Majestic Care Of Newburgh
Inspection history, citations, penalties and survey trends for this long-term care facility in Newburgh, Indiana.
- Location
- 5233 Rosebud Lane, Newburgh, Indiana 47630
- CMS Provider Number
- 155670
- Inspections on file
- 38
- Latest survey
- July 31, 2025
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Majestic Care Of Newburgh during CMS and state inspections, most recent first.
Surveyors found that two residents did not receive medications according to physician orders and facility policy. Medications were left unattended at the bedside, and staff did not consistently observe residents taking their medications. In some cases, required vital signs were not recorded before administration, and medications were held without proper physician orders.
The facility failed to ensure proper dish sanitization in the kitchen, as the dishwasher did not achieve the required chlorine levels and staff lacked knowledge on correct testing procedures. Despite inadequate sanitization, kitchen staff continued to use the dishwasher and serve meals on these dishes, and there was confusion about alternative cleaning methods when the dishwasher was not working.
Several residents who were dependent on staff for ADL assistance did not receive scheduled showers or bed baths as documented in facility records. Residents with conditions such as diabetes, epilepsy, and end stage renal disease reported missed hygiene care, and observations confirmed lapses in scheduled bathing routines. Staff interviews and documentation practices indicated that required hygiene care was not consistently provided according to facility policy.
Surveyors found multiple instances of improperly stored and unlabeled medications, including loose pills, undated liquids, and expired drugs in several medication and treatment carts. Staff interviews revealed gaps in knowledge and adherence to facility policies regarding medication labeling and expiration checks.
A Corporate Manager transferred clean laundry from the washer without wearing an apron, allowing items to touch her clothing and arms, contrary to facility policy and infection prevention protocols. The DON confirmed that staff should avoid contact between clean laundry and uniforms.
Two residents received PRN medications, including ondansetron, lorazepam, and Tylenol, from QMAs without the required preauthorization from a licensed nurse. Facility records and staff interviews confirmed that nurse authorization and documentation were not obtained prior to administration, contrary to facility policy.
A nurse failed to check gastric residuals before administering a tube feeding to a resident with a G-tube, despite physician orders and facility policy requiring this step. The resident, who had multiple medical conditions including dysphagia and a tracheostomy, did not consistently have residuals checked prior to feedings, as confirmed by staff, a family member, and the DON.
A resident with a laryngectomy did not receive proper airway management due to inaccurate documentation, lack of assessment for self-care ability, and absence of necessary equipment for the laryngectomy tube. Staff inconsistently performed and documented stoma care, and the care plan did not reflect the resident's involvement in self-care. The facility's policies and training did not address the specific requirements for laryngectomy care.
Two residents experienced deficiencies in clinical record documentation, including missing entries for abnormal vital signs, falls, and care plan interventions. For one resident, abnormal blood pressure and heart rate readings were not properly documented or communicated to a physician, and for another, fall incidents and related notifications were not recorded in the medical record. Facility policies requiring timely and complete documentation were not followed, and risk management reports were not integrated into the official clinical record.
A current nurse staffing sheet was not posted for one day during the survey period. The displayed sheet was outdated, and the process for updating the sheet depended on staff manually switching pre-filled sheets in the absence of the scheduler, without a formal policy in place.
A resident with hemiplegia was observed without prescribed hand splints and was given a straw to drink, contrary to physician orders. Despite documentation indicating compliance, staff were unaware of the no-straw order and failed to apply hand splints as required. The facility lacked a policy on following physician orders.
The facility was cited for failing to maintain a sanitary kitchen environment, with debris buildup observed on floors and equipment during inspections. Despite having cleaning schedules and policies in place, the facility did not adhere to them, resulting in unsanitary conditions.
A resident with an indwelling urinary catheter was not effectively assessed or monitored for adverse outcomes, leading to hospitalization for obstructive uropathy, sepsis, and acute kidney injury. Despite physician orders and a care plan, there were significant lapses in documentation and care, and staff failed to address reported issues of blood in the catheter tubing.
The facility failed to ensure that food was served at an appetizing temperature for multiple residents. Observations and interviews revealed consistent complaints about the food being cold, tough, overcooked, or burnt. A test tray showed food temperatures significantly below the expected serving temperatures, and the Dietary Manager confirmed the discrepancy with the facility's Food Preparation policy.
The facility failed to store and prepare food under sanitary conditions, with food items found open to air and without proper labeling or dating. Staff members were observed with improper hair restraints and inadequate hand hygiene practices, contrary to facility policies.
The facility failed to immediately notify the family of a resident involved in a resident-to-resident altercation. A resident with severe cognitive impairment was attacked by a roommate, resulting in bruising. The family was not informed until the next morning, despite the facility's policy to notify families immediately in such cases.
The facility failed to ensure accurate MDS assessments for three residents, leading to incorrect documentation of antipsychotic medication use, significant weight loss, and dental status. Errors were confirmed by staff, who admitted to relying on second-hand information and not adhering to the RAI Manual.
The facility failed to ensure care plan interventions were implemented for a resident reviewed for falls. The resident was observed with the call light not within reach on two occasions, despite care plan interventions specifying that the call light and personal items should be within reach. The resident has Alzheimer's Disease, dementia, and generalized anxiety disorder, and is a fall risk requiring substantial to maximum assistance for mobility, transfer, and eating.
The facility failed to revise the care plan for a resident with a history of falls and cognitive impairment after an unwitnessed fall resulted in fractures. The care plan was inappropriately updated to continue with current interventions, contrary to the facility's Fall Management policy.
A resident with hypotension and type 1 diabetes was given midodrine outside of prescribed parameters and IM glucagon without an active order during a hypoglycemic episode. The DON confirmed the medication errors and lack of proper documentation, leading to a deficiency in medication administration.
The facility failed to provide adequate nutritional and hydration care to two residents, resulting in significant weight loss and dehydration. One resident experienced severe weight loss due to lack of assistance with meals and failure to obtain weekly weights. Another resident was provided with insufficient fluids, leading to dehydration and a urinary tract infection. Staff interviews revealed ongoing issues with documentation and adherence to care plans.
The facility failed to ensure proper labeling of oxygen equipment and the presence of oxygen administration signs for three residents. Observations revealed undated oxygen tubing and missing warning signs, despite physician orders and care plans indicating the need for continuous oxygen and weekly tubing changes. A policy on oxygen equipment dating and labeling was requested but not provided.
The facility failed to provide appropriate pain assessments and management for a resident with severe cognitive impairment and multiple diagnoses, leading to inadequate pain management despite clear signs of distress.
The facility failed to ensure that a CNA had a current and valid certificate to work. Despite the expiration of the certificate, the CNA worked on 10 shifts. The facility's policy requiring non-certified placement or removal from the schedule until renewal was not followed.
The facility had a medication error rate of 7.7%, exceeding the acceptable 5%. Errors included a QMA not obtaining a required blood pressure reading and not checking the EDK for an unavailable medication, and an RN not priming an insulin pen needle before administration.
The facility failed to discard deteriorated medications for one of three medication carts observed. Several loose and unlabeled medications were found in the 100 Hall Cart 1. An LPN confirmed the issue and disposed of the medications. The facility's policy requires clear labeling of medications with specific information.
A resident with a documented lactose intolerance was repeatedly given milk with meals, despite clear dietary restrictions noted in their care plan and posted in the kitchen. This failure was confirmed by both a family member and the DON, indicating a lapse in the facility's adherence to its own dining and food preferences policy.
The facility failed to ensure complete and accurate resident records for three residents. Confusion regarding insulin administration for a resident, inaccurate documentation of medication refusal for another, and missing vital signs documentation after a fall for a third resident were observed.
The facility failed to ensure proper infection control practices during wound care for two residents. Staff did not change gloves or perform hand hygiene as required, leading to potential contamination during wound care procedures.
Failure to Follow Physician Orders and Medication Administration Protocols
Penalty
Summary
Surveyors identified that the facility failed to ensure physicians' orders were followed for two of three residents reviewed for medication administration. In one instance, a medication cup with pills was observed on a resident's bedside table, and the resident stated she delays taking her medications until after breakfast. Review of her clinical record showed multiple diagnoses, including hypertensive heart disease, chronic kidney disease, Parkinson's disease, and diabetes. The electronic medication administration record (EMAR) revealed several instances where blood pressure readings were not recorded, and medications were not signed as given, with code 4 (vitals outside parameters) used despite no physician's order specifying parameters for holding the medication. Additionally, another resident reported that medications were left on her over-bed table, and she took them without staff present, sometimes receiving additional medications shortly after. Interviews with staff confirmed that medications were sometimes left unattended at the bedside, contrary to facility policy, which requires staff to observe medication consumption and prohibits leaving medications unless the resident has been assessed for safe self-administration. Staff also indicated uncertainty regarding physician orders for holding medications based on vital signs.
Dishwasher Sanitization Failure and Staff Knowledge Deficit
Penalty
Summary
The facility failed to ensure that the dishwasher in the kitchen was properly sanitizing dishes and that staff were knowledgeable about how to test for proper sanitization. During multiple observations, the dishwasher's rinse cycle did not reach the required temperature, and chlorine test strips consistently read zero parts per million (ppm), indicating no chemical sanitization was occurring. Despite these findings, kitchen staff continued to use the dishwasher to clean dishes, and meals were served on these inadequately sanitized dishes. Staff interviews revealed a lack of understanding regarding proper testing procedures for the dishwasher's sanitization process, with some staff expressing difficulty in safely testing the water and others unfamiliar with the equipment's operation. The facility's policy required a low temperature dishwasher to use a final rinse with at least 50 ppm hypochlorite for a minimum of 10 seconds, but this standard was not met during the observed periods. The deficiency was further compounded by the fact that staff continued to use the dishwasher and serve food on dishes that had not been properly sanitized, and there was confusion among staff about alternative procedures when the dishwasher was not functioning correctly.
Failure to Provide Scheduled Showers or Bed Baths to Dependent Residents
Penalty
Summary
The facility failed to provide scheduled showers or complete bed baths to residents who were dependent on staff for assistance with activities of daily living (ADLs). Multiple residents, all of whom were cognitively intact and required varying levels of staff assistance for bathing, reported not receiving their scheduled showers or bed baths. Documentation in the Point of Care charting system and written shower sheets confirmed that these residents did not receive or refuse their scheduled hygiene care on specific dates. For example, one resident with diabetes mellitus had not received or refused showers on two scheduled days and was noted to have a strong, pungent odor. Another resident with epilepsy, who preferred morning showers due to seizure risk, did not receive or refuse showers on three scheduled days. A third resident with end stage renal disease preferred bed baths but did not receive or refuse them on two scheduled days and was observed with oily hair. Interviews with residents revealed that they were aware of their scheduled hygiene routines but reported missed care, sometimes being told by staff that they would be attended to if time allowed. A Certified Nurse Aide confirmed the facility's process for offering and documenting showers, bed baths, and refusals. The facility's policy required staff to assist residents with bathing according to schedule or resident request, but the documented lapses indicate that this policy was not consistently followed for several residents with significant medical needs.
Improper Storage and Labeling of Medications
Penalty
Summary
Surveyors observed that medications and biologicals were not properly stored or labeled in multiple medication and treatment carts throughout the facility. Specifically, loose pills of various types and unidentified medications were found in several medication carts, with no identifying information such as resident name or medication label. Liquid medications and creams were also found without open dates or proper labeling, and expired medications were present in the carts. Additionally, medication drawers were noted to be unclean, with sticky residues and dried drippings observed. These findings were consistent across four medication carts and one treatment cart. Interviews with staff revealed a lack of knowledge and training regarding the facility's policies for checking and labeling medications. Some staff members were unaware of how often to check the carts or how to identify and handle unlabeled or expired medications. Facility policies provided by the administrator indicated that medications should be labeled with open dates and checked regularly for expiration, but these procedures were not being followed as evidenced by the observations and staff interviews.
Failure to Follow Infection Prevention Practices During Laundry Handling
Penalty
Summary
During an observation of laundry services, the Corporate Manager was seen emptying the washer without wearing an apron, allowing clean laundry items to come into direct contact with her shirt, pants, and arms. An interview with the Director of Nursing confirmed that staff are expected to prevent clean laundry from touching their uniforms during transfer. A review of the facility's policy on Personal Laundry Handling and Processing indicated that items should be moved from the washer to the dryer in a manner that minimizes the risk of contamination or re-soiling. These actions did not align with the facility's infection prevention and control protocols.
PRN Medications Administered by QMAs Without Nurse Authorization
Penalty
Summary
The facility failed to ensure that as-needed (PRN) medications administered by Qualified Medication Aides (QMAs) were preauthorized by a licensed nurse, as required by facility policy and job descriptions. For one resident with gastroesophageal reflux disease, ondansetron was administered on two occasions by QMAs without prior authorization from a licensed nurse. The resident's records showed that the medication was given as needed for nausea and vomiting, but there was no documentation of nurse authorization as required. For another resident with generalized anxiety disorder, severe cognitive impairment, and osteoarthritis, both lorazepam and Tylenol Arthritis Pain Extended Release were administered by QMAs on multiple occasions without documented authorization from a licensed nurse. Facility documentation and staff interviews confirmed that QMAs are required to obtain and document nurse authorization before administering PRN medications, but this process was not followed for these residents during the review period.
Failure to Check Tube Feeding Residuals as Ordered
Penalty
Summary
A deficiency was identified when a nurse failed to check for gastric residuals prior to administering a tube feeding to a resident with a gastro/jejunal feeding tube, as required by physician orders and facility policy. Observation showed that the LPN administered the feeding without verifying residuals, and the nurse later confirmed that this step was not always performed before feedings. The resident's care plan and physician orders specifically required checking tube placement and residual volume before each feeding and medication administration, with instructions to hold feedings if residuals exceeded a certain amount. The resident involved had diagnoses including tracheostomy, neoplasm of the larynx, and dysphagia, and was cognitively intact, requiring supervision for certain activities. Review of the clinical record and interviews with staff and a family member confirmed that the practice of checking residuals was not consistently followed. The Director of Nursing also acknowledged that staff were expected to check residuals prior to each feeding, in accordance with facility policy and physician orders.
Failure to Provide Proper Laryngectomy Care and Airway Management
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident with a laryngectomy, resulting in improper airway management. The resident, who was cognitively impaired and required supervision with hygiene and other activities, had a history of laryngectomy, tracheostomy, and related complications. Observations revealed that the resident's laryngectomy tube was found out of place and the resident reinserted it himself. Documentation and care records indicated inconsistencies, such as staff documenting that they performed stoma care even when the resident did it himself, and a lack of accurate assessment of the resident's ability to perform self-care. Physician orders specified that staff should monitor the tube and stoma site every shift, cleanse the area, and reinsert the tube as needed, with specific instructions for emergency situations. However, the clinical record lacked an assessment of the resident's skills for laryngectomy care, and there were no physician orders permitting the resident to perform his own stoma care. The care plan did not reflect the resident's involvement in self-care, and staff were not consistently following the prescribed care procedures. Additionally, the facility did not have the correct equipment for the laryngectomy tube, and staff initially treated the stoma as a tracheostomy rather than a laryngectomy. Interviews with staff and family confirmed that the resident's stoma care was not being performed as ordered, and the facility lacked the necessary supplies for proper care. Staff training was inconsistent, with verbal instructions being relayed rather than formal training or skills assessments specific to laryngectomy care. The facility's policies and documentation did not address the unique needs of laryngectomy care, contributing to the deficiency.
Incomplete and Inaccurate Documentation of Resident Care and Incident Response
Penalty
Summary
The facility failed to ensure complete and accurate documentation in the clinical records for two residents, specifically regarding falls, abnormal vital signs, and changes in condition. For one resident with congestive heart failure, the clinical record showed an episode of abnormal low blood pressure and high heart rate, but lacked documentation of a rechecked blood pressure or physician notification. Although the administrator stated that a second set of vitals was obtained and found to be normal, there was no documentation to support this, and the information could not be provided upon request. Facility policies required timely and complete documentation of assessments, interventions, and notifications, which was not followed in this instance. For another resident with Alzheimer's Disease and a history of falls, the clinical record did not contain documentation that the physician and resident representative were notified of two separate falls, nor was there evidence of an assessment after one of the falls until the following morning. Additionally, a fall prevention intervention to keep the resident's door open for visualization was not consistently implemented, as the door was observed closed on multiple occasions. The care plan was not updated to reflect the resident's preference for a closed door, and discussions with the resident representative regarding this change were not documented in the clinical record. Risk management reports indicated that assessments and notifications were completed at the time of the incidents, but these reports were not part of the official medical record. The facility's documentation policies required that all relevant information be entered into the clinical record, but this was not done, resulting in incomplete and inaccurate records for both residents.
Failure to Post Current Nurse Staffing Sheet
Penalty
Summary
The facility failed to post a current nurse staffing sheet for one of five days during the survey period. On the morning of 6/29/25, the posted nurse staffing sheet displayed in the main lobby was found to be dated two days prior, indicating it was not current. Interviews with the Administrator revealed that the scheduler was responsible for preparing the staffing sheets, and when absent, would leave a pre-filled sheet for night shift staff to display. However, there was no formal policy in place for posting nurse staffing information, and the process relied on staff manually updating the sheet, which did not occur as required on the identified day.
Failure to Follow Physician Orders for Resident Care
Penalty
Summary
The facility failed to ensure physician orders were followed for a resident, identified as Resident B, who was observed without hand splints and was given a straw to drink with, contrary to the care plan and physician orders. Resident B, who has diagnoses including hemiplegia and hemiparesis following a cerebral infarction, was observed multiple times without the prescribed hand splints, which were to be applied for up to four hours in the morning and afternoon. Despite the nursing staff signing off on the application of hand splints in the electronic medication administration record, observations indicated that the splints were not applied during the specified times. Additionally, Resident B was observed being given a straw to drink with, despite a clear order for no straws due to dysphagia and the risk of aspiration. The nursing staff, including RN 1, were unaware of the no-straw order and had noticed unthickened liquids on Resident B's bedside table. The facility's policy on comprehensive care plans indicated that qualified staff should be notified of their roles and responsibilities, but there was no policy provided on following physician orders. This deficiency was related to complaints IN00434521 and IN00437811.
Unsanitary Kitchen Conditions
Penalty
Summary
The facility failed to maintain a sanitary environment in the kitchen, as observed during two separate inspections. On the first inspection, debris was found accumulated on the kitchen floors, particularly along the edges of the walls, under storage racks and tables, behind the stove and warmers, and under the dish machine and steam table. The dry pantry floor also had debris buildup, with condiment packets scattered on the floor and under food racks. Additionally, debris was noted on the sides of the stove, the shelf above the stove, and the shelves on the stainless steel table where the steamer was placed. These unsanitary conditions were observed again during a follow-up inspection. The facility's cleaning schedules were reviewed, indicating that the AM cook was responsible for cleaning the three-compartment sink and the stove, while the PM cook and servers were tasked with cleaning and sanitizing the floors and walls. Despite these schedules, the District Dietary Manager confirmed that the floors were only spot mopped during the day and fully swept and mopped at night. The facility's policy, revised in February 2023, required all food preparation and service areas to be maintained in a clean and sanitary condition, with a routine cleaning schedule for all cooking equipment and surfaces. However, the observations during the inspections indicated a failure to adhere to these policies, leading to the cited deficiency.
Failure to Monitor and Care for Resident with Indwelling Urinary Catheter
Penalty
Summary
The facility failed to ensure that a resident with an indwelling urinary catheter was effectively assessed and monitored for adverse outcomes, received appropriate treatment and services to prevent infection, and was monitored for complications. Resident 35, who had a history of UTIs, chronic kidney disease, and dementia, was admitted with an indwelling Foley catheter. Despite physician orders and a care plan that included regular catheter care and monitoring, there were significant lapses in documentation and care. The resident's medical record lacked necessary assessments and monitoring for signs of infection or complications related to the catheter, and there were multiple instances where catheter care was not documented as completed according to the physician's orders and the plan of care. On several occasions, the resident's family reported blood in the catheter tubing and bag, but staff did not take appropriate action, stating that they no longer changed catheters. The resident's condition deteriorated, showing signs of infection and sepsis, which were not adequately addressed by the facility staff. The resident was eventually hospitalized with obstructive uropathy, sepsis secondary to a UTI, and acute kidney injury. Hospital staff found that the Foley catheter balloon was inflated in the urethra, causing significant complications. Interviews with facility staff revealed that there was confusion and inconsistency in documenting catheter assessments and care. The Director of Nursing confirmed that if tasks were not initiated on the Treatment Administration Record (TAR), the task was not completed. The Infection Preventionist also indicated that the resident had not been tracked for UTI or related urinary symptoms since the previous year. The facility's policies on catheter care and monitoring were not followed, leading to the resident's severe health decline and subsequent hospitalization.
Failure to Serve Food at Appetizing Temperature
Penalty
Summary
The facility failed to ensure that food was served at an appetizing temperature for multiple residents. Observations and interviews with residents revealed consistent complaints about the food being cold, tough, overcooked, or burnt. Specific instances included Resident 21, Resident 246, Resident 74, Resident 73, Resident 87, Resident 4, Resident 24, Resident 55, and Resident 25, all of whom reported issues with the temperature and quality of their meals. A test tray obtained on 5/2/24 showed that the food temperatures were significantly below the expected serving temperatures, with baked chicken at 100 degrees F, mac and cheese at 92 degrees F, carrots at 88 degrees F, and pumpkin pie at 76 degrees F. The Dietary Manager confirmed that the expected serving temperatures for meat and vegetables were 155 degrees F and 140 degrees F, respectively. The facility's Food Preparation policy, revised in 2/2024, indicated that food items should be kept at temperatures greater than 41 degrees F and/or less than 135 degrees F, which was not adhered to in this instance.
Sanitation and Hygiene Deficiencies in Food Storage and Preparation
Penalty
Summary
The facility failed to store and prepare food under sanitary conditions during multiple kitchen and nutrition pantry observations. Specifically, food items in the freezer and refrigerators were found open to air and without proper labeling or dating. Additionally, expired food items were not disposed of, and the kitchen floor was observed to be dirty with food debris, liquid spills, and other contaminants. The dry pantry also had a sticky floor with a brown liquid and dented cans stored improperly. These observations were made during a full kitchen tour and follow-up walkthroughs with the Dietary Aide and Dietary Manager present. Furthermore, staff members were observed not adhering to proper hygiene protocols. Dietary Aides and the Dietary Manager were seen with loose hair coming out of their hair nets, and the Dietary Manager was observed multiple times without a beard net or wearing it incorrectly. Hand hygiene practices were also inadequate, with one Dietary Aide lathering her hands for significantly less than the required 20 seconds on multiple occasions. The Infection Preventionist confirmed that these practices were against the facility's policies, which mandate proper hair and beard restraints and a minimum of 20 seconds for handwashing.
Failure to Immediately Notify Family of Resident Altercation
Penalty
Summary
The facility failed to immediately notify the family of a resident involved in a resident-to-resident altercation. Resident 35, who had severe cognitive impairment and diagnoses including dementia and major depressive disorder, was attacked by a roommate with a walker and a drawer, resulting in bruising to Resident 35's hand. The incident occurred on the evening of 2/26/24, but the family was not notified until 11:07 A.M. the next morning, despite the facility's policy to notify families immediately in case of emergencies, which includes resident-to-resident altercations. Interviews and record reviews confirmed the delay in notification. A family member reported not being contacted until the morning after the incident. The Administrator and Director of Nursing (DON) acknowledged that the family should have been notified immediately, as per the facility's Change in Condition policy. Documentation showed that the notification was made late, and the facility's policy was not followed in this instance.
Inaccurate MDS Assessments for Three Residents
Penalty
Summary
The facility failed to ensure the MDS (Minimum Data Set) Assessment was completed accurately for three residents. Resident 25's MDS assessment inaccurately indicated that the resident did not receive antipsychotic medication during the seven-day look-back period, despite physician orders for Aripiprazole. The Social Worker confirmed the error, noting that the resident was on the medication during the assessment period. Resident 55's MDS assessment incorrectly reported no significant weight loss, despite clinical records showing an 18.37% weight loss within 30 days and 27.55% within 180 days. Both the MDS Coordinator and the Registered Dietician were unsure why the significant weight loss was not recorded accurately. Resident 246's MDS assessment inaccurately indicated that the resident was not edentulous and had no broken teeth, despite conflicting information in the clinical record. The Admission Nursing Assessment noted broken natural teeth, while the Admission Nutrition Assessment and care plan indicated the resident had no teeth and used full dentures. The MDS Coordinator admitted to not observing the resident's mouth and relying on second-hand information from other staff. The facility's RAI policy mandates the use of the current RAI Manual for comprehensive assessments, which was not adhered to in these cases.
Failure to Implement Care Plan Interventions for Fall Risk
Penalty
Summary
The facility failed to ensure care plan interventions were implemented for a resident reviewed for falls. On two separate occasions, the resident was observed with the call light not within reach, despite care plan interventions specifying that the call light and personal items should be within reach. The resident, who has Alzheimer's Disease with late onset, dementia, and generalized anxiety disorder, was identified as moderately cognitively impaired and a fall risk, requiring substantial to maximum assistance for mobility, transfer, and eating. The facility's Fall Management policy, revised in June 2023, mandates that all falls be discussed by the interdisciplinary team to determine root cause and other possible interventions to prevent future falls.
Failure to Revise Care Plan After Resident Fall
Penalty
Summary
The facility failed to ensure that documentation of interventions was revised for a resident who experienced a fall. Resident 56, who has a history of vascular dementia, aphasia following cerebral infarction, and fractures, was observed with a cast on her left arm. The resident's most recent MDS assessment indicated moderate cognitive impairment and a history of falls with major injury. Despite an unwitnessed fall resulting in two fractures to the right wrist, the care plan was not appropriately updated with new interventions to prevent future falls. An IDT note indicated that the resident had decreased safety awareness and communication deficits, and ambulated independently around the facility. However, the care plan was only updated to continue with current interventions, which the Director of Nursing acknowledged was not appropriate. The facility's Fall Management policy requires the interdisciplinary team to determine the root cause of falls and update the care plan with new interventions, which was not done in this case.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure medication was administered according to physician orders for Resident 246, who had diagnoses including hypotension and type 1 diabetes mellitus. Midodrine, a medication for low blood pressure, was given on three occasions when the resident's systolic blood pressure (SBP) was above the prescribed threshold of 110 mm/Hg. Additionally, the resident experienced a hypoglycemic episode and was administered intramuscular (IM) glucagon, despite the absence of an active order for this medication. The resident's clinical record indicated that the IM glucagon order had been discontinued and replaced with intranasal Baqsimi due to a back order of IM glucagon. However, the IM glucagon was still administered during the emergency without proper documentation or a new order from the primary care clinician. The Director of Nursing (DON) confirmed that midodrine was given outside of the prescribed parameters and that the IM glucagon administered was from a past order that had not been returned to the pharmacy. The DON also indicated that the nurse on duty had called the doctor for an order to administer IM glucagon but did not document the verbal order due to a busy night. The facility's policies on medication administration and unnecessary drugs were not followed, as medications were administered without proper orders and documentation. The clinical record lacked evidence of a verbal order for IM glucagon or instructions to hold the intranasal Baqsimi, leading to the deficiency in medication administration for Resident 246.
Failure to Provide Adequate Nutritional and Hydration Care
Penalty
Summary
The facility failed to provide adequate nutritional care and services to Resident 55, who experienced significant weight loss. Despite having severe cognitive impairment and requiring moderate assistance with eating, Resident 55 was often not assisted with meals. The clinical record showed multiple instances where the resident consumed 0% or less than 50% of their meals without being offered an alternative. Additionally, the facility failed to obtain weekly weights as ordered by the physician and did not notify the physician of the resident's significant weight loss. The care plan indicated that the resident should consume at least 50-75% of planned meals and be provided assistance with meals and hydration, but these interventions were not consistently followed. Observations and interviews confirmed that staff did not always assist the resident with meals, and documentation was often inaccurate or incomplete. Resident 75, who had diagnoses including failure to thrive, severe protein-calorie malnutrition, and type 2 diabetes mellitus with chronic kidney disease, also experienced inadequate care. The resident's care plan included measures to prevent dehydration, but documentation showed that the resident was provided with less than the minimum daily fluid requirement on multiple occasions. The clinical record lacked documentation of fluids offered or refused by the resident. The resident expressed concerns about excessive thirst and urination, and lab results indicated dehydration. The resident was eventually transferred to the hospital, where they were diagnosed with a urinary tract infection and received intravenous hydration. Interviews with staff, including the Director of Nursing and the Administrator, revealed ongoing issues with documentation and follow-through on care plans. The facility's policies on charting, documentation, and hydration were not consistently adhered to, leading to significant deficiencies in the care provided to the residents. The lack of proper documentation and failure to follow care plans contributed to the residents' weight loss and dehydration, highlighting systemic issues within the facility's care practices.
Failure to Ensure Proper Oxygen Equipment Labeling and Signage
Penalty
Summary
The facility failed to ensure proper labeling of oxygen equipment and the presence of oxygen administration signs for three residents. Resident 24 was observed wearing oxygen via a nasal cannula, with a CPAP machine at the bedside, but the tubing lacked a date and initials when changed. Additionally, there were no oxygen administration warning signs on the outside door frame. Resident 24's clinical record indicated diagnoses of COPD, heart failure, and anxiety, with physician orders for continuous oxygen at 3 liters per minute and weekly tubing changes. A CNA confirmed that rooms should have a sign indicating oxygen use and that tubing should be changed weekly by a nurse. Resident 73's oxygen tubing was observed draped across the concentrator without an oxygen administration sign on the outside door frame. The resident's clinical record showed diagnoses of COPD and dementia, with physician orders for oxygen administration as needed to maintain oxygen saturation above 88%. Resident 88's oxygen concentrator was found blocking airflow to the air intake, and the attached bag and tubing were not dated. The resident's clinical record included diagnoses of respiratory failure, COPD, and type 2 diabetes mellitus, with orders for continuous oxygen at 3 liters per minute. A policy on oxygen equipment dating and labeling was requested but not provided, and the existing policy on oxygen administration did not address the observed deficiencies.
Failure to Provide Appropriate Pain Management
Penalty
Summary
The facility failed to provide appropriate pain assessments and management for Resident 55, who was observed to be in significant pain. Despite the resident's severe cognitive impairment and diagnoses of Alzheimer's disease, Parkinson's disease, and low back pain, the facility did not consistently assess or manage her pain according to her comprehensive care plan. Observations noted the resident was restless, moaning, and crying out in pain, yet the administration records showed only a single as-needed pain medication administration over a span of three months. The care plan included interventions for non-verbal pain indicators and non-pharmacological interventions, but these were not effectively implemented or documented. Interviews with staff revealed that they were often unable to differentiate between the resident's pain and her usual restlessness due to her dementia. The facility's policy on pain assessment and management required the use of a standardized pain assessment instrument appropriate to the resident's cognition level, but this was not consistently applied. The failure to observe and report changes in the resident's condition, as well as the lack of consistent pain assessment, led to inadequate pain management for Resident 55.
Failure to Ensure CNA Certification
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA) had a current and valid certificate to work. CNA 2's certificate expired, and despite this, CNA 2 worked on 10 shifts over a specified period. The Administrator indicated that Human Resources (HR) was responsible for ensuring licenses stayed current and that they were working to get CNA 2's certificate renewed. The facility's policy stated that if a Care Team Member's license is not renewed prior to expiration, they should be placed in a non-certified position or removed from the schedule until the license is renewed and verified via the state portal. This policy was not followed in the case of CNA 2, leading to the deficiency.
Medication Error Rate Exceeds 5%
Penalty
Summary
The facility failed to ensure it was free from a medication error rate greater than 5%, resulting in an error rate of 7.7%. During a medication administration observation, a Qualified Medication Aide (QMA) prepared and administered medications to a resident without obtaining a required blood pressure reading and did not check the Emergency Drug Kit (EDK) for an unavailable medication. The resident refused a Miralax mixture, and the QMA crushed all pills together, including Depakote capsules, and mixed them with applesauce before administration. The resident's clinical record indicated that Losartan was not available, and no blood pressure reading was documented before administration, which was against the medication order requirements. In another instance, a Registered Nurse (RN) prepared and administered insulin to a resident without priming the insulin pen needle as required by the facility's policy. The RN used an alcohol pad to clean the insulin vial and drew the medication into a syringe, then attached an insulin pen needle to a Lispro insulin pen and administered both insulins to the resident's right upper arm. The resident's clinical record indicated specific insulin orders, but the RN did not follow the proper procedure for insulin pen preparation and administration. The Director of Nursing (DON) confirmed that medications should be documented if given and that staff should check the EDK for unavailable medications.
Failure to Discard Deteriorated Medications
Penalty
Summary
The facility failed to ensure deteriorated medications were discarded for one of three medication carts observed. During a medication storage observation of the 100 Hall Cart 1, several loose and unlabeled medications were found, including various pills with and without imprints. An LPN confirmed that loose pills in the medication cart should be disposed of and subsequently discarded all 16 medications into the sharps container. The facility's policy on medication labeling, dated 2/1/18, requires that medication labeling must be typed or printed and clearly indicate specific information such as the resident's full name, prescription number, drug strength, and expiration date, among other details.
Failure to Accommodate Resident's Lactose Intolerance
Penalty
Summary
The facility failed to provide food that accommodated a resident's lactose intolerance. Specifically, Resident 246, who had a documented lactose intolerance, was given milk with his meal. This was observed on multiple occasions, including an instance where an unopened carton of milk was found on the resident's breakfast tray. The resident's clinical record confirmed the diagnosis of lactose intolerance, and the dietary restrictions were clearly noted in the resident's nutrition care plan and on a sign posted in the kitchen. Despite these precautions, the resident continued to receive milk, which was confirmed by both a family member and the Director of Nursing (DON). The facility's policy on dining and food preferences, which mandates offering alternate selections for residents with food allergies or intolerances, was not followed. This oversight indicates a failure in the facility's system to ensure that dietary restrictions are consistently honored.
Incomplete and Inaccurate Resident Records
Penalty
Summary
The facility failed to ensure resident records were complete and accurate for three residents. For Resident 246, there was confusion regarding the insulin administration order. The order was unclear about whether insulin should be administered if the blood sugar level was between 151 and 209. This confusion was confirmed by both the LPN and the DON, who had to clarify the order with the Nurse Practitioner. The facility's policy required documentation to be complete and accurate, which was not adhered to in this case. Additionally, during a medication administration observation, QMA 9 prepared Miralax for Resident 15, who refused the medication. Despite the refusal, the administration record inaccurately indicated that the Miralax was administered. The facility's policy required documentation of medication refusals, which was not followed in this instance. For Resident 26, the facility failed to document vital signs on the Neurological Evaluation Flow Sheet after a fall. The resident, who was moderately cognitively impaired and a fall risk, was found on the floor mat after attempting to get more comfortable in bed. The flow sheet lacked documentation of vital signs at multiple time points, which was confirmed by RN 5. The facility's policy required all information, including vital signs, to be filled out on the neurological check flow sheet, which was not done in this case.
Infection Control Deficiencies During Wound Care
Penalty
Summary
The facility failed to ensure proper infection control practices during wound care for two residents. In the first instance, during wound care for Resident 12, LPN 8 and CNA 7 did not change gloves or perform hand hygiene after cleaning the resident's buttocks following a bowel movement. LPN 8 continued to touch the resident and clean linen with the same gloves, and CNA 7 also failed to perform hand hygiene before placing new gloves on. This lack of proper hand hygiene and glove changes during wound care procedures was observed on 5/3/24. In the second instance, on 5/2/24, RN 5 and NP 19 were observed performing wound care for Resident 11, who required enhanced barrier precautions. NP 19 did not perform hand hygiene after removing soiled gloves multiple times during the wound care process. Additionally, NP 19 used a phone to take photos of the wounds and placed the phone in her pocket without proper sanitization. RN 5 and NP 19 did not adhere to the facility's hand hygiene and glove use policies, which were confirmed during an interview with RN 11 on 5/9/24.
Latest citations in Indiana
Surveyors observed that dietary staff repeatedly worked in kitchen and meal service areas with uncovered facial hair, despite facility policy and state sanitation requirements mandating effective hair restraints. Two dietary aides with short beards or mustaches were seen walking through food preparation areas, taking food temperatures, handling food, and plating meals at steamtables in dining rooms without any facial hair coverings, while the current policy required all hair, including facial hair, to be restrained to prevent contamination.
The facility failed to consistently provide and document required bed-hold policy notices when several residents were transferred to the hospital. In multiple cases, residents with dementia, psychotic disorders, COPD, chronic respiratory failure, altered mental status, and cerebral infarction were sent out for acute changes in condition, and while transfer notes reflected physician and family notifications, they lacked documentation that the bed-hold policy was discussed with the resident or responsible party. Notices of Transfer or Discharge often indicated a copy of the bed-hold policy was sent with the resident, but the records did not show signed and dated acknowledgment by the resident or appropriate representative, including in situations where a resident had moderate cognitive impairment, short-term memory issues, or a documented need for a proxy and a financial POA authorizing an agent for health care decisions.
Surveyors found that the facility failed to provide trauma‑informed and culturally competent care by not incorporating two residents’ extensive trauma histories and specific behavioral triggers into their care plans. One resident with documented homelessness, polysubstance abuse, severe accidents with multiple fractures, viral encephalitis with coma, physical and sexual abuse, loss of family contact, and a past suicide attempt had multiple behavior‑focused care plans that referenced identifying triggers but listed none and did not mention their physical, sexual, medical, or psychosocial trauma. Another resident with TBI from being struck by a truck, an 11‑month coma, long‑term state hospital residence, alleged shooting of a parent, and diagnoses including intermittent explosive disorder and borderline personality disorder had a PASRR identifying a specific trigger and notes of inappropriate sexual behavior, yet their care plans omitted these traumatic events, the identified trigger, and the sexual behavior. Staff interviews confirmed that residents were screened for trauma, but the trauma histories and triggers were not reflected in the individualized plans of care.
A resident with schizophrenia, post‑stroke hemiparesis, and mild cognitive impairment expressed feeling down and wanting to kill himself, but staff did not document asking about a specific plan, did not notify the physician or psychiatric NP as expected, and did not develop or update a care plan addressing depression or suicidal ideation. The SSD documented offering support and initiating 15‑minute checks once, but there was no further follow‑up or documentation of interventions after subsequent suicidal statements made in a care plan meeting with the resident’s father. The DON and Administrator reported that facility policy requires immediate notification of key staff, assessment for a plan and means of self‑harm, and thorough documentation, which were not carried out or reflected in the medical record for this resident.
A resident with schizophrenia, post-stroke hemiparesis, and mild cognitive impairment verbalized suicidal ideation, but the care plan did not address depression or suicidal thoughts, and required assessments and services were not accurately or timely documented. An SSD note recorded the resident saying he wanted to kill himself and referenced 15‑minute checks and a care plan update, yet the active care plan lacked depression/suicidal ideation interventions. Multiple late-entry Social Services notes were later added, describing follow-up visits and the resident denying suicidal ideation, but the SSD later reported she did not typically ask about a suicide plan and did not personally provide individual follow-up visits as described. These practices conflicted with the facility’s policy requiring factual, first-hand, and timely documentation of assessments and services.
A resident was observed with an Albuterol inhaler on an overbed table and later reported keeping the inhaler in a nightstand drawer, with no staff present during these observations. Record review showed the resident had no cognitive impairment on the admission MDS but lacked any documented self-medication administration assessment. The DON acknowledged that the required assessment had not been completed, despite facility policy requiring staff and the practitioner to evaluate each resident’s mental and physical abilities before allowing self-administration of medications.
Surveyors found that the facility submitted inaccurate direct care staffing data to CMS through the PBJ system over multiple days in a quarter. CASPER reports showed apparent gaps in 24-hour licensed nurse coverage, low weekend staffing, and a 1-star staffing rating, while internal staffing sheets documented that licensed nurses were present and the facility was fully staffed on those days. The Administrator reported that the discrepancies were due to PBJ data entry errors, despite a facility policy requiring all PBJ entries to be accurate, auditable, and verifiable against payroll, invoices, or contracts.
Surveyors found that the facility did not provide or document required written transfer/discharge notices and bed-hold policy information for four residents who were sent to the hospital, including individuals with conditions such as dementia, CHF, chronic respiratory failure, and CKD. In each case, progress notes showed that the resident was transferred for acute issues, but the clinical records lacked evidence that written notices were given to the residents or their representatives, and in one case lacked documentation that required information was sent to the receiving provider. Facility leadership, including the ADON, DON, and Administrator, acknowledged that the records did not contain the required documentation, despite a written policy requiring such notices and information exchange.
A resident with Alzheimer’s disease and depression, previously on an antidepressant, exhibited intermittent refusals of medications and care, occasional yelling at staff, and reports of unusual perceptions, such as believing men were in or near her room. Nursing notes over several months documented these refusals and complaints but did not show that the behaviors were evaluated or recorded as dangerous, non-redirectable, or causing significant distress, nor did they document specific non-pharmacological interventions attempted or their outcomes. Despite this, a psychiatric NP later added new diagnoses of schizoaffective disorder, borderline personality disorder, and delusional disorder and ordered an antipsychotic (Seroquel) without a comprehensive evaluation in the record to support these diagnoses. The facility’s psychotropic medication policy, which requires identification and documentation of target behaviors, use of nonpharmacological interventions, and ongoing behavior monitoring, was not followed for this resident.
The facility failed to keep PASARR Level I screenings accurate and current for three residents when new mental health diagnoses and psychoactive medications were initiated. One resident’s PASARR omitted a PTSD diagnosis and an added antidepressant, despite documentation of PTSD on the MDS and care plan and a physician order for Pristiq. Another resident’s PASARR listed only depression and dementia, even after additional diagnoses such as borderline personality disorder, delusional disorder, and schizoaffective disorder were added and an antipsychotic (quetiapine) was ordered, with the MDS later reflecting psychotic disorder, schizophrenia, and depression with antipsychotic and antidepressant use. A third resident’s PASARR did not include a depression diagnosis or newly ordered escitalopram and lorazepam, although the admission MDS documented depression with antianxiety and antidepressant use. These omissions occurred despite facility policy requiring a new Level I review after significant mental status changes, including new mental health diagnoses or new psychotropic medications.
Uncovered Facial Hair During Food Preparation and Meal Service
Penalty
Summary
The deficiency involves the facility’s failure to ensure that food was served in a sanitary and safe manner in accordance with professional standards and facility policy during multiple kitchen and meal service observations. During an initial kitchen observation, two dietary aides were seen walking through the kitchen food preparation area with uncovered facial hair. One aide had facial hair above and below the lip and along the jaw line, approximately one-fourth inch in length, and the other had a mustache of similar length; neither used any facial hair covering. These observations occurred while staff were present in the kitchen area where food was stored and prepared. During subsequent observations on the same day, the same two dietary aides were again observed with uncovered facial hair while directly involved in meal preparation and service. One aide walked through the kitchen while the noon meal was being prepared and placed into a transport cart for service in the south dining room, and later was observed plating the noon meal at the steamtable in that dining room, still without a facial hair covering. The other aide walked through the kitchen while the noon meal was being prepared and placed into the steamtable for the north dining room, took food temperatures, assisted with plating meals at the steamtable, and retrieved food items and supplies from the kitchen, all while having an uncovered mustache approximately one-fourth inch in length. The Dietary Manager stated that staff hair was to be covered when in the kitchen and during meal service, and the facility’s written policy and the cited Indiana Food Establishment Sanitation Requirements both required effective hair restraints, including for facial hair, to prevent contamination of food, equipment, and utensils.
Failure to Provide and Document Bed-Hold Policy at Time of Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure that required bed-hold policy information was provided and documented for four residents transferred to the hospital. For a resident with dementia, psychotic disorder, and autistic disorder who had a BIMS score of 0 indicating severe cognitive impairment, progress notes documented physician notification and guardian notification when the resident was sent to the hospital, but there was no documentation that the bed-hold policy was provided to the responsible party. A Notice of Transfer or Discharge later indicated a copy of the bed-hold policy was sent with the resident. Another resident with COPD and chronic respiratory failure, cognitively intact with a BIMS score of 13, experienced a decline in condition and was transferred to the hospital by ambulance; progress notes documented family notification but did not document any discussion of the bed-hold policy, although a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident. A third resident with altered mental status and cerebral infarction, with a BIMS score of 10 indicating moderate cognitive impairment and documented short-term memory impairment, experienced changes in condition and was transferred to the hospital. Progress notes stated the resident was their own responsible party and that no other notification was completed, and transfer documentation did not include the bed-hold policy, although an untimed Notice of Transfer or Discharge indicated a copy of the bed-hold policy was signed by the resident. A financial power of attorney document in the record showed the resident had designated an agent to act in consent or refusal of health care. For a fourth resident with dementia and osteomyelitis, transfer documentation and a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident, and the transfer form noted the resident required a proxy for decision making. The facility’s policy required that at the time of transfer to a hospital, written notice specifying the duration of the bed-hold policy and information on return to the next available bed be provided, and that a signed and dated copy of the bed-hold notice given to the resident or representative be kept in the resident file, which was not consistently documented for these residents.
Failure to Integrate Trauma Histories and Behavioral Triggers Into Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to identify and incorporate residents’ trauma histories and specific behavioral triggers into their care plans, despite documented histories of significant trauma and behavioral health issues. For one resident, extensive social service and progress notes documented homelessness, polysubstance abuse, major depressive and anxiety disorders, chronic pain, a history of severe car accidents with multiple fractures, viral encephalitis resulting in a three‑month coma, loss of child custody, multiple divorces, physical abuse by a spouse, the death of a fiancé who was struck by a car while in a wheelchair, lack of family contact, and a past suicide attempt by Valium overdose. Additional documentation noted a history of rape by a brother at age eight and prior placement under direct supervision and 15‑minute checks related to suicidal ideation. Despite these documented traumatic events and behavioral health concerns, the resident’s care plans did not identify a history of physical trauma, sexual trauma, homelessness, substance abuse, medical trauma, or attempted suicide. For this same resident, the MDS showed no cognitive deficit and identified behaviors such as verbal aggression and rejection of care, along with diagnoses including seizure disorder, depression, chronic pain syndrome, homelessness, and anxiety disorder. Multiple care plans addressed behaviors such as drug‑seeking, pretending to have seizures for attention or medication, making false allegations, verbal aggression when unable to smoke, and a desire for intimate relationships with consenting male residents. These care plans referenced goals such as effective coping skills, seeking staff support, and compliance with the smoking policy, and they called for identification and reduction of behavioral triggers. However, none of these care plans actually listed any specific triggers. The care plan addressing the resident’s right to consensual intimate relationships focused on assessment and education regarding consent but did not integrate the resident’s extensive trauma history. Staff interviews indicated the resident had displayed sexual behaviors since admission, including an incident where the resident expressed anger at another resident for not buying a soda after engaging in sexual acts. A second resident with a documented history of traumatic brain injury (TBI), dementia, seizure disorder, borderline personality disorder, anxiety, intermittent explosive disorder, tobacco use, and other behavioral/emotional disorders was also affected by the same deficiency. Social history and progress notes documented that this resident sustained a TBI after being hit by a semi‑truck while riding a bicycle at age 18, resulting in an 11‑month coma, followed by 13 years in a state hospital and subsequent residence in a group home. Additional documentation indicated the resident allegedly shot their father at age 26 after being sworn at and had a PASRR identifying TBI, intermittent explosive disorder, and borderline personality disorder, with a specific trigger of hearing the name of the current U.S. President. Progress notes also described inappropriate sexual behavior toward staff, including touching themselves intimately during personal care and refusing to stop when redirected. Despite this, the resident’s care plans, which addressed explosive disorder and history of altercations, risk for decreased psychosocial well‑being, and refusal to bathe or shower, did not list any specific behavioral triggers, did not reference the traumatic events such as being hit by a truck or shooting their father, and did not document the inappropriate sexual behavior. The Administrator and Social Service Director acknowledged that residents were to be screened for trauma and that trauma responses and PTSD should be added to care plans, but the specific trauma histories and triggers for these two residents were not incorporated into their plans of care.
Failure to Assess and Care Plan for Resident Suicidal Ideation
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess, investigate, and care plan for a resident’s suicidal ideation in accordance with its own policy and staff expectations. The resident had diagnoses including schizophrenia, cerebral edema, and hemiparesis/hemiplegia following a cerebral infarction, and a current MDS showed mild cognitive impairment (BIMS score 12). A progress note documented that the resident told the Social Services Director (SSD) he was feeling down and wanted to kill himself; the SSD offered assistance, activities, and initiated 15‑minute checks, and the note stated the care plan was updated. However, the note did not indicate that the SSD asked whether the resident had a plan to kill himself, and there were no additional notes regarding suicidal ideation or follow‑up. Review of the current care plan showed no problem, goal, or interventions addressing depression or suicidal ideation, and progress notes over the following month contained no documentation of physician notification related to the suicidal statement. Further record and interview evidence showed that the care plan conference summary did not document interventions for suicidal ideation, and the SSD acknowledged she did not normally ask residents expressing suicidal ideation if they had a plan. The SSD reported that the resident had admission paperwork mentioning suicidal ideation related to depression after a stroke and that the resident again vocalized suicidal ideation during a care plan meeting with his father, after which emotional support was offered and the father took the resident out on a leave of absence; no further visits or follow‑up were done. The DON stated that, upon notification of suicidal verbalization, staff should assess the resident, ask if there is a plan, remove potential means of self‑harm, immediately notify the psychiatric NP, and document the occurrence, and that a detailed progress note and updated care plan were expected but not present for this resident. The Administrator similarly stated that staff should ask about a plan, document interventions, notify the physician and family, and update the care plan, and indicated the resident should have had a care plan addressing depression with suicidal ideation. The facility’s written policy required immediate notification of the DON, SSD, and physician, an interview including asking about a plan and assessing mood and means for self‑harm, and thorough documentation of mood, behavior, and all actions taken, which were not reflected in the resident’s record.
Incomplete and Inaccurate Documentation of Suicidal Ideation and Follow-Up
Penalty
Summary
The facility failed to ensure accurate, complete, and timely documentation of assessments and services for a resident who verbalized suicidal ideation. Resident 6, who had schizophrenia, cerebral edema, and right-sided hemiparesis/hemiplegia following a cerebral infarction, had a BIMS score of 12 indicating mild cognitive impairment. The resident’s admission paperwork mentioned suicidal ideation related to depression after a stroke, and a Social Services note on 3/11/2026 documented that the resident was feeling down and said he wanted to kill himself. The Social Services Director (SSD) documented that she talked with the resident, coordinated with Activities, advised the resident to contact SSD or nursing if he wanted to talk, and that the resident was scheduled for 15-minute checks and the care plan was updated. However, the current care plan initiated on 2/26/2026 did not address depression or suicidal ideation. Multiple Social Services progress notes were later entered as late entries in April, with effective dates in March, stating that the resident had no plan and no longer had suicidal ideation, that he felt much better after 1:1 time, and that he continued his daily routine and therapy. These late entries described follow-up visits and reassessments of suicidal ideation on several consecutive days, but in interviews the SSD stated she did not normally ask residents about having a plan when they verbalized suicidal ideation and did not recall any other occurrences beyond the initial event. She further indicated she did not personally provide individual follow-up visits with this resident regarding suicidal ideation, despite the late-entry notes describing such visits. The DON acknowledged that late entries had been added to address concern about suicidal verbalization, and the Administrator stated that upon suicidal statements staff should ask about a plan, notify the physician and family, and update the care plan, and that this resident should have had a care plan addressing depression with suicidal ideation. The facility’s documentation policy required factual, first-hand, timely documentation, which was not followed in this case.
Failure to Complete Required Self-Administration Assessment for Inhaler Kept at Bedside
Penalty
Summary
Surveyors identified that a resident was allowed to keep and access an Albuterol inhaler without the facility completing the required self-administration medication assessment. During an initial tour, the resident was observed sitting in a wheelchair with a handheld Albuterol inhaler on the overbed table and no staff present in the room or hallway. On a subsequent observation, the resident again was in a wheelchair and reported that the Albuterol inhaler was stored in the top drawer of the nightstand, where it was found. Review of the clinical record showed an admission MDS indicating no cognitive impairment, but there was no documentation of a self-medication administration assessment. In an interview, the DON confirmed that the resident did not have the required self-medication assessment, despite the facility’s policy stating that staff and the practitioner must assess each resident’s mental and physical abilities to determine whether self-administering medications is clinically appropriate. This failure to complete and document a self-administration medication assessment for a resident who had an Albuterol inhaler kept at bedside constituted noncompliance with the facility’s own policy and with 410 IAC 16.2-3.1-11(a).
Inaccurate PBJ Staffing Data Submission to CMS
Penalty
Summary
The deficiency involves the facility’s failure to electronically submit complete and accurate direct care staffing information to CMS through the Payroll-Based Journal (PBJ) system for 22 days in a fiscal quarter. A CASPER report review on 4/6/26 showed that, according to PBJ data, the facility did not have licensed nursing coverage 24 hours per day on multiple specific dates across three months, had low weekend staffing, and held a 1-star staffing rating. However, review of the facility’s internal staffing sheets for that quarter indicated the facility was fully staffed and had licensed nurse coverage on all of the dates in question. During an interview, the Administrator stated that the PBJ information must have contained data entry errors, as she had verified licensed staff coverage on the timesheets. The facility’s PBJ policy in effect stated that all staffing data entered into the PBJ system would be auditable and verifiable through payroll, invoices, or contracts, but the submitted PBJ data did not accurately reflect the facility’s actual licensed nurse staffing as documented on internal records. No specific residents or clinical conditions were mentioned in the report, and the deficiency centers solely on inaccurate staffing data submission rather than direct resident care events.
Failure to Provide and Document Required Transfer/Discharge and Bed-Hold Notices
Penalty
Summary
The deficiency involves the facility’s failure to provide and document required written notices of transfer/discharge and bed-hold policies, as well as required information to receiving providers, for four residents who were transferred or discharged to the hospital. For a resident with generalized anxiety disorder, major depressive disorder, and dementia, progress notes showed that the resident was sent to the hospital via 911 for chest pain, lower back pain, and shortness of breath and later returned to the facility, but the clinical record lacked documentation that a written Notice of Transfer/Discharge and the bed-hold policy were provided to the resident or representative, and lacked documentation that required information was conveyed to the receiving facility. The ADON and the Administrator both confirmed there was no documentation that these written notices were provided. For a resident with congestive heart failure and muscle weakness who was sent to the emergency room for painful urination and bloody urine, the clinical record lacked documentation that a Notice of Transfer/Discharge or bed-hold policy was given to the resident or representative, which the DON confirmed. Another resident with chronic respiratory failure and diabetes was discharged to the hospital for respiratory failure, and a resident with chronic kidney disease and dementia was discharged to the hospital, but in both cases there was no documentation that a written notice of transfer/discharge or bed-hold policy was provided to the residents or their representatives. Review of the facility’s Transfer and Discharge policy, dated 1/15/26, showed that the policy required the facility to provide written transfer/discharge notices and bed-hold information to residents and representatives and to provide specified information to receiving providers, but the records for these four residents did not contain the required documentation.
Failure to Document Target Behaviors and Non-Pharmacological Interventions Before Initiating Antipsychotic
Penalty
Summary
The deficiency involves the facility’s failure to document how a resident’s behaviors presented danger or distress to self or others, and failure to document non-pharmacological interventions attempted prior to initiating an antipsychotic medication. Resident 6 had documented diagnoses of Alzheimer’s disease, depression, and severe cognitive impairment, and was receiving sertraline for depression. A PASSAR identified only depression and dementia, and the admission MDS listed Alzheimer’s disease and depression as active diagnoses. Over several months, nursing progress notes documented that the resident intermittently reported unusual perceptions, such as believing there were men causing trouble, a man in her room, or a man wanting to marry her and yelling through the walls, but there was no documentation that these episodes caused danger to the resident or others or that they resulted in unmanageable distress. From late April through mid-July, nursing notes primarily described the resident’s frequent refusals of evening and morning medications, blood sugar checks, blood pressure checks, insulin administration, hygiene care, and showers. Staff documented that the resident sometimes yelled at staff, said “Get out!”, was visibly upset by a room move, was leery of staff and asked to see name badges, and became upset about a pillow under her head until it was removed, after which she calmed down. The notes also recorded instances where the resident believed housekeeping had not cleaned her room or that she had not received medications when she had. However, there were no progress notes or assessments indicating that these behaviors were evaluated as dangerous, non-redirectable, or causing significant distress or functional impairment, and no detailed behavior monitoring logs were present as required by facility policy. On a psychiatric NP visit for initial psychotropic medication management, new mental health diagnoses of schizoaffective disorder, borderline personality disorder, and delusional disorder were added, and Seroquel 25 mg, an antipsychotic, was ordered. The clinical record did not contain a comprehensive evaluation to support these new diagnoses, and there was no documentation of target behaviors meeting the facility’s policy criteria for psychotropic use, such as behaviors representing danger to self or others, causing distress and impairment in functional abilities, or clearly attributable to psychosis or mania. The resident’s representative reported that the resident had no prior history of mental health disorders or psychiatric hospitalization and was unaware of the new diagnoses. The facility’s own psychotropic medication policy required identification and documentation of specific target behaviors, use and documentation of nonpharmacological interventions, and ongoing monitoring of behaviors and interventions, which were not reflected in the record for this resident.
Failure to Update PASARR Screens for New Mental Health Diagnoses and Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that Preadmission Screening and Resident Review (PASARR) Level I screenings were accurate and updated when new mental health diagnoses and psychoactive medications were initiated for multiple residents. For one resident with dementia, anxiety, depression, and post-traumatic stress disorder (PTSD), the PASARR completed on admission listed anxiety, depression, and dementia with sertraline and quetiapine, but did not include the PTSD diagnosis or the antidepressant Pristiq, despite the admission MDS and care plan documenting PTSD and a subsequent physician’s order for Pristiq. For another resident with Alzheimer’s disease, borderline personality disorder, delusional disorder, schizoaffective disorder, and depression, the PASARR only reflected depression and dementia with sertraline, even though additional mental health diagnoses were added later and an antipsychotic (quetiapine) was ordered for borderline personality disorder, and the quarterly MDS documented psychotic disorder, schizophrenia, and depression with antipsychotic and antidepressant use. A third resident had diagnoses including Alzheimer’s disease, depression, anxiety disorder, irritability and anger, and nonrheumatic aortic valve stenosis. The PASARR for this resident listed dementia and anxiety with Risperdal but omitted the diagnosis of depression and the medications escitalopram and lorazepam, although physician’s orders were in place for escitalopram for depression and lorazepam for anxiety, and the admission MDS documented depression with antianxiety and antidepressant use. Interviews with the Assistant Director of Nursing confirmed that new Level I PASARR screens should have been completed when new mental health diagnoses and psychoactive medications were added, and that the PASARR for one resident, completed prior to arrival, should have included all mental health diagnoses and medications. The facility’s own policy required notification of the state mental health authority within 14 days after a significant change in mental condition and specified that a new Level I screen is required for new mental health diagnoses or newly prescribed psychotropic medications, which was not followed in these cases.
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