Homewood Health Campus
Inspection history, citations, penalties and survey trends for this long-term care facility in Lebanon, Indiana.
- Location
- 2494 N Lebanon St, Lebanon, Indiana 46052
- CMS Provider Number
- 155680
- Inspections on file
- 26
- Latest survey
- September 10, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Homewood Health Campus during CMS and state inspections, most recent first.
Staff did not follow Enhanced Barrier Precautions (EBP) for three residents with chronic wounds, as required by facility policy. During high-contact care activities, staff failed to use gowns and gloves, and there was no signage or PPE set up in the rooms. Physician orders for EBP were not in place until after the deficiencies were observed, despite residents having conditions such as diabetes, dementia, and chronic wounds.
The facility failed to provide adequate nursing staff and timely call light response, as shown by repeated resident complaints of long wait times and staff turning off call lights without assisting. An LPN who was injured during a resident incident could not be relieved due to the lack of available licensed staff, and the on-call backup was not a licensed nurse. Facility policies requiring prompt call light response and sufficient staffing were not consistently followed.
A resident with dementia and other mental health diagnoses was prescribed risperidone after a hospital stay, but the facility did not document that the resident or their representative was informed about the risks, benefits, or alternatives to the medication. Interviews confirmed that neither the family nor the POA were made aware of the medication changes or provided with necessary information, despite facility policy requiring informed consent.
A resident with an indwelling catheter, who was cognitively intact and had a history of Parkinson's disease and heart failure, preferred only female staff to perform catheter and peri-care. Although staff were aware of this preference, it was not documented in the care plan or clinical record, and male staff continued to provide care on several occasions, contrary to the resident's wishes.
A resident with a history of falls, chronic pain, and low back pain was transferred to the hospital after sustaining a tail bone fracture, but there was no documentation in the clinical record that the required bed hold policy was provided. The Corporate MDS nurse confirmed the policy was not given, despite facility policy requiring written and verbal notification before hospital transfer.
A resident with multiple respiratory conditions was observed receiving supplemental oxygen as ordered by a physician, but the MDS assessment failed to indicate that oxygen was being administered. Staff interviews confirmed the resident was on oxygen and that the MDS coding was incorrect.
A resident with multiple pain-related diagnoses received PRN acetaminophen and Norco from a QMA without documented assessment or authorization from a licensed nurse, contrary to facility policy and physician orders. Staff interviews confirmed that the required process for PRN medication administration was not followed or documented.
Staff did not obtain or document required vital signs before administering metoprolol, a medication with physician-ordered hold parameters, to a resident with multiple chronic conditions. The medication was given even when the resident's heart rate was below the specified threshold, and after a certain period, vital signs were not consistently recorded prior to administration, contrary to physician orders and facility policy.
Two residents at risk for falls did not receive required safety interventions: one did not have a perimeter mattress in place as specified in the care plan, and another was transferred without the required sit-to-stand lift, resulting in a fall. The DON confirmed the lapses in following care plans and lack of audits to ensure proper transfer methods.
Two residents with significant respiratory conditions received oxygen therapy that was not in accordance with physician orders or lacked a specific order for the amount to be administered. One resident received less oxygen than ordered, while another received oxygen without a documented order specifying the flow rate, contrary to facility policy and care plans.
A resident with multiple psychiatric diagnoses was prescribed olanzapine, an antipsychotic medication, but did not have a current Abnormal Involuntary Movement Scale (AIMS) assessment as required by facility policy. The last documented AIMS assessment was nearly a year prior, and staff confirmed that a current assessment was missing despite the care plan and policy requiring it every six months.
Medications and biologicals in two medication carts were found without required pharmacy labels and dates of opening, including ear drops, liquid Haloperidol, Spiriva inhalation spray, and insulin pens. Staff acknowledged that medications should be labeled and dated according to facility policy, but these requirements were not followed.
A resident with an indwelling urinary catheter and multiple medical conditions had their catheter output documented using qualitative terms instead of exact milliliter measurements, despite physician orders and facility policy requiring precise recording. Staff interviews and policy review confirmed that urine output should have been measured and recorded accurately, but this was not done.
Staff failed to follow infection control protocols by not properly securing PPE gowns, not changing gloves, and not performing hand hygiene between tasks while providing care to a resident. Both a QMA and an RN were observed performing multiple care activities, including wound care and handling medical equipment, without adhering to required infection prevention procedures as outlined in facility policy.
A resident with severe cognitive impairment eloped from a memory care unit, crossing the street before being returned by staff. The incident was not reported to the Indiana Department of Health due to miscommunication and alleged falsification of documentation by the facility's management. The resident had a history of exit-seeking behavior, and the facility lacked a clear policy for reporting such incidents.
A resident eloped from the facility, exiting through a door that triggered an alarm. Staff responded and found the resident across the street with a neighbor. The incident was not reported to the state in a timely manner due to communication issues and system outages. The resident was assessed with no injuries, but the facility's post-elopement procedures were not fully followed, leading to a delayed investigation and reporting process.
The facility failed to personalize care plans for advanced directives for five residents. Each resident had specific medical conditions and directives that were not accurately reflected in their care plans. For instance, a resident with a DNR order did not have this reflected in their care plan, while another with a full code order also lacked a corresponding care plan. The facility's policy requires comprehensive care plans to remain accurate and current, which was not adhered to in these cases.
The facility failed to properly dispose of medications for three discharged residents, resulting in unaccounted medications such as Amlodipine, Aspirin, and insulin pens. The Regional Support Nurse cited difficulties with the weekly pill pack system, and the pharmacy confirmed missing medication logs. The facility's policy required destruction or return of medications, but this was not adhered to.
The facility failed to date and label medications properly and did not remove expired medications from storage. Insulin pens, eye drops, and inhalers were not dated when opened, and expired medications like insulin pens and lorazepam were not removed. This was observed in two medication carts and one storage room. The facility's policy on medication storage was not followed, as confirmed by an RN during the survey.
A Dietary Aide failed to perform hand hygiene between resident interactions during meal service, as observed by surveyors. The aide handled wheelchairs and served drinks without washing hands, contrary to the facility's hand hygiene policy. The Infection Preventionist confirmed the expectation for staff to maintain hand hygiene before and after resident interactions.
The facility did not administer flu vaccinations in a timely manner for several residents during the 2023/2024 flu season. A lack of a designated infection control nurse led to delays, with some residents receiving their vaccinations months late. The Director of Health Services noted the absence of a functioning Infection Preventionist upon her arrival, which contributed to the oversight.
The facility failed to ensure resident safety during transfers and equipment use. A resident with Alzheimer's struggled during a transfer without a gait belt, risking injury. Another resident using an electronic wheelchair lacked a care plan for the seat belt, which he couldn't operate independently due to rheumatoid arthritis. A third resident's new mattress didn't fit the bed frame properly, creating a safety hazard. The facility lacked appropriate care plans and assessments for these situations.
A facility failed to properly store a resident's CPAP equipment, leaving it uncovered on the bedside table, contrary to policy. The resident, with conditions like OSA and COPD, had a care plan addressing respiratory risks and non-compliance. The facility's policy requires such equipment to be stored in a marked plastic bag, which was not followed.
The facility failed to document the rationale for medication use for two residents, leading to a deficiency. One resident with multiple diagnoses, including diabetes and heart disease, was prescribed several medications without specified indications. Another resident with conditions such as COPD and depression also had multiple medications lacking documented reasons for use. This non-compliance with the facility's medication order guidelines resulted in a deficiency.
The facility failed to treat two residents with respect and dignity during care observations. One resident, who had an incontinent episode, was improperly assisted during a transfer without a gait belt, causing distress and discomfort. The CNA used a stern tone and dismissive gestures, further impacting the resident's dignity. Another resident, who requested incontinent care, was not consulted about her pain and repositioning needs, and staff left without offering to reposition her, leaving her feeling like a burden. These actions demonstrated a lack of respect and dignity towards the residents.
A resident in a LTC facility, with diagnoses including Parkinson's disease and heart failure, was not provided with care that honored her ADL preferences. Observations showed she was often left unkempt, with matted hair and unbrushed teeth, and her care plans were outdated. Despite having specific orders for personal care, these were not consistently followed, leading to a deficiency in her care.
A resident in a LTC facility was not provided with a person-centered activity program, despite being alert and oriented. She was not invited to activities, lacked access to an activity calendar, and required assistance with transfers. Her care plan indicated a need for one-on-one activities, but these were not provided. Documentation inaccurately reflected her participation in activities she did not attend.
Failure to Implement Enhanced Barrier Precautions for Residents with Pressure Ulcers
Penalty
Summary
The facility failed to implement and follow Enhanced Barrier Precautions (EBP) for three residents with pressure ulcers during a facility tour and subsequent record review. For each of these residents, staff did not use the required personal protective equipment (PPE), such as gowns and gloves, during high-contact care activities involving chronic wounds. Specifically, one resident with a pressure ulcer on the right great toe was handled by staff without a gown, and there were no EBP signs or PPE set up in the room. Another resident with a sacrum wound was similarly handled by staff who did not don gowns before contact, and no EBP measures or signage were present. A third resident with a left heel wound also lacked EBP implementation, with no PPE or signage in place at the time of observation. The clinical records for all three residents showed relevant diagnoses, including type II diabetes mellitus, dementia, chronic kidney disease, and other comorbidities. Physician orders for wound care were present, but orders for Enhanced Barrier Precautions were not entered until after the surveyors' observations. Interviews with the Director and Assistant Director of Health Services confirmed that PPE should have been used and that EBP orders and signage were missing at the time of the survey. The facility's own policy required EBP for residents with chronic wounds, specifying the use of gloves and gowns during high-contact care, regardless of anticipated blood or body fluid exposure.
Deficient Staffing and Call Light Response
Penalty
Summary
The facility failed to provide sufficient qualified nursing staff to meet the needs of all residents, as evidenced by ongoing and repeated concerns regarding delayed call light response times and inadequate staff coverage. Resident council meeting notes over several months documented persistent complaints from residents about excessive wait times for assistance, with some residents reporting waits of over an hour and instances where staff would turn off call lights without providing the requested help. Observations confirmed that staff sometimes entered rooms, turned off call lights, and left without assisting residents, contrary to facility policy. A review of staffing records indicated the facility had a 1-star staffing rating for the first quarter of 2025. Additionally, a critical incident occurred when an LPN was assaulted by a resident and sustained a concussion. Despite being instructed to seek medical attention, the LPN was unable to leave the facility due to the lack of a replacement licensed nurse. The facility's backup plan for on-call staff was ineffective, as the on-call person was a Qualified Medical Assistant rather than a licensed nurse, and no licensed staff were available to cover the shift. Facility policies required that all staff answer call lights and provide the requested service before turning off the light, and that sufficient staff be available to meet resident needs. However, documentation and interviews revealed that these policies were not consistently followed, resulting in unmet resident needs and inadequate licensed nurse coverage during critical incidents.
Failure to Obtain Informed Consent for Antipsychotic Medication
Penalty
Summary
A deficiency occurred when the facility failed to obtain informed consent for the use of an antipsychotic medication for one resident. The resident, who had diagnoses including dementia with psychotic disturbance, anxiety, and depression, was prescribed risperidone following a hospital stay. The clinical record did not contain documentation that the resident or the resident's representative was informed about the risks, benefits, treatment alternatives, or the option to choose the preferred treatment related to the antipsychotic medication. Interviews revealed that the resident's family and Power of Attorney were not informed of the medication changes or provided with information about black box warnings or the risks and benefits of the new medication regimen after the resident returned from the hospital. The facility's policy required that consent be obtained and that the resident or responsible party be educated on these aspects, but this was not completed as required.
Failure to Document and Honor Resident's Gender Preference for Caregivers
Penalty
Summary
A resident with diagnoses including Parkinson's disease and heart failure, who was cognitively intact and had an indwelling catheter, expressed a preference for only female caregivers to perform catheter and peri-care. Despite this preference being known among staff, there was no documentation in the clinical record or care plan reflecting the resident's request prior to the survey. Interviews with the resident and staff confirmed that the preference for female caregivers was understood, but not formally recorded. Review of the Medication Administration Record showed that catheter care was performed by male staff, including RNs, LPNs, and CNAs, on multiple occasions. The facility's policy on resident rights emphasized the importance of dignity, respect, and resident input into care planning, but this was not followed in practice for this resident. The Director of Nursing acknowledged awareness of the resident's preference, describing it as an intermittent issue, yet the lack of documentation and continued assignment of male staff to provide catheter care demonstrated a failure to accommodate the resident's stated needs and preferences.
Failure to Provide Bed Hold Policy Documentation Upon Hospital Transfer
Penalty
Summary
The facility failed to provide documentation that the bed hold policy was given to a resident who was transferred to the hospital. The clinical record for a resident with diagnoses including falls, chronic pain, and low back pain showed that the resident sustained a tail bone fracture and was transported to the hospital. Upon review, there was no copy of the bed hold policy in the resident's clinical record. During an interview, the Corporate MDS nurse confirmed that the bed hold policy had not been provided. The facility's own policy requires that residents and their representatives be notified verbally and in writing about the bed hold policy before a transfer to the hospital, but this was not done in this case.
Inaccurate MDS Coding for Oxygen Administration
Penalty
Summary
The facility failed to ensure that a Minimum Data Set (MDS) assessment was accurately coded for a resident with significant respiratory diagnoses, including saddle embolus of the pulmonary artery with cor pulmonale, pulmonary fibrosis, and atelectasis. Multiple observations over several days confirmed that the resident was receiving supplemental oxygen via a portable tank, in accordance with a physician's order to administer four liters per minute as needed to maintain oxygen saturation above 92 percent. Despite this, the resident's quarterly MDS assessment indicated that the resident was not receiving oxygen administration. Interviews with the DON and the MDS Coordinator confirmed that the resident was on supplemental oxygen and that the MDS assessment was not coded correctly to reflect this.
Failure to Ensure PRN Medications Administered Under Licensed Nurse Direction
Penalty
Summary
The facility failed to ensure that as needed (PRN) medications were administered under the direction of a licensed nurse and that proper documentation was maintained for one resident reviewed for pain management. The resident had diagnoses including type 2 diabetes mellitus with diabetic neuropathy, spondylosis of the lumbar region, and pain, and had physician orders for acetaminophen and Norco to be given as needed for pain. Review of the Medication Administration Records (MAR) showed that a Qualified Medication Assistant (QMA) administered both acetaminophen and Norco on multiple occasions without documentation of a licensed nurse's assessment or permission, as required by facility policy and physician orders. Interviews with facility staff, including an LPN, a QMA, and a Clinical Support Nurse, confirmed that the established process required a licensed nurse to assess the resident and authorize PRN medication administration, with this process to be documented in the medical record. Facility policies and the QMA job description also specified that PRN medications administered by a QMA must be done under the direction of a licensed nurse and in accordance with facility procedures. The lack of documentation and failure to follow these procedures led to the deficiency cited in the report.
Failure to Document and Follow Hold Parameters for Medication Administration
Penalty
Summary
Staff failed to obtain and document a resident's vital signs prior to administering metoprolol, a medication with physician-ordered hold parameters. The resident had multiple diagnoses, including chronic obstructive pulmonary disease, type 2 diabetes mellitus with diabetic polyneuropathy and hypoglycemia, hypertension, cognitive communication deficit, edema, and bradycardia. Physician orders required that metoprolol be held if the heart rate was less than 55 or systolic blood pressure was less than 110, and that blood pressure and heart rate readings be obtained twice daily for seven days. The Medication Administration Record (MAR) showed that vital signs were documented as ordered from 4/18/25 through 4/26/25, but metoprolol was administered on several occasions when the heart rate was below the ordered threshold. After 4/26/25, the MAR did not include documentation of heart rate or blood pressure readings to verify the safety of administering metoprolol, except for one instance on 5/3/25. Despite the lack of required documentation, the medication continued to be administered. Interviews with staff confirmed that vital signs should have been obtained and recorded prior to administering medications with hold parameters, and that there was no verification of vital signs before administration as required by physician orders and facility policy.
Failure to Implement Fall Prevention and Safe Transfer Interventions
Penalty
Summary
The facility failed to implement and maintain fall prevention interventions and proper transfer techniques for two residents identified as being at risk for accidents. One resident, with a history of falls, chronic pain, and low back pain, was found on the floor after rolling out of bed. Although the care plan and interdisciplinary team (IDT) notes specified the use of a perimeter mattress as a fall precaution, observation revealed that the mattress was not in place. The Director of Nursing confirmed that the perimeter mattress had been moved during room remodeling and was not returned to the resident's room, despite it being a documented intervention. Another resident, diagnosed with osteoporosis and a history of falls, had a physician's order and care plan requiring the use of a sit-to-stand lift for transfers in and out of bed. However, staff failed to use the required lift, resulting in the resident losing strength and balance during a transfer and being assisted to the floor. The IDT review identified that the staff did not follow the prescribed transfer method, and the DON acknowledged that audits were not conducted to ensure other residents were being transferred according to their care plans.
Failure to Obtain and Follow Physician Orders for Oxygen Administration
Penalty
Summary
The facility failed to ensure that physician's orders for oxygen administration were obtained and followed for two residents. For one resident with a history of pulmonary embolus, pulmonary fibrosis, and atelectasis, observations showed the resident receiving oxygen at two liters per minute via nasal cannula, despite a physician's order for four liters per minute to maintain oxygen saturation at or above 92%. The discrepancy was confirmed by the DON during a review of the resident's orders, and the order was later changed to two liters per minute. The resident's care plan indicated the need to administer oxygen per physician's orders due to cardiovascular and pulmonary risks. For another resident with chronic respiratory failure, chronic lung disease, and emphysema, observations documented the resident receiving supplemental oxygen between 2.5 and 3 liters per minute via nasal cannula. However, the clinical record did not contain a physician's order specifying the amount of oxygen to be administered. The care plan directed staff to administer oxygen per physician's orders, but no such order was present in the record. Facility policy required verification of a physician's order for oxygen administration.
Failure to Complete Required AIMS Assessment for Resident on Antipsychotic Medication
Penalty
Summary
A deficiency was identified when the facility failed to complete Abnormal Involuntary Movement Scale (AIMS) assessments for a resident prescribed antipsychotic medication. The resident had multiple diagnoses, including psychosis, dementia with psychotic disturbance, and hallucinations, and was receiving olanzapine as ordered by a physician. The clinical record review revealed that the last documented AIMS assessment was completed nearly a year prior, despite ongoing antipsychotic therapy. The resident's care plan specifically noted the risk for adverse consequences related to antipsychotic medications and directed that AIMS testing be conducted according to guidelines. During an interview, a Clinical Support Nurse confirmed that there was no documented AIMS assessment available and acknowledged that one should have been performed. The facility's policy required AIMS assessments to be completed after admission, after antipsychotic medications are prescribed, with dosage changes, and to be repeated every six months. The lack of a current AIMS assessment for the resident on antipsychotic medication constituted a failure to follow both the care plan and facility policy.
Failure to Properly Label and Store Medications
Penalty
Summary
Surveyors observed that medications and biologicals in two medication carts were not properly labeled or stored according to facility policy and accepted professional standards. On the 100-hall medication cart, an open bottle of Carbamide Peroxide 6.5% ear drops and an open bottle of liquid Haloperidol were found without labels indicating the date they were opened. An LPN confirmed that these medications should have been labeled with the date of opening. On the 200-hall medication cart, a Spiriva inhalation spray was found with a discard sticker but lacked a date of opening, and two insulin injection pens (Lispro and Lantus) were missing pharmacy labels. A QMA stated that the pharmacy labels may have fallen off and acknowledged that all medications should be dated when opened. The facility's policy requires medications to be stored in containers with pharmacy labels and to be dated when opened, with expiration dating as specified by the manufacturer or policy.
Failure to Accurately Record Catheter Urine Output
Penalty
Summary
The facility failed to ensure accurate recording of catheter urine output for a resident with an indwelling urinary catheter. The resident had multiple diagnoses, including sepsis, infection and inflammatory reaction due to the catheter, bacteremia, hematuria, obstructive and reflux uropathy, and urinary retention. Physician orders required the monitoring of catheter output three times daily, and the resident was also receiving diuretic medication for edema. However, documentation from the facility showed that staff recorded urine output using qualitative terms such as 'small,' 'medium,' or 'large' instead of measuring and recording the exact amount in milliliters as required by both physician orders and facility policy. Interviews with staff confirmed that the expected practice was to use a calibrated measuring container to determine the precise urine output and document the amount in the medical record. Facility policies on emptying urinary bags and catheter care also specified the need for accurate measurement and recording of urine output. Despite these requirements, the medical record for the resident consistently lacked quantitative measurements, leading to a deficiency in the standard of care provided.
Failure to Follow Infection Control Protocols During Resident Care
Penalty
Summary
Staff failed to properly implement infection prevention and control protocols during care of a resident. Two staff members, a QMA and an RN, did not tie their PPE gowns at the waist before entering the resident's room, contrary to facility policy. The QMA, while wearing gloves, performed multiple tasks including oral care, handling a catheter drainage system, operating a mechanical lift, removing hearing aids, assisting with repositioning, handling the resident's oxygen line, removing the resident's pants, and handling cleaning wipes, all without changing gloves or performing hand hygiene between tasks. The QMA only removed her gloves after completing these tasks and acknowledged not changing gloves between them. The RN was observed cleaning the resident after a bowel movement, removing and discarding gloves, and then putting on a new pair of gloves without performing hand hygiene in between. The RN then performed wound care, cleaning the wound area in a manner inconsistent with proper technique, as confirmed by both the RN and the Director of Nursing during interviews. Facility policies reviewed indicated that gowns should be fastened at the neck and waist and that hand hygiene should be performed after removing gloves. These lapses were observed and confirmed through staff interviews and review of facility policies.
Failure to Report Resident Elopement Incident
Penalty
Summary
The facility failed to report an elopement incident involving a resident to the Indiana Department of Health. The incident occurred when a resident, identified as Resident B, exited the facility through the 300 hall door. The alarm was triggered, and a family member observed the resident leaving and informed the staff immediately. The staff responded promptly and returned the resident to the facility within three minutes. However, the incident was not reported to the state because the Corporate Support Nurse was not informed, and the Director of Nursing instructed CNAs to falsify documentation. The Executive Director was aware of the incident but did not ensure it was reported to the state. Resident B, who resided in the Legacy Memory Care Unit, had a history of exit-seeking behavior and was wearing a wander guard bracelet. She had severe cognitive impairment, as indicated by a Brief Interview for Mental Status (BIMS) score of 5. Prior to the incident, Resident B had attempted to exit the facility multiple times, and staff had responded by returning her to the common area or the locked memory care unit. Despite these precautions, the resident managed to leave the facility and cross the street before being returned by staff. The facility's failure to report the incident was compounded by the lack of a clear policy on reporting such incidents to the Indiana Department of Health. The Executive Director and the former Director of Nursing were both involved in the incident's aftermath, with the Director of Nursing allegedly instructing staff to falsify statements. The incident was eventually reported to the state 33 days after it occurred, following internal confusion and miscommunication among the facility's management.
Failure to Timely Investigate Resident Elopement
Penalty
Summary
The facility failed to timely investigate an elopement incident involving a resident, referred to as Resident B, who exited the campus through the 300 hall door. The alarm sounded, and a family member observed the resident leaving and reported it to the staff immediately. The staff responded and found the resident across the street with a neighbor. The incident occurred when the electronic medical record system was down, and the staff documented the event on paper. However, the incident was not reported to the state because the Corporate Support Nurse was not informed, and there was a lack of communication with the Director of Nursing, who did not respond or return to the facility. The incident was treated as if it had occurred recently, and a report to the state was in process at the time of the survey. The facility's documentation included witness statements from staff members who were involved in the incident. These statements indicated that the resident was last observed by a nurse at 8:22 p.m., and the resident was returned to the facility by 8:33 p.m. The resident was assessed and found to have no injuries, and her wander guard was in place. The Executive Director and Director of Nursing were notified, but there was a discrepancy in the instructions given to the CNAs regarding documentation. The facility's checklist for post-elopement procedures was not fully adhered to, as the investigation and reporting process was delayed. The facility's documents indicated that the incident was not immediately reported to the state, and there was confusion among staff regarding the proper procedures to follow. The neighbor who observed the resident outside did not provide a signed statement, and the facility's documentation lacked clarity on the immediate actions taken following the elopement.
Failure to Personalize Advanced Directive Care Plans
Penalty
Summary
The facility failed to personalize resident care plans for advanced directives for five residents. Each resident had specific medical conditions and directives that were not accurately reflected in their care plans. Resident 11, with diagnoses including urinary tract infection, COPD, and dementia, had a care plan that did not specify whether she was to receive CPR or be DNR, despite having a DNR order. Resident 19, diagnosed with COPD, type II diabetes, and heart failure, had an order for CPR but lacked a care plan addressing this directive. Similarly, Resident 32, with conditions such as bradycardia and type 2 diabetes, had a DNR order but no corresponding care plan. Resident 35, suffering from COPD and heart failure, had a full code order, yet her care plan did not reflect this. Lastly, Resident 40, with juvenile myoclonic epilepsy and dysphagia, had a DNR order but no care plan addressing it. The facility's policy requires comprehensive care plans to remain accurate and current, which was not adhered to in these cases.
Failure to Properly Dispose of Medications for Discharged Residents
Penalty
Summary
The facility failed to properly dispose of medications for three residents who were discharged. Resident 204, who had diagnoses including hypertension, hyperlipidemia, and hypothyroidism, was discharged with medications such as Amlodipine, Aspirin, and Atorvastatin unaccounted for. Similarly, Resident 205, with conditions like hypertension and diabetes mellitus type 2, was discharged with medications including Furosemide and insulin pens unaccounted for. Resident 50, who had hypertension and hyperlipidemia, was discharged with medications such as Miralax, Oxycodone, and Aspirin unaccounted for. The Regional Support Nurse indicated difficulties in accounting for medications due to the weekly individual pill packs system. The pharmacy confirmed the absence of medication disposition logs for the residents and stated that controlled substances should be destroyed at the facility level. The facility's policy required the destruction of controlled narcotic medications and the return of non-controlled medications to the pharmacy if they were unneeded, discontinued, expired, or if the resident was discharged. However, this policy was not followed, leading to the deficiency.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to properly date and label medications, as well as remove expired medications from their storage areas, which was observed during a survey. Specifically, insulin pens, eye drops, and inhalers were not dated when opened, and expired medications such as insulin pens and lorazepam were not removed from the medication carts and storage room. This issue was identified in two out of three medication carts and one medication storage room reviewed. The medications involved included lorazepam, basaglar insulin, lantus insulin, refresh eye drops, albuterol inhalers, trelegy ellipta inhalers, genteal tear solution, latanoprost solution, and carboxymethyl solution. The survey findings detailed specific instances of non-compliance, such as a bottle of lorazepam for a resident that had expired, and several insulin pens and eye drops that were either expired or lacked an opening date. Additionally, inhalers for multiple residents were found without dates indicating when they were opened. The facility's policy on medication storage, which requires certain medications to have an expiration date shorter than the manufacturer's expiration date once opened, was not adhered to. These observations were confirmed by RN 6 during the survey.
Failure in Hand Hygiene During Meal Service
Penalty
Summary
The facility failed to ensure proper hand hygiene was maintained by a Dietary Aide (DA) during meal service, as observed on May 14, 2024. During the lunch service, DA 12 was seen serving milk to a resident and then repositioning the resident's wheelchair without performing hand hygiene. Subsequently, DA 12 provided a drink to another resident without washing hands or using hand sanitizer after touching the wheelchair handles. The DA continued to handle items such as a clothing protector and a Styrofoam cup for different residents without performing any hand hygiene in between these actions. The Infection Preventionist (IP) confirmed that the expectation was for staff to perform hand hygiene before and after resident interactions, especially when handling food or drinks. The facility's policy on hand hygiene, dated December 31, 2023, emphasized the importance of handwashing in preventing infection transmission and required healthcare workers to use hand hygiene frequently and appropriately, including before and after preparing or serving meals. Despite these guidelines, the observed actions of DA 12 did not align with the facility's hand hygiene policy, leading to the deficiency noted in the report.
Failure to Timely Administer Flu Vaccinations
Penalty
Summary
The facility failed to adhere to its infection control program objectives regarding the timely administration of influenza vaccinations for residents during the 2023/2024 flu season. Specifically, five residents did not receive their flu vaccinations as required. Resident 46, for instance, had not been offered a flu vaccination for the 2023/24 season, with her last recorded vaccination being on January 27, 2023. The issue was attributed to the absence of a designated infection control nurse, which led to a lapse in the vaccination schedule. The Director of Health Services (DHS) acknowledged the oversight, noting that upon her arrival in February 2024, there was no functioning Infection Preventionist (IP) in place. The Assistant Director of Health Services (ADHS) was later appointed as the IP in March 2024. The facility's Preventive Health Care Report highlighted that several residents, including Residents 8, 22, 23, and 38, received their flu vaccinations late, with some not being vaccinated until March 2024. The facility's existing policies on immunizations and infection prevention were not effectively implemented, contributing to the delay in vaccinations.
Deficiencies in Resident Safety and Equipment Use
Penalty
Summary
The facility failed to prevent potential accidents during a resident's transfer, as observed when CNA 15 attempted to transfer Resident E without using a gait belt. Resident E, who has Alzheimer's disease and a history of falling, struggled to support her weight during the transfer. CNA 15 used the back of Resident E's saturated brief for support, which could tear, and did not adjust the bed height or apply a gait belt, despite Resident E's difficulty in standing and pivoting. Resident 8, who uses an electronic wheelchair due to rheumatoid arthritis, was observed with a seat belt that lacked a physician's order and care plan for its use. The facility did not conduct ongoing assessments for changes in Resident 8's ability to use the seat belt, which he could not operate independently due to his condition. The care plan was not revised to include the safety belt, and there was no documented monitoring of the device's appropriateness and safety. Resident C, who has a new Low-Air-Loss mattress, experienced issues with the mattress not fitting the bed frame properly, creating a gap that allowed her head to hang off the edge. Despite her complaints and the observation of the gap, there was no therapy referral to evaluate the mattress for proper positioning and safety. The facility lacked a policy related to the LAL mattress and bed frame, and the care plan did not include an order for the mattress.
Improper Storage of Respiratory Equipment
Penalty
Summary
The facility failed to ensure proper storage of respiratory equipment for a resident, specifically the continuous positive airway pressure (CPAP) facial equipment. On two separate occasions, the CPAP equipment for a resident with multiple respiratory and cognitive conditions was observed uncovered on the bedside table. The resident, who has diagnoses including obstructive sleep apnea, dementia, chronic obstructive pulmonary disease, and asthma, was noted to have a care plan addressing potential respiratory complications and non-compliance with physician orders. The facility's policy, which requires respiratory equipment to be stored in a plastic bag marked with the date and resident's name, was not followed. During an interview, the Regional Clinical Support confirmed that CPAP equipment should be covered when not in use, as per the facility's infection control guidelines. The failure to adhere to these guidelines was identified as a deficiency in the facility's practices.
Failure to Document Medication Indications for Two Residents
Penalty
Summary
The facility failed to provide a rationale for the use of medications for two residents, leading to a deficiency in medication management. Resident 33, who had diagnoses including type 2 diabetes mellitus, depression, and heart disease, was prescribed several medications without documented indications for their use. These medications included Atorvastatin, Basaglar Kwikpen insulin, Clonidine, Ferrous sulfate, Levothyroxine, Megace, and Metoprolol. Each of these medications lacked a specified reason for administration, which is a requirement according to the facility's policy on medication orders. Similarly, Resident 19, with diagnoses such as COPD, type II diabetes mellitus, morbid obesity, and major depression with psychotic symptoms, was also prescribed multiple medications without documented indications. These included Isosorbide mononitrate, Docusate sodium, Crestor, Cyanocobalamin, Ferrous sulfate, Finasteride, Potassium chloride, Miralax, Pregabalin, Protonix, Ranolazine, Tamsulosin, and Toprol XL. The absence of documented indications for these medications represents a failure to comply with the facility's guidelines, which require specifying the reason for each medication order.
Failure to Ensure Resident Dignity During Care
Penalty
Summary
The facility failed to ensure that Resident E was treated with respect and dignity during a transfer observation. On the observed date, Resident E, who had experienced an incontinent episode, was attempting to get out of bed. CNA 15, without using a gait belt, attempted to assist Resident E by grabbing the back of her saturated brief, causing the resident to struggle and become anxious. Despite Resident E's difficulty in supporting her weight, CNA 15 did not adjust the bed height or use a gait belt, and instead, used a stern tone and made dismissive gestures, such as eye-rolling, which further distressed the resident. This lack of proper assistance and respect during the transfer process led to Resident E feeling undignified and unsupported. Additionally, the facility failed to treat Resident B with respect and dignity during a treatment observation. Resident B, who had requested incontinent care, was not given the opportunity to respond to questions about her pain and repositioning needs, as QMA 7 dismissed her ability to tolerate repositioning without consulting her. After completing the care, the staff left without offering to reposition Resident B, leaving her feeling like a burden and unsupported. The facility's actions and inactions during these observations demonstrated a lack of respect and dignity towards the residents, as noted by the Executive Director and Director of Nursing.
Failure to Honor Resident's ADL Preferences
Penalty
Summary
The facility failed to honor and implement the Activities of Daily Living (ADL) preferences for a totally dependent resident, identified as Resident B. Observations and interviews revealed that Resident B was often left in an unkempt state, with matted hair, unbrushed teeth, and soiled briefs. Despite having a physician's order for a personal cleanser and special shampoo, these were not consistently used, and her scheduled showers were not adhered to. Grievance documentation indicated ongoing complaints about her care, including being left in soiled briefs and not receiving oral care. Resident B's medical records showed she had diagnoses including Parkinson's disease, hypertension, and heart disease with heart failure. Her care plans were outdated and lacked specific interventions to address her needs and preferences, such as the use of special shampoo and the frequency of oral care. The facility's failure to update and follow her care plans contributed to the neglect of her ADL preferences. Interviews with staff, including the Regional Clinical Support Nurse, highlighted that the facility did not have a specific policy for ADL care, relying instead on Indiana code and general resident rights guidelines. These guidelines emphasized treating residents with dignity and respect, yet Resident B's care did not reflect these principles. The facility's lack of detailed care planning and adherence to Resident B's preferences resulted in a deficiency in her care.
Failure to Provide Person-Centered Activities for Resident
Penalty
Summary
The facility failed to implement a person-centered and meaningful activity program for Resident B, who was observed to be alert and oriented but not engaged in any activities. Despite being in bed with the lights off and personal items obstructing her TV, Resident B expressed that she was not invited to activities and that staff did not assist her in getting ready in time. She required a Hoyer lift for transfers, which was often painful due to staff rushing the process. Additionally, Resident B did not have access to an activity calendar, which was out of her line of sight and reach. Resident B's care plan and assessments indicated a need for one-on-one activities and participation in group activities, but these were not being provided. She enjoyed genealogy research, bird identification, and reading, but her glasses were lost, and she could not hold books due to contractures. Despite her interest in activities like the Silly [NAME] event and the [NAME] Farm Tractor show, she was not assisted or invited to participate. The activity staff was observed inviting other residents to activities, but Resident B was consistently overlooked. The facility's documentation inaccurately reflected Resident B's participation in activities she was not invited to or could not attend. Her activity participation log included entries for activities she did not partake in, such as playing games on a phone she did not have and reading without glasses. The facility's policy on life enrichment programs emphasized the need for meaningful and diverse activities tailored to individual residents, but this was not adhered to in Resident B's case.
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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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