Peabody Retirement Community
Inspection history, citations, penalties and survey trends for this long-term care facility in North Manchester, Indiana.
- Location
- 400 W Seventh St, North Manchester, Indiana 46962
- CMS Provider Number
- 155655
- Inspections on file
- 37
- Latest survey
- May 6, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Peabody Retirement Community during CMS and state inspections, most recent first.
Dietary staff were observed repeatedly using the same gloves to handle food, kitchen equipment, and packaging without changing gloves or washing hands between tasks. This included touching ready-to-eat foods, opening packaging, and checking food temperatures, with inconsistent use of utensils like tongs. Interviews revealed confusion about proper glove use, and facility policy on minimizing foodborne illness risk was not followed, potentially affecting all residents receiving meals from the affected kitchen areas.
Staff failed to consistently use required PPE, including eye protection, and did not perform hand hygiene when entering or exiting rooms of residents on droplet precautions for respiratory illnesses. During meal assistance, a CNA was observed touching her face, sharing utensils between residents, and blowing on food, all without performing hand hygiene, contrary to facility policy. These lapses were confirmed by staff interviews and had the potential to affect all residents on droplet precautions and those receiving dining assistance.
A resident with paraplegia, bowel incontinence, and recent C. difficile infection was left sitting in feces for about an hour after being removed from his room for pest control spraying. Staff were aware of the soiling but did not provide prompt incontinence care due to uncertainty about where to assist the resident, resulting in a delay until the resident could return to his room. Facility policy and staff interviews confirmed that immediate care was expected to maintain dignity.
Two residents with moderate cognitive impairment were allowed to self-administer medications without proper assessment, physician orders, or care plans in place. Staff left medications at the bedside for one resident to dissolve in applesauce, despite documentation indicating she was not safe to self-administer. Another resident was found with pills on the floor and no evidence of a safety assessment or care plan for self-administration, contrary to facility policy.
A resident with multiple chronic conditions, including constipation and dementia, experienced several periods without a bowel movement, but staff did not consistently monitor or implement the facility's bowel protocol as ordered. Despite physician orders and facility policy requiring regular documentation and intervention for constipation, there was no evidence that appropriate actions were taken during these episodes.
Staff failed to provide prompt incontinence care to a resident with a pressure injury, leaving the individual sitting in feces for over an hour due to confusion about where to provide care after the resident's room was sprayed for pests. In a separate incident, an RN did not follow infection control protocols during wound care for another resident, placing supplies on an unclean surface and neglecting hand hygiene. Both residents had significant risk factors for pressure injuries, and required interventions were not implemented as outlined in their care plans and facility policy.
The facility failed to implement and document effective QAPI processes, resulting in repeated deficiencies in pressure injury care and infection prevention. Audits and interventions to promote healing and prevent wound contamination were not consistently carried out or documented, leading to ongoing issues for residents with pressure injuries.
A CNA in an LTC facility verbally abused a resident with severe cognitive impairment and neglected another resident who required assistance for showering. The first resident was told to 'shut up' and that permission to talk would be given by the CNA. The second resident was denied a shower by the CNA, who claimed to be too tired, but was later assisted by another CNA. The incidents were reported to the facility's DON, and the CNA involved was reported to the appropriate agencies and barred from working in the facility.
A cognitively impaired resident, identified as an elopement risk, was able to leave the facility unnoticed due to inadequate supervision. The resident was not checked on overnight and was found the next morning in a local park. Staff failed to communicate the resident's elopement risk, and the CNA responsible did not perform required checks.
A resident identified as an elopement risk left the facility without his walker and was later found in a local park. The facility's report inaccurately stated the family declined secured unit placement, which the family disputed. The DON reported the incident without complete information, and the Administrator acknowledged the report was not intended to be misleading.
The facility failed to follow physician orders for blood glucose monitoring, insulin administration, and elastic wraps for two residents. Resident 90 did not have blood sugar levels monitored or insulin administered as ordered, and Resident 82's legs were often not wrapped as required. Staff interviews confirmed lapses in following orders and documentation.
The facility failed to provide adequate monitoring and interventions for pressure injuries for two residents. One resident was observed wearing non-skid shoes despite a physician's order for no shoe on the left foot, and the clinical record lacked consistent documentation of wound care. Another resident frequently did not wear the required offloading boot, and the facility's documentation did not reflect the resident's refusal or staff's attempts to ensure its use. The facility's failure to adhere to physician's orders and provide consistent monitoring resulted in inadequate care.
The facility failed to develop and implement a system of individualized behavior monitoring and management for a resident with dementia. The clinical record lacked detailed documentation of behavioral episodes, and staff interviews revealed that behaviors were documented by exception, resulting in insufficient information for effective care planning.
The facility failed to label medications with resident identifiers and directions for two of five medication carts reviewed. Unlabeled bottles of morphine sulfate and various other medications were found, and staff acknowledged that all medications should have been labeled immediately upon receipt.
The facility failed to follow infection prevention and control strategies during wound care for two residents. LPNs did not adhere to proper hand hygiene and glove-changing protocols, increasing the risk of infection for residents with surgical wounds and other medical conditions.
The facility failed to make nursing staffing data readily available in a prominent, easily accessible location for residents and visitors. Surveyors observed that the required staffing information was either missing or incomplete in various units. Staff members, including the DON and the Administrator, were unaware of the exact location of the nurse staffing posting, indicating a lack of proper communication and procedure adherence within the facility.
The facility failed to ensure that an LPN had a valid Indiana nursing license or an active out-of-state license through an interstate compact agreement. The LPN, employed since February 2023, continued to work and provide wound care with a Texas single-state license, impacting all 164 residents.
A resident with dementia ingested a pencil sharpener blade due to inadequate supervision, requiring hospitalization for surgical removal. The resident was left unattended with a box of colored pencils, leading to the incident. Staff interviews and video footage revealed lapses in supervision, contrary to the facility's safety policy.
A cognitively impaired resident with a history of elopement managed to exit a secured unit through his bedroom window. Despite previous elopement attempts and documented exit-seeking behavior, the resident was able to remove the screen from his window and walk outside before being noticed by staff. The facility's policy on elopement risk assessment was not effectively implemented.
Failure to Maintain Safe and Sanitary Food Handling Practices
Penalty
Summary
The facility failed to prepare and distribute food in a safe and sanitary manner, as observed during multiple meal service periods. Dietary staff were seen repeatedly using the same pair of gloves to handle various food items, kitchen equipment, and packaging, without changing gloves or washing hands between tasks. For example, a dietary staff member donned gloves and used utensils to serve food, but then touched condiment containers, opened freezers, handled frozen chicken tenders, and placed them in the fryer, all without changing gloves. The same staff member also handled ready-to-eat foods, opened packaging, checked food temperatures, and manipulated kitchen equipment with the same gloves, only occasionally removing gloves and washing hands before donning new gloves. The use of gloves was inconsistent with safe food handling practices, as gloves were not changed between handling different items and surfaces, and tongs were not consistently used for serving food until prompted by the Dietary Manager. Interviews with the dietary staff and manager revealed a lack of consistent understanding and implementation of proper glove use and food handling protocols. The dietary staff member indicated he would change gloves if he touched something not food safe, but also believed it was acceptable to touch ready-to-eat items and clean kitchen handles with the same gloves. The Dietary Manager clarified that staff were not supposed to touch food items with gloved hands unless the gloves were clean and that gloves should be changed when touching other items. Facility policy required food to be stored, prepared, handled, and served to minimize the risk of foodborne illness, but these procedures were not followed during the observed meal services. This deficient practice had the potential to affect all 46 residents receiving meals from the Transitional Care Unit and Tulip Place kitchenette.
Failure to Adhere to Infection Control Practices for Droplet Precautions and Dining Services
Penalty
Summary
Surveyors identified multiple failures in infection prevention and control practices related to droplet precautions for six residents. Staff members, including CNAs, QMAs, and dietary aides, entered rooms with droplet precaution signage without donning required personal protective equipment (PPE) such as eye protection, and in several instances, did not perform hand hygiene upon exiting the rooms. Some staff members were observed entering rooms without first ensuring PPE was available, and others misunderstood or disregarded the requirements for face shields or goggles, despite clear signage and facility policy. These lapses occurred even though residents had active physician orders and care plans for droplet precautions due to diagnoses such as Influenza A, bronchitis, pneumonia, and other respiratory illnesses. The residents involved had varying degrees of cognitive and physical impairment, with some being dependent on staff for mobility and care. Additionally, during dining services, staff failed to follow infection control protocols while assisting residents with meals. One CNA was observed touching her face, handling multiple residents' utensils and cups without performing hand hygiene, and blowing on food before serving it to residents. The CNA also used the same utensils between residents and touched the tops of cups and bowls, contrary to facility policy and infection control standards. Interviews with staff and the Infection Preventionist confirmed that these actions were not in line with expected practices, which require frequent hand hygiene, avoidance of bare-hand contact with food, and not sharing utensils among residents. Facility policies reviewed by surveyors indicated clear requirements for transmission-based precautions, including the use of appropriate PPE and hand hygiene. The observed failures to adhere to these policies and CDC guidelines were confirmed through staff interviews, which revealed gaps in understanding and inconsistent application of infection control measures. These deficiencies had the potential to affect all residents on droplet precautions and those receiving dining assistance.
Failure to Provide Prompt Incontinence Care and Maintain Resident Dignity
Penalty
Summary
Staff failed to provide prompt incontinence care to a resident who was dependent on staff for all toileting needs and was always incontinent of bowel. The resident, who had a history of depression, bipolar disorder, paraplegia, and recent Clostridioides difficile infection, experienced a bowel movement as he was assisted out of his room, which was then closed for pest control spraying. Staff were aware the resident was soiled but did not know how to proceed since his room was unavailable and there were no empty rooms on the unit. The resident remained in the common area, sitting in feces for approximately an hour, while staff expressed uncertainty about where to provide care and did not immediately seek guidance from supervisors. Observations confirmed the resident remained soiled in the common area until staff were eventually directed to return him to his room after it was deemed safe. Upon being assisted to his room and transferred to bed, the resident was found to have feces on and between his buttocks, extending from his scrotum to a bandage on his sacral/coccyx area. Interviews with staff and management indicated that incontinence care should have been provided immediately and that alternative arrangements, such as using an empty room or therapy room, were expected when the resident's room was unavailable. Facility policy also required prompt response to toileting needs to maintain resident dignity.
Failure to Assess and Document Safety for Medication Self-Administration
Penalty
Summary
The facility failed to ensure that residents who self-administered medications were properly assessed for safety, as required. For one resident, a medication cup containing applesauce and several pills was observed on the bedside table. The resident explained that she needed her medications to dissolve in applesauce before swallowing, and staff would leave the cup with her for this purpose. However, her clinical record did not contain a physician's order for self-administration, and her Medication Self-Administration Safety Screen indicated she was not safe to self-administer medications, requiring staff presence during administration. There was also no care plan addressing medication self-administration for this resident. Another resident was found with medication pills on the floor and a medication cup on the bedside table. Staff removed the pills and cup, stating that medications should not be left in resident rooms and expressing uncertainty about how the pills ended up on the floor. This resident's clinical record also lacked a care plan for medication self-administration and did not include a Medication Self-Administration Safety Screen. Both residents were assessed as moderately cognitively impaired and had multiple medical diagnoses requiring complex medication regimens. Facility policy requires that only licensed or permitted staff administer medications unless the attending physician and interdisciplinary team determine a resident can safely self-administer. In both cases, there was no documentation of such determinations, and the required assessments and care planning for self-administration were missing, leading to the deficiency.
Failure to Monitor and Manage Constipation per Bowel Protocol
Penalty
Summary
The facility failed to monitor and manage constipation for a resident as required by physician orders and facility policy. The resident, who had diagnoses including Parkinson's disease, constipation, dementia, and other chronic conditions, reported experiencing hard bowel movements and periods of up to three days without a bowel movement. Despite a physician's order for a bisacodyl suppository as needed for constipation, there was no documentation that the bowel protocol or prescribed interventions were implemented during periods of constipation. Review of the resident's clinical record and bowel elimination logs revealed gaps in monitoring and documentation. The bowel elimination record showed multiple periods where the resident did not have a bowel movement for more than 72 hours, specifically between 3/16/25 to 3/18/25 and 3/24/25 to 3/31/25. Staff interviews confirmed that concerns about constipation were reported to nursing, but there was no evidence in the clinical record that the bowel protocol was followed or that interventions were provided during these times. The last documented use of the bowel protocol for this resident was in December 2024, despite ongoing issues. Facility policy required that bowel movements be documented every shift, that a bowel movement report be run nightly, and that residents with no bowel movement in 72 hours receive assessment and intervention. Interviews with staff, including CNAs, RNs, and the unit manager, confirmed that these procedures were not consistently followed for this resident. The lack of monitoring and failure to implement the bowel protocol as ordered resulted in the deficiency.
Failure to Provide Timely Pressure Ulcer Care and Maintain Infection Control
Penalty
Summary
A deficiency occurred when staff failed to provide timely incontinence care to a resident with a known pressure injury. The resident, who was paraplegic, cognitively intact, and always incontinent of bowel, was left sitting in feces in a common area after his room was sprayed for pests. Staff were aware of the resident's soiled condition but did not know where to take him for care, as his room was unavailable and there were no empty rooms on the unit. The resident remained in this state for over an hour, and when finally assisted, was found to have feces on and between his buttocks, extending to the area of his pressure injury, with reddened skin observed. The care plan for this resident required incontinence care after each episode, and facility policy stated that skin should be cleaned promptly after incontinence, but these interventions were not implemented as required. Another deficiency was identified in the infection prevention and control practices during wound care for a resident with a pressure injury on the right heel. During wound care, an RN failed to clean the overbed table or use a barrier before placing wound care supplies on it. The RN also did not perform hand hygiene after removing the resident's shoe and before beginning wound care. These lapses in infection control created a potential for contamination of the wound site. The facility's policy required cleaning the bedside stand and establishing a clean field before placing supplies, as well as proper hand hygiene, but these steps were not followed. Both residents involved had significant risk factors for pressure injuries and required specific interventions as outlined in their care plans and physician orders. The first resident had a history of C. difficile infection, was dependent on staff for all mobility and toileting, and had a stage 3 pressure injury that worsened over the week. The second resident had a right heel pressure injury and a recent hip fracture, requiring pressure-relieving devices and careful wound care. In both cases, staff actions and inactions directly led to failures in pressure ulcer care and infection prevention.
Repeat Deficiencies in Pressure Injury Care and Infection Control Due to Ineffective QAPI Implementation
Penalty
Summary
The facility failed to develop and implement effective approaches to maintain a Quality Assurance and Performance Improvement (QAPI) program, resulting in repeat deficiencies related to pressure injury care and infection prevention. During the last annual recertification and state licensure survey, the facility did not provide adequate monitoring of a pressure injury and did not implement interventions to promote healing. Additionally, the facility failed to utilize infection prevention and control strategies to prevent contamination of wounds during wound care. These deficiencies were again cited in a subsequent survey, where it was observed that interventions to promote healing and infection control strategies were not implemented for residents with pressure injuries. Interviews with facility leadership revealed that QAPI meetings were held at least quarterly, sometimes monthly, and covered previously identified areas of concern. However, the Director of Nursing (DON) was unable to provide documentation supporting the initiation of a Performance Improvement Plan (PIP) related to pressure ulcers after the previous survey. The facility's QAPI policy outlined a proactive approach to quality improvement, but the lack of implementation and documentation contributed to the recurrence of deficiencies in pressure injury management and infection control.
Verbal Abuse and Neglect by CNA in LTC Facility
Penalty
Summary
The facility failed to prevent staff-to-resident verbal abuse and neglect involving two residents. Resident D, who had severe cognitive impairment and was dependent on staff for all activities of daily living, was verbally abused by CNA 1. According to a written statement and an interview, CNA 1 told Resident D to 'shut up' and that she would give her permission to talk. This incident was reported by another resident, Resident C, who witnessed the verbal abuse. The incident was not reported to the facility until a later date. Resident E, who was cognitively intact and required moderate assistance for showering and dressing due to an intertrochanteric fracture of the right femur, was neglected by CNA 1. Resident E requested a shower, but CNA 1 refused, stating they were too tired to provide the service. Another CNA, CNA 2, eventually provided the shower. The facility's Director of Nursing (DON) confirmed the incident and indicated that CNA 1 was reported to the appropriate agencies and was no longer allowed to work in the facility.
Failure to Supervise Elopement Risk Resident
Penalty
Summary
The facility failed to ensure adequate supervision and safety measures for a cognitively impaired resident, identified as an elopement risk, leading to the resident's elopement. The resident, who had a history of dementia and was assessed as an elopement risk, was not observed overnight and was able to leave the facility unnoticed. The resident exited the facility without his walker and was found the next morning in a local park, approximately one-half mile away, after being unaccounted for overnight. The resident's care plan included interventions to prevent elopement, such as offering diversions and monitoring his whereabouts. However, these interventions were not effectively implemented. The CNA responsible for the resident did not check on him throughout the night, and the agency nurse on duty was not informed of the resident's elopement risk. The resident was last seen by staff around 9:30 p.m. and was not discovered missing until the following morning during routine rounds. Interviews with staff revealed a lack of communication and adherence to protocols. The CNA assigned to the resident did not perform the required checks, citing that the resident was independent and did not want her in his room. Additionally, the agency nurse was unaware of the resident's elopement risk, indicating a failure in communication during shift changes. The facility's policies on safety and supervision were not followed, contributing to the resident's ability to leave the facility undetected.
Removal Plan
- Inserviced all staff on care checks
- Systemic change of identifying residents who were an elopement risk
- Inserviced staff on the elopement and abuse/neglect policies
- Implemented colored background name plates for residents who are at risk for elopement
- Implemented ribbons on electronic health records noted for those residents who are an elopement risk
- Implemented documentation for safety checks for residents who were at risk for elopement and resided on an unsecured unit
- Conducted audits to ensure elopement assessments were completed with new admissions and appropriate interventions were in place
Inaccurate Reporting of Resident Elopement Incident
Penalty
Summary
The facility failed to report accurate information regarding an elopement incident involving a resident identified as moderately cognitively impaired and at risk for elopement. The resident was admitted for rehabilitation services, and although the family was informed of the elopement risk, they declined placement in a secured unit. On the night of the incident, the resident left his room and exited the facility without his walker. He was later found in a local park and returned to the facility without incident. The initial facility report inaccurately stated the family had declined secured unit placement, which the family later disputed. The facility's Director of Nursing (DON) admitted to reporting the incident without complete information, and the Administrator acknowledged the report was not intended to be misleading. Video footage confirmed the resident's exit from the facility, and interviews with staff and family highlighted discrepancies in the facility's account of events. The facility's policy for reporting incidents was not clearly followed, contributing to the inaccurate reporting of the elopement incident.
Failure to Follow Physician Orders for Blood Glucose Monitoring, Insulin Administration, and Elastic Wraps
Penalty
Summary
The facility failed to follow physician orders regarding blood glucose monitoring, insulin administration, and elastic wraps for two residents. Resident 90, diagnosed with type 2 diabetes mellitus and hypothyroidism, had specific physician orders for blood glucose monitoring and insulin administration. However, the facility did not obtain the resident's blood sugar as ordered on multiple occasions and failed to administer insulin according to the sliding scale. The clinical record lacked documentation indicating the resident refused the blood glucose monitoring or medication, and the resident was not on leave of absence during the mentioned dates and times. Interviews with staff confirmed the lapses in following physician orders and documentation. Resident 82, diagnosed with morbid obesity, diabetes mellitus, gout, and chronic peripheral venous insufficiency, had physician orders to apply elastic wraps to both legs daily. Observations revealed that the resident's legs were often not wrapped as ordered, and the resident expressed concern about his legs and pain relief from the wraps. The electronic treatment administration record lacked documentation for certain days, and interviews with staff indicated that the resident sometimes refused care, which should have been documented in the electronic medical record. The facility's policy on physician orders, revised recently, indicated that the facility is responsible for carrying out physician orders as written. However, the facility failed to adhere to this policy for both residents, leading to deficiencies in care. Staff interviews confirmed that the orders were not consistently followed, and documentation was incomplete or missing for the specified dates and times.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide adequate monitoring and interventions for pressure injuries for two residents. Resident 5, who had multiple diagnoses including type 2 diabetes mellitus and chronic kidney disease, was observed multiple times wearing non-skid shoes on both feet despite having a physician's order for no shoe on the left foot due to a pressure injury. The clinical record lacked consistent documentation of wound descriptions, measurements, and treatment orders for the pressure injury on the left heel. The wound was initially identified upon readmission from the hospital, but the facility did not implement appropriate interventions or monitor the wound effectively, leading to its deterioration over time. Interviews with staff revealed a lack of awareness and adherence to the treatment orders, and the Kardex report did not include the necessary care interventions for the left heel pressure injury. Resident 120, who had diagnoses including adult failure to thrive and unspecified protein-calorie malnutrition, was observed multiple times without the required offloading boot on his left foot, despite a physician's order for the boot to be worn at all times except during showers and morning or night care. The resident's clinical record indicated a history of a stage 3 pressure ulcer on the left heel, but observations and interviews revealed that the resident frequently did not wear the offloading boot. The facility's documentation did not consistently reflect the resident's refusal to wear the boot or the staff's attempts to ensure its use. The Unit Manager acknowledged the lack of proper documentation and monitoring for the resident's pressure injury care. The facility's failure to adhere to physician's orders and provide consistent monitoring and interventions for pressure injuries resulted in inadequate care for both residents. The lack of proper documentation, staff awareness, and adherence to care plans contributed to the deficiencies observed during the survey. The facility's policies and procedures for pressure ulcer care were not effectively implemented, leading to the identified issues in pressure injury management for Residents 5 and 120.
Failure to Implement Individualized Behavior Monitoring for Dementia Resident
Penalty
Summary
The facility failed to develop and implement a system of individualized behavior monitoring and management for a resident diagnosed with dementia. Resident 85, who has diagnoses including unspecified dementia, Parkinson's disease, delusional disorder, and major depressive disorder, was observed multiple times in a calm state. However, the clinical record lacked detailed documentation of behavioral episodes, including the location, preceding events, staff present, and specific interventions attempted. The facility's documentation primarily consisted of check marks without narrative descriptions, failing to provide comprehensive information necessary for individualized care planning. The resident's care plan included monitoring and recording occurrences of target behaviors and documenting them per facility protocol. Despite this, the progress notes from February 2024 lacked detailed documentation of behavioral events, such as the environment, specific behaviors displayed, and the effectiveness of interventions. Interviews with staff indicated that behaviors were documented by exception and only dangerous behaviors required detailed documentation. This approach resulted in insufficient information to assess and manage the resident's behaviors effectively. The facility's policy on behavior management emphasized the importance of identifying and investigating mood and behavior symptoms to provide appropriate interventions. However, the lack of detailed documentation and individualized behavior monitoring for Resident 85 indicates a failure to adhere to this policy. The deficiency highlights the need for a more thorough and systematic approach to behavior management and documentation to ensure the resident's needs are adequately addressed.
Failure to Label Medications with Resident Identifiers and Directions
Penalty
Summary
The facility failed to ensure medications were labeled with resident identifiers and directions for two of five medication carts reviewed. During an observation, an opened and unlabeled bottle of morphine sulfate oral solution was found in the narcotic drawer of Rehabilitation Unit Medication Cart 2. The bottle lacked identifiers and directions, and the Qualified Medication Aide (QMA) present was uncertain why it was not labeled. The QMA acknowledged that all medications required labels, including resident identifiers, drug name, drug dose, route of administration, and directions for use. She admitted that she should have noticed the unlabeled morphine bottle during her controlled medication count at the beginning of her shift. Additionally, Rehabilitation Unit Medication Cart 1 contained several opened and unlabeled medication bottles, including aspirin, pain relievers, supplements, and other medications, all without resident identifiers or directions for use. The QMA and Licensed Practical Nurse (LPN) present during the observation confirmed that the bottles should have been labeled immediately upon receipt. The facility's policy, revised in April 2019, indicated that all medications maintained in the facility should be properly labeled in accordance with current state and federal guidelines and regulations.
Infection Control Deficiencies During Wound Care
Penalty
Summary
The facility failed to utilize infection prevention and control strategies during wound care for two residents. For Resident 154, the LPN did not follow proper hand hygiene and glove-changing protocols during wound care. The LPN moved an uncleaned overbed table, handled a contaminated marker, and continued with wound care without changing gloves or performing hand hygiene. This included cleansing and treating abdominal wounds with the same gloves used to handle potentially contaminated items, increasing the risk of infection for the resident who had a history of necrotic pancreatitis, muscle weakness, and required assistance with personal care. The resident had surgical wounds that were worsening and showed signs of infection, as indicated by purulent drainage and dehiscence noted in wound assessments. For Resident 467, the LPNs also failed to follow proper infection control procedures during wound care. One LPN used gloved hands to touch the bed controller and then continued with wound care without changing gloves or performing hand hygiene. Additionally, the LPN used the same gauze to cleanse multiple surgical incisions on the resident's back, rather than using a new gauze for each incision. This resident had a history of spinal fractures and multiple surgical incisions, requiring substantial assistance from staff for daily activities. The improper handling of wound care supplies and failure to maintain hand hygiene protocols posed a risk of infection for the resident. Interviews with the LPNs and the Director of Nursing confirmed that the observed practices did not align with the facility's hand hygiene policy, which mandates hand hygiene before and after handling clean or soiled dressings and after contact with objects in the immediate vicinity of the resident. The facility's policy emphasizes hand hygiene as the primary means to prevent the spread of infections, which was not adhered to during the observed wound care procedures.
Failure to Post Nursing Staffing Information
Penalty
Summary
The facility failed to make nursing staffing data readily available in a prominent, easily accessible location for residents and visitors. On multiple occasions, surveyors observed that the required staffing information was either missing or incomplete. For instance, a binder labeled Nursing Daily Schedules was found at the reception desk but lacked specific hours worked and nursing roles such as RN and LPN. Additionally, no staffing information was posted in various units including Evergreen Park, [NAME] Way, Magnolia Lane, Tulip Place, and TCU units during the survey dates. The receptionist and other staff members, including the DON and the Administrator, were unaware of the exact location of the nurse staffing posting, indicating a lack of proper communication and procedure adherence within the facility. During an interview, the DON eventually located the staffing posting behind the reception desk, where it was not visible or accessible to the public. The posting was positioned parallel to a wall, making it difficult to read. The facility's policy on Daily Nursing Staffing Data Posting was provided, which stated that the data should be posted in a visible area and include the number of hours worked by each type of staff. However, the facility failed to adhere to this policy, resulting in the deficiency noted by the surveyors.
Failure to Ensure Valid Nursing License
Penalty
Summary
The facility failed to ensure that an LPN employed in the nursing department had a valid Indiana nursing license or an active out-of-state license valid through an interstate compact agreement. The LPN, who had been employed since February 2023, was found to have a Texas single-state license, which was verified in January 2024. Despite this, the LPN continued to work as a nurse supervisor and provide wound care to residents without the proper licensure for Indiana. The Human Resources Director and Administrator acknowledged the issue but did not provide an explanation for why the compact status was not clarified earlier. The facility's policy required employees to notify the Director of Human Resources of any changes to the status of their licensure. However, this policy was not followed, leading to the LPN working without a valid license for Indiana. The LPN had applied for an Indiana license by endorsement as of the date of the survey, but the deficiency had the potential to impact all 164 residents in the facility. The facility did not offer an explanation as to why the clarification of the compact status had not been obtained following the January 2024 verification, which indicated the employee had a Texas single-state license.
Failure to Supervise Resident with Dementia Leads to Ingestion of Pencil Sharpener Blade
Penalty
Summary
The facility failed to ensure effective supervision for a cognitively impaired resident with dementia, resulting in the resident ingesting a pencil sharpener blade and requiring hospitalization for surgical removal. The resident, diagnosed with Alzheimer's disease and other cognitive impairments, was observed in a wheelchair in the common area and dining room without adequate supervision. The resident's clinical record indicated she required extensive assistance for various activities and was rarely/never understood, with no exhibited behaviors noted in the recent assessment. On the day of the incident, the resident was left unattended with a box of colored pencils, which contained a small pencil sharpener. The resident was found chewing on the sharpener by a CNA, who, along with a nurse, removed plastic fragments and a screw from the resident's mouth but could not locate the blade. The resident was sent to the ER, where an x-ray confirmed the presence of the blade in her stomach, and it was subsequently removed via endoscopy. The resident returned to the facility with minor cuts in her upper airway and throat but no new orders or limitations. Interviews with staff revealed that the pencil sharpener was not typically left out and was usually stored in a toolbox or the medication cart. Video footage showed the resident being left alone at the table multiple times, with staff intermittently checking on her. The facility's policy on safety and supervision emphasized the importance of resident supervision based on individual needs and environmental hazards, which was not adequately followed in this case.
Failure to Prevent Elopement of Cognitively Impaired Resident
Penalty
Summary
The facility failed to identify effective, individualized interventions to prevent the elopement of a cognitively impaired resident with a known elopement risk. Resident C, who had a history of elopement and was moderately cognitively impaired, managed to exit the secured unit through his bedroom window. Despite being on a secured unit and having an ankle monitor, Resident C was able to remove the screen from his window and climb outside, walking around the facility before being noticed by staff. This incident occurred after multiple previous elopement attempts and behaviors indicating a desire to leave the facility, which were documented in his clinical records and nurses' notes. Resident C's clinical record indicated multiple diagnoses, including unspecified dementia, depression, and anxiety, among others. He had a history of exit-seeking behavior and had previously eloped from the facility and other locations. Despite these behaviors, a quarterly elopement risk assessment dated 2/20/24 indicated that the resident was not at risk for elopement. However, on 3/25/24, Resident C was found outside the facility after removing the screen from his window and climbing out. He stated that he wanted to talk to someone about residents coming into his room and expressed a desire to have a lock on his door, which was not allowed due to safety concerns. Interviews with staff and observations of video footage confirmed that there was a lapse in supervision, allowing Resident C to exit the building. The CNA and LPN on duty were aware of his agitation and desire to leave but did not prevent his elopement. The resident was observed walking outside without his walker, and staff had to escort him back into the building. The facility's policy on elopement risk assessment was not effectively implemented, as evidenced by the resident's ability to elope despite being on a secured unit and having a history of exit-seeking behavior.
Latest citations in Indiana
Surveyors observed that dietary staff repeatedly worked in kitchen and meal service areas with uncovered facial hair, despite facility policy and state sanitation requirements mandating effective hair restraints. Two dietary aides with short beards or mustaches were seen walking through food preparation areas, taking food temperatures, handling food, and plating meals at steamtables in dining rooms without any facial hair coverings, while the current policy required all hair, including facial hair, to be restrained to prevent contamination.
The facility failed to consistently provide and document required bed-hold policy notices when several residents were transferred to the hospital. In multiple cases, residents with dementia, psychotic disorders, COPD, chronic respiratory failure, altered mental status, and cerebral infarction were sent out for acute changes in condition, and while transfer notes reflected physician and family notifications, they lacked documentation that the bed-hold policy was discussed with the resident or responsible party. Notices of Transfer or Discharge often indicated a copy of the bed-hold policy was sent with the resident, but the records did not show signed and dated acknowledgment by the resident or appropriate representative, including in situations where a resident had moderate cognitive impairment, short-term memory issues, or a documented need for a proxy and a financial POA authorizing an agent for health care decisions.
Surveyors found that the facility failed to provide trauma‑informed and culturally competent care by not incorporating two residents’ extensive trauma histories and specific behavioral triggers into their care plans. One resident with documented homelessness, polysubstance abuse, severe accidents with multiple fractures, viral encephalitis with coma, physical and sexual abuse, loss of family contact, and a past suicide attempt had multiple behavior‑focused care plans that referenced identifying triggers but listed none and did not mention their physical, sexual, medical, or psychosocial trauma. Another resident with TBI from being struck by a truck, an 11‑month coma, long‑term state hospital residence, alleged shooting of a parent, and diagnoses including intermittent explosive disorder and borderline personality disorder had a PASRR identifying a specific trigger and notes of inappropriate sexual behavior, yet their care plans omitted these traumatic events, the identified trigger, and the sexual behavior. Staff interviews confirmed that residents were screened for trauma, but the trauma histories and triggers were not reflected in the individualized plans of care.
A resident with schizophrenia, post‑stroke hemiparesis, and mild cognitive impairment expressed feeling down and wanting to kill himself, but staff did not document asking about a specific plan, did not notify the physician or psychiatric NP as expected, and did not develop or update a care plan addressing depression or suicidal ideation. The SSD documented offering support and initiating 15‑minute checks once, but there was no further follow‑up or documentation of interventions after subsequent suicidal statements made in a care plan meeting with the resident’s father. The DON and Administrator reported that facility policy requires immediate notification of key staff, assessment for a plan and means of self‑harm, and thorough documentation, which were not carried out or reflected in the medical record for this resident.
A resident with schizophrenia, post-stroke hemiparesis, and mild cognitive impairment verbalized suicidal ideation, but the care plan did not address depression or suicidal thoughts, and required assessments and services were not accurately or timely documented. An SSD note recorded the resident saying he wanted to kill himself and referenced 15‑minute checks and a care plan update, yet the active care plan lacked depression/suicidal ideation interventions. Multiple late-entry Social Services notes were later added, describing follow-up visits and the resident denying suicidal ideation, but the SSD later reported she did not typically ask about a suicide plan and did not personally provide individual follow-up visits as described. These practices conflicted with the facility’s policy requiring factual, first-hand, and timely documentation of assessments and services.
A resident was observed with an Albuterol inhaler on an overbed table and later reported keeping the inhaler in a nightstand drawer, with no staff present during these observations. Record review showed the resident had no cognitive impairment on the admission MDS but lacked any documented self-medication administration assessment. The DON acknowledged that the required assessment had not been completed, despite facility policy requiring staff and the practitioner to evaluate each resident’s mental and physical abilities before allowing self-administration of medications.
Surveyors found that the facility submitted inaccurate direct care staffing data to CMS through the PBJ system over multiple days in a quarter. CASPER reports showed apparent gaps in 24-hour licensed nurse coverage, low weekend staffing, and a 1-star staffing rating, while internal staffing sheets documented that licensed nurses were present and the facility was fully staffed on those days. The Administrator reported that the discrepancies were due to PBJ data entry errors, despite a facility policy requiring all PBJ entries to be accurate, auditable, and verifiable against payroll, invoices, or contracts.
Surveyors found that the facility did not provide or document required written transfer/discharge notices and bed-hold policy information for four residents who were sent to the hospital, including individuals with conditions such as dementia, CHF, chronic respiratory failure, and CKD. In each case, progress notes showed that the resident was transferred for acute issues, but the clinical records lacked evidence that written notices were given to the residents or their representatives, and in one case lacked documentation that required information was sent to the receiving provider. Facility leadership, including the ADON, DON, and Administrator, acknowledged that the records did not contain the required documentation, despite a written policy requiring such notices and information exchange.
A resident with Alzheimer’s disease and depression, previously on an antidepressant, exhibited intermittent refusals of medications and care, occasional yelling at staff, and reports of unusual perceptions, such as believing men were in or near her room. Nursing notes over several months documented these refusals and complaints but did not show that the behaviors were evaluated or recorded as dangerous, non-redirectable, or causing significant distress, nor did they document specific non-pharmacological interventions attempted or their outcomes. Despite this, a psychiatric NP later added new diagnoses of schizoaffective disorder, borderline personality disorder, and delusional disorder and ordered an antipsychotic (Seroquel) without a comprehensive evaluation in the record to support these diagnoses. The facility’s psychotropic medication policy, which requires identification and documentation of target behaviors, use of nonpharmacological interventions, and ongoing behavior monitoring, was not followed for this resident.
The facility failed to keep PASARR Level I screenings accurate and current for three residents when new mental health diagnoses and psychoactive medications were initiated. One resident’s PASARR omitted a PTSD diagnosis and an added antidepressant, despite documentation of PTSD on the MDS and care plan and a physician order for Pristiq. Another resident’s PASARR listed only depression and dementia, even after additional diagnoses such as borderline personality disorder, delusional disorder, and schizoaffective disorder were added and an antipsychotic (quetiapine) was ordered, with the MDS later reflecting psychotic disorder, schizophrenia, and depression with antipsychotic and antidepressant use. A third resident’s PASARR did not include a depression diagnosis or newly ordered escitalopram and lorazepam, although the admission MDS documented depression with antianxiety and antidepressant use. These omissions occurred despite facility policy requiring a new Level I review after significant mental status changes, including new mental health diagnoses or new psychotropic medications.
Uncovered Facial Hair During Food Preparation and Meal Service
Penalty
Summary
The deficiency involves the facility’s failure to ensure that food was served in a sanitary and safe manner in accordance with professional standards and facility policy during multiple kitchen and meal service observations. During an initial kitchen observation, two dietary aides were seen walking through the kitchen food preparation area with uncovered facial hair. One aide had facial hair above and below the lip and along the jaw line, approximately one-fourth inch in length, and the other had a mustache of similar length; neither used any facial hair covering. These observations occurred while staff were present in the kitchen area where food was stored and prepared. During subsequent observations on the same day, the same two dietary aides were again observed with uncovered facial hair while directly involved in meal preparation and service. One aide walked through the kitchen while the noon meal was being prepared and placed into a transport cart for service in the south dining room, and later was observed plating the noon meal at the steamtable in that dining room, still without a facial hair covering. The other aide walked through the kitchen while the noon meal was being prepared and placed into the steamtable for the north dining room, took food temperatures, assisted with plating meals at the steamtable, and retrieved food items and supplies from the kitchen, all while having an uncovered mustache approximately one-fourth inch in length. The Dietary Manager stated that staff hair was to be covered when in the kitchen and during meal service, and the facility’s written policy and the cited Indiana Food Establishment Sanitation Requirements both required effective hair restraints, including for facial hair, to prevent contamination of food, equipment, and utensils.
Failure to Provide and Document Bed-Hold Policy at Time of Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure that required bed-hold policy information was provided and documented for four residents transferred to the hospital. For a resident with dementia, psychotic disorder, and autistic disorder who had a BIMS score of 0 indicating severe cognitive impairment, progress notes documented physician notification and guardian notification when the resident was sent to the hospital, but there was no documentation that the bed-hold policy was provided to the responsible party. A Notice of Transfer or Discharge later indicated a copy of the bed-hold policy was sent with the resident. Another resident with COPD and chronic respiratory failure, cognitively intact with a BIMS score of 13, experienced a decline in condition and was transferred to the hospital by ambulance; progress notes documented family notification but did not document any discussion of the bed-hold policy, although a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident. A third resident with altered mental status and cerebral infarction, with a BIMS score of 10 indicating moderate cognitive impairment and documented short-term memory impairment, experienced changes in condition and was transferred to the hospital. Progress notes stated the resident was their own responsible party and that no other notification was completed, and transfer documentation did not include the bed-hold policy, although an untimed Notice of Transfer or Discharge indicated a copy of the bed-hold policy was signed by the resident. A financial power of attorney document in the record showed the resident had designated an agent to act in consent or refusal of health care. For a fourth resident with dementia and osteomyelitis, transfer documentation and a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident, and the transfer form noted the resident required a proxy for decision making. The facility’s policy required that at the time of transfer to a hospital, written notice specifying the duration of the bed-hold policy and information on return to the next available bed be provided, and that a signed and dated copy of the bed-hold notice given to the resident or representative be kept in the resident file, which was not consistently documented for these residents.
Failure to Integrate Trauma Histories and Behavioral Triggers Into Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to identify and incorporate residents’ trauma histories and specific behavioral triggers into their care plans, despite documented histories of significant trauma and behavioral health issues. For one resident, extensive social service and progress notes documented homelessness, polysubstance abuse, major depressive and anxiety disorders, chronic pain, a history of severe car accidents with multiple fractures, viral encephalitis resulting in a three‑month coma, loss of child custody, multiple divorces, physical abuse by a spouse, the death of a fiancé who was struck by a car while in a wheelchair, lack of family contact, and a past suicide attempt by Valium overdose. Additional documentation noted a history of rape by a brother at age eight and prior placement under direct supervision and 15‑minute checks related to suicidal ideation. Despite these documented traumatic events and behavioral health concerns, the resident’s care plans did not identify a history of physical trauma, sexual trauma, homelessness, substance abuse, medical trauma, or attempted suicide. For this same resident, the MDS showed no cognitive deficit and identified behaviors such as verbal aggression and rejection of care, along with diagnoses including seizure disorder, depression, chronic pain syndrome, homelessness, and anxiety disorder. Multiple care plans addressed behaviors such as drug‑seeking, pretending to have seizures for attention or medication, making false allegations, verbal aggression when unable to smoke, and a desire for intimate relationships with consenting male residents. These care plans referenced goals such as effective coping skills, seeking staff support, and compliance with the smoking policy, and they called for identification and reduction of behavioral triggers. However, none of these care plans actually listed any specific triggers. The care plan addressing the resident’s right to consensual intimate relationships focused on assessment and education regarding consent but did not integrate the resident’s extensive trauma history. Staff interviews indicated the resident had displayed sexual behaviors since admission, including an incident where the resident expressed anger at another resident for not buying a soda after engaging in sexual acts. A second resident with a documented history of traumatic brain injury (TBI), dementia, seizure disorder, borderline personality disorder, anxiety, intermittent explosive disorder, tobacco use, and other behavioral/emotional disorders was also affected by the same deficiency. Social history and progress notes documented that this resident sustained a TBI after being hit by a semi‑truck while riding a bicycle at age 18, resulting in an 11‑month coma, followed by 13 years in a state hospital and subsequent residence in a group home. Additional documentation indicated the resident allegedly shot their father at age 26 after being sworn at and had a PASRR identifying TBI, intermittent explosive disorder, and borderline personality disorder, with a specific trigger of hearing the name of the current U.S. President. Progress notes also described inappropriate sexual behavior toward staff, including touching themselves intimately during personal care and refusing to stop when redirected. Despite this, the resident’s care plans, which addressed explosive disorder and history of altercations, risk for decreased psychosocial well‑being, and refusal to bathe or shower, did not list any specific behavioral triggers, did not reference the traumatic events such as being hit by a truck or shooting their father, and did not document the inappropriate sexual behavior. The Administrator and Social Service Director acknowledged that residents were to be screened for trauma and that trauma responses and PTSD should be added to care plans, but the specific trauma histories and triggers for these two residents were not incorporated into their plans of care.
Failure to Assess and Care Plan for Resident Suicidal Ideation
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess, investigate, and care plan for a resident’s suicidal ideation in accordance with its own policy and staff expectations. The resident had diagnoses including schizophrenia, cerebral edema, and hemiparesis/hemiplegia following a cerebral infarction, and a current MDS showed mild cognitive impairment (BIMS score 12). A progress note documented that the resident told the Social Services Director (SSD) he was feeling down and wanted to kill himself; the SSD offered assistance, activities, and initiated 15‑minute checks, and the note stated the care plan was updated. However, the note did not indicate that the SSD asked whether the resident had a plan to kill himself, and there were no additional notes regarding suicidal ideation or follow‑up. Review of the current care plan showed no problem, goal, or interventions addressing depression or suicidal ideation, and progress notes over the following month contained no documentation of physician notification related to the suicidal statement. Further record and interview evidence showed that the care plan conference summary did not document interventions for suicidal ideation, and the SSD acknowledged she did not normally ask residents expressing suicidal ideation if they had a plan. The SSD reported that the resident had admission paperwork mentioning suicidal ideation related to depression after a stroke and that the resident again vocalized suicidal ideation during a care plan meeting with his father, after which emotional support was offered and the father took the resident out on a leave of absence; no further visits or follow‑up were done. The DON stated that, upon notification of suicidal verbalization, staff should assess the resident, ask if there is a plan, remove potential means of self‑harm, immediately notify the psychiatric NP, and document the occurrence, and that a detailed progress note and updated care plan were expected but not present for this resident. The Administrator similarly stated that staff should ask about a plan, document interventions, notify the physician and family, and update the care plan, and indicated the resident should have had a care plan addressing depression with suicidal ideation. The facility’s written policy required immediate notification of the DON, SSD, and physician, an interview including asking about a plan and assessing mood and means for self‑harm, and thorough documentation of mood, behavior, and all actions taken, which were not reflected in the resident’s record.
Incomplete and Inaccurate Documentation of Suicidal Ideation and Follow-Up
Penalty
Summary
The facility failed to ensure accurate, complete, and timely documentation of assessments and services for a resident who verbalized suicidal ideation. Resident 6, who had schizophrenia, cerebral edema, and right-sided hemiparesis/hemiplegia following a cerebral infarction, had a BIMS score of 12 indicating mild cognitive impairment. The resident’s admission paperwork mentioned suicidal ideation related to depression after a stroke, and a Social Services note on 3/11/2026 documented that the resident was feeling down and said he wanted to kill himself. The Social Services Director (SSD) documented that she talked with the resident, coordinated with Activities, advised the resident to contact SSD or nursing if he wanted to talk, and that the resident was scheduled for 15-minute checks and the care plan was updated. However, the current care plan initiated on 2/26/2026 did not address depression or suicidal ideation. Multiple Social Services progress notes were later entered as late entries in April, with effective dates in March, stating that the resident had no plan and no longer had suicidal ideation, that he felt much better after 1:1 time, and that he continued his daily routine and therapy. These late entries described follow-up visits and reassessments of suicidal ideation on several consecutive days, but in interviews the SSD stated she did not normally ask residents about having a plan when they verbalized suicidal ideation and did not recall any other occurrences beyond the initial event. She further indicated she did not personally provide individual follow-up visits with this resident regarding suicidal ideation, despite the late-entry notes describing such visits. The DON acknowledged that late entries had been added to address concern about suicidal verbalization, and the Administrator stated that upon suicidal statements staff should ask about a plan, notify the physician and family, and update the care plan, and that this resident should have had a care plan addressing depression with suicidal ideation. The facility’s documentation policy required factual, first-hand, timely documentation, which was not followed in this case.
Failure to Complete Required Self-Administration Assessment for Inhaler Kept at Bedside
Penalty
Summary
Surveyors identified that a resident was allowed to keep and access an Albuterol inhaler without the facility completing the required self-administration medication assessment. During an initial tour, the resident was observed sitting in a wheelchair with a handheld Albuterol inhaler on the overbed table and no staff present in the room or hallway. On a subsequent observation, the resident again was in a wheelchair and reported that the Albuterol inhaler was stored in the top drawer of the nightstand, where it was found. Review of the clinical record showed an admission MDS indicating no cognitive impairment, but there was no documentation of a self-medication administration assessment. In an interview, the DON confirmed that the resident did not have the required self-medication assessment, despite the facility’s policy stating that staff and the practitioner must assess each resident’s mental and physical abilities to determine whether self-administering medications is clinically appropriate. This failure to complete and document a self-administration medication assessment for a resident who had an Albuterol inhaler kept at bedside constituted noncompliance with the facility’s own policy and with 410 IAC 16.2-3.1-11(a).
Inaccurate PBJ Staffing Data Submission to CMS
Penalty
Summary
The deficiency involves the facility’s failure to electronically submit complete and accurate direct care staffing information to CMS through the Payroll-Based Journal (PBJ) system for 22 days in a fiscal quarter. A CASPER report review on 4/6/26 showed that, according to PBJ data, the facility did not have licensed nursing coverage 24 hours per day on multiple specific dates across three months, had low weekend staffing, and held a 1-star staffing rating. However, review of the facility’s internal staffing sheets for that quarter indicated the facility was fully staffed and had licensed nurse coverage on all of the dates in question. During an interview, the Administrator stated that the PBJ information must have contained data entry errors, as she had verified licensed staff coverage on the timesheets. The facility’s PBJ policy in effect stated that all staffing data entered into the PBJ system would be auditable and verifiable through payroll, invoices, or contracts, but the submitted PBJ data did not accurately reflect the facility’s actual licensed nurse staffing as documented on internal records. No specific residents or clinical conditions were mentioned in the report, and the deficiency centers solely on inaccurate staffing data submission rather than direct resident care events.
Failure to Provide and Document Required Transfer/Discharge and Bed-Hold Notices
Penalty
Summary
The deficiency involves the facility’s failure to provide and document required written notices of transfer/discharge and bed-hold policies, as well as required information to receiving providers, for four residents who were transferred or discharged to the hospital. For a resident with generalized anxiety disorder, major depressive disorder, and dementia, progress notes showed that the resident was sent to the hospital via 911 for chest pain, lower back pain, and shortness of breath and later returned to the facility, but the clinical record lacked documentation that a written Notice of Transfer/Discharge and the bed-hold policy were provided to the resident or representative, and lacked documentation that required information was conveyed to the receiving facility. The ADON and the Administrator both confirmed there was no documentation that these written notices were provided. For a resident with congestive heart failure and muscle weakness who was sent to the emergency room for painful urination and bloody urine, the clinical record lacked documentation that a Notice of Transfer/Discharge or bed-hold policy was given to the resident or representative, which the DON confirmed. Another resident with chronic respiratory failure and diabetes was discharged to the hospital for respiratory failure, and a resident with chronic kidney disease and dementia was discharged to the hospital, but in both cases there was no documentation that a written notice of transfer/discharge or bed-hold policy was provided to the residents or their representatives. Review of the facility’s Transfer and Discharge policy, dated 1/15/26, showed that the policy required the facility to provide written transfer/discharge notices and bed-hold information to residents and representatives and to provide specified information to receiving providers, but the records for these four residents did not contain the required documentation.
Failure to Document Target Behaviors and Non-Pharmacological Interventions Before Initiating Antipsychotic
Penalty
Summary
The deficiency involves the facility’s failure to document how a resident’s behaviors presented danger or distress to self or others, and failure to document non-pharmacological interventions attempted prior to initiating an antipsychotic medication. Resident 6 had documented diagnoses of Alzheimer’s disease, depression, and severe cognitive impairment, and was receiving sertraline for depression. A PASSAR identified only depression and dementia, and the admission MDS listed Alzheimer’s disease and depression as active diagnoses. Over several months, nursing progress notes documented that the resident intermittently reported unusual perceptions, such as believing there were men causing trouble, a man in her room, or a man wanting to marry her and yelling through the walls, but there was no documentation that these episodes caused danger to the resident or others or that they resulted in unmanageable distress. From late April through mid-July, nursing notes primarily described the resident’s frequent refusals of evening and morning medications, blood sugar checks, blood pressure checks, insulin administration, hygiene care, and showers. Staff documented that the resident sometimes yelled at staff, said “Get out!”, was visibly upset by a room move, was leery of staff and asked to see name badges, and became upset about a pillow under her head until it was removed, after which she calmed down. The notes also recorded instances where the resident believed housekeeping had not cleaned her room or that she had not received medications when she had. However, there were no progress notes or assessments indicating that these behaviors were evaluated as dangerous, non-redirectable, or causing significant distress or functional impairment, and no detailed behavior monitoring logs were present as required by facility policy. On a psychiatric NP visit for initial psychotropic medication management, new mental health diagnoses of schizoaffective disorder, borderline personality disorder, and delusional disorder were added, and Seroquel 25 mg, an antipsychotic, was ordered. The clinical record did not contain a comprehensive evaluation to support these new diagnoses, and there was no documentation of target behaviors meeting the facility’s policy criteria for psychotropic use, such as behaviors representing danger to self or others, causing distress and impairment in functional abilities, or clearly attributable to psychosis or mania. The resident’s representative reported that the resident had no prior history of mental health disorders or psychiatric hospitalization and was unaware of the new diagnoses. The facility’s own psychotropic medication policy required identification and documentation of specific target behaviors, use and documentation of nonpharmacological interventions, and ongoing monitoring of behaviors and interventions, which were not reflected in the record for this resident.
Failure to Update PASARR Screens for New Mental Health Diagnoses and Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that Preadmission Screening and Resident Review (PASARR) Level I screenings were accurate and updated when new mental health diagnoses and psychoactive medications were initiated for multiple residents. For one resident with dementia, anxiety, depression, and post-traumatic stress disorder (PTSD), the PASARR completed on admission listed anxiety, depression, and dementia with sertraline and quetiapine, but did not include the PTSD diagnosis or the antidepressant Pristiq, despite the admission MDS and care plan documenting PTSD and a subsequent physician’s order for Pristiq. For another resident with Alzheimer’s disease, borderline personality disorder, delusional disorder, schizoaffective disorder, and depression, the PASARR only reflected depression and dementia with sertraline, even though additional mental health diagnoses were added later and an antipsychotic (quetiapine) was ordered for borderline personality disorder, and the quarterly MDS documented psychotic disorder, schizophrenia, and depression with antipsychotic and antidepressant use. A third resident had diagnoses including Alzheimer’s disease, depression, anxiety disorder, irritability and anger, and nonrheumatic aortic valve stenosis. The PASARR for this resident listed dementia and anxiety with Risperdal but omitted the diagnosis of depression and the medications escitalopram and lorazepam, although physician’s orders were in place for escitalopram for depression and lorazepam for anxiety, and the admission MDS documented depression with antianxiety and antidepressant use. Interviews with the Assistant Director of Nursing confirmed that new Level I PASARR screens should have been completed when new mental health diagnoses and psychoactive medications were added, and that the PASARR for one resident, completed prior to arrival, should have included all mental health diagnoses and medications. The facility’s own policy required notification of the state mental health authority within 14 days after a significant change in mental condition and specified that a new Level I screen is required for new mental health diagnoses or newly prescribed psychotropic medications, which was not followed in these cases.
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