantial to maximal assistance with ADLs and were frequently incontinent, making timely response to call lights critical for their dignity and hygiene. Grievance forms documented repeated complaints about long wait times, with some forms lacking evidence of resolution or follow-up. In several cases, residents or their families reported that grievances were not addressed, and staff actions were limited to verbal reassurances or corrective actions without systemic improvement. The facility's policy on resident rights emphasized dignity and prompt grievance resolution, but the documented practices did not align with these standards.
Failure to Address Resident Council Concerns Over Prolonged Call Light Response Times
Penalty
Summary
The facility failed to effectively address and resolve concerns raised by the Resident Council regarding prolonged call light response times. During a meeting with the surveyor, all seven residents present confirmed that the Resident Council had repeatedly complained about long wait times for call lights to be answered, with two residents reporting ongoing delays. One resident specifically stated he had waited as long as an hour for assistance in recent weeks. Review of Resident Council meeting minutes showed that these concerns had been documented multiple times over the past year. The Executive Director (ED) acknowledged awareness of the issue and identified two potential causes: the call light system required a 2-3 second hold to reset, and some staff ignored alarms, assuming they had already been addressed. Although the facility had included call light response times in its QAPI meetings and implemented Performance Improvement Projects (PIPs) in response to complaints, the problem persisted. The ED reported that staff had been educated on the system, but could not provide documentation of this education. Additionally, interventions such as running daily call light reports and having administrators monitor pagers were implemented, but there was no monitoring during evening and night shifts, and staff did not follow up with residents who experienced long wait times. A review of call light reports revealed numerous instances where response times exceeded 30 minutes, with several cases surpassing one or even two hours. The ED was unable to define a reasonable maximum response time, stating it would vary depending on staff workload. Despite repeated interventions and ongoing monitoring, the facility did not resolve the issue, and residents continued to experience significant delays in call light responses.
Failure to Timely Complete and Submit Discharge MDS Assessment
Penalty
Summary
The facility failed to ensure that the Discharge Minimum Data Set (MDS) assessment was completed and submitted within the required timeframe for one resident. Record review showed that a resident with diagnoses including hypertension, atrial fibrillation, and arthritis was discharged, but the Discharge MDS assessment was not completed and submitted until 122 days after discharge. During an interview, the DON confirmed that the assessment was not completed or submitted in a timely manner and stated that the facility did not have a specific policy for MDS assessment completion, instead relying on the Resident Assessment Instrument (RAI) manual for guidance. According to the RAI User's Manual, a Discharge assessment must be completed within 14 days after discharge and submitted within 14 days of completion, which was not followed in this case.
Failure to Develop Comprehensive Care Plans for Bowel and Skin Issues
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents with specific clinical needs. For one resident with diagnoses including Parkinson's disease and chronic kidney disease, the record showed moderate cognitive impairment and occasional bowel incontinence. Despite physician orders for three different medications to manage constipation, there was no care plan addressing the resident's bowel issues or the use of these medications. This was confirmed by the Assistant Director of Nursing during an interview. Another resident, who had a G-tube and diagnoses such as cerebral infarction, rhabdomyolysis, dysphagia, and chronic kidney disease, developed blisters on the abdomen attributed to friction from the G-tube tubing. Observations and nurse documentation indicated the presence of new and previous blisters, but there was no care plan in place to address skin issues related to the G-tube. The Director of Nursing confirmed that a care plan should have been created for G-tube care after admission, and there was no facility policy for creating care plans, relying instead on general nursing standards.
Failure to Provide Timely Treatment and Care Planning for G-Tube-Related Skin Blisters
Penalty
Summary
A resident with a G-tube developed a dime-sized blister below the G-tube site, which was observed by an LPN during medication administration. The LPN attributed the blister to friction from the G-tube tubing being too long and noted that a similar blister had developed several days earlier. The resident's medical record showed diagnoses including cerebral infarction, rhabdomyolysis, dysphagia, and chronic kidney disease. Documentation indicated that the blister was possibly due to friction and that the tubing was repositioned and the blister covered, but there was no documentation that the provider had been notified, that treatment orders had been obtained, or that a care plan had been created after either blister developed. Interviews with the Clinical Care Coordinator (CCC) and the Director of Nursing (DON) revealed that the CCC had been verbally notified of the blister but failed to follow up, and neither the provider nor the family had been notified. The resident's plan of care was not updated, and no physician orders were obtained for treatment or prevention. The DON confirmed that a care plan should have been created after the first blister and that the facility did not have a specific policy for provider notification or care plan creation, instead relying on general nursing standards of practice.
Failure to Adequately Monitor Antipsychotic Medication with Timely AIMS Assessments
Penalty
Summary
The facility failed to adequately monitor the use of an antipsychotic medication for a resident diagnosed with bipolar disorder, among other conditions. The resident was prescribed Aripiprazole to be taken six times weekly, and the care plan required quarterly AIMS (Abnormal Involuntary Movement Scale) assessments to monitor for side effects. Despite pharmacy recommendations in August and September for an AIMS assessment, there was a significant delay, and the assessment was not completed until January of the following year. The care plan was updated to include quarterly AIMS assessments, but this intervention was not followed as required during the period in question. Interviews with facility staff revealed inconsistencies in the understanding and monitoring of AIMS assessments. The Assistant Director of Nursing (ADON) stated that the facility standard was to perform AIMS assessments every six months, despite the care plan specifying quarterly assessments. The Social Services Worker, responsible for care plan creation and monitoring, was unsure how AIMS assessment completion was being tracked. There was no written facility policy regarding the frequency of AIMS assessments for residents on antipsychotic medications.
Failure to Maintain Kitchen Sink in Working Order
Penalty
Summary
A deficiency was identified when the facility failed to ensure that kitchen equipment, specifically the northernmost sink in the cooking area, was in proper working order. Observation revealed that the sink was leaking underneath from the drain pipe and the faucet was slowly running and could not be turned off. The Dietary Manager stated that Maintenance was aware of the issue and waiting for a part to fix the sink, but the Maintenance Director later reported that he had never received a work order and was unaware of any broken sink. Additionally, the Registered Dietician was also unaware of the leaking sink, stating she had not noticed anything during her rounds. Facility policies provided indicated that the Director of Dining Services is responsible for safety, sanitation, and maintenance programs, and the Registered Dietitian is responsible for monitoring performance and addressing issues.
Failure to Follow Enhanced Barrier Precautions for Residents with Isolation Needs
Penalty
Summary
The facility failed to ensure that enhanced barrier precautions (EBP) were properly implemented for two residents who required isolation due to their medical conditions. For one resident with diagnoses including diabetes mellitus, septicemia, obstructive uropathy, and an indwelling catheter, a CNA entered the resident's room without donning the required personal protective equipment (PPE) such as a gown and mask. The CNA only performed hand hygiene and wore gloves after entering the room, then assisted the resident with a transfer. The CNA stated she was unaware of the need for enhanced barrier precautions, as she had not been informed by the nurse. In another instance, an LPN administered a water flush to a resident's gastrostomy tube while only wearing gloves, despite an EBP sign being posted on the resident's door and a physician's order for EBP in place. The LPN acknowledged that a gown should have been worn during the procedure. Both residents had current care plans and physician orders indicating the need for EBP, and the facility's policy required the use of gown and gloves for high-contact care activities for residents with indwelling medical devices.
Nonfunctional and Leaking Faucets Not Addressed in Multiple Rooms
Penalty
Summary
The facility failed to ensure that water faucets were functional in four rooms within the long-term care unit. Observations revealed that in one room, the faucet was running continuously and could not be turned off, with a resident reporting it had been this way for an extended period and that the issue had been reported but not resolved. In another room, the faucet was missing and water was continuously dripping down the back of the sink. Two additional rooms had faucets that were dripping continuously. The Maintenance Director acknowledged multiple leaking sinks, stated that parts had been ordered months prior and had arrived, but repairs were delayed pending the arrival of a necessary tool, which had just been delivered. No documentation of work orders, invoices, or purchase orders for the repairs was provided during the survey. The Executive Director confirmed that the facility did not have a policy for building maintenance.
Failure to Provide Required Transfer Assistance Leads to Resident Injury
Penalty
Summary
The facility failed to ensure that Resident E received the required transfer assistance, leading to an accident hazard. Resident E, who had a history of cerebrovascular accident and osteoporosis, was assessed to have moderately impaired cognition and was dependent on staff for all activities of daily living, including transfers. The care plan specified that Resident E required the extensive assistance of two staff members for transfers. However, during an investigation into a potential fall and leg injury reported by Resident E's family member, it was revealed that a CNA had transferred Resident E without assistance from another staff member. An x-ray conducted two days after the incident confirmed that Resident E had sustained a non-displaced fracture of the right tibia and fibula, necessitating hospital admission. Interviews with the CNA involved indicated that she was aware of the care requirements but did not provide a reason for transferring Resident E alone. The Director of Nursing (DON) confirmed that the facility lacked a policy regarding adherence to residents' care plans and noted no other reported issues with the CNA not following care plans.
Failure to Maintain Appropriate Food Temperatures
Penalty
Summary
The facility failed to maintain appropriate food temperatures for meal trays on St. Paul's Unit, potentially affecting 21 residents. During an interview, a resident reported that meals served in the dining area were often cold, and although he initially requested reheating, he eventually stopped asking due to the consistent issue. An observation conducted by the Dietary Project Manager revealed that the food temperatures were below the required serving temperature, with cabbage at 135 degrees Fahrenheit and pot roast at 141 degrees Fahrenheit. The Dietary Project Manager acknowledged that these temperatures were inadequate and initiated reheating of all meal trays to reach 145 degrees Fahrenheit. The facility's policy, dated January 2024, mandates that food and drinks be served at safe and appetizing temperatures to ensure resident satisfaction and meet nutritional needs.
Sanitation and Food Storage Deficiencies in Facility
Penalty
Summary
The facility failed to maintain sanitary conditions in its kitchen and pantry areas, as observed during a survey. In the kitchen, ice scoops were found lying uncovered on top of the ice machine, contrary to the facility's policy which requires scoops to be stored in a self-draining container protected from contamination. Additionally, various food items in the dry storage and freezer were either expired, undated, or improperly sealed, which violates the facility's policy on food storage that mandates labeling and dating of opened food items. Further observations revealed that a Sous Chef was preparing food without a hair restraint, despite having facial hair longer than the facility's policy allows without a beard guard. In the dining room, a CNA assisted a resident with eating using bare hands, which was against the facility's hygiene practices. The CNA expressed confusion about glove usage, indicating a lack of clear guidance from the DON, who confirmed the absence of a specific policy on assisting residents with meals. The survey also identified issues with the storage of food brought in by outside sources. Several nourishment refrigerators contained unlabeled and undated food items, including personal food items belonging to staff, which were stored alongside residents' food. This practice was against the facility's policy that requires outside food to be labeled with the resident's name, room number, and use-by date, and prohibits storing staff food in resident refrigerators. The presence of treatment ice packs in freezers with food items further highlighted the facility's failure to adhere to its own storage policies.
Failure to Provide Transfer Notice and Bed Hold Policy
Penalty
Summary
The facility failed to provide a resident or their representative with a notice of transfer/discharge or a copy of the bed hold policy during a hospitalization event. Resident 65, who has a medical history including partial amputation of the right foot and diabetes mellitus, was hospitalized for pneumonia after being sent to the emergency room due to a change in condition. Despite having intact cognition, there was no documentation indicating that Resident 65 received the necessary notice or bed hold policy upon transfer to the hospital. The Director of Nursing (DON) confirmed the absence of such documentation and noted that there was no existing policy addressing the required documents for hospital transfers, although a checklist was provided.
Lack of Person-Centered Care Plan for Resident with Depression
Penalty
Summary
The facility failed to develop a person-centered care plan for a resident diagnosed with major depressive disorder, chronic obstructive pulmonary disease, and heart failure. The care plan, dated 4/29/2024, noted mood and behavior concerns related to depression but lacked specific interventions to address the resident's triggers and appropriate interventions. During an interview, the Assistant Director of Nursing confirmed the absence of person-centered interventions in the care plan. Additionally, the Director of Nursing indicated that the facility did not have a policy for developing person-centered care plans.
Failure to Revise Care Plans and Conduct Quarterly Care Conferences
Penalty
Summary
The facility failed to ensure that care plans were revised and care conferences were held quarterly for two residents. For one resident, observations revealed inconsistencies in the application of a soft splint to the right hand, which was prescribed by a physician's order. The care plan, dated several years prior, indicated the need for the splint to be worn daily, yet observations showed it was not consistently applied. Interviews with staff confirmed the care plan required revision, and the resident's family reported not being invited to a care conference for over a year. The facility's Director of Nursing (DON) acknowledged the lack of a care conference in the past year. For another resident, the record review showed no documentation of a care conference within a specified period, and the family reported not being invited to a care conference for 6-9 months. The DON confirmed that care conferences were not held quarterly as required. Additionally, the facility was unable to provide policies for revising care plans and conducting care conferences upon request during the survey.
Deficiencies in ADL Assistance and Hygiene Care
Penalty
Summary
The facility failed to provide adequate assistance with Activities of Daily Living (ADLs) for two residents, leading to deficiencies in personal hygiene and care. Resident 37, who has severe cognitive impairment and is dependent on staff for mobility and hygiene, was observed with long and dirty fingernails over several days. The resident's care plan indicated a need for assistance with personal hygiene, yet records showed only two bed baths over a month, with no documented refusals of care. Interviews with staff confirmed that nail care should be part of regular hygiene routines, but the Director of Nursing (DON) acknowledged gaps in care provision. Resident 46, who requires extensive assistance due to hemiplegia and other conditions, reported not being shaved regularly, despite expressing a preference for daily shaving. Observations confirmed the resident was often unshaven, and interviews with staff revealed inconsistencies in providing morning care, including shaving. Additionally, the resident reported not being turned every two hours as required to prevent pressure sores, and observations confirmed prolonged periods in the same position. The DON admitted there was no policy on turning and repositioning, and staff documentation was lacking. The facility's failure to adhere to care plans and resident preferences resulted in unmet hygiene needs and potential risks for skin breakdown. The DON acknowledged the absence of specific policies and the need for improved documentation and communication among staff to ensure residents receive the necessary care and assistance with ADLs.
Failure to Apply Prescribed Splint for Resident with Limited Range of Motion
Penalty
Summary
The facility failed to ensure that a resident with a limited range of motion received appropriate treatments and services to prevent further decrease in range of motion. Resident 46, who has a history of cardiovascular accident, hemiplegia, hemiparesis, peripheral vascular disease, and depression, was observed multiple times without the prescribed left hand splint. The physician's order, dated November 3, 2022, required the application of an orthosis/splint twice a day, specifically upon rising and off prior to bed. However, observations on several dates in May 2024 revealed that the splint was not applied as ordered, and it was often found on the resident's nightstand instead of on the resident's hand. Interviews with the staff, including the Director of Nursing (DON) and an LPN, revealed inconsistencies in following the physician's orders. The LPN admitted to sometimes applying the splint after noon due to a heavy medication pass, despite the order to apply it upon rising. The DON acknowledged the lack of a policy for splints or braces and expressed an expectation for staff to follow physician orders. The Treatment Administration Record (TAR) indicated that the splint was applied on specific dates, but observations contradicted these records, highlighting a deficiency in the facility's adherence to prescribed treatments for maintaining the resident's range of motion.
Medication Labeling Deficiency
Penalty
Summary
The facility failed to ensure that medications stored in the medication cart were labeled according to accepted professional standards. During an observation of the medication cart on St. John's Way, a half-full bottle of milk of magnesia was found without a pharmacy label or any information to identify the resident to whom it belonged. An LPN present during the observation indicated she did not know to whom the milk of magnesia belonged and acknowledged that it should not be kept in the cart. The facility's policy on the storage and expiration dating of medications, dated 8/7/23, requires that medications with missing labels be destroyed and reordered.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to adhere to infection control standards during the care of two residents, leading to deficiencies in preventing the transmission of infections. For Resident 181, an RN did not wash his hands before donning gloves to perform a blood glucose check, and he fanned the cleansed area with his gloved hand, which is against infection control practices. The RN acknowledged the oversight and was unaware that fanning the area was an infection control issue. For Resident 16, an LPN did not wear a gown during a wound dressing change, despite the resident being under Enhanced Barrier Precautions (EBP) due to a stage 3 pressure ulcer. The LPN indicated that the required personal protective equipment was not available in the resident's room, which led to the failure to follow the physician's orders and the facility's infection control policy. The Director of Nursing confirmed that a gown and gloves should be worn during such procedures, and the facility lacked a specific policy on dressing changes, relying instead on standard practices and physician orders.
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Surveyors observed that dietary staff repeatedly worked in kitchen and meal service areas with uncovered facial hair, despite facility policy and state sanitation requirements mandating effective hair restraints. Two dietary aides with short beards or mustaches were seen walking through food preparation areas, taking food temperatures, handling food, and plating meals at steamtables in dining rooms without any facial hair coverings, while the current policy required all hair, including facial hair, to be restrained to prevent contamination.
The facility failed to consistently provide and document required bed-hold policy notices when several residents were transferred to the hospital. In multiple cases, residents with dementia, psychotic disorders, COPD, chronic respiratory failure, altered mental status, and cerebral infarction were sent out for acute changes in condition, and while transfer notes reflected physician and family notifications, they lacked documentation that the bed-hold policy was discussed with the resident or responsible party. Notices of Transfer or Discharge often indicated a copy of the bed-hold policy was sent with the resident, but the records did not show signed and dated acknowledgment by the resident or appropriate representative, including in situations where a resident had moderate cognitive impairment, short-term memory issues, or a documented need for a proxy and a financial POA authorizing an agent for health care decisions.
Surveyors found that the facility failed to provide trauma‑informed and culturally competent care by not incorporating two residents’ extensive trauma histories and specific behavioral triggers into their care plans. One resident with documented homelessness, polysubstance abuse, severe accidents with multiple fractures, viral encephalitis with coma, physical and sexual abuse, loss of family contact, and a past suicide attempt had multiple behavior‑focused care plans that referenced identifying triggers but listed none and did not mention their physical, sexual, medical, or psychosocial trauma. Another resident with TBI from being struck by a truck, an 11‑month coma, long‑term state hospital residence, alleged shooting of a parent, and diagnoses including intermittent explosive disorder and borderline personality disorder had a PASRR identifying a specific trigger and notes of inappropriate sexual behavior, yet their care plans omitted these traumatic events, the identified trigger, and the sexual behavior. Staff interviews confirmed that residents were screened for trauma, but the trauma histories and triggers were not reflected in the individualized plans of care.
A resident with schizophrenia, post‑stroke hemiparesis, and mild cognitive impairment expressed feeling down and wanting to kill himself, but staff did not document asking about a specific plan, did not notify the physician or psychiatric NP as expected, and did not develop or update a care plan addressing depression or suicidal ideation. The SSD documented offering support and initiating 15‑minute checks once, but there was no further follow‑up or documentation of interventions after subsequent suicidal statements made in a care plan meeting with the resident’s father. The DON and Administrator reported that facility policy requires immediate notification of key staff, assessment for a plan and means of self‑harm, and thorough documentation, which were not carried out or reflected in the medical record for this resident.
A resident with schizophrenia, post-stroke hemiparesis, and mild cognitive impairment verbalized suicidal ideation, but the care plan did not address depression or suicidal thoughts, and required assessments and services were not accurately or timely documented. An SSD note recorded the resident saying he wanted to kill himself and referenced 15‑minute checks and a care plan update, yet the active care plan lacked depression/suicidal ideation interventions. Multiple late-entry Social Services notes were later added, describing follow-up visits and the resident denying suicidal ideation, but the SSD later reported she did not typically ask about a suicide plan and did not personally provide individual follow-up visits as described. These practices conflicted with the facility’s policy requiring factual, first-hand, and timely documentation of assessments and services.
A resident was observed with an Albuterol inhaler on an overbed table and later reported keeping the inhaler in a nightstand drawer, with no staff present during these observations. Record review showed the resident had no cognitive impairment on the admission MDS but lacked any documented self-medication administration assessment. The DON acknowledged that the required assessment had not been completed, despite facility policy requiring staff and the practitioner to evaluate each resident’s mental and physical abilities before allowing self-administration of medications.
Surveyors found that the facility submitted inaccurate direct care staffing data to CMS through the PBJ system over multiple days in a quarter. CASPER reports showed apparent gaps in 24-hour licensed nurse coverage, low weekend staffing, and a 1-star staffing rating, while internal staffing sheets documented that licensed nurses were present and the facility was fully staffed on those days. The Administrator reported that the discrepancies were due to PBJ data entry errors, despite a facility policy requiring all PBJ entries to be accurate, auditable, and verifiable against payroll, invoices, or contracts.
Surveyors found that the facility did not provide or document required written transfer/discharge notices and bed-hold policy information for four residents who were sent to the hospital, including individuals with conditions such as dementia, CHF, chronic respiratory failure, and CKD. In each case, progress notes showed that the resident was transferred for acute issues, but the clinical records lacked evidence that written notices were given to the residents or their representatives, and in one case lacked documentation that required information was sent to the receiving provider. Facility leadership, including the ADON, DON, and Administrator, acknowledged that the records did not contain the required documentation, despite a written policy requiring such notices and information exchange.
A resident with Alzheimer’s disease and depression, previously on an antidepressant, exhibited intermittent refusals of medications and care, occasional yelling at staff, and reports of unusual perceptions, such as believing men were in or near her room. Nursing notes over several months documented these refusals and complaints but did not show that the behaviors were evaluated or recorded as dangerous, non-redirectable, or causing significant distress, nor did they document specific non-pharmacological interventions attempted or their outcomes. Despite this, a psychiatric NP later added new diagnoses of schizoaffective disorder, borderline personality disorder, and delusional disorder and ordered an antipsychotic (Seroquel) without a comprehensive evaluation in the record to support these diagnoses. The facility’s psychotropic medication policy, which requires identification and documentation of target behaviors, use of nonpharmacological interventions, and ongoing behavior monitoring, was not followed for this resident.
The facility failed to keep PASARR Level I screenings accurate and current for three residents when new mental health diagnoses and psychoactive medications were initiated. One resident’s PASARR omitted a PTSD diagnosis and an added antidepressant, despite documentation of PTSD on the MDS and care plan and a physician order for Pristiq. Another resident’s PASARR listed only depression and dementia, even after additional diagnoses such as borderline personality disorder, delusional disorder, and schizoaffective disorder were added and an antipsychotic (quetiapine) was ordered, with the MDS later reflecting psychotic disorder, schizophrenia, and depression with antipsychotic and antidepressant use. A third resident’s PASARR did not include a depression diagnosis or newly ordered escitalopram and lorazepam, although the admission MDS documented depression with antianxiety and antidepressant use. These omissions occurred despite facility policy requiring a new Level I review after significant mental status changes, including new mental health diagnoses or new psychotropic medications.
Uncovered Facial Hair During Food Preparation and Meal Service
Penalty
Summary
The deficiency involves the facility’s failure to ensure that food was served in a sanitary and safe manner in accordance with professional standards and facility policy during multiple kitchen and meal service observations. During an initial kitchen observation, two dietary aides were seen walking through the kitchen food preparation area with uncovered facial hair. One aide had facial hair above and below the lip and along the jaw line, approximately one-fourth inch in length, and the other had a mustache of similar length; neither used any facial hair covering. These observations occurred while staff were present in the kitchen area where food was stored and prepared. During subsequent observations on the same day, the same two dietary aides were again observed with uncovered facial hair while directly involved in meal preparation and service. One aide walked through the kitchen while the noon meal was being prepared and placed into a transport cart for service in the south dining room, and later was observed plating the noon meal at the steamtable in that dining room, still without a facial hair covering. The other aide walked through the kitchen while the noon meal was being prepared and placed into the steamtable for the north dining room, took food temperatures, assisted with plating meals at the steamtable, and retrieved food items and supplies from the kitchen, all while having an uncovered mustache approximately one-fourth inch in length. The Dietary Manager stated that staff hair was to be covered when in the kitchen and during meal service, and the facility’s written policy and the cited Indiana Food Establishment Sanitation Requirements both required effective hair restraints, including for facial hair, to prevent contamination of food, equipment, and utensils.
Failure to Provide and Document Bed-Hold Policy at Time of Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure that required bed-hold policy information was provided and documented for four residents transferred to the hospital. For a resident with dementia, psychotic disorder, and autistic disorder who had a BIMS score of 0 indicating severe cognitive impairment, progress notes documented physician notification and guardian notification when the resident was sent to the hospital, but there was no documentation that the bed-hold policy was provided to the responsible party. A Notice of Transfer or Discharge later indicated a copy of the bed-hold policy was sent with the resident. Another resident with COPD and chronic respiratory failure, cognitively intact with a BIMS score of 13, experienced a decline in condition and was transferred to the hospital by ambulance; progress notes documented family notification but did not document any discussion of the bed-hold policy, although a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident. A third resident with altered mental status and cerebral infarction, with a BIMS score of 10 indicating moderate cognitive impairment and documented short-term memory impairment, experienced changes in condition and was transferred to the hospital. Progress notes stated the resident was their own responsible party and that no other notification was completed, and transfer documentation did not include the bed-hold policy, although an untimed Notice of Transfer or Discharge indicated a copy of the bed-hold policy was signed by the resident. A financial power of attorney document in the record showed the resident had designated an agent to act in consent or refusal of health care. For a fourth resident with dementia and osteomyelitis, transfer documentation and a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident, and the transfer form noted the resident required a proxy for decision making. The facility’s policy required that at the time of transfer to a hospital, written notice specifying the duration of the bed-hold policy and information on return to the next available bed be provided, and that a signed and dated copy of the bed-hold notice given to the resident or representative be kept in the resident file, which was not consistently documented for these residents.
Failure to Integrate Trauma Histories and Behavioral Triggers Into Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to identify and incorporate residents’ trauma histories and specific behavioral triggers into their care plans, despite documented histories of significant trauma and behavioral health issues. For one resident, extensive social service and progress notes documented homelessness, polysubstance abuse, major depressive and anxiety disorders, chronic pain, a history of severe car accidents with multiple fractures, viral encephalitis resulting in a three‑month coma, loss of child custody, multiple divorces, physical abuse by a spouse, the death of a fiancé who was struck by a car while in a wheelchair, lack of family contact, and a past suicide attempt by Valium overdose. Additional documentation noted a history of rape by a brother at age eight and prior placement under direct supervision and 15‑minute checks related to suicidal ideation. Despite these documented traumatic events and behavioral health concerns, the resident’s care plans did not identify a history of physical trauma, sexual trauma, homelessness, substance abuse, medical trauma, or attempted suicide. For this same resident, the MDS showed no cognitive deficit and identified behaviors such as verbal aggression and rejection of care, along with diagnoses including seizure disorder, depression, chronic pain syndrome, homelessness, and anxiety disorder. Multiple care plans addressed behaviors such as drug‑seeking, pretending to have seizures for attention or medication, making false allegations, verbal aggression when unable to smoke, and a desire for intimate relationships with consenting male residents. These care plans referenced goals such as effective coping skills, seeking staff support, and compliance with the smoking policy, and they called for identification and reduction of behavioral triggers. However, none of these care plans actually listed any specific triggers. The care plan addressing the resident’s right to consensual intimate relationships focused on assessment and education regarding consent but did not integrate the resident’s extensive trauma history. Staff interviews indicated the resident had displayed sexual behaviors since admission, including an incident where the resident expressed anger at another resident for not buying a soda after engaging in sexual acts. A second resident with a documented history of traumatic brain injury (TBI), dementia, seizure disorder, borderline personality disorder, anxiety, intermittent explosive disorder, tobacco use, and other behavioral/emotional disorders was also affected by the same deficiency. Social history and progress notes documented that this resident sustained a TBI after being hit by a semi‑truck while riding a bicycle at age 18, resulting in an 11‑month coma, followed by 13 years in a state hospital and subsequent residence in a group home. Additional documentation indicated the resident allegedly shot their father at age 26 after being sworn at and had a PASRR identifying TBI, intermittent explosive disorder, and borderline personality disorder, with a specific trigger of hearing the name of the current U.S. President. Progress notes also described inappropriate sexual behavior toward staff, including touching themselves intimately during personal care and refusing to stop when redirected. Despite this, the resident’s care plans, which addressed explosive disorder and history of altercations, risk for decreased psychosocial well‑being, and refusal to bathe or shower, did not list any specific behavioral triggers, did not reference the traumatic events such as being hit by a truck or shooting their father, and did not document the inappropriate sexual behavior. The Administrator and Social Service Director acknowledged that residents were to be screened for trauma and that trauma responses and PTSD should be added to care plans, but the specific trauma histories and triggers for these two residents were not incorporated into their plans of care.
Failure to Assess and Care Plan for Resident Suicidal Ideation
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess, investigate, and care plan for a resident’s suicidal ideation in accordance with its own policy and staff expectations. The resident had diagnoses including schizophrenia, cerebral edema, and hemiparesis/hemiplegia following a cerebral infarction, and a current MDS showed mild cognitive impairment (BIMS score 12). A progress note documented that the resident told the Social Services Director (SSD) he was feeling down and wanted to kill himself; the SSD offered assistance, activities, and initiated 15‑minute checks, and the note stated the care plan was updated. However, the note did not indicate that the SSD asked whether the resident had a plan to kill himself, and there were no additional notes regarding suicidal ideation or follow‑up. Review of the current care plan showed no problem, goal, or interventions addressing depression or suicidal ideation, and progress notes over the following month contained no documentation of physician notification related to the suicidal statement. Further record and interview evidence showed that the care plan conference summary did not document interventions for suicidal ideation, and the SSD acknowledged she did not normally ask residents expressing suicidal ideation if they had a plan. The SSD reported that the resident had admission paperwork mentioning suicidal ideation related to depression after a stroke and that the resident again vocalized suicidal ideation during a care plan meeting with his father, after which emotional support was offered and the father took the resident out on a leave of absence; no further visits or follow‑up were done. The DON stated that, upon notification of suicidal verbalization, staff should assess the resident, ask if there is a plan, remove potential means of self‑harm, immediately notify the psychiatric NP, and document the occurrence, and that a detailed progress note and updated care plan were expected but not present for this resident. The Administrator similarly stated that staff should ask about a plan, document interventions, notify the physician and family, and update the care plan, and indicated the resident should have had a care plan addressing depression with suicidal ideation. The facility’s written policy required immediate notification of the DON, SSD, and physician, an interview including asking about a plan and assessing mood and means for self‑harm, and thorough documentation of mood, behavior, and all actions taken, which were not reflected in the resident’s record.
Incomplete and Inaccurate Documentation of Suicidal Ideation and Follow-Up
Penalty
Summary
The facility failed to ensure accurate, complete, and timely documentation of assessments and services for a resident who verbalized suicidal ideation. Resident 6, who had schizophrenia, cerebral edema, and right-sided hemiparesis/hemiplegia following a cerebral infarction, had a BIMS score of 12 indicating mild cognitive impairment. The resident’s admission paperwork mentioned suicidal ideation related to depression after a stroke, and a Social Services note on 3/11/2026 documented that the resident was feeling down and said he wanted to kill himself. The Social Services Director (SSD) documented that she talked with the resident, coordinated with Activities, advised the resident to contact SSD or nursing if he wanted to talk, and that the resident was scheduled for 15-minute checks and the care plan was updated. However, the current care plan initiated on 2/26/2026 did not address depression or suicidal ideation. Multiple Social Services progress notes were later entered as late entries in April, with effective dates in March, stating that the resident had no plan and no longer had suicidal ideation, that he felt much better after 1:1 time, and that he continued his daily routine and therapy. These late entries described follow-up visits and reassessments of suicidal ideation on several consecutive days, but in interviews the SSD stated she did not normally ask residents about having a plan when they verbalized suicidal ideation and did not recall any other occurrences beyond the initial event. She further indicated she did not personally provide individual follow-up visits with this resident regarding suicidal ideation, despite the late-entry notes describing such visits. The DON acknowledged that late entries had been added to address concern about suicidal verbalization, and the Administrator stated that upon suicidal statements staff should ask about a plan, notify the physician and family, and update the care plan, and that this resident should have had a care plan addressing depression with suicidal ideation. The facility’s documentation policy required factual, first-hand, timely documentation, which was not followed in this case.
Failure to Complete Required Self-Administration Assessment for Inhaler Kept at Bedside
Penalty
Summary
Surveyors identified that a resident was allowed to keep and access an Albuterol inhaler without the facility completing the required self-administration medication assessment. During an initial tour, the resident was observed sitting in a wheelchair with a handheld Albuterol inhaler on the overbed table and no staff present in the room or hallway. On a subsequent observation, the resident again was in a wheelchair and reported that the Albuterol inhaler was stored in the top drawer of the nightstand, where it was found. Review of the clinical record showed an admission MDS indicating no cognitive impairment, but there was no documentation of a self-medication administration assessment. In an interview, the DON confirmed that the resident did not have the required self-medication assessment, despite the facility’s policy stating that staff and the practitioner must assess each resident’s mental and physical abilities to determine whether self-administering medications is clinically appropriate. This failure to complete and document a self-administration medication assessment for a resident who had an Albuterol inhaler kept at bedside constituted noncompliance with the facility’s own policy and with 410 IAC 16.2-3.1-11(a).
Inaccurate PBJ Staffing Data Submission to CMS
Penalty
Summary
The deficiency involves the facility’s failure to electronically submit complete and accurate direct care staffing information to CMS through the Payroll-Based Journal (PBJ) system for 22 days in a fiscal quarter. A CASPER report review on 4/6/26 showed that, according to PBJ data, the facility did not have licensed nursing coverage 24 hours per day on multiple specific dates across three months, had low weekend staffing, and held a 1-star staffing rating. However, review of the facility’s internal staffing sheets for that quarter indicated the facility was fully staffed and had licensed nurse coverage on all of the dates in question. During an interview, the Administrator stated that the PBJ information must have contained data entry errors, as she had verified licensed staff coverage on the timesheets. The facility’s PBJ policy in effect stated that all staffing data entered into the PBJ system would be auditable and verifiable through payroll, invoices, or contracts, but the submitted PBJ data did not accurately reflect the facility’s actual licensed nurse staffing as documented on internal records. No specific residents or clinical conditions were mentioned in the report, and the deficiency centers solely on inaccurate staffing data submission rather than direct resident care events.
Failure to Provide and Document Required Transfer/Discharge and Bed-Hold Notices
Penalty
Summary
The deficiency involves the facility’s failure to provide and document required written notices of transfer/discharge and bed-hold policies, as well as required information to receiving providers, for four residents who were transferred or discharged to the hospital. For a resident with generalized anxiety disorder, major depressive disorder, and dementia, progress notes showed that the resident was sent to the hospital via 911 for chest pain, lower back pain, and shortness of breath and later returned to the facility, but the clinical record lacked documentation that a written Notice of Transfer/Discharge and the bed-hold policy were provided to the resident or representative, and lacked documentation that required information was conveyed to the receiving facility. The ADON and the Administrator both confirmed there was no documentation that these written notices were provided. For a resident with congestive heart failure and muscle weakness who was sent to the emergency room for painful urination and bloody urine, the clinical record lacked documentation that a Notice of Transfer/Discharge or bed-hold policy was given to the resident or representative, which the DON confirmed. Another resident with chronic respiratory failure and diabetes was discharged to the hospital for respiratory failure, and a resident with chronic kidney disease and dementia was discharged to the hospital, but in both cases there was no documentation that a written notice of transfer/discharge or bed-hold policy was provided to the residents or their representatives. Review of the facility’s Transfer and Discharge policy, dated 1/15/26, showed that the policy required the facility to provide written transfer/discharge notices and bed-hold information to residents and representatives and to provide specified information to receiving providers, but the records for these four residents did not contain the required documentation.
Failure to Document Target Behaviors and Non-Pharmacological Interventions Before Initiating Antipsychotic
Penalty
Summary
The deficiency involves the facility’s failure to document how a resident’s behaviors presented danger or distress to self or others, and failure to document non-pharmacological interventions attempted prior to initiating an antipsychotic medication. Resident 6 had documented diagnoses of Alzheimer’s disease, depression, and severe cognitive impairment, and was receiving sertraline for depression. A PASSAR identified only depression and dementia, and the admission MDS listed Alzheimer’s disease and depression as active diagnoses. Over several months, nursing progress notes documented that the resident intermittently reported unusual perceptions, such as believing there were men causing trouble, a man in her room, or a man wanting to marry her and yelling through the walls, but there was no documentation that these episodes caused danger to the resident or others or that they resulted in unmanageable distress. From late April through mid-July, nursing notes primarily described the resident’s frequent refusals of evening and morning medications, blood sugar checks, blood pressure checks, insulin administration, hygiene care, and showers. Staff documented that the resident sometimes yelled at staff, said “Get out!”, was visibly upset by a room move, was leery of staff and asked to see name badges, and became upset about a pillow under her head until it was removed, after which she calmed down. The notes also recorded instances where the resident believed housekeeping had not cleaned her room or that she had not received medications when she had. However, there were no progress notes or assessments indicating that these behaviors were evaluated as dangerous, non-redirectable, or causing significant distress or functional impairment, and no detailed behavior monitoring logs were present as required by facility policy. On a psychiatric NP visit for initial psychotropic medication management, new mental health diagnoses of schizoaffective disorder, borderline personality disorder, and delusional disorder were added, and Seroquel 25 mg, an antipsychotic, was ordered. The clinical record did not contain a comprehensive evaluation to support these new diagnoses, and there was no documentation of target behaviors meeting the facility’s policy criteria for psychotropic use, such as behaviors representing danger to self or others, causing distress and impairment in functional abilities, or clearly attributable to psychosis or mania. The resident’s representative reported that the resident had no prior history of mental health disorders or psychiatric hospitalization and was unaware of the new diagnoses. The facility’s own psychotropic medication policy required identification and documentation of specific target behaviors, use and documentation of nonpharmacological interventions, and ongoing monitoring of behaviors and interventions, which were not reflected in the record for this resident.
Failure to Update PASARR Screens for New Mental Health Diagnoses and Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that Preadmission Screening and Resident Review (PASARR) Level I screenings were accurate and updated when new mental health diagnoses and psychoactive medications were initiated for multiple residents. For one resident with dementia, anxiety, depression, and post-traumatic stress disorder (PTSD), the PASARR completed on admission listed anxiety, depression, and dementia with sertraline and quetiapine, but did not include the PTSD diagnosis or the antidepressant Pristiq, despite the admission MDS and care plan documenting PTSD and a subsequent physician’s order for Pristiq. For another resident with Alzheimer’s disease, borderline personality disorder, delusional disorder, schizoaffective disorder, and depression, the PASARR only reflected depression and dementia with sertraline, even though additional mental health diagnoses were added later and an antipsychotic (quetiapine) was ordered for borderline personality disorder, and the quarterly MDS documented psychotic disorder, schizophrenia, and depression with antipsychotic and antidepressant use. A third resident had diagnoses including Alzheimer’s disease, depression, anxiety disorder, irritability and anger, and nonrheumatic aortic valve stenosis. The PASARR for this resident listed dementia and anxiety with Risperdal but omitted the diagnosis of depression and the medications escitalopram and lorazepam, although physician’s orders were in place for escitalopram for depression and lorazepam for anxiety, and the admission MDS documented depression with antianxiety and antidepressant use. Interviews with the Assistant Director of Nursing confirmed that new Level I PASARR screens should have been completed when new mental health diagnoses and psychoactive medications were added, and that the PASARR for one resident, completed prior to arrival, should have included all mental health diagnoses and medications. The facility’s own policy required notification of the state mental health authority within 14 days after a significant change in mental condition and specified that a new Level I screen is required for new mental health diagnoses or newly prescribed psychotropic medications, which was not followed in these cases.
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