Oak Grove Christian Retirement Village
Inspection history, citations, penalties and survey trends for this long-term care facility in Demotte, Indiana.
- Location
- 221 W Division St, Demotte, Indiana 46310
- CMS Provider Number
- 155667
- Inspections on file
- 31
- Latest survey
- February 5, 2026
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Oak Grove Christian Retirement Village during CMS and state inspections, most recent first.
A resident with COPD, heart failure, dementia, and other conditions, who was on oxygen therapy, developed a cough and later received a new order for albuterol nebulizer treatments twice daily for the cough. The medical record lacked documentation that the resident’s representative was informed of this change in condition and new medication order. In interview, an LPN confirmed she did not document any communication with the representative, and the DON stated that such communication and documentation should have occurred.
A resident with COPD and other comorbidities, who was on oxygen and cognitively impaired, developed a cough that led an LPN to contact a physician and obtain an order for albuterol nebulizer treatments twice daily. Although the treatments were administered as scheduled, the record contained no documentation of the respiratory assessment that prompted the new order and no pre- and post-treatment respiratory assessments, despite facility policy requiring baseline vital signs and respiratory assessments for nebulizer use. The LPN acknowledged not documenting her assessment, and the DON confirmed that required pre- and post-assessments were not found in the record.
A resident with Alzheimer's disease, heart failure, and hypertensive chronic kidney disease did not receive prescribed metoprolol as ordered. The medication was held on several occasions when blood pressure and heart rate were within the parameters for administration, or when no vital signs were recorded to justify withholding the dose. The DON could not provide further information regarding these decisions.
Two residents with cardiac and respiratory conditions did not receive necessary care and treatment related to oxygen therapy, including failures to monitor oxygen saturation, ensure oxygen tanks were filled, and document respiratory assessments as required by physician orders and facility policy.
The facility did not maintain complete and accurate clinical records for two residents, resulting in missing documentation for the administration of prescribed medications, oxygen therapy, and respiratory treatments. The MARs lacked entries for several scheduled doses and interventions, and the DON was unable to provide additional documentation to account for these omissions.
Two residents suffered serious injuries after staff failed to follow established care plans and safety protocols. One resident, dependent for transfers, was manually lifted by a CNA without using the required mechanical lift, resulting in leg and rib fractures. Another high fall-risk resident was left unattended in the bathroom and fell, sustaining a head laceration requiring staples.
A resident who returned from the ER with a fractured tibia and multiple rib fractures did not receive thorough or frequent nursing assessments as required. Documentation lacked detailed evaluation of the injuries, and follow-up assessments were not completed, despite ongoing pain and changes in condition. The DON confirmed that expected monitoring and documentation were missing.
The facility failed to ensure a sanitary kitchen environment due to inadequate dishwasher temperature monitoring. Observations revealed that the dishwasher's wash cycle temperature was below the required 180 degrees Fahrenheit, and the temperature logs showed frequent non-compliance with the required standards. The facility's policy on recording water temperatures before each meal was not consistently followed, potentially affecting all 52 residents receiving meals from the Main Kitchen.
A facility failed to maintain accurate documentation and accountability for narcotic medications, affecting a resident on a routine pain regimen. Discrepancies were found in the narcotic sign-out sheet, with missing doses and altered entries. An LPN reported the irregularities, leading to an investigation that revealed further documentation issues by a nurse who did not record administered medications in the MAR. The facility could not determine who was responsible for the missing medications.
A facility failed to notify a resident's Responsible Party in writing about a hospital transfer. The resident, with conditions like heart failure and diabetes, was significantly impaired in decision-making. Despite standard procedures, the State-approved transfer form was not completed, and the Responsible Party was not informed. Interviews confirmed the oversight.
A facility failed to provide a resident and their Responsible Party with the bed hold policy before and upon hospital transfer. The resident, with conditions including heart failure and diabetes, was significantly impaired in decision-making. Despite procedures to send the policy with the resident, documentation was missing, and the DON could not locate it.
A facility failed to update a resident's care plan to reflect the discontinuation of IV fluids. The resident, with a history of serious medical conditions, was observed without IV supplies and confirmed not receiving IV fluids since returning from the hospital. Despite this, the care plan still indicated a need for IV fluids, and there were no physician's orders for such treatment. The DON acknowledged the need for care plan modification.
A facility failed to establish parameters for physician notification regarding weight changes for a resident with CHF, diabetes, and fluid overload. The resident was weighed thrice weekly, but the physician's order lacked specific guidelines for notifying weight changes. The DON later received orders to notify the nurse practitioner if there was a five-pound increase in a week.
A facility failed to provide proper wound care for a resident with pressure ulcers, as the Wound Care Nurse did not follow hand hygiene protocols and was unaware of the daily treatment changes required by the physician's orders. The resident, who had multiple health issues and required assistance for mobility, did not receive the necessary treatment to promote healing, as the nurse did not adhere to the specified wound care regimen.
A resident with a history of infection had their urinary catheter bag improperly placed, uncovered, and hanging off a garbage can, contrary to care plan instructions. The resident, who was moderately cognitively impaired and required significant assistance, had a care plan that included specific catheter care instructions. Despite this, the catheter bag was not maintained properly, as observed by staff.
The facility failed to implement non-pharmacological interventions before administering anti-anxiety medication to a resident with Alzheimer's and depression, as documented in their medication administration record. Additionally, another resident with dementia and depression was not monitored for side effects of prescribed antidepressants, despite the care plan indicating a risk for adverse effects. The Director of Nursing confirmed the lack of documentation and monitoring, which is inconsistent with the facility's policy.
A facility failed to ensure complete and accurate clinical records for a resident's self-medication assessment. The resident, with moderate cognitive impairment and multiple medical conditions, was permitted to self-administer medication. However, the evaluation form lacked the resident's name, as the ADON mistakenly wrote her own name instead.
A Wound Care Nurse failed to follow infection control guidelines during a wound treatment for a resident, neglecting to perform hand hygiene and change gloves between tasks. The nurse also did not sanitize hands after reaching into her pocket during the procedure. The nurse later acknowledged the lapse in protocol, and the facility administrator could not provide further information or a policy.
The facility failed to provide proper respiratory care for three residents, leading to deficiencies in oxygen equipment maintenance and administration. A resident with COPD had outdated respiratory equipment, while another resident's oxygen concentrator was set at an incorrect flow rate. A third resident also had outdated equipment, contrary to facility policy requiring weekly changes.
The facility failed to document oxygen administration and saturation levels for two residents with COPD and cognitive impairments. Resident B's records lacked documentation for specific shifts in July, despite a care plan requiring saturation checks every shift. Similarly, Resident C's records were incomplete for a specific shift. The DON confirmed the missing documentation, which violated the facility's policy on oxygen administration.
The facility failed to report an allegation of abuse/neglect to the Administrator and IDOH for a resident with reddened skin after spilling hot coffee. Despite the Responsible Party's accusation of neglect, the DON did not conduct an investigation or report the incident, violating the facility's abuse policy.
The facility failed to provide adequate supervision and follow care plan interventions, resulting in a fall for one resident and a hot coffee spill for another. Resident D, with dementia, was left alone in her room and fell, hitting her head. Resident C, with Alzheimer's, was served hot coffee in her room, leading to a spill and skin redness. Staff interviews confirmed that care plan interventions were not followed.
The facility failed to ensure a resident received necessary treatment and services after a fall. The resident, with Alzheimer's and fractures, was lowered to the floor during a transfer. Initial assessments were incomplete, and no further assessments were done until the next morning, revealing significant injuries. The DON confirmed that post-fall assessments should have been conducted for 72 hours, but this was not done.
Failure to Notify Resident Representative of Change in Condition and New Breathing Treatment
Penalty
Summary
The facility failed to ensure a resident’s representative was informed of a change in condition and new treatment order. A cognitively impaired resident with diagnoses including COPD, heart failure, hypertension, dementia, atrial fibrillation, and depression, and who was receiving oxygen therapy, was noted in a progress note on 12/21/25 at 6:22 a.m. to have slept well overnight, with staff noticing a cough and clear lung sounds. Later that day at 10:07 p.m., a progress note documented a physician’s order for albuterol sulfate nebulization twice daily for cough until 12/27/25, indicating a change in the resident’s condition and treatment. Record review showed no documentation that the resident’s representative was informed of this change in condition or the new breathing medication order. During interview, the LPN acknowledged she did not document that she spoke with the resident’s representative about the change in condition and new medication, and the DON stated the nurse should have documented that she spoke with the family regarding the change in condition and medication change.
Failure to Document Respiratory Assessments for Nebulizer Treatments
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care by not documenting a respiratory assessment when a resident experienced a change in condition and by not completing required pre- and post-nebulizer assessments. The resident had multiple diagnoses including COPD, heart failure, hypertension, dementia, atrial fibrillation, and depression, and was receiving oxygen therapy. A quarterly MDS indicated the resident was cognitively impaired. On one date, a progress note documented that the resident appeared to sleep well but staff noticed a cough, with lungs described as clear. Later that same day, a physician’s order was obtained to start albuterol sulfate nebulizer treatments twice daily for cough for a specified period, and the MAR showed the medication was administered as ordered. Despite the initiation and ongoing administration of nebulizer treatments, the clinical record lacked documentation of the respiratory assessment that led to the new breathing treatment order, as well as any pre- and post-respiratory assessments for each nebulizer treatment. In an interview, an LPN stated that a CNA had reported the resident’s cough, that she performed a respiratory assessment, and then contacted the physician who ordered the nebulizer, but she acknowledged she did not document her assessment and that pre- and post-assessments should have been completed. The DON confirmed that the nurse should have documented the respiratory assessment supporting the start of nebulizer therapy and that staff should have completed and documented pre- and post-assessments with each treatment, but she was unable to find any such documentation. The facility’s nebulizer policy required obtaining vital signs and performing respiratory assessments to establish a baseline.
Failure to Administer Medication as Ordered
Penalty
Summary
A deficiency was identified when a resident with diagnoses including Alzheimer's disease, heart failure, and hypertensive chronic kidney disease did not receive medication as ordered. The resident's care plan required administration of metoprolol tartrate 25 mg twice daily, with instructions to check blood pressure (BP) before administration and to hold the medication if BP was less than 100/50 or heart rate was less than 60. Review of the Medication Administration Records (MAR) for June, July, and August showed that the medication was held on several occasions when the resident's BP and heart rate were within the parameters to administer, or when no vital signs were recorded to justify holding the dose. Specifically, the medication was withheld on multiple dates despite recorded BP and heart rate readings that did not meet the criteria for holding the medication, and in some instances, there was no documentation of vital signs to support the decision to withhold. During an interview, the Director of Nursing was unable to provide further information regarding the rationale for holding the medication when the parameters were not met. This failure to administer medication as ordered constituted a deficiency in following physician orders and the resident's care plan.
Failure to Ensure Safe and Appropriate Respiratory Care and Oxygen Monitoring
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents who required oxygen therapy. For one resident with diagnoses including heart failure and chronic pulmonary edema, there were multiple incidents where the resident's portable oxygen tank was found empty, both in the morning and at dinner time, resulting in low oxygen saturation levels. Documentation did not show that a respiratory assessment was completed after the resident was found without oxygen, and there was a lack of consistent monitoring and documentation of oxygen saturation. The resident experienced episodes of respiratory distress and was ultimately sent to the hospital after her oxygen saturation dropped significantly despite interventions. Another resident with heart failure and atrial fibrillation was observed receiving continuous oxygen therapy via nasal cannula, although the physician's order specified oxygen as needed for shortness of breath to maintain saturation above 90%. The medication administration record did not indicate that oxygen had been administered as needed, and the last documented oxygen saturation was several days prior, showing the resident was on room air. There was no ongoing documentation of oxygen saturation monitoring as required by the physician's order and facility policy. Facility policy required that oxygen be administered per physician order, with initial and ongoing assessment and documentation of the resident's condition and response to therapy. The policy also required staff to check portable oxygen tanks for sufficient supply and to regularly monitor tanks while in use. These requirements were not consistently met, as evidenced by the lack of respiratory assessments, insufficient monitoring of oxygen saturation, and failure to ensure oxygen tanks were adequately filled for residents requiring oxygen therapy.
Incomplete Documentation of Medication and Oxygen Administration
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for two residents regarding the documentation of medications and oxygen administration. For one resident with diagnoses including heart failure, chronic pulmonary edema, and hypertension, the medical record review revealed missing documentation for the administration of BiPAP, oxygen therapy, and several prescribed medications on specific dates and times. The resident's care plan required continuous oxygen and BiPAP use at bedtime and during naps, with instructions to chart refusals, but the Medication Administration Records (MARs) lacked entries for these interventions. The Director of Nursing was unable to provide any additional documentation to account for the missing records. Another resident, diagnosed with Alzheimer's disease, COPD, and chronic respiratory failure with hypoxia, also had incomplete MARs. The records showed that prescribed inhalers and nebulizer treatments were not documented as administered on several occasions. The care plan required administration of aerosol or bronchodilators as ordered, but the MARs for June and July were missing entries for specific medications at scheduled times. The Director of Nursing confirmed that no further information was available to explain the missing documentation.
Failure to Prevent Accidents Due to Inadequate Supervision and Noncompliance with Care Plans
Penalty
Summary
The facility failed to ensure that residents were protected from accident hazards and received adequate supervision to prevent accidents. In one incident, a CNA transferred a dependent resident with a history of traumatic brain injury, cognitive deficit, and peripheral vascular disease from bed to a chair without using the required mechanical lift and without the assistance of a second staff member, as specified in the resident's care plan. The CNA manually lifted the resident, resulting in the resident sustaining a nondisplaced spiral fracture of the right tibia and multiple left lower rib fractures. Documentation and staff statements confirmed that the mechanical lift was not used, and the transfer was not performed according to the resident's plan of care. Another incident involved a resident with a history of stroke, osteoporosis, severe cognitive impairment, and a high risk for falls. The resident required moderate to maximum assistance for transfers and was identified as a fall risk. While being assisted in the bathroom, the CNA left the resident unattended to retrieve socks, during which time the resident attempted to self-toilet and fell, resulting in a head laceration that required staples. The care plan and CNA care card indicated that the resident should not be left alone due to the high risk of falls, but this protocol was not followed at the time of the incident. Both incidents demonstrate a failure to follow established care plans and safety protocols for residents with significant physical and cognitive impairments. The lack of adherence to transfer and supervision requirements directly led to serious injuries, including fractures and a head laceration, for two residents who were dependent on staff for safe mobility and toileting.
Failure to Assess and Monitor Resident After Return with Fractures
Penalty
Summary
A resident with a history of peripheral vascular disease, traumatic brain injury, and cognitive deficit sustained a spiral fracture of the right tibia and multiple fractured ribs following a facility incident. Upon returning from the emergency room, the resident was assisted to bed with an immobilizer on the right lower leg and complained of pain. Documentation shows that while the immobilizer was noted to be in place, there was no thorough assessment of the right leg or the resident's overall status at that time. No nursing assessments were completed the following day, and subsequent notes focused on pain management without detailed evaluation of the injuries. Further documentation revealed that the resident experienced pain and distress, with pain medication being adjusted accordingly. Edema of the lower extremities was later observed, but again, no comprehensive assessment of the fractured leg or ribs was documented. The Director of Nursing confirmed that follow-up assessments were expected but not found in the records. The facility's acute condition change policy required monitoring and documentation of the resident's progress and response to treatment, which was not consistently followed in this case.
Dishwasher Temperature Monitoring Deficiency
Penalty
Summary
The facility failed to maintain a sanitary kitchen environment due to issues with the dishwasher temperatures not reaching the required levels and a lack of consistent temperature monitoring for a high-temperature dish machine. During an initial kitchen tour, it was observed that the dishwasher's wash cycle temperature was only 105 degrees Fahrenheit, whereas it should have been 180 degrees. The rinse cycle was recorded at 191 degrees, but the Dietary Manager was unsure of the correct temperature for this cycle. A review of the Dish Machine Temperature Log for October 2024 revealed several instances where the recorded temperatures did not meet the required standards, with wash temperatures frequently falling below the necessary 160 degrees. Additionally, there were gaps in the temperature recordings for breakfast, lunch, and dinner throughout the month. The facility's policy on dishwasher temperatures mandates that water temperatures be measured and recorded before each meal or after the dishwasher is emptied or refilled for cleaning. However, this policy was not consistently followed, as evidenced by the incomplete temperature logs and the failure to maintain the required wash temperatures. This deficiency had the potential to affect all 52 residents who received meals from the Main Kitchen.
Deficiency in Narcotic Medication Documentation and Accountability
Penalty
Summary
The facility failed to maintain an accurate system for accounting, reconciling, and ensuring the disposition of controlled drugs, specifically narcotic medications, for one of the residents reviewed. This deficiency was identified during a review of Resident 211's records, who was cognitively intact and on a routine pain medication regimen that included opioids. The issue arose when discrepancies were found in the documentation of narcotic medications, with missing doses and altered narcotic count sheets. The investigation revealed that the narcotic sign-out sheet had been tampered with, using whiteout to conceal previous entries, and new documentation was written over it. The irregularities were first noticed by an LPN who reported them to the Director of Nursing (DON). Further investigation by the facility's administrator uncovered discrepancies in the Medication Administration Records (MAR) and narcotic count sheets, particularly involving a nurse who failed to document administered medications in the MAR. This nurse was also frequently responsible for administering as-needed narcotics. Despite the audits and investigation, the facility could not conclusively determine who was responsible for the missing medications or the alterations on the narcotic count sheet. The Director of Nursing admitted to not conducting any audits on narcotic medications prior to the incident.
Failure to Notify Resident's Responsible Party of Hospital Transfer
Penalty
Summary
The facility failed to ensure proper notification procedures were followed for a resident's transfer to the hospital. Resident 15, who had diagnoses including heart failure, diabetes mellitus, and fluid overload, was significantly impaired in daily decision-making. The resident was sent to the hospital and returned to the facility, but there was no documentation indicating that the State-approved transfer form was completed or that the resident's Responsible Party received written notification of the transfer. Interviews with RN 4 and the Director of Nursing revealed that while certain documents were typically sent with residents, the required State-approved transfer form could not be located.
Failure to Provide Bed Hold Policy Notification
Penalty
Summary
The facility failed to ensure that a resident and their Responsible Party were provided with the facility's bed hold and reserve bed payment policy before and upon transfer to the hospital. This deficiency was identified for one of the two residents reviewed for hospitalization. The resident in question had diagnoses including heart failure, diabetes mellitus, and fluid overload, and was significantly impaired in daily decision-making. The resident was transferred to the hospital and later returned to the facility, but there was no documentation indicating that the bed hold policy was completed and sent with the resident or that the Responsible Party received written notification of the policy. Interviews with facility staff revealed that while the procedure was to send the bed hold policy with the resident, the Director of Nursing was unable to locate the policy documentation.
Failure to Update Care Plan for IV Fluids
Penalty
Summary
The facility failed to ensure that care plans were reviewed and revised to reflect changes in the treatment of a resident, specifically regarding the administration of IV fluids. Resident D, who has a medical history including malignant neoplasm of the kidney, urinary tract infection, pathological fracture, bone cancer, paraplegia, and neuromuscular dysfunction of the bladder, was observed without IV supplies or equipment in her room. The resident confirmed that she had not received IV fluids since returning from the hospital. Despite this, her care plan, dated 9/14/24, indicated a need for IV fluids due to dehydration, with interventions such as administering IV fluids and monitoring the IV site. However, there were no physician's orders for IV fluids, and the Director of Nursing acknowledged that the care plan required modification.
Lack of Weight Monitoring Parameters for Resident with CHF
Penalty
Summary
The facility failed to establish parameters for physician notification concerning weight monitoring for a resident with congestive heart failure, diabetes mellitus, and fluid overload. The resident was significantly impaired in daily decision-making, as indicated by the Quarterly Minimum Data Set assessment. A physician's order required the resident to be weighed every Monday, Wednesday, and Friday due to congestive heart failure, but did not specify when to notify the physician of weight changes. The resident's Fluid Maintenance Care Plan highlighted the risk of fluid volume overload and included interventions such as monitoring electrolytes and assessing for edema. However, it lacked specific parameters for weight change notification. During an interview, the Director of Nursing acknowledged the absence of these parameters and noted that orders were later received to notify the nurse practitioner if there was a five-pound increase in a week.
Failure to Follow Wound Care Protocols for a Resident with Pressure Ulcers
Penalty
Summary
The facility failed to provide appropriate wound care for a resident with pressure ulcers, as evidenced by the observation of the Wound Care Nurse not following proper hand hygiene protocols and not adhering to the physician's orders for wound treatment. During the wound care observation, the nurse did not perform hand hygiene between glove changes and used a marker from her pocket without changing gloves, which could compromise the sterility of the wound care process. Additionally, the nurse was unaware of the daily treatment changes required by the physician's orders, indicating a lack of communication or understanding of the current treatment plan. The resident in question had multiple diagnoses, including cellulitis, acute kidney failure, and heart failure, and was significantly impaired in daily decision-making, requiring staff assistance for transfers and bed mobility. The physician's orders specified the application of medical-grade honey gel and bordered gauze on specific days, but the wound care progress report indicated a need for daily treatment changes. The discrepancy between the physician's orders and the nurse's actions highlights a failure to ensure the resident received the necessary treatment and services to promote healing of the pressure ulcers.
Improper Catheter Care for Resident
Penalty
Summary
The facility failed to ensure proper care for a resident with an indwelling urinary catheter, leading to a deficiency. On two separate occasions, the resident's catheter bag was observed uncovered and hanging off the top of a garbage can, with the bag touching the top and side of the can, which contained trash. This was noted during observations on the same day, first at 10:37 a.m. and later at 3:15 p.m., with the Assistant Director of Nursing confirming the improper placement of the catheter bag. The resident, identified as having a history of infection, was moderately cognitively impaired and required substantial assistance with daily activities. The care plan for the resident included catheter care with specific instructions to keep the catheter bag covered and below the waist, and to ensure the tubing did not touch the floor. Despite these orders, the catheter bag was not maintained according to the care plan, as evidenced by its placement on the garbage can. The resident had a recent history of a urinary tract infection, for which they were prescribed an antibiotic, Cipro, indicating the potential for infection was a known risk.
Failure to Implement Non-Pharmacological Interventions and Monitor Medication Side Effects
Penalty
Summary
The facility failed to ensure that non-pharmacological interventions were attempted prior to administering anti-anxiety medication to Resident 37, who had diagnoses including Alzheimer's dementia and depression. The resident's medication administration record indicated that alprazolam was given on multiple occasions without documentation of non-pharmacological interventions being attempted, except for two instances. The Director of Nursing confirmed the lack of documentation for the remaining days, which is contrary to the facility's policy requiring such interventions before administering psychotropic drugs. Additionally, the facility did not monitor Resident 48 for side effects of antidepressant medications, despite the resident's diagnoses of unspecified dementia and depression. The resident was prescribed sertraline and buproprion, and the care plan indicated a risk for adverse effects from these medications. However, there was no physician's order or documentation in the resident's record to indicate monitoring for side effects, which the Director of Nursing acknowledged should occur every shift. This oversight is inconsistent with the facility's policy that mandates monitoring for side effects and documenting the resident's response to psychotropic medications.
Incomplete Clinical Records for Self-Medication Assessment
Penalty
Summary
The facility failed to ensure that clinical records were complete and accurately documented, specifically regarding a self-medication administration assessment for a resident. The deficiency involved Resident 23, who had a range of medical conditions including repeated falls, hemiplegia due to a stroke, aphasia, hypertension, and right foot drop. The resident's Quarterly Minimum Data Set (MDS) assessment indicated moderate cognitive impairment and a need for assistance with daily activities. A physician's order allowed the resident to self-administer Econazole nitrate powder topically. However, the Self-Administration of Medication Evaluation form, dated the same day as the physician's order, did not include the resident's name. During an interview, the Assistant Director of Nursing (ADON) admitted to mistakenly writing her own name on the form instead of the resident's.
Infection Control Deficiency in Wound Care
Penalty
Summary
The facility failed to adhere to infection control guidelines during a wound treatment procedure for a resident. The Wound Care Nurse was observed performing wound care on a resident's right heel, ankle, and lower leg without following proper hand hygiene and glove use protocols. After removing the old dressings, the nurse changed gloves without performing hand hygiene. She continued to clean each wound without changing gloves or sanitizing her hands between each wound care task. Additionally, the nurse reached into her pocket to retrieve a marker, wrote on a foam dressing, and continued the procedure without changing gloves or sanitizing her hands. During an interview, the Wound Care Nurse acknowledged that she should have performed hand hygiene between glove changes and should have changed gloves after reaching into her pocket. The facility administrator was unable to provide further information or a corresponding policy when requested. This incident highlights a deficiency in the facility's infection prevention and control practices, specifically regarding hand hygiene and glove use during wound care procedures.
Deficiencies in Respiratory Care for Residents
Penalty
Summary
The facility failed to provide appropriate respiratory care for three residents, resulting in deficiencies related to the maintenance and administration of oxygen therapy. Resident B was observed with outdated respiratory equipment, including a humidification bottle and nebulizer mask dated 10/6/24, despite physician orders requiring weekly changes. Resident B, diagnosed with heart failure, respiratory failure, and COPD, was moderately cognitively impaired and dependent on supplemental oxygen. LPN 1 confirmed the equipment was outdated and should have been changed. Resident C, who had diagnoses including cancer, hypertension, depression, and COPD, was observed with an oxygen concentrator set at an incorrect flow rate of 2 to 2.5 liters, contrary to the physician's order of 3 liters continuously. The ADON confirmed the incorrect setting. Resident D, with diagnoses such as malignant neoplasm of the kidney and paraplegia, was found with an outdated water bottle in her oxygen concentrator, also dated 10/6/24. LPN 1 acknowledged the bottle should have been changed weekly. The facility's policy required weekly changes of oxygen equipment, which was not adhered to in these cases.
Incomplete Documentation of Oxygen Administration for Two Residents
Penalty
Summary
The facility failed to ensure complete and accurate documentation of medical records related to oxygen administration and saturation levels for two residents. Resident B, who had diagnoses including COPD, hypertension, and dementia, was cognitively impaired and received oxygen therapy. The care plan required checking oxygen saturation every shift. However, documentation was missing for specific dates and shifts in July 2024, where the oxygen administration and saturation levels were not recorded. The Director of Nursing confirmed the lack of documentation during an interview. Similarly, Resident C, with diagnoses including COPD, diabetes mellitus, hypertension, and dementia, was moderately cognitively impaired and also received oxygen therapy. The care plan required continuous oxygen administration, but documentation was missing for a specific date and shift in July 2024. The Director of Nursing was unable to provide further information regarding the missing documentation. The facility's policy on oxygen administration required staff to document the initial and ongoing assessment of the resident's condition and response to oxygen therapy, which was not adhered to in these cases.
Failure to Report Allegation of Abuse/Neglect
Penalty
Summary
The facility failed to report an allegation of abuse/neglect to the Administrator and the Indiana Department of Health (IDOH) for a resident with an allegation of abuse/neglect voiced by a family member. The resident, who had diagnoses including Alzheimer's disease, dementia, and diabetes mellitus, was found with reddened skin on the upper abdomen and underneath the left breast after spilling hot coffee. The incident was reported to the Responsible Party, who accused the facility of willful and criminal neglect. However, the Director of Nursing (DON) did not conduct an investigation or report the allegation to the Administrator or IDOH, as required by the facility's abuse policy. The incident was documented in the Nurse's Progress Notes, and the Responsible Party was informed after multiple attempts to reach them. Despite the Responsible Party's accusation of neglect, the DON did not observe any redness when she checked the resident and did not consider it necessary to report the allegation. The facility's abuse policy mandates that all allegations of abuse, neglect, and exploitation be reported immediately to the Administrator and relevant authorities, but this protocol was not followed in this case.
Failure to Provide Adequate Supervision and Follow Care Plan Interventions
Penalty
Summary
The facility failed to ensure adequate supervision and adherence to care plan interventions, resulting in two separate incidents involving residents. Resident D, who has dementia and is dependent on assistance for mobility, was left alone in her room while in a wheelchair, contrary to her care plan. This led to a fall where she hit her head, resulting in a laceration that required two staples. The incident occurred because the resident forgot to lock her wheelchair brakes and attempted to reach for a TV remote, causing her to slide out of the wheelchair. Staff interviews confirmed that the resident was left alone, and the care plan intervention to not leave her alone in her room was not followed. Resident C, who has Alzheimer's disease and dementia, was served hot coffee in her room despite a care plan intervention that prohibited hot drinks in her room or with meals. This led to the resident spilling the hot coffee on herself, causing reddened and tender skin on her upper abdomen and underneath her left breast. The incident was documented by an Agency LPN, and subsequent notes indicated that the redness and tenderness subsided with cold compresses. Interviews with the Director of Nursing and Assistant Director of Nursing confirmed that staff had access to the care plan, which included the intervention against serving hot drinks in the resident's room.
Failure to Conduct Timely Post-Fall Assessments
Penalty
Summary
The facility failed to ensure a resident received the necessary treatment and services after a fall. Resident B, who had diagnoses including Alzheimer's disease and fractures in the left knee and right ankle, was assisted by an Agency CNA during a transfer and was lowered to the floor in the bathroom. The initial assessment noted no injuries, and vital signs were within normal limits. However, the after-fall assessment was not thorough, lacking significant findings and actual vital signs. No further assessments were completed until the following morning, when significant swelling, bruising, and deformity were observed in the resident's right ankle, leading to a hospital transfer and diagnosis of a right tibia/fibula fracture. The Director of Nursing (DON) confirmed that post-fall assessments should have been conducted for 72 hours following the fall, but no assessments were documented until the morning after the incident. The facility's policy required observation for delayed complications for approximately 48 hours post-fall, with documentation of any signs or symptoms. The failure to conduct timely and thorough assessments after the fall resulted in a delay in identifying the resident's injuries and providing appropriate care.
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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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