Majestic Care Of South Bend
Inspection history, citations, penalties and survey trends for this long-term care facility in South Bend, Indiana.
- Location
- 52654 N Ironwood Rd, South Bend, Indiana 46635
- CMS Provider Number
- 155219
- Inspections on file
- 39
- Latest survey
- January 16, 2026
- Citations (last 12 mo.)
- 56
Citation history
Health deficiencies cited at Majestic Care Of South Bend during CMS and state inspections, most recent first.
The facility failed to ensure safe and sanitary food service by not consistently monitoring and documenting food temperatures before meals were served. Over an extended period, Service Line Checklist logs showed frequent missing or incomplete temperature records for beverages, main entrées, alternate entrées, meats, vegetables, fruits, starches, and desserts, with some meals lacking any recorded temperatures. Multiple residents reported that meals, especially breakfast, were often served cold, that hot food was never very hot, and that posted menus were not consistently followed. These practices did not align with the facility’s Food Production policy, which required safe food handling and specified minimum internal cooking temperatures for various food items.
A resident with severe cognitive impairment, behavioral disturbances, and multiple neurocognitive diagnoses experienced significant weight loss over several months while on a regular diet with monthly weights ordered. Care plans identified behavioral refusal of vital signs, potential nutritional risk, a prior weight refusal, and significant recent weight loss, with interventions to document intake and notify the physician of abnormal findings. Weight records showed a marked decline in body weight, meal intake records contained multiple missing entries and several meals with 0–25% intake, and a later ER record documented further weight loss. Despite facility policies requiring notification of the physician and resident representative for significant or abnormal weight changes, interviews with the DON and a family member confirmed there was no documentation or evidence that the physician or family were notified of the resident’s weight refusals or significant weight loss.
The facility failed to conduct quarterly care plan conferences for four residents, as required. One resident's family reported no conference for the current year, while another resident had not had a meeting since January. Two other residents also missed required conferences, despite facility policy mandating interdisciplinary team involvement in care planning.
The facility failed to maintain sanitary food storage and preparation practices. During a kitchen tour, several food items in the walk-in cooler were found without proper labeling, such as cheese cups and salad bowls, lacking 'made on' or 'use by' dates. Additionally, expired spices were found in the dry storage area. The Dietary Manager acknowledged these lapses, which did not comply with the facility's policy requiring labeling of refrigerated foods held for more than 24 hours.
A facility failed to provide a resident with a necessary assistive device, specifically a wheelchair, resulting in the resident remaining in bed without mobility assistance. Despite the resident's medical conditions, including hemiplegia and an acquired absence of the right leg, staff interviews revealed a lack of process for obtaining a wheelchair. The Director of Rehab acknowledged the oversight, and the facility lacked a policy for accommodating residents' needs.
A facility failed to provide a SNF-ABN to a resident who was discharged from Medicare skilled services but remained in the facility. Although a NOMNC was issued, the SNF-ABN, which informs beneficiaries about potential non-coverage by Medicare, was not provided. The facility's policy lacked guidance on when to issue the SNF-ABN.
The facility failed to provide two residents with the required Notice of Transfer/Discharge when they were hospitalized multiple times. Both residents had intact cognition and various medical conditions, but there was no documentation of the notices being given. The Executive Director confirmed the absence of such documentation, despite the facility's policy requiring it.
The facility failed to provide two residents with a copy of the Bed Hold Policy during their hospitalizations, despite both having intact cognition. The Executive Director confirmed the absence of documentation for both residents, contrary to the facility's policy requiring written notice within 24 hours of an emergency transfer.
A facility failed to develop a person-centered care plan for a resident with diabetes and congestive heart failure, who had a physician's order for a 2000 ml daily fluid restriction. The care plan did not specify how much fluid each shift and department were allotted, despite the resident being at risk for fluid imbalance. The Unit Manager acknowledged the omission.
The facility failed to provide adequate personal hygiene and oral care for two residents. One resident did not receive scheduled showers, resulting in poor nail hygiene, while another had significant oral hygiene issues due to insufficient assistance. Despite care plans requiring regular hygiene support, documentation and staff interviews revealed lapses in care provision and adherence to facility policies.
The facility failed to follow Physician's orders for G-tube care for two residents. One resident's G-tube was not flushed as required, with discrepancies in staff documentation. Another resident's G-tube system was not changed daily, and labeling was incomplete. Staff interviews confirmed these deficiencies.
The facility exceeded the acceptable medication error rate, with errors involving two residents. One resident did not receive Fluticasone Propionate due to unavailability, while another resident's Albuterol inhalers lacked opened dates, leading the nurse to withhold administration. The DON confirmed the availability of Albuterol in the emergency kit and outlined procedures for obtaining medications. These issues resulted in an 8% medication error rate.
The facility failed to maintain proper infection control practices, including unsanitized glucometer storage, improper glove use during catheter care, and inadequate storage of a bipap mask. A QMA did not sanitize a glucometer after use, and staff did not change gloves appropriately during catheter care for a resident with a urinary tract infection. Additionally, a resident's bipap mask was improperly stored, and there was confusion about cleaning responsibilities. Existing policies were not adhered to, leading to these deficiencies.
The facility failed to maintain a safe environment by not monitoring personal refrigerator temperatures and disposing of expired food for three residents. Observations showed unrecorded temperatures and expired food items in residents' refrigerators. Interviews revealed confusion among staff about responsibilities, with the facility's policy not being followed.
The facility failed to arrange alternative dialysis services for residents after the closure of its in-house dialysis center, resulting in missed treatments and hospitalizations. Despite advance notice of the closure, the facility did not secure outpatient dialysis or provide adequate monitoring for residents, leading to critical health issues for some.
A facility failed to ensure proper medication administration standards were followed when an LPN left a resident's medications unattended on a bedside table. The resident, who was alert and oriented, was not informed of the medication's presence, leading to them often ending up on the floor. The facility's policy required observation of medication ingestion, which was not followed.
The facility failed to provide necessary transfer documentation, including notification of transfer, appeal rights, and bed hold policy, for three residents transferred to a hospital for dialysis. The residents, with diagnoses such as ESRD and heart failure, were sent without physician orders or proper documentation, as confirmed by the Unit Manager and Regional Nurse Consultant.
A resident with a Full Code status was found unresponsive, but staff failed to immediately initiate CPR, leading to the resident's death. Despite the resident's medical history and requests for ER transfer due to discomfort, there was a delay in response as staff did not promptly verify the code status or start CPR, highlighting a deficiency in emergency procedures.
The facility failed to maintain adequate staffing of licensed nurses on the Skilled/Rehabilitation Unit, affecting resident care. A resident with complex medical needs experienced an unwitnessed fall, and required neurological assessments were not completed. The resident was later found unresponsive and passed away. Staffing schedules and PPD calculations were below required levels, and interviews revealed challenges in managing workloads due to insufficient staffing.
The facility failed to maintain cleanliness in a shower room on the South Unit, affecting 55 residents. Observations revealed wipes, brief packages, smears of substances, used towels, a wet sheet, and trash in the room. Interviews indicated unclear responsibilities for cleaning, with no specific policy in place. The 'Routine Cleaning' policy did not address shower room cleaning responsibilities.
The facility failed to administer medications and treatments as ordered for several residents, including missed blood sugar checks, insulin injections, and wound care treatments. Residents with conditions such as diabetes and pressure ulcers did not receive consistent care, and facility policies on medication administration were not adhered to.
The facility did not report a resident-to-resident physical altercation to local law enforcement within 24 hours, as required by their policy. The incident involved two residents who sustained forehead bruising. Despite immediate separation and assessments, the facility's administrator and DON did not believe reporting was necessary due to the lack of serious injuries. The facility's policy, however, mandates reporting such incidents to law enforcement, regardless of injury severity.
A facility failed to thoroughly investigate a resident-to-resident altercation resulting in bruising. Two residents were involved in a physical altercation while waiting to smoke, leading to forehead bruising. The facility separated the residents and conducted assessments but did not interview staff or witnesses, contrary to their abuse prevention policy. The Administrator and DON did not see the need for further investigation due to the absence of injuries, resulting in a deficiency citation.
Failure to Monitor and Document Food Temperatures Resulting in Cold Meals
Penalty
Summary
The deficiency involves the facility’s failure to ensure food was served under safe and sanitary conditions by not consistently monitoring and documenting food temperatures before serving. Resident grievances and Resident Council minutes documented repeated complaints that meals, particularly breakfast, were often served cold and that food was not served on time, resulting in hot foods arriving cold. Specific grievances noted that food was served cold every day and that residents did not want their food served cold. A detailed review of the Service Line Checklist logs over an extended period showed pervasive gaps in temperature monitoring and documentation for multiple meals. Numerous entries listed temperatures without identifying the food items, and many days lacked temperature recordings for beverages, main entrées, alternate entrées, meats, vegetables, fruits, starches, and desserts. On some days, there were no food temperatures recorded at all for certain meals. These omissions occurred repeatedly across breakfast, lunch, and dinner, indicating that the facility did not consistently follow its own procedures for checking and recording food temperatures. Interviews with several residents corroborated the documentation issues, as they reported that meals were frequently cold when served and that the posted menus were not consistently followed. One resident stated that meals were frequently cold and that the kitchen did not follow the posted menus. Another resident reported that the meals were not very good, the menu was not closely followed, biscuits and gravy were served too often, and hot food was never very hot. A third resident indicated that the kitchen did not always follow the menu and that hot food was not always hot. The facility’s policy on Food Production required safe food handling practices and specified minimum internal cooking temperatures for various meats and casseroles, but the observed practices and documentation did not demonstrate adherence to these standards.
Failure to Notify Physician and Family of Significant Weight Loss and Weight Refusals
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s physician and responsible party of repeated refusals to be weighed and of significant, documented weight loss. The resident, who had Alzheimer’s disease, neurocognitive disorder with behavioral disturbance, delusional disorder, insomnia, and muscle weakness, was admitted with an initial weight of 178 lbs. A quarterly MDS dated 10/22/25 showed the resident weighed 170 lbs, had severe cognitive impairment, exhibited negative behaviors, wandered daily, and was receiving antipsychotic and antianxiety medications. A discharge MDS dated 11/26/25 documented inattention, disorganized thinking, multiple behavioral symptoms including rejection of care, and a weight of 156 lbs. Physician’s orders included a regular diet and monthly weights starting 7/23/25. The care plan identified behavioral symptoms including refusal of vital signs, with interventions to reapproach the resident and notify the physician and psychiatric services for increased behavioral symptoms. Another care plan, dated 10/19/25, identified potential nutritional risk related to diagnoses, a weight refusal in October, and significant weight loss of 14.7% over the prior 90 days, with interventions to document food and fluid intake and notify the physician of abnormal findings. Weight records showed a decline from 178 lbs in late July to 170 lbs in early September, then to 152 lbs on 11/6/25 and 156 lbs on 11/11/25, reflecting approximately 14% loss in less than five months; an ER record on 11/26/25 documented a weight of 146 lbs, over 17% loss in five months. Meal intake documentation between 10/1/25 and 11/26/25 showed multiple missing entries for breakfasts, lunches, and suppers, and several recorded intakes of 0–25% at various meals. A nutrition review on 8/1/25 noted good intake (76–100% of most meals) and made no dietary recommendations. A dietary note on 11/21/25 recorded that no weights had been entered for 30 days, that the resident had lost 26 lbs in 90 days (14.6% loss from 170 to 152 lbs), and that the resident’s BMI was 29.5, with no recommendations made and a plan to continue monitoring. During interview, the DON confirmed there was no documentation that the physician or responsible party had been notified of the significant weight loss or weight refusals, and the family member reported they were never informed of the resident’s significant weight loss. Facility policies on weight monitoring and change in condition required notification of the physician and family/guardian for verified significant weight changes and abnormal weights, and documentation of such notifications, which did not occur in this case.
Failure to Conduct Quarterly Care Plan Conferences
Penalty
Summary
The facility failed to ensure that care plan conferences were conducted quarterly for four residents, leading to a deficiency in care planning. Resident 13's family reported that no care plan conference had been held for the current year, and a record review confirmed the last conference was in April 2023. Resident 26 reported not having a care plan meeting, and the Social Service Director acknowledged that a conference should have occurred in June or July 2024. Resident 8 also indicated not attending a care conference, with records showing the last meeting in January 2024, despite a quarterly assessment in July 2024 indicating intact cognition and participation in planning. Resident 59 expressed uncertainty about being invited to a care conference, and records showed a significant gap between meetings from September 2023 to September 2024. The Unit Manager confirmed that required care conferences had not been conducted for Residents 8 and 59. The facility's policy, dated December 2023, mandates that comprehensive care plans be prepared by an interdisciplinary team, including the resident and their representative, to the extent practicable. This policy was not adhered to, resulting in the identified deficiency.
Deficiency in Food Storage and Preparation Practices
Penalty
Summary
The facility failed to store and prepare food in a sanitary manner, as observed during a kitchen tour. In the walk-in cooler, several food items were found without proper labeling, including eight single-serve cheese cups, a half bag of salad mix, a bag of celery, and seven bowls of salad. These items lacked 'made on' or 'use by' dates, which are necessary to ensure food safety and compliance with the facility's policy. The Dietary Manager (DM) acknowledged that these items should have been labeled with the appropriate dates. Additionally, in the dry storage area, several spices were found to be expired or lacking an 'opened on' date. These included whole celery seed, poultry seasoning, cayenne pepper, and a brand of sprinkles. The DM and District Dietary Manager (DDM) confirmed that spices should not be used past their expiration dates, although the facility did not have a specific policy regarding spices. The facility's existing policy on food preparation requires that refrigerated, ready-to-eat foods held for more than 24 hours be labeled with a prepared date and a use by date, which was not adhered to in this instance.
Failure to Provide Assistive Device for Resident
Penalty
Summary
The facility failed to provide a dependent resident, identified as Resident 3, with an assistive device, specifically a wheelchair, which was necessary for the resident to get out of bed. The deficiency was identified through observations and interviews conducted over several days. During a family interview, the responsible party for Resident 3 expressed concern that the resident did not have a wheelchair and was always in bed during visits. Observations confirmed that Resident 3 was consistently in bed without a wheelchair present in the room. The resident's medical history included hemiplegia, vascular dementia, and an acquired absence of the right leg below the knee, indicating a need for assistance with mobility. Interviews with facility staff revealed that Resident 3 had not been provided with a wheelchair due to a lack of process for obtaining one. A Qualified Medication Aide (QMA) mentioned having previously obtained a wheelchair from the therapy department for Resident 3, but it was returned after use. The Director of Rehab acknowledged that Resident 3 should have had a chair and noted that some residents preferred to stay in bed, although there was no documentation of Resident 3 refusing to get out of bed. The facility lacked a policy related to accommodating residents' needs, contributing to the oversight in providing necessary assistive devices for Resident 3.
Failure to Provide SNF-ABN to Resident Post-Medicare Discharge
Penalty
Summary
The facility failed to provide a Skilled Nursing Facility-Advanced Beneficiary Notice (SNF-ABN) to a resident who was discharged from Medicare skilled services but remained in the facility. During a review of Beneficiary Notification forms, it was found that a Notice of Medicare Non-Coverage (NOMNC) was given to the resident, indicating the end of Medicare coverage. However, the SNF-ABN, which informs beneficiaries that Medicare may not pay for certain services or items, was not provided. Interviews with the Social Services Director and a review of the facility's policy confirmed that the SNF-ABN was not issued, and the policy did not specify when this form should be provided.
Failure to Provide Transfer Notices to Residents
Penalty
Summary
The facility failed to provide timely notification to two residents, or their representatives, regarding their transfer to a hospital, as required by regulations. Resident 8, who had intact cognition and diagnoses including type 2 diabetes mellitus with neuropathy, bladder cancer, anxiety, and depression, was hospitalized on three occasions. However, there was no documentation that the facility provided a Notice of Transfer/Discharge for any of these hospitalizations. The Executive Director confirmed the absence of such documentation during an interview. Similarly, Resident 59, who also had intact cognition and diagnoses including end-stage renal disease, chronic obstructive pulmonary disease, and type 1 diabetes with neuropathy, was hospitalized four times. The facility again failed to provide the required Notice of Transfer/Discharge for any of these hospitalizations. The Executive Director acknowledged the lack of documentation for Resident 59 as well. The facility's policy, which mandates providing a notice of transfer and the facility's bed hold policy to the resident and representative, was not followed in these cases.
Failure to Provide Bed Hold Policy to Hospitalized Residents
Penalty
Summary
The facility failed to provide two residents, who were hospitalized, with a copy of the Bed Hold Policy, as required. Resident 8, who had diagnoses including type 2 diabetes mellitus with neuropathy, bladder cancer, anxiety, and depression, was hospitalized on three occasions. Despite having intact cognition, there was no documentation that Resident 8 received the Bed Hold Policy during any of these hospitalizations. The Executive Director confirmed the absence of such documentation. Similarly, Resident 59, with diagnoses including end-stage renal disease, chronic obstructive pulmonary disease, and type 1 diabetes with neuropathy, was hospitalized multiple times. Although Resident 59's cognition was also intact, there was no record of the Bed Hold Policy being provided during any of these hospitalizations. The Executive Director acknowledged the lack of documentation for Resident 59 as well. The facility's current policy, dated December 12, 2023, mandates that written notice of the Bed Hold Policy be provided within 24 hours of an emergency transfer.
Failure to Develop Person-Centered Fluid Restriction Care Plan
Penalty
Summary
The facility failed to develop a person-centered care plan regarding fluid needs for a resident with type 2 diabetes mellitus with neuropathy and congestive heart failure. The resident had a physician's order for a 2000 ml daily fluid restriction due to edema and congestive heart failure, and was prescribed Furosemide for hypertensive heart disease and congestive heart failure. The current care plan, initiated in September 2022, identified the resident as at risk for fluid imbalance related to acute kidney failure and diuretic use. However, the care plan lacked specific instructions on how much fluid each shift and department were allotted to maintain the ordered fluid restrictions. During an interview, the Unit Manager acknowledged that the fluid restriction should have been detailed in the care plan to specify the amount of fluids per shift and department.
Deficiencies in Personal Hygiene and Oral Care
Penalty
Summary
The facility failed to ensure proper personal hygiene and shower assistance for residents, as evidenced by the case of Resident 3. Despite being scheduled for showers twice a week, documentation revealed that Resident 3 had not received a shower from 9/1/2024 to 10/1/2024, with no records of refusal or behaviors that would justify the lack of care. Observations noted long, dirty fingernails, and interviews with staff indicated that while some morning care was provided, comprehensive bathing and nail care were neglected. The care plan for Resident 3 included interventions for bathing and nail care, but these were not consistently implemented, and the documentation did not reflect any refusals of care. Similarly, Resident 24 was observed with significant oral hygiene issues, including a thick white substance on her bottom teeth. Despite requiring assistance with oral care due to severe cognitive impairment and physical limitations, documentation showed that oral care was only offered once daily on several occasions, contrary to the care plan's directive for twice-daily oral care. Interviews with staff confirmed that Resident 24 needed encouragement and manual assistance for oral hygiene, which was not adequately provided, leading to visible plaque build-up. The facility's policies on routine nail care and oral care were not adhered to, as evidenced by the lack of regular nail inspections and oral hygiene assistance. The Director of Nursing acknowledged the absence of documentation for bathing and oral care refusals, indicating a failure to offer and document necessary care consistently. The facility's failure to follow its policies and care plans resulted in deficiencies in the provision of essential daily living activities for the residents involved.
Failure to Follow G-Tube Care Protocols
Penalty
Summary
The facility failed to adhere to the Physician's orders regarding the care of gastrointestinal tubes (G-tubes) for two residents. Resident 222 reported that his G-tube, which was not being used for nutrition or medications, was supposed to be flushed twice daily but had only been flushed once since his admission. Observations confirmed the absence of medical equipment for flushing in his room, and documentation discrepancies were noted in the Treatment Administration Record (TAR). Interviews with staff revealed inconsistencies in the reported completion of G-tube flushes, with one LPN admitting to mistakenly documenting a flush that was not performed. For Resident 7, the facility failed to change the G-tube tubing and syringe every 24 hours as per the Physician's orders. Observations showed that the tube feeding formula and clear liquid bags were not labeled correctly, and a syringe was found with an outdated label. An RN acknowledged the discrepancies in labeling and the failure to change the system daily. The facility's policies on documentation and enteral feeding were provided, indicating the expected standards of practice, but these were not followed in the cases of Residents 222 and 7.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5 percent, as evidenced by observations during a medication pass involving two residents. For Resident 28, the medication Fluticasone Propionate was not available for administration, and the nurse indicated she would contact the pharmacy to obtain it. This resident had diagnoses including chronic pain syndrome and allergies, with a physician's order for Fluticasone Propionate dated several months prior. The absence of this medication during the scheduled administration contributed to the facility's medication error rate. For Resident 35, the nurse found two inhalers in the medication drawer without opened dates and decided not to administer the medication, opting instead to notify the pharmacy for a new one. This resident had a diagnosis of chronic obstructive pulmonary disease, with a physician's order for Albuterol Sulfate. The Director of Nursing later indicated that Albuterol was available in the emergency kit, and if not, the nurse should notify the pharmacy. The facility's policy on medication administration, which includes procedures for obtaining medications not readily available, was provided by the DON. These incidents resulted in a medication error rate of 8 percent, exceeding the acceptable threshold.
Infection Control Deficiencies in Equipment Storage and Care Practices
Penalty
Summary
The facility failed to ensure proper infection control practices in several areas, including the storage of respiratory equipment, catheter care, and blood sugar monitoring. During an observation, a Qualified Medication Aide (QMA) did not sanitize a glucometer after use and placed it unsanitized on top of supplies. The QMA was unsure about the correct procedure for cleaning the glucometer. Additionally, during catheter care for a resident with a urinary tract infection and other conditions, staff did not change gloves after cleaning stool and before placing a clean bed pad and brief on the resident, despite the use of enhanced barrier precautions. Furthermore, a resident's bipap mask was observed to be improperly stored on the bed and floor without a protective bag, and with a brown substance on the inside seal. Staff interviews revealed confusion about responsibilities for cleaning and storing the bipap mask, and no policy was provided regarding its storage. The facility's existing policies on blood glucose monitoring and glucometer disinfection were not followed, contributing to the deficiencies observed.
Failure to Monitor Refrigerator Temperatures and Expired Food
Penalty
Summary
The facility failed to maintain a safe and sanitary environment by not properly monitoring personal refrigerator temperatures and disposing of expired food for three residents. Observations revealed that the temperature logs for Residents 21 and 44's personal refrigerators were not recorded for any dates in August, while Resident 45's log for July had only a few recorded temperatures. Additionally, Resident 45's refrigerator contained several expired food items, including a pre-made salad, honey ham lunch meat, chocolate pudding cups, and a squeeze bottle of Miracle Whip. Interviews with various staff members, including the Social Services Director, Interim Executive Director, Maintenance Director, Environment Services Director, and Unit Manager, highlighted inconsistencies and confusion regarding the responsibility for checking refrigerator temperatures and removing expired food. The facility's policy indicated that maintenance staff should record temperatures weekly, but this was not being followed. The Magic Makers system, which assigned management staff to check on residents and their refrigerators, was not effectively implemented, leading to the oversight of expired food and unrecorded temperatures.
Failure to Provide Dialysis Services After In-House Unit Closure
Penalty
Summary
The facility failed to ensure the continuation of dialysis services for residents who required such services after the closure of the facility-based dialysis center. This resulted in six out of seven residents missing their scheduled dialysis treatments. The closure of the dialysis center was communicated to the facility months in advance, but the necessary arrangements for alternative dialysis services were not made in time. As a result, residents who depended on regular dialysis treatments were left without care, leading to critical health issues for some. Resident E, who had a history of end-stage renal disease, congestive heart failure, and respiratory failure, missed two dialysis treatments and was admitted to the hospital with critical lab results indicating fluid overload. Despite being aware of the impending closure of the in-house dialysis unit, the facility did not secure alternative dialysis arrangements or provide adequate monitoring for signs of fluid overload. The resident's family was not informed of any arrangements, and the facility failed to provide transportation to an alternative dialysis center. Similarly, Resident D, who also had end-stage renal disease and other health issues, missed dialysis treatments and was admitted to the hospital with critical lab levels. The facility did not document any efforts to secure outpatient dialysis services for Resident D, and there was no communication with the resident about the lack of arrangements. The facility's inaction and lack of communication led to significant health risks for the residents, who were left without essential medical care.
Failure to Follow Medication Administration Standards
Penalty
Summary
The facility failed to ensure that a Licensed Nurse followed the standards of practice during medication administration for a resident, identified as Resident Q. During a random observation, it was noted that Resident Q had a breakfast tray and a small clear cup containing multiple medications on his bedside table, approximately five feet from his bed. Resident Q indicated he was unaware that the medications were on the table and mentioned that it was not unusual for them to be left in the room. He also stated that his medications often ended up on the floor because he was not informed that they had been left on the bedside table. An agency staffing nurse, identified as LPN 11, confirmed that the medications belonged to Resident Q and had left them on the bedside table after the resident expressed a desire to wait before taking them. LPN 11 believed it was acceptable to leave the medications unattended in the room, as Resident Q was alert and oriented. The medications included Morphine Sulfate, Cetirizine, Ondansetron, Sertraline, Aspirin, Plavix, Divporex, Gabapentin, Thera-M, Escitalopram, Docusate, Quetiapine, and Tamsulosin. The facility's policy on oral medication administration, provided by the Interim Director of Nursing, required that licensed nurses or authorized personnel observe the resident ingest all medications, which was not adhered to in this instance.
Failure to Provide Required Transfer Documentation for Residents
Penalty
Summary
The facility failed to ensure that three residents, who were transferred to a local hospital for dialysis treatments, received the necessary documentation including a statement of notification of the transfer, appeal rights, a copy of the bed hold policy, and the Ombudsman's information. Resident E, who had diagnoses including End Stage Renal Disease (ESRD), congestive heart failure, and respiratory failure, was transferred to the emergency room without any nursing assessments documented for the days leading up to the transfer. There was no physician's order for the transfer, and the required documentation was not provided to Resident E. Resident F, with diagnoses of ESRD, diabetes, and hypertension, was noted to have shortness of breath and an overall decline. The Nurse Practitioner ordered a transfer to the emergency room, but again, there was no documentation provided to the resident regarding the transfer, appeal rights, or bed hold policy. Similarly, Resident D, who had multiple diagnoses including ESRD and heart failure, was sent to the hospital for dialysis without a physician's order or the necessary transfer documentation. The Unit Manager LPN admitted to sending Residents E and D to the hospital without completing the required transfer forms. The Regional Nurse Consultant confirmed the absence of transfer documentation for all three residents. The facility's policy on transfers and discharges, which includes providing a notice of transfer and the facility's bed hold policy, was not followed in these cases.
Failure to Initiate CPR for Full Code Resident
Penalty
Summary
The facility failed to immediately initiate Cardiopulmonary Resuscitation (CPR) for a resident, identified as Resident D, who was found unresponsive. Despite having a physician's order and an advanced directive indicating the resident was a Full Code, staff did not promptly begin CPR when the resident was discovered unresponsive. This delay in initiating CPR occurred on the evening when the resident was found by an aide during dinner tray distribution, and the resident subsequently died. Resident D had a complex medical history, including necrotizing fasciitis, insulin-dependent diabetes, end-stage renal disease requiring hemodialysis, and a history of cardiac arrest. The resident had been experiencing persistent hyperkalemia and had refused dialysis treatments, which were critical for her condition. On the day of the incident, the resident had expressed discomfort, including stomach pain and vomiting, and had requested to be sent to the emergency room (ER). However, the request was not acted upon, and the resident's condition was not adequately monitored or documented throughout the day. Interviews with staff revealed a lack of communication and coordination in responding to the resident's needs and emergency situation. The Qualified Medication Aide (QMA) and Registered Nurse (RN) on duty did not promptly verify the resident's code status or initiate CPR. Instead, there was a delay as the QMA sought assistance from the RN, who was stationed on another unit. This delay in response and failure to follow the resident's advanced directive for a Full Code contributed to the resident's death, highlighting a significant deficiency in the facility's emergency response procedures.
Removal Plan
- Nursing staff education/in-service on CPR, basic process with emphasis on immediately implementing CPR, in accordance with resident's advanced directive
- One staff member calling the code, while another staff member dials 911 and another staff member documenting code process
- Mock codes completed for each shift
- Resident code status and Care plans updated
- Ongoing audits to review Progress Notes for a change of condition and/or requests to be sent to ER
Inadequate Staffing Leads to Deficient Care in Skilled/Rehabilitation Unit
Penalty
Summary
The facility failed to ensure adequate staffing of licensed nurses (RN/LPN) on the Skilled/Rehabilitation Unit, which directly affected the care of several residents. Specifically, the facility did not maintain the necessary number of licensed nurses to meet the care needs of residents, as evidenced by the staffing schedules and Per Patient Day (PPD) calculations that fell below the facility's own assessment of required staffing levels. This deficiency was highlighted by the Payroll Based Journal (PBJ) staffing data report, which indicated low staffing levels, particularly on weekends. Resident D, who had complex medical conditions including necrotizing fasciitis, diabetes, and end-stage renal disease, experienced an unwitnessed fall. The required neurological assessments following the fall were not completed as scheduled, and there was a significant gap in progress notes. The resident was later found unresponsive and passed away despite CPR efforts. This incident underscores the impact of insufficient staffing on the ability to provide timely and adequate care. Interviews with residents and staff further revealed issues related to staffing shortages. Residents reported delays in receiving medications and care, while staff described challenges in managing workloads, particularly during meal times and weekends. The facility's scheduling practices did not consistently ensure the presence of a licensed nurse on the Skilled/Rehabilitation Unit, leading to increased responsibilities for other staff members and potential lapses in resident care.
Failure to Maintain Cleanliness in Shower Room
Penalty
Summary
The facility failed to ensure cleanliness in one of the three shower rooms on the South Unit, potentially affecting all 55 residents residing there. On two separate occasions, surveyors observed an opened package of wipes on the sink, brief packages on a dresser, a moderate-sized smear of a brown substance in front of the toilet, a smear of a white substance on the left assist bar for the toilet, used towels on a cart, a large chair with a wet sheet on it, and trash bags on the floor near the door. These observations were made in the presence of the Unit Manager, who acknowledged that the staff responsible for completing the showers should have removed trash and linens, and housekeeping should have cleaned the floor, toilets, and sink. Interviews with the Unit Manager and Housekeeping Manager revealed a lack of clarity regarding the responsibilities for cleaning the shower rooms. The Housekeeping Manager indicated that housekeepers were supposed to clean the shower room floor first thing in the morning, and CNAs were to contact a housekeeper if further cleaning was needed. However, there was no policy specifying who was responsible for cleaning the shower rooms and when it should be done. The Administrator provided a policy titled 'Routine Cleaning,' which emphasized the importance of routine cleaning and disinfection to maintain a safe and sanitary environment, but it did not address the specific responsibilities for shower room cleaning.
Medication and Treatment Administration Deficiencies
Penalty
Summary
The facility failed to ensure that residents received medications and treatments in accordance with physician orders and facility policy for four of the six residents reviewed. Resident B, who was cognitively intact and had multiple diagnoses including diabetes and pressure ulcers, did not receive scheduled blood sugar checks and insulin injections on several occasions. Additionally, wound care treatments were not documented as completed on specific dates, and the resident expressed concerns about the inconsistency in blood sugar monitoring. Resident L, who was severely cognitively impaired and had a history of stroke and diabetes, also did not receive scheduled blood sugar checks and insulin injections as ordered. Furthermore, the resident missed doses of prescribed medications such as Lexapro and Metformin, as well as nutritional supplements. These omissions were documented in the resident's medication and treatment records, indicating a failure to adhere to physician orders. Resident K, who was cognitively intact and had multiple diagnoses including bipolar disorder and diabetes, experienced similar issues with missed blood sugar checks and insulin injections. Additionally, the resident did not receive a prescribed dose of Zofran and missed a scheduled wound treatment. Resident D, with diagnoses including necrotizing fasciitis and diabetes, did not receive scheduled doses of Heparin and missed blood sugar checks and insulin administration. The facility's policies on medication administration and wound treatment management were not followed, contributing to these deficiencies.
Failure to Report Resident-to-Resident Abuse to Law Enforcement
Penalty
Summary
The facility failed to report an allegation of resident-to-resident abuse to local law enforcement within 24 hours, as required by their policy. The incident involved two residents who were allegedly involved in a physical altercation, resulting in forehead bruising to both individuals. The incident was reported to the Indiana State Department of Health, and it was noted that the residents were separated immediately, and head-to-toe assessments were conducted. The physician, administrator, and family were notified, and Resident B was placed on 15-minute safety checks. However, the facility did not report the incident to local law enforcement, as the administrator and the Director of Nursing (DON) believed that the policy did not require reporting if there were no serious injuries. Resident B's clinical records indicated diagnoses of bipolar disorder, schizoaffective disorder, anxiety, intermittent explosive disorder, and post-traumatic stress disorder. The progress notes detailed that Resident B had head-butted Resident C, resulting in a 1x1 reddened area on Resident B's forehead. Resident C's records showed diagnoses of hemiplegia following a stroke, dementia with behavioral disturbance, anxiety, and chronic obstructive pulmonary disease, with a 1x2 red area on the forehead noted after the incident. Both residents were assessed with no complaints of headache, dizziness, or pain. The facility's abuse prevention policy, dated March 2022, required notification of law enforcement for resident-to-resident abuse incidents, even if they did not result in serious bodily injury, which was not adhered to in this case.
Inadequate Investigation of Resident Altercation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of resident-to-resident abuse involving two residents, Resident B and Resident C, who were allegedly involved in a physical altercation. The incident occurred in the hallway while the residents were waiting to smoke, resulting in bruising on the foreheads of both residents. The facility's response included separating the residents, conducting head-to-toe assessments, notifying the physician, administrator, and family, and placing Resident B on 15-minute safety checks. However, the investigation was deemed insufficient as no staff or resident statements were taken, and potential witnesses were not interviewed. The Administrator and Director of Nursing did not conduct interviews with staff or residents regarding the incident, as they believed it was unnecessary due to the lack of injuries. The Environmental Service Manager, who was thought to be a witness, was not interviewed, and no statements were collected from other residents who were present during the incident. The facility's policy on abuse prevention requires interviews with witnesses and staff involved, but this protocol was not followed. Resident B's clinical records indicated a history of bipolar disorder, schizoaffective disorder, anxiety, intermittent explosive disorder, and PTSD. Resident C's records included diagnoses of hemiplegia following a stroke, dementia with behavioral disturbance, anxiety, and COPD. Both residents were assessed after the incident, and their progress notes documented the altercation and subsequent actions taken. Despite these assessments, the lack of a comprehensive investigation into the incident led to the deficiency cited in the report.
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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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