Plainfield Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Plainfield, Indiana.
- Location
- 3700 Clarks Creek Rd, Plainfield, Indiana 46168
- CMS Provider Number
- 155215
- Inspections on file
- 35
- Latest survey
- March 11, 2026
- Citations (last 12 mo.)
- 11 (1 serious)
Citation history
Health deficiencies cited at Plainfield Health Care Center during CMS and state inspections, most recent first.
A resident admitted with documented deep tissue injuries and bandaged lower extremity wounds did not receive timely or consistent wound assessment and treatment. Admission and early provider notes alternately documented no wounds or nonspecific open areas without measurements, and there were no wound care orders for several days after admission despite the resident reporting that leg dressings had not been changed since the hospital. Care planning addressed only potential pressure ulcers, not the existing non‑pressure wounds, and weekly skin assessments were signed but lacked detailed wound descriptions. As the resident’s leg wounds progressed to cellulitis and multiple abscesses, nursing notes continued to state no change in skin integrity, NP notes often did not include direct wound assessment, and documentation of wound status remained incomplete and inconsistent with facility policy. Ultimately, the resident was transferred to the hospital with multiple extensive lower extremity wounds and septic shock secondary to those wounds.
A resident with severe cognitive deficit, malnutrition, and documented stage 3 and stage 2 pressure ulcers was re-admitted with open areas to the coccyx and left thigh, but the facility failed to complete and record required weekly skin assessments and wound progress notes. The care plan called for monitoring and documenting wound location, size, and treatment, yet the wound report showed the last assessments for the coccyx and thigh ulcers were only recorded at admission, with no subsequent entries until a later unstageable wound was noted. The wound NP, who had recently begun seeing the resident, lacked EMR access, could not review prior wound history, and could not document directly in the EMR, while the Administrator confirmed there was no dedicated wound nurse and that hall nurses were responsible for treatments, contributing to missing and incomplete wound documentation.
A resident with severe vascular dementia, a history of aggression, and frequent medication refusals repeatedly exhibited agitation, wandering into others’ rooms, and combativeness, including striking staff and forcibly removing another resident from a wheelchair, causing facial bruising and swelling. Although existing care plans noted some behavioral issues and psychotropic use, they were not updated after multiple serious incidents of physical aggression and intrusive behavior, and lacked specific interventions for physical aggression and wandering. Staff and family reported fear of the resident, and observations showed ongoing attempts to enter rooms, take equipment, and exit-seek, with staff using ad hoc redirection. The failure to revise and individualize the care plan and provide adequate supervision and interventions for this aggressive dementia resident led to the cited deficiency.
A resident with severe cognitive impairment and a history of falls was found by a family member with a swollen, darkly bruised eye on the memory care unit, and staff reported they did not know the cause and had not arranged further assessment. Documentation showed the eye injury was noted by staff, but there was no record that the physician, appropriate personnel, or the resident’s spouse were notified, and no timely assessment or investigation was completed, despite facility policy requiring physician notification and documentation for unexplained injuries.
A resident with severe cognitive impairment, Alzheimer’s disease, and a history of wandering and high fall risk was found by his spouse with a swollen, darkly bruised eye of unknown origin. Staff stated they did not know how the injury occurred and had no plans for diagnostic tests, and documentation only noted the puffed, dark eye with a plan to monitor, without a full assessment. The DON, covering for the Administrator, was not informed of the injury until two days later and was unaware who first discovered it. The incident was not promptly reported to facility leadership as required by policy for unexplained injuries and suspected abuse/neglect, and no timely investigative interviews or assessments were completed.
A resident with severe cognitive impairment, high fall risk, and wandering behavior was observed by his spouse and later by surveyors with a swollen, darkly bruised eye, while staff reported they did not know the cause and had no immediate plans for further testing. Documentation noted the puffed, dark eye but lacked any assessment of VS, neuro status, or the orbital area, and there was no evidence of timely notification of the physician, leadership, or the spouse. The DON learned of the injury days later, was unsure who discovered it, and although a risk management entry was made, no prompt interviews or investigation were completed, contrary to the facility’s policy for unexplained injuries.
Surveyors found that staff failed to follow physician-ordered monitoring and medication parameters for two residents and did not properly assess or document an unexplained eye injury for another resident. One resident with multiple cardiac conditions and a pacemaker had a standing order for daily HR checks, but no HRs were documented for several months. Another resident with vascular dementia and HTN had orders to hold losartan and metoprolol when SBP fell below specified thresholds, yet these medications were administered despite SBP readings below the ordered hold parameters. In a separate case, a resident with Alzheimer’s disease and severe cognitive impairment was observed with a swollen, bruised left eye; staff could not explain the cause, and the record lacked vital sign, neuro, or focused eye assessments, as well as documentation of physician, internal personnel, or family notification, contrary to the facility’s incident/accident reporting policy.
Three residents with high fall risk experienced multiple falls without documented IDT post-fall assessments or updates to their care plans with new interventions. The DON confirmed that although IDT reviews were held, documentation and care plan modifications were not completed as required by facility policy.
Two residents with complex medical conditions did not receive or have documented weekly skin assessments as ordered by their physicians. In both cases, the clinical records lacked required documentation of completed assessments or resident refusals, despite facility policy and care plans specifying these actions. The DON confirmed that assessments and refusals should be documented, but this was not done.
A resident with diabetes and other comorbidities experienced multiple blood sugar readings outside the parameters set by the physician's orders. Nursing staff failed to notify the physician as required and did not document these notifications in the clinical record, despite facility policy mandating such documentation.
A resident with severe cognitive impairment and multiple diagnoses did not receive or have documented weekly skin assessments as ordered by a physician. After one assessment was completed, subsequent weekly assessments were missed and not recorded, despite facility policy and staff confirmation that these should have been done.
The facility did not provide enough nursing staff to meet residents' daily care needs, leading to long wait times for assistance, missed showers, and inadequate hygiene. Multiple residents reported delays, especially on weekends and nights, and observations confirmed residents left in soiled conditions and lacking proper care. Staff interviews and staffing records showed low CNA and nurse coverage, with insufficient laundry support contributing to shortages of clean linens.
Multiple residents reported ongoing issues with delayed call light responses, insufficient staff, and unaddressed grievances, particularly affecting a dependent resident with severe cognitive impairment. Grievances about missed care and staff interactions were repeatedly dismissed or inadequately investigated, with audits and follow-ups lacking clear documentation or effective interventions. Despite repeated concerns raised by the Resident Council, the facility did not implement performance improvement measures, leaving residents feeling their complaints were not taken seriously.
Surveyors found that insulin pens for two residents were not dated and an expired insulin vial for another resident was present in a medication room. An RN reported challenges in keeping up with medication management due to staffing levels. Facility policy requires immediate removal of outdated or improperly stored medications, but this was not done.
Several residents with major mental illness diagnoses did not have their PASARR Level II status accurately coded on their MDS assessments, and one resident receiving hospice care was not identified as such on the MDS. These inaccuracies occurred during a transition in the Social Service Director role, resulting in multiple assessment errors.
A resident with a major mental illness diagnosis did not have a PASARR Level I or II on file, as required. Although the PASARR Level II had been completed at a previous facility and was available online, it was not transferred to the current facility's records during a change in Social Service Directors. This omission led to the resident's care plan and MDS assessment not reflecting her Level II status.
A resident with multiple diagnoses, including dementia and depression, had a change in medication following a hospital stay, resulting in the discontinuation of an antidepressant. However, the care plan was not updated to reflect this change and continued to reference the need for antidepressant medication, contrary to facility policy requiring ongoing care plan updates.
Two dependent residents did not receive necessary ADL care, as evidenced by repeated observations of poor hygiene, soiled linens, and lack of grooming. Despite documentation indicating that ADLs were completed, both residents were found with unaddressed hygiene needs, and care plans were not updated to reflect or manage care refusals or behavioral challenges.
A resident with a recent amputation and multiple health issues developed bowel incontinence and diarrhea after starting antibiotics, but staff continued administering stool softeners and instructed the resident to use briefs instead of a bed pan, resulting in soiled wound dressings and increased pain. Staff did not promptly adjust the bowel regimen or consistently implement interventions to restore normal bowel function, and the facility did not provide a policy on bowel incontinence when requested.
A resident with multiple medical conditions did not have documentation of COVID-19 vaccination or a declination in her record. Review and staff interview confirmed the absence of both vaccination and declination documentation, despite facility policy requiring such records.
A resident with dementia entrusted her debit card to a Social Service Assistant (SSA) for small purchases, but the SSA allegedly used it for unauthorized transactions, leading to significant financial loss. The facility failed to document the resident's concerns or conduct a thorough investigation, contributing to the deficiency.
A resident with dementia reported unauthorized use of her debit card by a former SSA, leading to over $4000 in unapproved charges. The facility failed to investigate or report the incident to authorities, relying on the bank's investigation instead. The resident's concerns were not documented, and the facility lacked a policy on staff handling of resident funds.
A resident with dementia gave her debit card to a Social Service Assistant (SSA) for shopping, but the SSA retained the card after leaving the facility, leading to unauthorized charges. Despite the resident's concerns and police involvement, the facility did not conduct its own investigation or notify authorities promptly, resulting in a deficiency.
A resident with dementia was found with two Exalon patches on two occasions, despite physician orders to apply only one patch daily and remove the old one. The facility staff failed to document the removal of the old patch and the site of application, leading to significant medication errors. The resident's wife reported the issue, and the facility acknowledged the errors, noting that the task to remove the old patch was not included in the order during the resident's second stay.
A facility failed to complete an admission inventory and properly document discharge medications for a resident discharged against medical advice. The resident, with multiple diagnoses including dementia, was sent home with medications without a comprehensive discharge medication disposition list, except for the narcotic clonazepam. Interviews revealed that the facility did not follow its policy for medication disposition, leading to the deficiency.
A resident with severe cognitive impairment and an arterial ulcer developed a blister on the left hip, but the facility failed to notify the resident's representative about the wound. Despite the facility's policy requiring timely communication of significant changes in a resident's condition, no documentation was provided to show that the representative had been informed.
A resident with severe cognitive impairment and an arterial ulcer developed wounds on both hips, but the facility failed to document care plans with interventions for these wounds. The right hip wound was attributed to skin failure, while the left hip wound was due to the resident's brief, clothing, and movement in bed. The facility's policy required updating the care plan and notifying the responsible party, which was not done.
A resident with Alzheimer's and generalized weakness fell in the dining room, tripping on a chair leg. Despite severe leg pain and inability to move, staff moved the resident to a wheelchair before sending them to the ER, where a femur fracture was diagnosed. The facility's fall response policy was not followed, leading to a deficiency in care.
A facility failed to notify a resident's responsible party of a change in condition, including a pneumonia diagnosis and medication orders. Despite the facility's policy requiring prompt notification, the resident's family was not informed, as confirmed by nurse progress notes and an anonymous interview.
A facility failed to document a respiratory services order for a resident with acute respiratory failure and pneumonitis. Despite a physician's order for albuterol nebulizer treatments and the need for oxygen, there was no documented order for oxygen delivery. The resident's condition deteriorated rapidly, leading to their passing before emergency services arrived. Staff interviews indicated that orders should be entered immediately, but this was not done, violating the facility's policy requiring a physician's order for oxygen therapy.
A resident with acute respiratory failure and pneumonia did not receive prescribed medications due to a failure in the facility's medication management process. The ordered Augmentin suspension was not delivered by the pharmacy, and the facility did not have it in their emergency drug kit. The resident's condition worsened, leading to their passing before emergency services arrived. Interviews with staff revealed issues in accessing and administering medications from the STAT Safe.
The facility's pest control program was ineffective, resulting in a gnat infestation observed over three days. Staff and residents reported numerous flying insects in the kitchen, dining room, and resident rooms. The Maintenance Supervisor and Administrator acknowledged the issue, but efforts to control the pests were insufficient. The local pest technician identified cleanliness issues in the kitchen as a significant factor, with the root cause of the gnat problem remaining unaddressed.
A resident with COPD and an ileostomy experienced inadequate assessment and care, leading to severe skin breakdown and infection. Despite expressing feeling unwell, timely intervention was delayed, resulting in hospitalization. The facility's documentation lacked evidence of care refusals, and staff interviews revealed unawareness of the resident's skin issues at discharge.
A resident with multiple medical conditions, including a cervical fracture and Alzheimer's, was allowed to shower independently despite requiring assistance. The resident fell during the shower, resulting in severe injuries and subsequent death. Staff interviews revealed a lack of awareness of the resident's needs and medical conditions, contributing to the incident.
A cognitively impaired resident with Alzheimer's exited a second-story locked memory care unit through an open window, resulting in multiple fractures. Despite displaying exit-seeking behaviors and verbalizing the intention to leave, the facility failed to conduct an elopement assessment or implement adequate interventions.
A facility failed to provide individualized dementia care and supervision for a newly admitted resident with Alzheimer's dementia, resulting in the resident exiting the locked memory care unit through a second-story window and sustaining multiple fractures. The resident exhibited exit-seeking behaviors, but the facility did not provide effective interventions or additional supervision, and staff were not adequately informed or trained to handle the situation.
A resident with Alzheimer's dementia exited a second-floor window using a gait belt and sustained multiple fractures. The facility failed to accurately report the incident, and the family was not fully informed. The facility's investigation lacked documentation, and the resident's injuries were not reported to the Indiana State Department of Health Survey System.
Failure to Identify and Provide Ongoing Wound Care for Lower Extremity Ulcers
Penalty
Summary
The deficiency involves the facility’s failure to identify, assess, and provide ordered wound care services for a resident admitted with lower extremity wounds, resulting in prolonged periods without appropriate treatment and incomplete documentation. The resident was admitted from a hospital with documented deep tissue injuries to both lower extremities and was discharged with large bandages on her legs. The admission nursing skin assessment noted bruises, edema, weeping areas on both lower extremities, and other skin issues, but early NP and PA visit notes on 1/9 and 1/12 documented no wounds. A skin assessment on 1/12 recorded open areas on the front of both lower legs but lacked any detailed wound description or measurements. Despite the presence of dressings, the NP on 1/13 documented that dressings were present but did not observe the wounds, and the care plan initiated on 1/14 addressed only potential pressure ulcer development, with no care plan or interventions for non‑pressure wounds. From admission through 1/20, the record shows inconsistent and incomplete skin assessments and a lack of timely wound care orders. Daily skilled nursing notes from 1/16 through 1/22 repeatedly indicated no change in skin integrity, and skin assessments were not completed or documented on some days. The NP note on 1/20 recorded that the resident reported her anterior bilateral leg bandages had not been changed since the hospital and that the left leg wound had drainage, yet the medical record contained no wound care orders from admission until 1/21. When wound care orders were finally entered on 1/21 for both legs, they were discontinued on 1/23 and replaced with new orders, including evening‑shift dressing changes, but the record still lacked detailed wound assessments, including measurements and descriptions, and lacked documentation of treatment or antibiotics when cellulitis was diagnosed on 1/23. Weekly skin assessments were signed on the TAR, but the underlying documentation again noted open areas on both lower legs without measurements or full descriptions, and NP notes continued to reference intact dressings and daily dressing changes without assessing the wounds beneath. As the resident’s condition progressed, documentation remained incomplete and inconsistent with the facility’s wound management policy. On 1/29, the NP documented a quarter‑sized ulcer on the right shin and a large ulcer with slough and eschar on the left lower leg, noted heavy edema, and ordered Santyl and Medihoney, as well as a referral to a consultant wound care service. Subsequent skilled nursing notes on 1/30, 1/31, and 2/3 still indicated no changes in skin integrity while referencing dressing changes per orders. An antibiotic (doxycycline) was ordered on 2/4 for left lower extremity cellulitis, and an NP note on 2/5 mentioned cellulitis and extreme edema but did not document wound assessment or interventions. On 2/11, the facility wound nurse documented only one venous stasis ulcer on the right lower extremity, while the consultant wound NP identified four abscess wounds on both legs with specific measurements. Later that day, the resident experienced extremely low blood pressure and difficulty breathing, was transferred to the hospital ICU, and was diagnosed with septic shock secondary to her wounds, multiple lower extremity wounds, cellulitis, and significant hypotension. Interviews with the former NP, LPNs, the wound nurse, and the Regional Nurse confirmed that wounds were not consistently assessed, that the NP did not always look at wounds, that wound documentation was poor, and that required weekly skin assessments and admission wound documentation with measurements and photos were not reliably completed, contrary to the facility’s wound management policy. The facility’s own policy required thorough skin assessments on admission, weekly, and as needed, with measurement and documentation of any new wounds and immediate implementation of physician‑ordered treatments, as well as notification of the attending physician and IDT for new wounds or pressure injuries. However, the record for this resident lacked timely wound care orders from admission, lacked consistent and complete wound assessments (including measurements and descriptions), and lacked appropriate care planning for non‑pressure wounds. Staff interviews corroborated that the NP did not always assess wounds, that documentation often “fell through the cracks,” and that the wound nurse was initially advised the resident had no wounds on admission despite hospital documentation and the admission skin assessment indicating otherwise. These actions and omissions led to a failure to provide necessary wound treatment and services to promote healing and prevent worsening of the resident’s lower extremity wounds.
Failure to Document Ongoing Pressure Ulcer Assessments and Treatment Progress
Penalty
Summary
The deficiency involves the facility’s failure to document ongoing assessment and treatment progress for pressure ulcers for one resident with multiple risk factors and existing wounds. The resident was re-admitted from the hospital with an open area on the coccyx and an open area on the left thigh, and had diagnoses including dislocation of an internal left hip prosthesis, age-related osteoporosis, and unspecified protein-calorie malnutrition. A care plan identified a stage 3 pressure ulcer to the coccyx and a stage 2 pressure ulcer to the left thigh, with interventions directing staff to follow facility protocols for treatment and to monitor and document the location, size, and treatment of the skin injuries. A 5-day Medicare MDS documented severe cognitive deficit and unhealed pressure ulcers. Despite these findings and the facility’s policy requiring weekly skin assessments and weekly documentation of the effectiveness of pressure injury prevention techniques, the medical record lacked any weekly skin assessments. A facility wound report later showed that the last documented wound assessments for the coccyx and left thigh pressure ulcers were on the date of admission, with no subsequent assessments recorded until an unstageable pressure wound was assessed on a later date. The wound NP reported that she had been seeing the resident for only a couple of weeks, did not have access to the EMR, and therefore could not review or document the resident’s wound history or current care in the system. She stated that when she began seeing the resident, she did not find ulcerations on the coccyx or left knee and had only seen a heel wound, but could not determine prior wounds or treatments due to lack of documentation. The Regional Clinical Consultant confirmed that the NP did not have EMR access, and the Administrator acknowledged there was no wound nurse on staff, that the NP came weekly with a staff nurse, and that hall nurses were responsible for wound treatments, while she was unfamiliar with where wound notes were located in the EMR. These circumstances resulted in incomplete and missing documentation of the resident’s pressure ulcer assessments and treatment progress.
Failure to Supervise and Care Plan Aggressive Dementia Behaviors Resulting in Resident Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and appropriate interventions for a resident with severe vascular dementia and a history of aggressive behavior, resulting in physical harm to another resident. The aggressive resident was a tall, muscular man with diagnoses including severe vascular dementia with behavioral disturbance, anxiety disorder, history of alcohol dependence, and major depressive disorder. His care plans, initiated earlier in the year, identified behaviors such as hiding or refusing medications, verbal aggression, exit-seeking, refusal of showers, moving furniture, and making threats like “I’m going to hit you.” Interventions listed included monitoring behavioral episodes, determining underlying causes, documenting behaviors, protecting the rights and safety of others, and diverting or removing the resident from situations as needed. Another care plan addressed psychotropic medication use for aggressive behavior, with instructions to monitor and document target behaviors such as pacing, wandering, disrobing, inappropriate responses, and violence or aggression toward staff and others. Despite these documented behavioral issues and the resident’s known background as an Olympic boxer, the facility did not update his care plans or add specific interventions after multiple serious incidents of physical aggression and wandering. On one occasion, the resident attempted to enter another resident’s room while a visitor was present; when staff tried to redirect him, he balled his fist, hit a CNA in the face, threatened to “get them all,” and attempted to hit another CNA who approached him. On another occasion, he believed a female resident’s wheelchair was his car, grabbed the handles, pulled the wheelchair back at an angle, and caused her to fall to the floor, resulting in bruising and swelling to her right eye and nose after her eyeglasses hit the floor. Staff and behavior monitoring sheets documented repeated episodes of agitation, wandering into other residents’ rooms, and combativeness over multiple days, yet the resident’s record lacked care plans or interventions specifically addressing his physical aggression toward staff and residents or his wandering into others’ rooms. Additional events further demonstrated the resident’s ongoing aggressive and intrusive behaviors without corresponding care plan updates. A nurse practitioner documented that the resident was at high risk to himself and others, noting intermittent aggressive behaviors, resistance to care, and frequent medication refusals. The resident was found lying in a bed in a female resident’s room while she was in her own bed, and he became combative when staff attempted to remove him, requiring assistance from additional male CNAs to get him out of the room. Staff interviews indicated that the resident could be unpredictable and violent, had previously hit a CNA in the face, assumed a fighting stance when agitated, and that residents stayed away from him. A family member of another memory care resident reported being afraid of him and requesting an escort off the unit after visits. Observations showed the resident attempting to take other residents’ equipment and exit doors, with staff using ad hoc redirection. The facility’s documentation lacked behavior monitoring prior to the 15-minute monitoring period and did not reflect the incidents of 12/12, 12/30, or 1/13 in the care plan, resulting in a failure to implement and document appropriate, individualized interventions and supervision for an aggressive dementia resident. The cumulative effect of these actions and inactions—failure to update care plans after significant aggressive incidents, lack of documented targeted interventions for physical aggression and wandering, and reliance on informal staff redirection despite known risks—led to the deficiency cited by surveyors. The aggressive resident’s behaviors, including striking staff, forcibly removing another resident from a wheelchair causing injury, entering other residents’ rooms, and resisting redirection, were repeatedly observed and reported, yet the facility did not revise the resident’s care planning to address these escalating behaviors as required.
Failure to Notify Physician and Family After Unexplained Resident Injury
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s physician and family after an injury of unknown origin was identified. The resident, who had diagnoses including Alzheimer’s disease, anxiety disorder, major depressive disorder, and cognitive communication deficit, had a quarterly MDS showing severe cognitive impairment and required partial to moderate assistance with toilet hygiene, transfer, and bed mobility. A care plan identified the resident as high risk for falls related to lack of safety awareness. On 1/10/26 around midday, the resident’s wife visited the memory care unit and found the resident with a swollen, darkly bruised left eye. She reported that staff told her they did not know why he had a black eye and that she had not received any call from the facility about the injury. She also stated that staff had not planned any X‑ray or test to fully assess the injury and that staff were dismissive of her concerns. On observation on 1/15/26, the resident was seen in a common area with a visibly swollen and discolored left eye. A general progress note dated 1/10/26 documented that the resident’s left eye was puffed and dark in color and that staff would continue to monitor, but the clinical record contained no documentation that the physician, appropriate personnel, or the resident’s spouse were notified of the black eye. The DON, who was covering for the Administrator, reported he was not informed of the injury until 1/12/26 and did not know who first discovered it. He acknowledged that no assessments or interviews were completed on 1/12/26 or 1/13/26 and that the incident had not been reported to proper personnel or thoroughly investigated. The facility’s Incident/Accident Reporting policy required staff to notify the physician and document the notification in the medical record when an unexplained injury such as a bruise is identified, which was not done in this case.
Failure to Report and Assess Unexplained Facial Injury
Penalty
Summary
Facility staff failed to follow policies and procedures requiring immediate reporting and investigation of an unexplained injury when a resident was found with a swollen, darkly bruised left eye of unknown origin. The resident, who had diagnoses including Alzheimer's disease, anxiety disorder, major depressive disorder, and cognitive communication deficit, had a quarterly MDS showing severe cognitive impairment and a care plan identifying high fall risk and wandering behaviors, including entering others' rooms and non-compliance with wearing shoes and socks. On the date of the incident, the resident's wife visited around midday and discovered his black, swollen eye; staff told her they did not know what had happened and indicated there were no plans for any X-ray or further testing to assess the injury. A general progress note later documented that the resident's left eye was puffed and dark in color and stated they would continue to monitor, but no assessment of the injury was recorded in the clinical record. The DON, who was covering for the Administrator during a vacation period, reported that he was not informed of the resident's injury until two days after it was first noted, learning of it only during a morning meeting. He did not know who initially discovered the injury, whether it was nursing staff or the resident's spouse. Although a Risk Management assessment entry was made by the DON on that later date, no interviews or assessments related to the injury had been completed, and the incident was not reported to the proper personnel as required. The facility’s Incident/Accident Reporting policy defined unexplained injury as a situation where no incident is observed but the resident exhibits evidence of injury, and required prompt notification of the Administrator, DON, or department head on duty if abuse or neglect is suspected or there is a complaint of abuse or neglect. These required notifications and investigative steps were not carried out for this resident’s unexplained black eye.
Failure to Assess and Investigate Resident’s Unexplained Eye Injury
Penalty
Summary
The deficiency involves the facility’s failure to investigate and clinically assess an injury of unknown origin for a resident with severe cognitive impairment. The resident, who had diagnoses including Alzheimer’s disease, anxiety disorder, major depressive disorder, and cognitive communication deficit, was care planned as a high fall risk and noted to wander and enter other residents’ rooms. On one day, the resident’s wife found him on the memory care unit with a swollen, darkly bruised left eye and reported that staff told her they did not know what had happened and had no plans for diagnostic tests such as an X-ray. She expressed worry that staff were dismissive of his injury. Observation by surveyors later showed the resident seated in a common area with a visibly swollen and discolored left eye, while he appeared calm and engaged in conversation. Record review showed that a progress note documented the resident’s left eye as puffed and dark in color, with a plan to continue monitoring, but there was no documented assessment of vital signs, neurological status, or the left orbital area when the injury was discovered. A skilled evaluation note both before and after the injury documentation stated there were no changes in skin integrity. The clinical record lacked documentation of notification to the physician, appropriate facility personnel, or the resident’s spouse regarding the injury. The DON reported he was not informed of the injury until several days later and did not know who first discovered it. Although a risk management assessment was entered days after the injury, no interviews or assessments were completed at that time, and the incident was not promptly reported or thoroughly investigated as required by the facility’s Incident/Accident Reporting policy for unexplained injuries.
Failure to Follow Medication Parameters and Assess Unexplained Eye Injury
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders and ordered parameters for monitoring and medication administration for two residents. For one resident with type 2 diabetes mellitus, stage 3 chronic kidney disease, heart failure, edema, and a cardiac pacemaker, there was a physician order dated 3/18/25 to check heart rate daily and monitor for signs and symptoms of altered cardiac output or pacemaker malfunction. Record review for November 2025, December 2025, and January 2026 showed no documented heart rate measurements for this resident during those months, despite the standing order. The Regional Reimbursement Nurse confirmed that the ordered daily heart rate checks were not completed as required. For another resident diagnosed with vascular dementia, essential HTN, and stage 2 chronic kidney disease, the facility failed to follow ordered blood pressure and heart rate parameters when administering antihypertensive medications. A physician order dated 3/18/25 directed administration of losartan 100 mg daily with instructions to hold the dose for systolic BP less than 110. The eMAR showed that on multiple dates in December 2025 and January 2026, the resident’s systolic BP readings were below the ordered threshold (ranging from 94 to 107), yet losartan was still administered. A separate physician order dated 5/8/25 for metoprolol tartrate 12.5 mg twice daily required holding the dose for systolic BP less than 100 or HR less than 60. On one January 2026 date, the resident’s systolic BP was 96, but the metoprolol dose was administered. The DON acknowledged that medications should have been held when physician-ordered parameters indicated they should not be given. A separate deficiency concerns the facility’s failure to assess and document an unexplained injury and to follow its incident/accident reporting policy for another resident. This resident, with Alzheimer’s disease, anxiety disorder, major depressive disorder, and severe cognitive impairment, was found by his wife with a swollen, darkly bruised left eye. She reported that staff could not explain the cause of the injury, had not notified her of any incident, and had not planned diagnostic tests to assess the injury. Observation confirmed swelling and discoloration of the left eye. The clinical record contained a general progress note stating the left eye was puffed and dark in color and that staff would continue to monitor, but there was no documented assessment of vital signs, neurological status, or the left orbital area at the time the injury was discovered. The record also lacked documentation of physician notification, notification of appropriate personnel, or notification of the spouse, despite a facility policy requiring immediate assessment, use of a neurological assessment tool for suspected head trauma or unwitnessed falls, and documentation and notifications following unexplained injuries.
Failure to Document IDT Post-Fall Assessments and Update Care Plans
Penalty
Summary
The facility failed to complete Interdisciplinary Team (IDT) post-fall assessments and implement post-fall interventions for three residents identified as high risk for falls. For each resident, multiple falls occurred, but the clinical records lacked documentation of IDT reviews and updates to care plans with new interventions following these incidents. Specifically, Resident B, with a history of stroke, epilepsy, and dementia, experienced several falls without corresponding IDT review or care plan updates. Resident E, diagnosed with senile degeneration of the brain, convulsions, and gait issues, also had multiple falls without documented IDT review or added interventions. Resident F, with a history of traumatic brain injury, Parkinson's disease, and repeated falls, similarly lacked IDT review and care plan modifications after several falls. During an interview, the DON acknowledged that while IDT reviews were conducted during morning meetings, there was a failure to document the root cause analysis, the IDT review itself, and to update care plans with new interventions for some falls. The facility's policy requires the IDT to review each fall and modify the plan of care as indicated, but this process was not followed or documented as required for the residents involved.
Failure to Complete and Document Weekly Skin Assessments as Ordered
Penalty
Summary
The facility failed to complete physician-ordered weekly skin assessments or document resident refusals for two of four residents reviewed for quality of care. For one resident with diagnoses including rhabdomyolysis, type II diabetes, a history of coccyx fracture, and morbid obesity, the clinical record lacked documentation of weekly skin assessments on multiple specified dates, despite an active order for these assessments. The resident's care plan noted a history of refusing care, with interventions to monitor and document behavior and potential causes. A progress note later indicated a worsening wound with redness, warmth, odor, and necrotic tissue, leading to new medical orders for antibiotics and a specialty mattress. Another resident, diagnosed with COPD, diabetes, dementia, and toe contusions, also had missing documentation for weekly skin assessments as ordered. The care plan identified a risk for pressure ulcers due to decreased mobility and incontinence, with interventions including weekly head-to-toe skin assessments. The DON confirmed that assessments should be completed and documented as ordered, and refusals should be documented if they occur. Facility policy required weekly skin assessments and notification of the physician and IDT if residents refused treatment, but these procedures were not followed as required.
Failure to Notify Physician of Out-of-Range Blood Sugar Values
Penalty
Summary
The facility failed to notify the physician as required when a resident's blood sugar (BS) values were outside the parameters specified in the physician's orders. The resident in question had diagnoses including diabetes mellitus type II, dementia, and exocrine pancreatic insufficiency, and was receiving insulin therapy. The physician's order directed staff to hold insulin for BS less than 110 and to call the physician for BS less than 70 or greater than 400. However, review of the clinical record and electronic Medication Administration Record (eMAR) revealed multiple instances where the resident's BS readings were either below 70 or above 400, but there was no documentation that the physician was notified as required. Additionally, there were occasions where insulin was administered despite BS values being below the ordered threshold, again without documented physician notification. During interviews, facility staff confirmed that there was no documentation of physician notification for these out-of-range BS values, and the facility's policy required such notifications to be documented, including the time, method, and response. The lack of documentation and failure to follow physician orders for notification constituted the deficiency. The report specifically notes that all physician notifications should be recorded in the clinical record and that the physician's orders were not followed in these instances.
Failure to Complete and Document Weekly Skin Assessments
Penalty
Summary
The facility failed to complete and document weekly skin assessments as ordered for one resident with diagnoses including Alzheimer's disease, diabetes mellitus type II, and major depressive disorder. The resident, who had severe cognitive impairment, was wheelchair-bound, and dependent on staff for all activities of daily living, had a physician's order for weekly skin assessments every Friday. Review of the clinical record showed that after an assessment on 8/22/25, no further weekly skin assessments were documented for 8/29/25, 9/5/25, and 9/12/25. During interview, the Corporate Nurse Consultant confirmed that all ordered skin assessments should have been completed and documented as scheduled. Facility policy required weekly skin assessments by a licensed nurse, but these were not performed or recorded for the specified dates.
Insufficient Nursing Staff Resulting in Delayed ADL Care and Poor Resident Hygiene
Penalty
Summary
The facility failed to provide a sufficient number of nursing staff to meet the daily needs of all residents, resulting in delays in activities of daily living (ADL) care and laundry services. Multiple residents reported having to wait extended periods for assistance, particularly on weekends and night shifts. Observations confirmed that call lights remained unanswered for several minutes, and staff were often not present in hallways or at the nurses' station. Residents described incidents where they were told to manage on their own until staff could assist, leading to accidents and frustration. One resident with frequent diarrhea due to antibiotics was told to use a brief instead of a bedpan, resulting in soiling of a wound vacuum, which caused pain during changes. Direct observations throughout the week revealed that some residents remained in bed, undressed, and in soiled conditions for extended periods. For example, one resident with a gastrostomy tube was observed in a hospital gown all week, with poor hygiene, greasy and matted hair, and signs of inadequate oral care. This resident was found with a strong odor of urine and bowel, and her bedding and clothing were soaked with urine and feces. Another resident was observed in similar conditions, with greasy, matted hair and spending most of the week in bed in a hospital gown. Residents and the Resident Council consistently reported insufficient staff, missed showers, and lack of available linens, especially on night shifts. Staff interviews corroborated these findings, indicating that staffing levels were often inadequate, particularly when there were call-ins or unfilled shifts. CNAs reported difficulty keeping up with care needs, especially on high-acuity halls, and noted that laundry staff reductions led to shortages of clean linens and washcloths. Payroll and staffing records showed low staffing hours per resident, especially on weekends and holidays, with some shifts providing less than 30 minutes of direct care per resident. Despite these issues, facility leadership did not recognize a staffing problem and had not implemented any quality improvement plans to address the ongoing concerns.
Failure to Address Resident Grievances and Call Light Response Issues
Penalty
Summary
The facility failed to ensure that residents' grievances were followed up with adequate and effective interventions to address and prevent recurring concerns, particularly regarding staff interactions with a dependent resident and nursing staff call light response times. During a Resident Council meeting, multiple residents reported persistent issues with insufficient nursing and laundry staff, especially on the night shift, resulting in long wait times for assistance. Residents described situations where staff would turn off call lights without providing help and noted that some residents, including one with severe cognitive impairment and total dependence for toileting, were ignored or dismissed by staff. Grievances about missed showers and lack of linens were also reported, with residents feeling their concerns were not believed or properly investigated. A review of grievances over a six-month period revealed repeated complaints about staff behavior, call light response times, and care quality, particularly during the night shift. Investigations into these grievances often relied on staff denials or incomplete audits, with little evidence of meaningful follow-up or resolution. For example, grievances filed on behalf of a dependent resident with dementia indicated she was left waiting for extended periods after soiling herself or was ignored when requesting help, but investigations concluded with minimal action or were dismissed based on staff statements. Call light audits conducted in response to complaints were inconsistently documented, lacked clear resolution, and did not specify whether response times were appropriate or if findings were communicated to the concerned residents. Despite ongoing concerns raised by the Resident Council and individual residents, the facility did not implement any performance improvement plans or other approaches to address the pattern of delayed call light responses, staff availability, or staff attitudes. The facility's grievance policy required immediate action and investigation, but documentation showed that grievances were not effectively addressed, and the Quality Assurance and Performance Improvement (QAPI) committee had not identified or acted on these recurring issues. As a result, residents felt discouraged from participating in council meetings, believing their concerns were not taken seriously or resolved.
Failure to Properly Label and Remove Expired Insulin
Penalty
Summary
Surveyors observed that drugs and biologicals were not consistently labeled and stored according to professional standards. Specifically, three insulin pens for one resident and two insulin pens for another resident on the 500-hall medication cart were not dated. Additionally, an insulin vial for a third resident in the Caring Heart medication room was found to be expired. During interviews, an RN acknowledged difficulty in keeping up with medication management due to the number of nurses working in the area. Facility policy requires that outdated or improperly stored medications be immediately removed and disposed of, but this was not followed in these instances.
Inaccurate Coding of MDS Assessments and PASARR Status
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were accurately coded to reflect the conditions and services of several residents. Specifically, for six residents with diagnoses including bipolar disorder, major depressive disorder, schizoaffective disorder, and PTSD, the most recent comprehensive or admission MDS assessments did not accurately code their Pre-Admission Screen and Resident Review (PASARR) Level II status, despite documentation indicating the presence of major mental illness. In one case, there was no PASARR Level I or II on file for a resident with a relevant diagnosis. The Regional MDS Consultant attributed these errors to a transition in the Social Service Director position, during which several items were incorrectly coded. Additionally, another resident with diagnoses such as senile degeneration of the brain and falls, who had an active hospice order and was receiving hospice services, was not coded as receiving hospice care on the MDS assessment. The MDS consultant confirmed that hospice services had started prior to the assessment, but the MDS did not reflect this status. Facility policy requires the RAI process to be used in accordance with specified formats and timeframes to ensure comprehensive and accurate assessments, but this was not followed in these instances.
Failure to Maintain PASARR Documentation and Update Care Plan
Penalty
Summary
A resident with a diagnosis that included bipolar disorder did not have a Pre-Admission Screen and Resident Review (PASARR) Level I or II on file at the facility. The resident was a long-term care admission, and although a Level II PASARR had been completed at a previous facility and was available online, it was not transferred to the current facility's records during a change in Social Service Directors. As a result, the resident's care plan was not revised to reflect her Level II status, and her admission Minimum Data Set (MDS) assessment did not code her PASARR Level II status. There was no facility policy in place, but staff indicated they follow federal and state regulations.
Care Plan Not Updated After Medication Change
Penalty
Summary
The facility failed to update the care plan for a resident after a change in his medication regimen. The resident, who had diagnoses including Alzheimer's disease, dementia, anxiety, hypertension, and reduced mobility, was hospitalized and upon return, his medications were changed, specifically, he was no longer prescribed an antidepressant. Despite this change, his care plan continued to indicate a need for antidepressant medication and included a goal related to avoiding discomfort or adverse reactions to the antidepressant. The oversight was confirmed during an interview with the Regional Nurse Consultant, who acknowledged that the care plan was not updated to reflect the medication changes following the resident's hospital stay. A review of facility policy indicated that changes to the comprehensive care plan should be made on an ongoing basis for the duration of the resident's stay, but this was not done in this case.
Failure to Provide ADL Care for Dependent Residents
Penalty
Summary
The facility failed to provide necessary Activities of Daily Living (ADL) care for two dependent residents. One resident, who was totally dependent due to a history of stroke, paralysis, and muscle atrophy, was repeatedly observed over several days in bed with poor hygiene, including long nails with debris, greasy and matted hair, dry lips, tacky teeth and gums, and foul breath. On one occasion, the resident was found with a strong odor of urine and bowel, and her brief, bed linens, and gown were soaked with urine and feces, indicating she had not been changed throughout the night. The resident's care plan required total assistance for all ADLs, but there was no evidence of care plan implementation or revision to address behaviors such as refusing care. Documentation indicated that ADLs had been completed, which conflicted with direct observations. Another resident, also fully dependent due to cerebral palsy, developmental disorder, and severe cognitive impairment, was observed multiple times over several days in bed with greasy, matted hair and dried drool at the corners of her mouth. Her care plan required total staff assistance for all ADLs, but there was no documentation of care plan adjustments for behaviors like care refusal. Staff interviews revealed that the resident often refused bed baths and could become combative, yet her records indicated ADLs were completed without complications, except for one documented refusal. Observations and staff comments suggested that her hair had not been brushed recently, and her hygiene needs were not consistently met. Facility policy required that all residents receive necessary care and services based on comprehensive assessments and individualized care plans, with sufficient staff to provide these services. However, the observed conditions of both residents and discrepancies between documentation and actual care provided demonstrated a failure to ensure that dependent residents received adequate ADL care as required.
Failure to Provide Appropriate Bowel Incontinence Care and Restore Normal Function
Penalty
Summary
A resident with a recent above-the-knee amputation, multiple comorbidities including diabetes, malnutrition, chronic osteomyelitis, and a stage 3 sacral pressure ulcer, was admitted to the facility and began experiencing bowel incontinence after starting antibiotic therapy. The resident reported that he had not been incontinent of bowel prior to the antibiotics and attributed the new onset of incontinence to the medication. Despite this, staff placed the resident in briefs as a preventive measure and instructed him to use the brief instead of a bed pan, which led to soiling of his wound vacuum dressing and increased pain during dressing changes. Record review showed that the resident was receiving both antibiotics and a stool softener (senna-docusate sodium) even as he developed frequent episodes of diarrhea and bowel incontinence. Documentation indicated that the resident was sometimes continent and sometimes incontinent, with several episodes of diarrhea noted. Staff interviews revealed that the LPNs were aware of the resident's incontinence and the ongoing administration of stool softeners despite the presence of diarrhea. The nurse manager acknowledged that stool softeners should be held if a resident is experiencing loose stools, but this was not done in a timely manner. The care plan addressed the potential for adverse effects from antibiotics, including diarrhea, and called for monitoring and intervention. However, staff did not promptly adjust the resident's bowel regimen or consistently use interventions to restore normal bowel function, such as offering a bed pan as requested by the resident. The facility also failed to provide a policy on bowel incontinence when requested by surveyors.
Lack of COVID-19 Vaccination Documentation for Resident
Penalty
Summary
A deficiency was identified when a resident with diagnoses including migraines, muscle weakness, chronic pain syndrome, and acute respiratory failure did not have documentation of COVID-19 vaccination or a declination in her medical record. During a record review, it was found that there was no evidence of the resident receiving the COVID-19 vaccine or formally declining it. An interview with the MDS consultant confirmed that neither vaccination nor declination documentation could be located in the system. The facility's policy requires adherence to CMS, CDC, and governmental guidance for COVID-19 prevention and management, but this was not reflected in the resident's records.
Failure to Protect Resident from Misappropriation of Property
Penalty
Summary
The facility failed to protect a resident from the misappropriation of her property, specifically her debit card, which was used without her authorization. The resident, who had a diagnosis of dementia with psychotic disturbance but was assessed as cognitively intact, noticed unauthorized charges on her bank statement. She had previously entrusted her debit card to a Social Service Assistant (SSA) to make purchases on her behalf. However, the SSA left the facility's employment without returning the card, leading to numerous unauthorized transactions amounting to significant financial loss for the resident. The resident's bank statements showed a pattern of unauthorized transactions, including purchases from DoorDash, big-box stores, and online retailers, which the resident could not have made herself. Despite the resident's concerns and the involvement of local police, the facility's records lacked documentation of any investigation into the SSA's involvement in the misuse of the resident's debit card. The facility's Business Office Manager (BOM) and Administrator (ADM) were aware of the situation, but there was no evidence of a thorough investigation or appropriate documentation of the incident in the resident's records. Interviews with the resident and her family revealed that the SSA had been trusted to make small purchases for the resident, but instead, the SSA allegedly used the card for personal gain. The facility's failure to document the resident's concerns, notify the physician, or conduct a comprehensive investigation into the misappropriation of funds contributed to the deficiency. The facility also lacked a clear policy regarding staff handling of resident money or cards, which may have contributed to the oversight.
Failure to Report and Investigate Misappropriation of Resident Funds
Penalty
Summary
The facility failed to implement policies and procedures for reporting a reasonable suspicion of a crime, specifically regarding the misappropriation of funds from a resident. A family member of the resident reported concerns about unauthorized use of the resident's debit card, which was given to a Social Service Assistant (SSA) for shopping purposes. The SSA left the facility without returning the card, and the resident later discovered unauthorized charges amounting to over $4000. Despite being informed of the situation, the facility did not conduct a thorough investigation or report the incident to the appropriate authorities in a timely manner. The resident, who was diagnosed with dementia but assessed as cognitively intact, had trusted the SSA with her debit card for small purchases. However, the resident noticed large unauthorized transactions on her bank statements, including charges to various stores and services she did not use. The facility's Business Office Manager (BOM) assisted the resident in contacting the bank to dispute the charges and deactivate the card. Despite these actions, the facility did not document the resident's concerns or conduct an investigation into the SSA's involvement until the police were involved months later. The facility's Administrator admitted to not reporting the misappropriation or conducting an investigation, relying instead on the bank's investigation. The facility lacked documentation of the SSA's possession of the resident's debit card and did not have a policy in place regarding staff handling of resident money or cards. The facility's failure to act promptly and investigate the resident's concerns led to a deficiency in ensuring the safety and security of the resident's financial assets.
Failure to Investigate Misappropriation of Resident's Debit Card
Penalty
Summary
The facility failed to thoroughly investigate an allegation of misappropriation of property involving a resident, identified as Resident B, who had given her debit card to a Social Service Assistant (SSA) for shopping purposes. The SSA retained possession of the card for 38 days after leaving employment, during which time suspicious charges appeared on the resident's bank statements. Despite the resident's concerns and the involvement of the bank and police, the facility did not conduct its own investigation or notify authorities promptly, relying instead on external investigations. Resident B, who has a diagnosis of dementia with psychotic disturbance, noticed unauthorized charges on her bank statements, including purchases from DoorDash and other locations she would not have frequented. The resident had trusted the SSA, who had not returned the debit card upon leaving the facility. The facility's Business Office Manager (BOM) assisted the resident in contacting the bank to dispute the charges and deactivate the card, but no formal grievance or concern forms were filed, and the facility's records lacked documentation of the SSA's possession of the card. Interviews with the resident and her family revealed that the facility was aware of the situation but did not take adequate steps to investigate or address the misappropriation. The facility's Theft/Loss Prevention policy requires the Administrator to investigate all reports of stolen items and notify relevant authorities, but these actions were not taken in a timely manner. The facility's failure to act promptly and thoroughly investigate the allegations led to the deficiency cited in the report.
Medication Error with Transdermal Patches
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors related to the administration of transdermal patches. Resident Q, who was admitted for rehabilitation, was found with two Exalon patches on two separate occasions. The first incident occurred on 12/25/24 when Resident Q was discharged from the hospital and admitted to the facility. Upon arrival at the emergency room, two patches were discovered on him. The second incident was on 1/1/25, when Resident Q's wife found two patches on him again and reported it to the facility staff. Resident Q's medical history included neurocognitive disorder with Lewy bodies, dementia, disorientation, and visual hallucinations. The physician's orders specified the application of one Rivastigmine patch daily, with instructions to remove the old patch before applying a new one. However, the facility staff failed to adhere to these instructions, resulting in the resident wearing two patches simultaneously. The facility's Director of Nursing Services and Regional Nurse Consultant acknowledged the error, noting that the task to remove the old patch was not included in the order during Resident Q's second stay at the facility. The facility's policy on transdermal patch application required staff to read the label, check the medication administration record, select an appropriate site for application, and document the administration, including the site of application. Despite these guidelines, the staff did not document the removal of the old patch or the site of application, leading to the medication errors. The facility completed a medication/treatment error report following the incidents, identifying transcription and other medication-related errors as the causes.
Failure to Document Admission Inventory and Discharge Medications
Penalty
Summary
The facility failed to complete an admission inventory and ensure proper documentation of discharge medications for a resident, identified as Resident Q, who was reviewed for medication disposition. Resident Q was admitted with several diagnoses, including neurocognitive disorder with Lewy bodies, dementia, disorientation, and visual hallucinations. His medication list included several drugs such as Sertraline HCL, Rivastigmine transdermal patch, melatonin, olanzapine, clonazepam, acetaminophen, magnesium hydroxide suspension, and docusate sodium. Upon discharge against medical advice, the facility did not document an admission inventory list or a comprehensive discharge medication disposition list, except for the narcotic clonazepam, which was signed out by the resident's wife. Interviews with the Director of Nursing Services (DNS) and the Regional Nurse Consultant (RNC) revealed that the facility did not follow its policy for medication disposition during discharge against medical advice. The DNS indicated that only narcotics were counted and documented, and no discharge summary or medication disposition list was completed. The RNC confirmed that a medication disposition form should have been filled out as per the physician's order. The facility's policy required that all medications be counted and documented upon discharge, but this was not adhered to, leading to the deficiency noted in the report.
Failure to Notify Resident's Representative of Wound
Penalty
Summary
The facility failed to notify the representative of a resident, identified as Resident C, about a wound on the resident's left hip. The resident, who had severe cognitive impairment and an arterial ulcer, was found to have a blister on the left hip during a nursing progress note on 9/27/24. The blister measured 1 cm by 0.5 cm and showed no signs of infection, and the resident did not complain of pain. However, the medical record did not document any notification to the resident's responsible party about this wound. Interviews conducted during the survey revealed that the Director of Nursing (DON) acknowledged the need to notify the resident's representative about the wound, but this was not done. The resident's representative confirmed not being informed about the left hip wound. The facility's policy on Change of Condition Notification mandates timely communication with residents, their families, legal representatives, and physicians about significant changes in the resident's condition. Despite this policy, no additional documentation was provided to show that the representative had been notified, leading to the citation.
Failure to Implement Care Plan for Resident's Wounds
Penalty
Summary
The facility failed to implement care plan interventions to prevent further development of wounds for a resident with severe cognitive impairment and an arterial ulcer. The resident's medical record indicated a lack of documentation for a care plan with interventions for wounds on both hips. On 9/13/24, the resident developed an open area and a blister on the right hip, which was treated with wound cleanser and a dry dressing, and the resident was repositioned. New orders were received for wound team consultation and specific wound care. However, there was no care plan created for these wounds. Additionally, on 9/27/24, the resident developed a blister on the left hip, but the medical record lacked documentation of a care plan for this wound as well. The Director of Nursing (DON) indicated that the root cause of the right hip wound was skin failure, while the left hip wound was due to the resident's brief, clothing, and movement in bed. The facility's policy on wound management required updating the resident's care plan as necessary, which was not done in this case. Furthermore, the resident's responsible party was not notified of the new left hip wound, as required by the facility's policy.
Failure to Properly Handle Resident Fall
Penalty
Summary
The facility failed to ensure that a resident who fell was not moved before seeking treatment, which led to a deficiency in care. Resident B, who had a history of Alzheimer's disease and generalized weakness, fell in the main dining room after tripping on a chair leg. Despite complaining of severe pain in the right leg and being unable to move it, the nursing staff moved the resident into a wheelchair before sending him to the emergency room. The resident was later diagnosed with a left femur fracture, which required surgical repair. The fall care plan for Resident B indicated a high risk for falls due to confusion, cognitive impairment, and unsteady gait. After the fall, the resident was assessed by nursing staff, who noted severe pain and inability to bear weight on the affected leg. Despite these observations, the resident was not immediately sent to the hospital. Instead, pain medication was administered, and x-rays were ordered. The resident continued to experience excruciating pain and requested to be sent to the ER, which was eventually approved by the Nurse Practitioner. Interviews with facility staff revealed that the standard procedure for handling falls was not followed. The Assistant Director of Nursing indicated that residents suspected of having a broken bone should not be moved and should be sent to the hospital via emergency services. However, in this case, the resident was moved into a wheelchair and not sent to the hospital until several hours later. The facility's policy on responding to falls emphasized prompt assessment and treatment, but this was not adhered to in Resident B's case.
Failure to Notify Responsible Party of Change in Condition
Penalty
Summary
The facility failed to notify the responsible party of a change in condition for a resident who was admitted with acute respiratory failure and pneumonitis due to inhalation of food and vomit. The resident had a physician order for Amoxicillin and Augmentin to be administered via G-tube for pneumonia, as well as albuterol nebulizer treatments for shortness of breath. Despite these significant medical interventions and a visit from a Nurse Practitioner to address a change in condition, the resident's responsible party was not informed of the change in condition, the NP visit, or the pneumonia diagnosis. The facility's policy, titled 'Change of Condition Notification,' requires prompt notification of the resident's legal representative in the event of a significant change in condition. However, a review of the nurse progress notes and an anonymous interview during the survey confirmed that the resident's family was not notified of the medication orders or the change in condition. This deficiency was related to complaints IN00441980, IN00441976, and IN00442404.
Failure to Document Respiratory Services Order
Penalty
Summary
The facility failed to ensure that a respiratory services order was obtained and entered into the medical record for a resident who required respiratory care. The resident, who was admitted with acute respiratory failure and pneumonitis due to inhalation of food and vomit, had a physician order for albuterol nebulizer treatments and required respiratory evaluations before and after each treatment. Despite the nurse practitioner's visit and the noted need for oxygen delivery, there was no evidence of a physician order for oxygen delivery in the medical record. The resident experienced a rapid decline in condition, with noted hypoxia and low oxygen saturation levels, leading to the application of oxygen and administration of breathing treatments. However, the resident's condition deteriorated quickly, and they passed away before the ambulance arrived. Interviews with staff revealed that orders should be entered immediately after being given by a physician or NP, but this was not done in this case. The facility's policy required a physician's order to initiate oxygen therapy, except in emergencies, which was not adhered to, contributing to the deficiency.
Medication Administration Failure Leads to Resident's Deterioration
Penalty
Summary
The facility failed to ensure medications were provided as ordered by the physician for a resident, identified as Resident B, who was admitted with acute respiratory failure and pneumonia. The physician had ordered albuterol nebulizer treatments and Augmentin for pneumonia. However, there were discrepancies in the administration of these medications. The Augmentin suspension was ordered but not delivered by the pharmacy, and the facility did not have it available in their emergency drug kit. Consequently, the medication was not administered as prescribed. The facility's records indicated that the Augmentin suspension was ordered late in the evening, and the pharmacy was closed at that time. The order was processed the following day but was subsequently canceled. A new order for Augmentin tablets was placed, but it was not processed until several days later. During this period, the resident's condition deteriorated, and they experienced a rapid acute change in their respiratory status, leading to their passing before the ambulance arrived. Interviews with facility staff, including a Qualified Medication Aide and a Licensed Practical Nurse, revealed that the medication administration process involved entering orders into the medical record before accessing the STAT Safe for medications. However, the Augmentin suspension was not available, and the Augmentin tablets were not administered in a timely manner. The facility's Regional Nurse Consultant acknowledged that the medication was not administered as recorded in the Medication Administration Record, indicating a failure in the medication management process.
Ineffective Pest Control Program Leads to Gnat Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of flying insects, particularly gnats, throughout the building over a three-day observation period. The Maintenance Supervisor and Administrator acknowledged the issue, with the Maintenance Supervisor using insect spray and drain chemicals in an attempt to control the pests. Despite these efforts, numerous flying insects were observed in various areas, including the dining room, kitchen, and resident rooms. The Assistant Dietary Manager and other staff members also noted the presence of insects, indicating ongoing challenges in keeping the bugs out. Observations revealed multiple instances of flying insects in the kitchen, including around the juice machine dispenser, on the condiment cart, and in the dish room. The Air Cooler refrigerator was noted to leak due to condensation, contributing to a damp environment that may attract pests. Residents reported seeing gnats around their food and in their rooms, with some indicating that the problem had persisted for months. The kitchen and dining areas were identified as problem areas, with insects observed around food preparation and serving areas. Interviews with staff and residents highlighted the persistent nature of the gnat problem, with several residents expressing frustration over the insects landing on their food. The facility's pest control policy, dated 8/2020, outlined procedures for maintaining a pest-free environment, but the implementation appeared inadequate. The local pest technician confirmed the facility's cleanliness issues, particularly in the kitchen, as a significant factor in the ongoing pest problem. Despite monthly pest control visits, the technician noted that the root cause of the gnat issue had not been addressed, emphasizing the need for a clean and dry kitchen environment.
Failure in Timely Assessment and Care for Resident with Ileostomy
Penalty
Summary
The facility failed to provide timely and effective assessment, skin care, and monitoring for Resident G, who had a history of Chronic Obstructive Pulmonary Disease (COPD) exacerbation and was admitted for rehabilitation before moving to long-term care. The resident's care plan, initiated and revised in October 2023, included interventions for managing her ileostomy but lacked documentation of any revisions for behaviors such as picking at the area or refusing care. On July 12, 2024, Resident G expressed feeling unwell and requested to go to the hospital, but her vital signs were normal, and the nurse waited for a response from the MD. The Nurse Practitioner (NP) later assessed her, noting symptoms of chest pain, shortness of breath, and dysuria, and the resident was eventually sent to the hospital at the family's insistence. Upon arrival at the hospital, Resident G was found with significant skin breakdown, erythema, and a nonadherent ostomy bag. She was drenched in urine with a foul odor, and her skin condition was severe, requiring transfer to a second hospital for further treatment. The second hospital noted urosepsis and the need for central line access, with a fungal rash throughout her torso. The facility's documentation did not support a pattern of Resident G refusing care, and interviews with staff indicated a lack of awareness of her skin integrity issues at the time of discharge. The facility's policies on care planning, ostomy care, perineal care, and change of condition notification were reviewed, highlighting the need for timely documentation and intervention in cases of acute changes in condition. Despite the facility's policies, there was a failure to adequately assess and respond to Resident G's deteriorating condition, leading to her hospitalization with severe skin breakdown and infection.
Failure to Supervise Resident During Shower Leads to Fatal Fall
Penalty
Summary
The facility failed to provide adequate supervision for a resident, identified as Resident C, during a shower, which resulted in a fall. Resident C had multiple medical conditions, including a cervical fracture, Alzheimer's disease, and a history of falls, which necessitated partial to moderate assistance with activities such as bathing. Despite these needs, Resident C was allowed to shower independently after expressing a preference to do so, leading to a fall that resulted in severe injuries and ultimately his death. On the day of the incident, Resident C informed a Certified Nursing Assistant (CNA) that he wished to shower without assistance. The CNA, despite being uncomfortable with leaving him alone due to his fall risk, complied with his request. The CNA was unaware of Resident C's neck fracture, Alzheimer's disease, or dementia. After the CNA left the shower room, Resident C fell, and the Registered Nurse (RN) found him on the floor. The fall resulted in significant head injuries, and Resident C was subsequently hospitalized and passed away the following day. Interviews with staff and family members revealed that Resident C was not independent in his showering needs and required supervision. The Occupational Therapist confirmed that Resident C was never independent and required contact guard assistance. The resident's daughter had also communicated to the facility that he was at risk for falls and should not shower without assistance. Despite these warnings, the facility's failure to provide necessary supervision during the shower led to the tragic incident.
Failure to Prevent Elopement of Cognitively Impaired Resident
Penalty
Summary
The facility failed to provide effective supervision to prevent a cognitively impaired resident from exiting the second story locked memory care unit through an open window. The resident, who had a diagnosis of Alzheimer's, was observed with exit-seeking behaviors throughout the day. Despite multiple indications of the resident's intention to leave, including verbalizing the need to go home and attempting to open windows, the facility did not conduct an elopement assessment or implement adequate interventions. The resident ultimately used a gait belt tied to a chair to lower herself out of the window, resulting in multiple fractures and injuries when she fell approximately 13 feet to the ground. The resident's medical record lacked documentation of a physician's order to reside in a secured memory care unit, a wandering/elopement assessment, and a baseline care plan indicating the resident had wandering and exit-seeking behaviors. Staff observations and progress notes repeatedly noted the resident's exit-seeking behavior, but no effective measures were taken to assess or mitigate the risk. The resident's family was not adequately informed about the resident's condition and the facility's failure to prevent the elopement. On the day of the incident, staff observed the resident attempting to open a window and later found the window open with a gait belt hanging out. The resident was found outside, crawling in the parking lot with a pillow that had blood on it. Despite the resident's combative behavior, staff followed her until emergency medical services arrived. The resident was diagnosed with multiple fractures, including a burst thoracic spine vertebra, and was transported to the hospital for further treatment.
Removal Plan
- The facility assessed all residents at risk for wandering and elopement.
- Interventions were implemented for residents at risk for wandering and elopement.
- Residents with current wandering and elopement risk were reviewed for appropriate care and interventions.
- Care plans were updated for residents with wandering and elopement risk.
- Nursing staff were in-serviced regarding residents with wandering and elopement behaviors.
Failure to Provide Individualized Dementia Care and Supervision
Penalty
Summary
The facility failed to provide individualized dementia care and supervision for a newly admitted resident with Alzheimer's dementia, resulting in the resident exiting the locked memory care unit through a second-story window. The resident, who had been admitted from an assisted living facility and required minimal assistance with ADLs, exhibited exit-seeking behaviors throughout the day. Despite these behaviors, the facility did not provide effective treatment or services to ensure the resident did not leave the facility unattended. On the evening of the incident, the resident was found outside the facility below the open window, having sustained multiple fractures from the fall. The resident's medical record lacked documentation of a physician's order to reside in a secured memory care unit, a wandering/elopement assessment, and a care plan to address the resident's exit-seeking behaviors. Progress notes indicated that the resident verbalized the intent to leave the facility and exhibited exit-seeking behaviors, but there was no documentation of effective interventions or additional supervision provided by the facility staff. The facility staff failed to notify the physician, DON, Administrator, or a nurse manager of the resident's exit-seeking behaviors. Interviews with facility staff revealed that they were not adequately informed or trained to handle the resident's exit-seeking behaviors. The staff did not take appropriate actions to prevent the resident from leaving the facility, and there was a lack of communication and documentation regarding the resident's behaviors and the necessary interventions. The facility's failure to provide individualized dementia care and supervision resulted in the resident's fall and subsequent injuries.
Failure to Accurately Report Resident Elopement Incident
Penalty
Summary
The facility failed to ensure a resident's elopement incident was accurately reported after the resident exited an open window on the second floor sunroom and sustained injuries. Resident B, who had Alzheimer's dementia, managed to unlock the safety latch of the window and used a gait belt tied to a chair to lower herself to the ground. She was found crawling in the parking lot by an LPN, who initiated the elopement protocol. Despite the resident's combative behavior and refusal to be assessed by facility staff, she was eventually transferred to a local hospital where multiple injuries were discovered, including fractured vertebrae, pelvis, and feet. The family of Resident B was not fully informed about the incident. They were told that the resident had tied a gait belt to a chair, climbed out of the window, and fell on a car below. However, the family later learned from the hospital that Resident B had sustained multiple fractures and required further assessment. The resident had a history of vision deficits and dementia but had not exhibited exit-seeking behaviors prior to this incident. The family believed they had placed her in a secure memory care unit for her safety. The facility's investigation lacked documentation of evidence that Resident B had lowered herself to the ground. The distance from the window to the ground was measured to be 13 feet, and the gait belt was only two feet long. Despite the resident indicating to EMS that her foot was hurting and the presence of blood on the pillow, this information was not reported to the Indiana State Department of Health Survey System. The facility's report was filed before obtaining statements from the staff, and it was considered a preliminary report. The facility staff were unable to assess the resident, and she did not inform them of her injuries.
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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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