North Capitol Nursing & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Indianapolis, Indiana.
- Location
- 2010 N Capitol Ave, Indianapolis, Indiana 46202
- CMS Provider Number
- 155226
- Inspections on file
- 34
- Latest survey
- January 29, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at North Capitol Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found that the facility failed to protect residents from misappropriation of fentanyl patches and did not maintain accurate controlled substance documentation. Multiple residents had orders for 72‑hour fentanyl patches, with MARs showing regular application primarily by an RN and an LPN, but corresponding controlled substance logs were missing for extended periods and, when present, conflicted with MAR entries. Logs frequently lacked required witnesses for patch removals, omitted documentation of removals when new patches were applied, and showed the same RN signing as both administering nurse and witness. Pharmacy records showed that numerous fentanyl patches delivered for several residents were unaccounted for, and a hospice nurse reported that no fentanyl patches were available for a resident despite a recent delivery. The DNS acknowledged that narcotic logs were not routinely reviewed for accuracy and that shift‑change controlled substance verification forms were missing or undated, contrary to facility policy requiring complete storage, documentation, inventory, and accounting of controlled substances.
Surveyors found that the facility did not consistently administer ordered fentanyl patches or verify their placement every shift for four residents with chronic pain or neuralgia. For several residents who were non-verbal or rarely understood and showed non-verbal signs of pain, care plans and MD orders required 72-hour fentanyl patches every three days and every-shift verification. MARs showed missed patch applications attributed to unavailable medication or need for a new prescription, as well as multiple shifts with no documented verification of patch placement. The DON reported issues involving two nurses and fentanyl patch diversion on the affected unit.
A facility failed to ensure accurate acquisition, administration, and accounting of fentanyl patches for four residents with chronic pain or neuralgia. Physician orders and MARs showed regular application of 72‑hour fentanyl patches, primarily by an RN and an LPN, but controlled substance logs were missing for extended periods and, when present, often contradicted the MARs on application dates. Numerous patch removals lacked a witness, some new patch applications had no corresponding removal documented, and the RN frequently signed as her own witness. Pharmacy records showed multiple fentanyl patches delivered for each resident with several unaccounted for. The DNS reported that required shift‑to‑shift controlled substance counts, proper witnessing, and scanning of controlled substance records into resident documents were not consistently performed, and narcotic logs were not routinely reviewed for accuracy unless a discrepancy was reported.
A resident with Alzheimer's disease, under hospice care and with a documented DNR order, experienced a fall with seizure activity and head injury. Despite the DNR status, an LPN initiated chest compressions after being instructed by a 911 dispatcher, even though the resident had a heartbeat and was breathing. The advanced directive was present in the resident's record, and the resident's representative was upset that CPR was performed.
A resident was admitted with a surgical wound on the right buttock and a dehisced abdominal wound, but the facility failed to obtain timely treatment orders. The abdominal wound was mistakenly treated as a second ostomy, leading to inadequate care. The oversight was acknowledged by staff, and the resident was eventually transferred to a hospital when the wound condition worsened.
A resident with complex medical needs missed several critical medical appointments due to the facility's failure to arrange transportation and ensure accompaniment by a respiratory therapist. The facility's policies for scheduling and documenting appointments were not followed, resulting in a deficiency in care.
A resident with cerebral palsy and muscular dystrophy fell during a transfer using a mechanical sling lift when a CNA failed to secure the sling clip properly. The resident sustained injuries and was taken to the emergency room. The CNA reported previous issues with the clip not locking and was retrained after the incident.
The facility failed to properly store and label food in the kitchen, affecting 60 residents. Observations included unlabeled thawing meat, expired lactose-free milk, milk stored on the fridge floor, and unlabeled pre-poured drinks. The Dietary Manager's mustache was uncovered, and a trash can lacked a lid. These actions violated the facility's Food Storage policy and sanitation requirements.
The facility failed to maintain a clean and homelike environment, with issues such as splintered chair rails, exposed drywall, and stained linens observed in several residents' rooms. Equipment like wheelchairs and feeding pump poles were unclean, and housekeeping practices were inadequate, as noted by an RN. The executive director acknowledged ongoing problems, and interviews with residents and family members highlighted complaints about stained linens and worn furniture.
A resident was found with a medication cup containing unidentified pills in a common area, expressing concern about the medications and refusing to take them. The LPN believed the resident had taken the medications, but the resident denied this. The resident's clinical record lacked a Self-Administration of Medication assessment, despite her diagnoses and moderate cognitive deficit. The facility's policy requires an assessment by the IDT, which was not conducted.
Two residents with pressure ulcers were found with non-functioning low air loss (LAL) mattresses due to improper connections. Resident D, with multiple health issues, was observed over two days with a non-operational mattress until a respiratory therapist corrected the plug connection. Similarly, Resident 45, with a history of pressure injuries, had a disconnected pump that was fixed by the therapist. The facility's policy required functioning pressure redistribution mattresses, which was not followed.
A resident with multiple health conditions, including chronic respiratory failure and muscle weakness, fell after tripping on loose flooring while transferring from a wheelchair to a bed. The bed was not locked, contributing to the fall. The facility's policy on fall management was not effectively implemented, as the flooring issue was known but not addressed in time to prevent the accident.
A facility failed to maintain infection control during incontinence care and did not follow up on changes in urinary output for a resident with an indwelling catheter. The resident, with multiple health issues, was observed receiving improper perineal care and had a catheter bag positioned incorrectly. Subsequent observations showed sediment in the catheter tubing and bag, but the facility did not communicate these changes as per their policy.
The facility failed to provide adequate respiratory care for residents with tracheostomies, as evidenced by improper infection control practices during trach care for a resident, failure to change oxygen tubing as ordered for another resident, and lack of comprehensive documentation following a trach removal incident for a third resident.
A resident with multiple health conditions did not have scheduled laboratory tests obtained as ordered by the physician. The facility's guidelines for lab tracking were not followed, resulting in missing lab results. Interviews revealed a lack of awareness and record of the lab orders, contributing to the deficiency.
The facility failed to maintain infection control practices during a bed bath for a resident and medication administration for multiple residents. A CNA used the same gloves and washcloth for different body areas without changing gloves, and an LPN placed fingers inside medication cups and pill crusher sleeves without performing hand hygiene. Additionally, PPE was not available outside the room of a resident on transmission-based precautions, leading staff to enter without proper PPE.
The facility failed to provide privacy curtains in shared rooms, affecting four residents. A cognitively intact resident and another resident shared a room without a privacy curtain between their beds. Another resident with an anoxic brain injury and a resident with moderately impaired cognition due to diabetes shared a room lacking a privacy curtain on one side of the bed. The Executive Director confirmed that privacy curtains should be present.
The facility failed to provide adequate care for three residents, including oral hygiene, complete bed baths, hair care, and emptying of bedside commodes. A resident with multiple health issues was observed with a coated tongue despite orders for oral care. Another resident's bedside commode was not emptied for hours, and a third resident received an incomplete bed bath, with greasy hair observed over several days. These deficiencies highlight neglect in providing necessary assistance with ADLs.
Misappropriation and Poor Accountability of Fentanyl Patches
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from misappropriation of their narcotic medications, specifically fentanyl patches, and to ensure accurate storage, documentation, and accounting of these controlled substances. The DNS reported that approximately thirty fentanyl patches were unaccounted for and that multiple Fentanyl/Duragesic Controlled Substance Record logs were missing. The DNS stated that narcotic logs were not routinely reviewed for accuracy or completeness and were only examined when staff reported a discrepancy. She also noted that the logs that were available contained entries that did not make sense, such as an LPN documented as witnessing an RN’s fentanyl patch application despite the two not working the same shift. For Residents C, D, E, and F, physician orders required application of 72‑hour fentanyl patches every three days, and MARs for July, August, and September documented regular application of these patches, almost exclusively by one RN and one LPN. However, for each of these residents, there were no corresponding controlled substance logs for significant time periods, and the available logs contradicted the MARs. For Resident F, there were no fentanyl logs from early July to mid‑August, and the later logs showed application dates that did not match the MARs, lacked required witnesses for removals, documented instances where no removal was recorded when a new patch was applied, and showed the RN acting as her own witness on multiple dates. Pharmacy delivery records indicated that 49 patches were delivered for Resident F, with 13 unaccounted for. A hospice clinical director reported that when hospice requested a fentanyl patch change for this resident, no patches were available despite a recent delivery. Resident C’s MARs showed regular fentanyl patch application every three days, but there were no controlled substance logs from early July to mid‑August, and the existing logs for mid‑August through late September conflicted with the MARs. The logs showed missing witnesses for multiple removals, missing documentation of removals when new patches were applied, and the RN serving as her own witness on several dates. Pharmacy records showed 31 patches delivered for Resident C, with 4 unaccounted for. Resident E’s MARs also documented regular fentanyl patch application, with almost all applications by the same RN and LPN, but there were no logs for early July to mid‑August, and the later logs again conflicted with the MARs, showed missing witnesses, missing removals when new patches were applied, duplicate entries for the same date and time, and the RN acting as her own witness. Pharmacy records showed 40 patches delivered for Resident E, with 14 unaccounted for. Resident D had orders for a 72‑hour fentanyl patch with shift‑by‑shift verification of placement. MARs documented regular application every three days, primarily by the same RN and LPN, but there were no controlled substance logs for early July to mid‑August or for mid‑September to late September. The available logs for mid‑August to late September conflicted with the MARs, showed application dates that did not align with the MARs, lacked witnesses for multiple removals, omitted documentation of removals when new patches were applied, and again showed the RN serving as her own witness on several dates. Pharmacy documentation indicated that 40 fentanyl patches were associated with Resident D, with 19 unaccounted for. Interviews documented in the investigative file showed that the RN acknowledged applying patches, and the LPN reported being allergic to fentanyl and stated that the RN applied the patches; the LPN also reported taking Percocet and had a positive urine drug screen for opioids during the investigation. The facility’s own policies required that controlled substances be stored, recorded, accounted for, and documented on both the MAR and the resident’s controlled substance record, with shift‑to‑shift counts and maintenance of verification forms, and defined misappropriation as wrongful use of a resident’s property or money without consent. The DNS acknowledged that she was unsure whether the pharmacist routinely reviewed narcotic logs and that one month’s shift‑change controlled substance verification form was missing while another was undated and could not be definitively tied to a specific month. The facility’s investigation, based on pharmacy delivery records, physician orders, MARs, and the limited available controlled substance logs, concluded that there were unaccounted‑for fentanyl patches for all four residents, calculated as the difference between the number of patches delivered, the number ordered to be administered, and the number remaining. The survey findings also cross‑referenced failures to verify placement of fentanyl patches as ordered and failures to implement pharmaceutical procedures that assured accurate acquiring, receiving, dispensing, and administering of narcotic medications.
Failure to Administer and Verify Ordered Fentanyl Patches for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered fentanyl transdermal patches and to verify their placement every shift for four residents with chronic pain or neuralgia. For one resident with chronic pain who was non-verbal and required staff to anticipate her needs, the care plan directed staff to administer medications as ordered and to verify fentanyl patch placement every shift. Physician orders required application of a 72-hour fentanyl patch every three days and verification of patch placement each shift. The MAR showed the patch was not applied on one date because the medication was unavailable, and multiple shifts in July, August, and September did not have documented verification of patch placement as ordered. Another resident with chronic pain, who could not reliably participate in a pain interview and exhibited daily non-verbal indicators of pain, had orders for a 72-hour fentanyl patch every three days and for every-shift verification of patch placement. The MAR showed a gap between patch applications, missing two ordered applications, with one missed application documented as due to medication unavailability, and missing verification entries on specified shifts. A third resident with chronic pain had an order for a 72-hour fentanyl patch every three days and every-shift verification; the MAR documented a missed application due to the need for a new prescription and missing verification entries on two first shifts. A fourth resident with neuralgia had long-standing orders for a 72-hour fentanyl patch every three days and every-shift verification; the MAR showed at least one shift where verification of patch placement was not documented. The DNS reported there had been issues involving two nurses and fentanyl patch diversion on the unit where these residents resided.
Unaccounted Fentanyl Patches and Inaccurate Controlled Substance Documentation
Penalty
Summary
The deficiency involves the facility’s failure to implement pharmaceutical procedures that ensured accurate acquiring, receiving, dispensing, administering, and accounting of fentanyl patches for four residents with chronic pain or neuralgia. For Resident F, who had chronic pain and was newly admitted to hospice, the hospice nurse discovered that a fentanyl patch due for application was unavailable despite a recent delivery. Physician orders required a 72‑hour 25 mcg/hr fentanyl patch every three days over several periods in 2025. The MARs for July, August, and September documented regular patch applications on specific dates, almost exclusively by two nurses (an RN and an LPN). However, there were no corresponding controlled substance record logs for early July through mid‑August, and the available logs from mid‑August to late September contradicted the MARs regarding application dates. The logs also showed missing witness signatures for multiple patch removals, instances where no removal was documented when a new patch was applied, and entries where the RN signed as her own witness. Pharmacy records showed that 49 patches were delivered for this resident during the review period, with 13 unaccounted for. For Resident C, who also had chronic pain and nonverbal indicators of pain such as grimacing and facial expressions, physician orders required a 72‑hour 75 mcg/hr fentanyl patch every three days. The MARs for July through September showed patches applied as ordered, except for one date when the medication was unavailable, again almost exclusively by the same RN and LPN. There were no fentanyl controlled substance logs for early July through mid‑August. The logs from mid‑August to late September conflicted with the MARs on application dates and showed multiple patch removals without a witness, missing documentation of patch removals when new patches were applied, and instances where the RN signed as her own witness. Pharmacy documentation indicated that 31 patches were delivered for this resident in the review period, with 4 unaccounted for. The DNS later produced only one undated shift‑change controlled substance verification form for either August or September and confirmed that the other month’s form was missing. Resident E, with chronic pain and an order for a 72‑hour 25 mcg/hr fentanyl patch every three days, had MARs documenting regular patch applications in July, August, and September, almost all by the same RN and LPN. There were no controlled substance logs for early July through mid‑August. The logs from mid‑August to late September contradicted the MARs on application dates and showed multiple undocumented or unwitnessed patch removals, including several dates where new patches were applied without any recorded removal. One date showed two separate entries for patch application at the same time, and the RN again signed as her own witness on multiple occasions. Pharmacy records showed 40 patches delivered for this resident, with 14 unaccounted for. Resident D, diagnosed with neuralgia and ordered a 72‑hour 50 mcg/hr fentanyl patch every three days with shift‑by‑shift verification of patch placement, had MARs indicating regular patch applications in July, August, and September, primarily by the same RN and LPN. There were no controlled substance logs for early July through mid‑August or for mid‑September through late September. The available logs from mid‑August to late September conflicted with the MARs on application dates and showed multiple patch removals without a witness, missing documentation of removals when new patches were applied, and several entries where the RN signed as her own witness, including dates with duplicate entries. Pharmacy documentation indicated that 40 patches were administered or delivered for this resident, with 19 unaccounted for. The DNS stated that the facility’s policy required the nurse who removed the old fentanyl patch and applied the new one every 72 hours to complete the controlled substance record, with the same nurse documenting both removal and application and a different nurse serving as witness. She acknowledged that the logs did not make sense, including instances where the LPN was documented as witnessing the RN’s application despite not working the same shift. She also stated that completed logs were supposed to be filed and uploaded into the residents’ electronic records, but multiple logs were missing, particularly for Resident D’s recent deliveries. The DNS reported that no one at the facility routinely reviewed narcotic logs for accuracy or to ensure all narcotic medications were accounted for; she only reviewed them when staff reported discrepancies. The facility’s written policy on controlled substances required that administration be documented both on the MAR and on the resident’s controlled substance inventory record at the time of administration, and that shift‑change verification forms and addition/removal logs be maintained for 24 months and scanned into resident documents, but these procedures were not consistently followed for the four residents.
Failure to Honor DNR Order During Emergency Response
Penalty
Summary
A deficiency occurred when facility staff failed to honor a resident's Do Not Resuscitate (DNR) advanced directive. The resident, who had Alzheimer's disease and was receiving hospice services, had a clearly documented DNR status in the clinical record, care plan, and physician orders. Despite this, after the resident experienced an unwitnessed fall resulting in a head laceration and seizure activity, a Licensed Practical Nurse (LPN) initiated chest compressions on the resident. The LPN, upon finding the resident on the floor with seizure activity and snoring respirations, checked the code status and then called 911. While on the phone with the dispatcher, the LPN was instructed to begin CPR and performed light chest compressions, even though the resident had a heartbeat and was still breathing. The resident subsequently came out of the seizure, and her breathing returned to normal before EMS arrived and transported her to the hospital for evaluation. Interviews with facility staff and the resident's representative confirmed that the advanced directive was known and accessible in the resident's chart. The resident's representative expressed distress that CPR was initiated despite the DNR order. The facility's policy stated that care should reflect the resident's wishes as expressed in the advanced directive, but this was not followed during the incident.
Failure to Obtain Timely Treatment Orders for Surgical Wounds
Penalty
Summary
The facility failed to timely identify and obtain physician's orders for a surgical wound present upon admission for a resident. The resident, who had a history of an anal abscess and colostomy, was admitted with a significant wound on her right buttock. Despite the presence of this wound, the facility did not have a treatment order for it upon admission. The admitting nurse attempted to contact the discharging hospital for treatment orders but was unsuccessful, and the orders were not obtained until two days later. The resident also had a dehisced abdominal wound, which was initially mistaken for a second ostomy by the nursing staff. This misunderstanding led to inadequate care for the wound, as it was covered with an ostomy bag instead of being treated as a surgical wound. The facility's staff did not obtain a physician's order for the abdominal wound upon admission, and it was not until several days later that the wound's condition worsened, prompting a hospital transfer. Interviews with facility staff revealed a lack of clarity and communication regarding the resident's wound care needs. The Assistant Director of Nursing Services and other staff members acknowledged the oversight in obtaining timely treatment orders and the misinterpretation of the resident's abdominal wound. The facility's policies required a thorough assessment and notification of the physician for treatment orders upon admission, which was not followed in this case.
Failure to Provide Transportation for Resident's Medical Appointments
Penalty
Summary
The facility failed to ensure that Resident C, who required follow-up care with an ENT physician, was provided with transportation to attend scheduled medical appointments. Resident C had a complex medical history, including malignant neoplasm of the oropharynx, tongue cancer, and hydrocephalus, and resided on the ventilator unit. The clinical record indicated several missed appointments due to the lack of transportation arrangements, despite the resident's need for a respiratory therapist to accompany him. The facility's Executive Director and Director of Nursing acknowledged the lapses in coordination and communication that led to the missed appointments. The ED indicated that the previous RT manager was responsible for ensuring transportation and accompaniment by an RT, but failed to do so. The DON noted that the admitting nurse should have reviewed the discharge summary to ensure follow-up appointments were scheduled, but this was not done. Additionally, the facility's transportation provider confirmed that no attempts were made to arrange transportation for several appointments. The facility's Scheduled Appointment Policy outlined the procedures for maintaining continuity of care during outside appointments, including documenting appointments in the electronic medical record and reviewing them during administrative meetings. However, these procedures were not followed, resulting in Resident C missing multiple critical medical appointments. The report highlights the facility's failure to adhere to its own policies, leading to a deficiency in providing necessary care for Resident C.
Resident Falls Due to Improper Use of Mechanical Sling Lift
Penalty
Summary
The facility failed to ensure the safety of a resident during a transfer using a mechanical sling lift, resulting in the resident falling to the floor. The incident involved a resident with cerebral palsy, muscular dystrophy, and contractures, who required a mechanical lift for transfers. During the transfer, a certified nursing assistant (CNA) did not secure the sling clip properly to the peg on the lift, causing the resident to fall and sustain injuries, including pain in the head, neck, and back, and a small amount of bleeding from the head. The resident was subsequently transferred to a local emergency room. The Director of Nursing and the Regional Nurse Consultant demonstrated the operation of the mechanical lift and confirmed that the clip strap was not locked in place, leading to the fall. The CNA involved in the incident reported previous difficulties with the clip straps not locking properly and believed it was due to a faulty pad. Despite being trained on the lift's operation, the CNA continued to experience issues with securing the clip. The instructional video for the sling lift indicated the proper method for securing the clip, which was not followed in this instance.
Improper Food Storage and Labeling in Kitchen
Penalty
Summary
The facility failed to properly store foods in the kitchen, affecting 60 residents who consume food prepared there. During an initial tour of the kitchen, several deficiencies were observed. In the walk-in fridge, a metal pan containing a package of meat was found thawing without a label indicating the type of meat and the date it was removed from the freezer, which is necessary to ensure its use within 72 hours of thawing. Additionally, two unopened half gallons of lactose-free milk were found to be expired, and two unopened gallon jugs of milk were improperly stored on the floor of the fridge. A tray on a multi-shelf rack contained pre-poured glasses of milk and orange juice that were not labeled, despite the tray being marked with a use-by date. Other observations included the Dietary Manager's mustache not being covered by a hair net, despite being more than an inch long, and a large trash can not in use was found without a lid. The facility's Food Storage policy requires that food be stored at appropriate temperatures and methods to prevent contamination, with items clearly labeled with the name, preparation date, and consumption or discard date. The policy also specifies that food should be stored a minimum of six inches above the floor and that thawed items should be used within 72 hours unless otherwise specified by the manufacturer. The Retail Food Establishment Sanitation Requirements also mandate that receptacles containing food residue be kept covered when not in continuous use.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for its residents, as evidenced by multiple observations of damaged and unclean conditions in resident rooms and common areas. Specific issues included splintered chair rails, chipped walls with exposed drywall, and exposed wires from telephone jacks in several residents' rooms. Additionally, there were reports of mismatched and loose flooring, worn and scratched furniture, and stained bed linens and towels. These deficiencies were observed in the rooms of ten residents, indicating a widespread issue within the facility. The facility also failed to ensure that equipment and furnishings were clean and well-maintained. Observations included wheelchairs with dried substances on the wheels, feeding pump poles with stains and dried formula, and floors with brown spots. The facility's housekeeping practices were inadequate, as noted by a registered nurse who reported that rooms were not being thoroughly cleaned and that there were staffing issues in the housekeeping department. The executive director acknowledged these ongoing problems during an environmental tour, noting that some repairs and cleaning had not been completed as required. Interviews with residents and family members further highlighted the facility's failure to provide a clean environment. Complaints were made about stained linens and the worn appearance of furniture, particularly on the vent unit. The facility's deep cleaning schedule was found to be lacking, with no logs available to track when deep cleaning had been completed. The facility's policy required monthly deep cleaning and the use of a quality control checklist, but these procedures were not being followed, contributing to the deficiencies observed.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that the Interdisciplinary Team (IDT) determined and documented a self-medication assessment for a resident who was observed with medications by their side in a common area. During a random observation, a resident was found sitting in a lounge with a medication cup containing several unidentified pills. The resident expressed concern about the number of medications and refused to take them without knowing what they were. An LPN, who had administered the medications, believed the resident had taken them, but the resident denied spitting them out and stated she had not attempted to take them due to her concerns. Upon reviewing the resident's clinical record, it was found that there was no Self-Administration of Medication assessment documented. The resident's diagnoses included paranoid schizophrenia, anxiety disorder, and major depressive disorder, and she had a moderate cognitive deficit according to a recent assessment. Additionally, the resident's care plan did not include any information regarding her ability to self-administer medications. The facility's policy requires that alert residents be informed of their right to self-administer medications and that an assessment be conducted by the IDT, but this was not done for the resident in question.
Failure to Ensure Functioning Low Air Loss Mattresses
Penalty
Summary
The facility failed to ensure that low air loss (LAL) mattresses were functioning properly for two residents with pressure ulcers. Resident D, who had diagnoses including hypertension, congestive heart failure, diabetes mellitus, and muscle weakness, was observed multiple times over two days lying on a mattress with a pump that was not functioning, as indicated by the absence of lights on the pump. The resident's care plan required the use of a pressure-reducing mattress due to impaired skin integrity and limited mobility. It was only after a respiratory therapist checked the outlet and plugged the mattress in properly that the pump began to function. Similarly, Resident 45, who had a history of chronic respiratory failure, congestive heart failure, and multiple pressure ulcers, was also found with a non-functioning LAL mattress. The resident's care plan included the use of a pressure-reducing mattress due to a history of pressure injuries. The issue was identified when the respiratory therapist discovered that the plug connecting the pump to the mattress had come undone. Once reconnected, the mattress began to function as intended. The facility's policy on wound prevention required the use of pressure redistribution mattresses for all residents, but this was not adhered to in these cases.
Resident Falls Due to Loose Flooring
Penalty
Summary
The facility failed to maintain safe flooring conditions, leading to an accident involving a resident, identified as Resident E. Resident E, who had a history of chronic respiratory failure, tracheostomy status, dependence on a ventilator, muscle weakness, morbid obesity, and diabetes mellitus, required assistance with activities of daily living (ADLs) such as bed mobility, transfers, and toileting. During an interview, Resident E reported tripping on a piece of flooring that was not level, which caused her to fall while attempting to transfer from her wheelchair to her bed. The bed was not locked at the time, contributing to her fall. The flooring issue was confirmed by an observation that noted mismatched wood flooring under the wheels of Resident E's bed. The incident was documented in a fall event report, which indicated that Resident E tripped on a loose floorboard. Maintenance was notified and subsequently repaired the flooring. An interdisciplinary team note identified the root cause of the fall as the loose flooring. A registered nurse confirmed that the flooring had been coming up throughout the unit, starting on the 4th floor and affecting the unit where Resident E resided. The facility's Fall Management policy, revised in August 2022, emphasized the importance of providing adequate supervision and assistance to prevent falls, but this was not effectively implemented in this case.
Infection Control and Catheter Care Deficiency
Penalty
Summary
The facility failed to maintain proper infection control practices during incontinence care and did not ensure appropriate follow-up for changes in urinary output from an indwelling urinary catheter for a resident. The resident, who had multiple diagnoses including respiratory failure, diabetes mellitus, obesity, and neuromuscular dysfunction of the bladder, was dependent on a ventilator and had an indwelling catheter. During a bed bath, a CNA was observed using the same part of a washcloth to clean the resident's perineal area twice, and improperly positioned the urinary catheter bag above the level of the bladder, which is against the care plan instructions. Further observations revealed that the urinary catheter tubing contained a milky and gray liquid, which later turned cloudy and dark yellow, and eventually showed clumps of a white substance. The RN noted sediment in the catheter tubing and bag, indicating a potential issue with sediment in residents with long-term indwelling catheters. Despite a previous progress note indicating clear urine, the facility did not communicate these changes to the physician or family as required by their Change of Condition Policy.
Deficiencies in Tracheostomy Care and Documentation
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for residents with tracheostomies, as evidenced by multiple deficiencies observed during tracheostomy care. For Resident D, respiratory therapists did not maintain proper infection control practices. They used the same gloves for multiple tasks, including removing the inner cannula, handling soiled gauze, and applying a new trach collar. Additionally, sterile gloves were contaminated during the procedure, and the inner cannula was not replaced immediately after removal, violating the facility's tracheostomy care competency guidelines. Resident E's care was also deficient, as the facility did not adhere to the physician's order to change oxygen tubing weekly. Observations revealed that Resident E was wearing a trach collar dated several weeks prior, indicating that the tubing had not been changed as required. This oversight suggests a lapse in following prescribed respiratory care protocols, potentially compromising the resident's respiratory health. For Resident 60, the facility failed to document a comprehensive assessment after the resident's trach was inadvertently removed and reinserted by an LPN. The clinical record lacked details on the resident's tolerance of the procedure, the appearance of the stoma, and any potential concerns following the incident. This omission contravenes the facility's policy, which mandates thorough documentation of tracheostomy care, including any changes in the resident's condition or complications arising from the care provided.
Failure to Obtain Timely Laboratory Tests
Penalty
Summary
The facility failed to timely obtain laboratory tests as ordered by the physician for a resident with multiple diagnoses, including diabetes, hypertension, and epilepsy. The resident's care plan, initiated in 2018, included interventions to obtain labs as ordered to maintain adequate tissue perfusion. However, the clinical record did not contain laboratory results for the tests scheduled on March 29, 2024, which included a CBC with differential, CMP, HgbA1c, TSH, vitamin D level, valproic acid level, and a lipid profile. Interviews conducted during the investigation revealed that the Assistant Director of Nursing was unaware of why the labs were not drawn, and the Laboratory Associate confirmed that no lab orders were recorded for the specified date. The facility's guidelines for lab and radiology tracking require that all lab orders be entered into the system and the lab provider be notified, but this process was not followed, leading to the deficiency.
Infection Control Deficiencies in Medication Administration and PPE Use
Penalty
Summary
The facility failed to maintain proper infection control practices during medication administration and personal care activities. During a bed bath for Resident F, a CNA used the same gloves and washcloth to clean different areas of the resident's body, including the anal area and posterior thighs, without changing gloves or performing hand hygiene. This was contrary to the facility's skills competency document, which required changing gloves and performing hand hygiene after changing bath water and providing perineal care. Additionally, during medication administration, an LPN was observed placing his fingers inside medication cups and pill crusher sleeves, which is not in line with proper infection control practices. The LPN also failed to perform hand hygiene before donning and after doffing gloves while preparing medications for multiple residents. The facility lacked a specific policy regarding the handling of medication cups and pill crusher sleeves, and the nursing skills competency for gloves emphasized the importance of hand hygiene before and after glove use. Furthermore, the facility did not ensure that PPE was available outside the room of Resident 56, who was on transmission-based precautions for a contagious infection. The PPE cart was located inside the resident's room, contrary to the facility's policy, which required PPE to be available outside the room for staff to don before entry. Staff members, including a CNA and a respiratory therapist, were observed entering the room without donning PPE beforehand, which was against the facility's transmission-based precautions policy.
Lack of Privacy Curtains in Shared Rooms
Penalty
Summary
The facility failed to ensure privacy curtains were present in rooms shared by two residents, affecting four of the fifteen residents reviewed for environmental conditions. Resident 14, who was cognitively intact, and Resident 36 shared a room that lacked a privacy curtain between their beds. During an observation with the Executive Director, Resident 14 confirmed that the privacy curtain had been missing for an extended period. Similarly, Resident 43, with an anoxic brain injury, and Resident 53, who had moderately impaired cognition due to diabetes, shared a room where the privacy curtain was absent on the doorway side of Resident 53's bed. Resident 53 reported that the privacy curtain had never been present since his admission to the room. The Executive Director acknowledged that resident rooms should have privacy curtains.
Deficiencies in Resident Care and Hygiene
Penalty
Summary
The facility failed to provide adequate care for three residents in terms of oral hygiene, complete bed baths, hair care, and emptying of bedside commodes. Resident D, who had diagnoses including hypertension, congestive heart failure, and diabetes mellitus, was observed multiple times with a white coated substance on his tongue and foam in his mouth, despite a physician's order for oral care three times a day. This indicates a lack of adherence to the care plan for oral hygiene. Resident E, with chronic respiratory failure and dependence on a ventilator, was found with a bedside commode containing yellow liquid that had not been emptied for several hours, despite requiring substantial assistance with toileting hygiene. Resident F, who was dependent on a ventilator and had multiple health issues including respiratory failure and obesity, was observed receiving an incomplete bed bath. The CNA did not wash Resident F's face, hair, or legs below the knees, and her hair appeared greasy and unkempt over several days. The last recorded instance of hair washing was weeks prior, indicating neglect in personal hygiene care. These observations highlight the facility's failure to provide necessary assistance with activities of daily living for these residents.
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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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