Premier Healthcare Of New Harmony
Inspection history, citations, penalties and survey trends for this long-term care facility in New Harmony, Indiana.
- Location
- 251 Highway 66, New Harmony, Indiana 47631
- CMS Provider Number
- 155370
- Inspections on file
- 41
- Latest survey
- December 4, 2025
- Citations (last 12 mo.)
- 28
Citation history
Health deficiencies cited at Premier Healthcare Of New Harmony during CMS and state inspections, most recent first.
Two residents with severe cognitive impairment and histories of wandering were not adequately supervised or monitored, leading to one resident entering another's room and causing a physical altercation that resulted in a bite wound and skin tear. Staff did not consistently document behaviors or update care plans, and there was no policy in place for behavior and wandering prevention.
A resident with no cognitive impairment was found self-administering an unlabeled antacid medication (Tums) from a plastic cup in her room, without a physician's order for the medication. Nursing staff confirmed there was no order for the antacid, and facility policy requiring reporting and removal of unauthorized bedside medications was not followed.
The facility failed to revise care plans quarterly for multiple residents, including those with UTIs and siderails, as required. Care conferences were often not conducted or documented, and catheter care was not consistently implemented. The DON acknowledged the lack of documentation for MDS meetings, contributing to the deficiency.
The facility failed to properly store and label medications, with loose pills found in medication carts and incomplete temperature logs in the medication storage room. Items in the treatment cart were not labeled or stored correctly, and a bottle of Tylenol lacked a resident label. The facility's policies on medication storage and labeling were not followed, resulting in these deficiencies.
The facility failed to properly store, label, and date food items, and did not adequately monitor chemical sanitization during kitchen observations. Items in storage were found unlabeled or past their use-by dates, and the kitchen staff did not maintain a log of sanitization test results, violating food safety standards.
The facility failed to ensure accurate documentation and management of falls for several residents, including those with cognitive impairments. Clinical records lacked neuro checks, IDT discussions, and care plan updates following falls, highlighting systemic issues in maintaining accurate medical records and resident safety.
The facility failed to implement Enhanced Barrier Precautions for a resident with a catheter and did not ensure proper hand hygiene during care activities. Staff were observed not sanitizing hands before and after glove use, and equipment was not cleaned between resident uses. These actions indicate non-compliance with infection control protocols.
The facility did not provide an emergency call system in a public restroom used by residents, as observed during a survey. The restroom, located in the main hallway across from the beauty shop, lacked this essential safety feature. The Director of Nursing confirmed that residents used this restroom, and the facility's policy did not address the need for call lights, leading to the deficiency.
The facility was found to have persistent urine odors in the entrance hallway, conference room, and [NAME] Unit hallways over six days. Despite attempts to mask the smell with air freshener, the odors remained. The Administrator acknowledged the issue, and the facility's policy on maintaining a clean environment was provided.
The facility failed to ensure proper self-administration of medications for two residents. One resident had eye relief drops and pain relief medication at the bedside without a physician order, assessment, or care plan, despite being cognitively intact. Another resident with COPD also lacked the necessary documentation for self-medication. The DON confirmed that medications should not be left at the bedside without proper authorization and assessment.
A facility failed to notify a resident's representative of significant changes in the resident's condition and medication regimen. The resident, with severe cognitive impairment and multiple diagnoses, experienced medication adjustments and a hospital visit for a nasal fracture without the POA being informed, contrary to facility policy.
A resident with Alzheimer's and mobility issues was transferred to the hospital without proper clinical documentation. The facility's policy required that transfer forms and Advanced Directives accompany the resident, but this was not done. The ADON confirmed the paperwork was incomplete and missing.
A resident with Alzheimer's and mobility issues was transferred to the emergency department without receiving a notice of transfer. The facility's policy requires such notices to be provided, but the necessary paperwork was not completed, as confirmed by the ADON.
A resident with Alzheimer's Disease was transferred to the hospital without receiving a bed hold notice, as required by the facility's policy. The ADON confirmed that the necessary paperwork was not completed, resulting in a deficiency.
The facility failed to accurately complete MDS assessments for several residents, leading to discrepancies in documentation of restraints, medications, and falls. A resident's MDS inaccurately indicated bed rails as a restraint, while another's assessment incorrectly documented medication use, including anticoagulants and opioids. Additionally, a resident's fall was not recorded, and opioid use was omitted. The DON acknowledged errors in coding and misclassification of medications, despite the facility's adherence to the RAI Manual.
The facility failed to develop care plans for two residents with new diagnoses and medication orders, including a UTI and multiple medications. Additionally, care plan interventions were not followed for another resident, with missing documentation for monitoring side effects and behaviors. These deficiencies were acknowledged by the DON and highlighted by the facility's Comprehensive Care Plans policy.
A facility failed to document the rationale for a schizophrenia diagnosis for a resident with Alzheimer's, anxiety, and major depressive disorder. The resident's record lacked any assessment or explanation for the new diagnosis, despite receiving multiple medications. The ADON confirmed the absence of documentation, and the facility could not provide a relevant policy, leading to a deficiency finding.
The facility failed to monitor and document pressure ulcers for two residents, leading to deficiencies in wound care. One resident with multiple sclerosis and peripheral vascular disease had incomplete skin assessments, despite physician orders for daily care. Another resident with hemiplegia lacked wound assessments and rationale for treatments. The ADON confirmed missing documentation, contrary to the facility's policy for complete and accurate records.
A resident with Alzheimer's experienced multiple unwitnessed falls resulting in injuries due to inadequate supervision and failure to update care plans. The facility did not conduct thorough post-fall assessments or implement new interventions. Another resident exhibited unsafe wandering behaviors without appropriate care plans in place, highlighting deficiencies in managing exit-seeking behaviors.
The facility failed to provide proper respiratory care for two residents, with issues in oxygen equipment labeling and adherence to care plans. One resident received oxygen without proper labeling, and the facility lacked a system to document equipment changes. Another resident's care plan for pulse oximetry was not consistently implemented, with no physician order in place.
A facility failed to complete required Pre and Post Dialysis Assessments and Dialysis Communication Records for a resident with end-stage renal disease. Despite being marked as done in the MAR, multiple instances of missing documentation were found. The ADON confirmed that staff were supposed to complete these forms, highlighting a lapse in adherence to the facility's Hemodialysis policy, which requires coordination and communication with the dialysis facility.
A facility failed to monitor medication side effects and consider pharmacy recommendations for a resident with Alzheimer's, anxiety, and depression. Despite warnings of drug interactions and adverse symptoms like hallucinations and lethargy, the facility increased medication dosages without proper documentation or monitoring. Interviews revealed a lack of psychiatric services and inconsistent documentation of pharmacy recommendations.
A resident with bacteremia was re-hospitalized after a facility failed to administer an IV antibiotic as ordered. The resident returned from the hospital without antibiotic orders, and subsequent blood culture results were not communicated to the physician. An antibiotic order was delayed, and there was no documentation of IV care or communication with the pharmacy about the missing medication. The resident was sent back to the hospital for treatment after the resident's son intervened.
The facility failed to ensure food was stored and labeled appropriately, and the kitchen areas were free of food and debris. Observations included undated containers of various food items and food debris on the floors. Interviews with staff confirmed the need for proper dating and storage of food items.
Failure to Supervise and Monitor Residents with Dementia Resulting in Resident-to-Resident Altercation
Penalty
Summary
The facility failed to ensure adequate supervision and monitoring of residents with dementia and wandering behaviors, resulting in a resident-to-resident altercation that caused injury. One resident with severe cognitive impairment and a history of wandering was not properly observed or redirected, despite physician orders to monitor and document behaviors every shift. The resident's care plan identified wandering and impaired safety awareness, but documentation of behavioral monitoring was incomplete, and there was no evidence that staff consistently followed the monitoring protocol. Progress notes indicated multiple incidents of the resident entering other residents' rooms, exhibiting agitation, and being difficult to redirect prior to the altercation. An incident occurred in which the resident with wandering behaviors entered another resident's room, leading to a physical altercation where the resident bit another resident's forearm, resulting in a skin tear and bruising. The injured resident, who also had severe cognitive impairment, required wound care and was assessed for further injury. Documentation showed that the injured resident complained of pain and received treatment as ordered by the physician. Observations confirmed the presence of a healing wound on the resident's forearm following the incident. Interviews with staff revealed that the facility did not have a policy regarding resident behavior and wandering prevention. Additionally, the care plan for the resident who was injured was not updated following the increase in wandering and agitation behaviors observed in the other resident. The lack of adequate supervision, incomplete documentation, and failure to update care plans contributed to the occurrence of the altercation and subsequent injury.
Resident Self-Administered Unordered and Unlabeled Medication
Penalty
Summary
A resident was observed self-administering an antacid medication (Tums, calcium carbonate) from an unlabeled plastic cup in her room. The cup contained multi-colored tablets with no identifying information, and the resident indicated she was using the medication for stomach discomfort. Review of the resident's medical record showed no physician order for calcium carbonate or any antacid medication, although there was an order allowing the resident to self-administer insulin and keep insulin and accu-check supplies at bedside. The resident's most recent assessment indicated no cognitive impairment, and a prior self-administration assessment confirmed capability to self-administer medications. During interviews, nursing staff confirmed that the resident did not have a physician's order to self-administer any medication other than insulin, and it was suggested that the antacid medication was likely brought in by the resident's family without notifying staff. Facility policy requires that any unauthorized medication found at the bedside be reported to the charge nurse and returned to the family or responsible party. This policy was not followed in this instance, resulting in the resident having access to and self-administering a medication that was not ordered or properly labeled.
Deficiency in Care Plan Revisions and Documentation
Penalty
Summary
The facility failed to ensure that care plans were revised quarterly for 12 out of 13 residents reviewed for care planning and conferences, as well as for residents with urinary tract infection catheters and siderails. This deficiency was identified through interviews and record reviews, revealing that care plans were not updated as required, and care conferences were either not conducted or not documented. For instance, Resident 7's clinical record lacked documentation of care plan conferences prior to February 2024, despite multiple offers being declined by the Power of Attorney. Resident 11's care plan was not implemented for catheter care on numerous dates across July, August, and September 2024, and the Director of Nursing acknowledged that catheter care should be done every shift with output documented. Additionally, the care plan for Resident 11's restraint use was not adequately updated, and care conferences were not conducted before February 2024. Similarly, Resident 17's care plan was not revised to reflect the current needs, and care conferences were not held as required. The report also highlights that several residents, including Residents 18, 23, and R, lacked documentation of care plan conferences over the past year. The facility's policy mandates that comprehensive care plans be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment, but this was not adhered to. The Director of Nursing admitted that MDS meetings were held weekly but were not documented, contributing to the deficiency in care planning and conference documentation.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications across multiple areas, including three medication carts, one treatment cart, and a medication storage room. Observations revealed loose pills in the drawers of the medication carts on the 200-M, 300, and 400 Halls, with some pills lacking proper labeling. Additionally, the 200-M Hall treatment cart contained opened items such as Triple Antibiotic Ointment and Therahoney Gel that were not labeled or stored in individual resident bags. A bottle of Tylenol was found in the 300 Hall medication cart without a resident name or label, which was acknowledged by an LPN who indicated a label would be printed. The medication storage room also exhibited deficiencies, as the refrigerator temperature logs were incomplete for several days in September 2024. The Assistant Director of Nursing indicated that either nurses or Qualified Medication Aides were responsible for cleaning out the medication carts. The facility's policies on medication storage and labeling, provided by the Regional Consultant, emphasize the importance of proper labeling and temperature monitoring, yet these were not adhered to, leading to the observed deficiencies.
Improper Food Storage and Sanitization Monitoring
Penalty
Summary
The facility failed to ensure proper storage, labeling, and dating of food items in accordance with professional standards during two kitchen observations. During the initial tour of the kitchen, several items in the dry storage area, walk-in freezer, and walk-in fridge were found to be improperly labeled or undated. These included a bottle of apple cider vinegar, bags of Spanish rice, coffee cake, jalapenos, tomatoes, raw meat, pizza sauce, biscuits, pitchers of various liquids, and condiments such as ketchup and mustard. Many of these items were either past their use-by dates or lacked any labeling to indicate their freshness, which is a violation of food safety standards. Additionally, the facility did not adequately monitor the chemical sanitization process. The kitchen manager indicated that while a high-temperature dishwasher was used for most items, some were handwashed in a three-compartment sink. However, the kitchen staff did not maintain a log of the sanitization test results, which is necessary to ensure the effectiveness of the sanitization process. The regional consultant provided documentation outlining the requirements for date marking and manual warewashing, which the facility failed to adhere to, further contributing to the deficiency.
Deficiencies in Fall Documentation and Management
Penalty
Summary
The facility failed to ensure accurate and complete documentation of falls for several residents, leading to deficiencies in their care. Resident 9, diagnosed with Alzheimer's disease, experienced multiple falls, some of which were unwitnessed. The clinical records for these incidents lacked documentation of neuro checks and discussions by the Interdisciplinary Team (IDT). Additionally, the care plan was not consistently updated with new interventions following each fall, indicating a lapse in the facility's protocol for managing fall risks. Resident 12, with severe cognitive impairment, also experienced multiple unwitnessed falls. The clinical records for these incidents were incomplete, missing neuro checks and documentation of IDT discussions. In one instance, the facility failed to document the fall entirely, including the notification of the physician and the resident's representative. This lack of documentation and follow-up highlights a significant gap in the facility's fall prevention and management practices. Other residents, including Residents 19, 7, and 11, also experienced falls with similar documentation deficiencies. These included missing post-fall evaluations, neuro checks, and updates to care plans. The facility's failure to adhere to its fall prevention protocol and ensure comprehensive documentation for each fall incident reflects a systemic issue in maintaining accurate medical records and safeguarding resident safety.
Infection Control and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with an indwelling catheter. Over several days, surveyors observed that there was no EBP sign on the resident's door, despite the resident's medical conditions, including chronic kidney disease and benign prostatic hyperplasia, which necessitated the use of a catheter. The resident was dependent on staff for various activities, and the lack of EBP signage indicated a failure to adhere to infection prevention protocols. Additionally, the facility did not ensure proper hand hygiene practices during incontinence care and medication administration. On multiple occasions, staff members were observed not sanitizing their hands before and after glove use, and after performing tasks such as incontinence care and medication administration. This included instances where staff touched items in the resident's room with contaminated gloves and failed to perform hand hygiene before entering and after leaving residents' rooms. The facility also failed to clean equipment between resident uses. Observations included a blood pressure cuff and glucometer not being cleaned after use on residents. During wound care, a nurse was seen applying medication directly to a wound bed without using sterile applicators and not performing adequate hand hygiene during glove changes. These actions demonstrate a lack of adherence to the facility's policies on hand hygiene and equipment cleaning, contributing to the risk of infection transmission.
Lack of Emergency Call System in Resident-Used Restroom
Penalty
Summary
The facility failed to ensure the safety of residents by not providing an emergency call system in a public restroom used by residents. During a survey conducted from September 9 to September 16, 2024, it was observed that the visitor restroom located in the main hallway across from the beauty shop lacked an emergency call system. This restroom was used by residents visiting the beauty shop, as confirmed by the Director of Nursing during an interview on September 16, 2024. The facility's policy on Personal Property-Home Like Environment, provided by the Regional Clinical Support Nurse, did not include information regarding the requirement for call lights, contributing to the deficiency.
Persistent Urine Odors in Facility
Penalty
Summary
The facility failed to maintain a safe and sanitary environment, as evidenced by persistent urine odors observed over a period of six days in various areas, including the entrance hallway, conference room, and [NAME] Unit hallways. Specific observations included the presence of urine odors in the entrance hallway and conference room on multiple occasions, as well as in the [NAME] Hall Unit Nurses Station and the hallway outside the conference room. The strong smell of urine was noted despite attempts to mask it with air freshener. During an interview, the Administrator acknowledged that the facility should be free of smells and clean. The facility's policy on maintaining a home-like environment, which includes daily cleaning to eliminate odors, was provided by the Regional Clinical Support Nurse.
Failure to Ensure Proper Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that residents who had medications at their bedside had the necessary physician orders, self-administration assessments, and care plans in place. Resident 14 was observed on multiple occasions with eye relief drops and cooling pain relief medication on the bedside table. Despite being cognitively intact and requiring partial assistance with daily activities, Resident 14's clinical record lacked a physician order, self-administration assessment, and care plan for the self-administration of these medications. Similarly, Resident 36, who was diagnosed with COPD and was cognitively intact, was found to be independent with some activities but needed supervision with mobility and transfer. The clinical record for Resident 36 also lacked the necessary order and care plan for self-medication. The Director of Nursing confirmed that medications should not be left at the bedside without an order and self-medication administration assessment. The facility's policy requires an interdisciplinary team to determine the appropriateness of self-administration, considering factors such as cognitive status and comprehension of medication instructions.
Failure to Notify Resident's Representative of Condition Changes
Penalty
Summary
The facility failed to notify a resident's representative during a change in condition, specifically for a resident with severely impaired cognition who was reviewed for unnecessary medications. The resident, who was admitted with diagnoses including Alzheimer's Disease, anxiety, major depressive disorder, and visual/auditory hallucinations, was completely dependent on staff for daily activities and was receiving multiple psychotropic medications. Despite significant changes in medication dosages, such as increases in Olanzapine and Sertraline, and the initiation of Haloperidol, there was no documentation of notification to the resident's power of attorney (POA). Additionally, the resident was seen in a hospital office for a nasal bone fracture, and the physician noted that the POA was unaware of the visit and the discussion of treatment options. The facility's policy requires notifying the resident's representative of any new events, changes in condition, or order updates, which was not adhered to in this case. The assistant director of nursing confirmed that staff are expected to notify the resident's representative under such circumstances, highlighting a lapse in following the facility's notification policy.
Failure to Provide Documentation During Resident Transfer
Penalty
Summary
The facility failed to ensure proper clinical documentation was sent with a resident during a transfer to the hospital. Resident 37, who was admitted with diagnoses including Alzheimer's Disease and abnormalities of gait and mobility, was completely dependent on staff for daily activities and was on multiple medications. On a specific date, Resident 37 was transferred to the emergency department by ambulance, but the clinical record lacked documentation of the paperwork sent with the resident. The Assistant Director of Nursing confirmed that the necessary paperwork was not completed and did not exist. The facility's policy required that original copies of the transfer form and Advanced Directive accompany the resident, with copies retained for the medical record, but this was not adhered to in this instance.
Failure to Provide Transfer Notice to Resident
Penalty
Summary
The facility failed to provide a notice of transfer to a resident or their representative during a hospital transfer. This deficiency was identified for one of the four residents reviewed for hospital transfers. The resident in question, who was admitted with diagnoses including Alzheimer's Disease and mobility issues, was transferred to the emergency department by ambulance. The clinical record did not contain documentation of the notice of transfer being provided to the resident or their representative. During an interview, the Assistant Director of Nursing (ADON) confirmed that the necessary paperwork for the transfer was not completed and did not exist. The facility's policy requires that a notice of transfer and the facility's bed hold policy be provided to the resident and their representative, and that copies of notices for emergency transfers be sent to the Ombudsman. However, this procedure was not followed in the case of the resident transferred on the specified date.
Failure to Provide Bed Hold Notice During Hospital Transfer
Penalty
Summary
The facility failed to provide a bed hold notice upon the transfer of a resident to the hospital. Resident 37, who was admitted with diagnoses including Alzheimer's Disease and abnormalities of gait and mobility, was transferred to the emergency department by ambulance. The resident's clinical record did not contain documentation of the bed hold notice being provided at the time of transfer. During an interview, the Assistant Director of Nursing (ADON) confirmed that the necessary paperwork for the transfer on the specified date was not completed and did not exist. The facility's policy on transfer and discharge requires that a notice of transfer and the facility's bed hold policy be provided to the resident and their representative, but this was not adhered to in the case of Resident 37.
Inaccurate MDS Assessments for Restraints, Medications, and Falls
Penalty
Summary
The facility failed to ensure accurate completion of the Minimum Data Set (MDS) assessments for several residents, leading to discrepancies in the documentation of restraints, medications, and falls. For Resident 11, the MDS assessment inaccurately indicated the use of bed rails as a restraint, despite physician orders for bilateral 1/2 siderails for assistance with positioning and turning. Similarly, Resident 19's MDS assessment incorrectly documented the use of anticoagulants and opioids, although the resident was not on anticoagulants and had a prescription for hydrocodone-acetaminophen for pain management. The assessment also inaccurately noted the use of bed rails as a restraint. Resident 37's MDS assessment failed to record a fall that occurred since the previous assessment and omitted the use of opioids, despite the resident receiving such medication. The Director of Nursing (DON) acknowledged errors in coding the MDS assessments, including misclassifying Plavix as an anticoagulant instead of an antiplatelet and incorrectly documenting the use of restraints. These inaccuracies highlight a lack of adherence to the Resident Assessment Instruction (RAI) Manual, which the facility claims to follow.
Deficiencies in Care Planning and Documentation
Penalty
Summary
The facility failed to develop care plans for residents with new diagnoses and medication orders, leading to deficiencies in care planning for two residents. Resident 12, who had a new diagnosis of a urinary tract infection (UTI) and was prescribed Ciprofloxacin, did not have a care plan addressing the UTI or antibiotic use. This oversight was acknowledged by the Director of Nursing (DON), who indicated that care plans should be developed for residents with new infections or antibiotic orders. Similarly, Resident 7, who was on multiple medications including antiplatelets and anticoagulants, lacked a care plan for these medications, which was also confirmed by the DON. Additionally, the facility failed to follow care plan interventions for Resident 17, who was on several medications including antipsychotics, antidepressants, and anticoagulants. The Medication Administration Record (MAR) and Treatment Administration Record (TAR) for August and September 2024 showed multiple instances where documentation was lacking, and care plan interventions were not followed, such as monitoring for side effects and behaviors. The facility's Comprehensive Care Plans policy, provided by the Regional Consultant, emphasized the need for care plans to describe services necessary to maintain residents' well-being, highlighting the deficiencies in the facility's care planning and documentation practices.
Failure to Document Rationale for Schizophrenia Diagnosis
Penalty
Summary
The facility failed to ensure that a practitioner's diagnostic practices met professional standards of care for a resident diagnosed with schizophrenia. The resident, who was over a certain age and had been admitted with diagnoses including Alzheimer's Disease, anxiety, major depressive disorder, and visual/auditory hallucinations, received a new diagnosis of schizophrenia. However, the clinical record lacked documentation explaining the rationale for this diagnosis or any assessment that led to it. The resident's Minimum Data Set (MDS) assessment indicated severe cognitive impairment and complete dependence on staff for daily activities, and the resident was receiving multiple medications, including antipsychotics and antidepressants. During an interview, the Assistant Director of Nursing (ADON) confirmed that there was no documented rationale for the schizophrenia diagnosis. Additionally, the facility was unable to provide a policy related to ensuring services met professional standards. This lack of documentation and policy adherence contributed to the deficiency identified by the surveyors.
Deficiency in Pressure Ulcer Monitoring and Documentation
Penalty
Summary
The facility failed to adequately monitor and document the progression of pressure ulcers for two residents, leading to deficiencies in wound care management. Resident 23, who has multiple sclerosis and peripheral vascular disease, was found to have incomplete skin assessments for several weeks in August and September. Despite having physician orders for daily wound care and weekly skin assessments, the documentation was lacking. The Assistant Director of Nursing (ADON) confirmed that a contracted wound physician had been following the resident's wound progress, but staff were still required to document weekly assessments, which they failed to do. Similarly, Resident 18, diagnosed with hemiplegia and hemiparesis, also experienced a lack of proper wound documentation. The resident's clinical record did not include wound assessments or a rationale for the application of wound treatments to the lumbar and thoracic spine. Weekly skin assessments were also missing for several weeks in August and September. The ADON indicated that the dressings were applied for pressure prevention, but no documentation was completed. The facility's policy was to follow standard nursing practice and ensure complete and accurate documentation, which was not adhered to in these cases.
Inadequate Fall Prevention and Supervision in LTC Facility
Penalty
Summary
The facility failed to provide adequate care and supervision to prevent accidents for Resident 37, who experienced multiple unwitnessed falls resulting in injuries, including a nose fracture. The resident, diagnosed with Alzheimer's Disease and other conditions, was on multiple psychotropic medications, which were not adequately monitored for interactions and side effects. Despite the resident's high fall risk, the care plan was not updated after falls, and there was a lack of thorough post-fall assessments and interventions. Resident 37's clinical records showed a pattern of inadequate documentation and follow-up after falls. The care plan was not revised after the initial fall, and subsequent falls were not properly evaluated by the interdisciplinary team to determine their causes or to implement new interventions. The facility's failure to conduct complete neuro assessments and fall risk evaluations further contributed to the resident's repeated falls and injuries. Additionally, the facility failed to address unsafe wandering behaviors for Resident 201, who exhibited exit-seeking behaviors. Despite multiple documented instances of wandering and attempts to exit the facility, there were no care plans in place to manage these behaviors. The facility's policies on elopement and wandering were not effectively implemented, as evidenced by the resident's ability to open a door to a restricted area without staff intervention.
Deficiencies in Respiratory Care and Equipment Management
Penalty
Summary
The facility failed to ensure proper respiratory care for two residents, leading to deficiencies in oxygen equipment labeling and adherence to care plans. Resident 15 was observed receiving oxygen via nasal cannula without proper labeling on the oxygen tubing or humidification bottle. The oxygen concentrator was left on while the resident was not in the room, and the tubing was improperly stored. The clinical record for Resident 15 lacked an order to change the oxygen tubing and humidification bottle, despite the resident's diagnoses of chronic respiratory failure and COPD. Resident 11's care plan included an intervention for pulse oximetry twice daily, but the facility failed to implement this consistently. The vital sign record showed infrequent pulse oximetry readings, and there was no physician order for pulse oximetry. Interviews with the DON and ADON revealed that the facility did not have a system to document or monitor the changing of oxygen equipment, and staff were expected to check dates on equipment without a formal process in place. The facility's policy on oxygen administration was not followed, contributing to the deficiencies observed.
Failure to Complete Dialysis Assessments and Communication Records
Penalty
Summary
The facility failed to provide ongoing assessment and monitoring for a resident requiring dialysis, specifically by not completing Pre Dialysis Assessments, Post Dialysis Assessments, and Dialysis Communication Records as required. Resident 15, who was cognitively intact and required dialysis due to end-stage renal disease, attended dialysis sessions three times a week. However, the clinical record showed multiple instances where the required assessments and communication records were not completed, despite being marked as done in the Medication Administration Record (MAR). The Assistant Director of Nursing (ADON) confirmed that staff were supposed to complete these forms and that marking them as complete on the MAR without actual documentation was incorrect. The facility's Hemodialysis policy emphasized the importance of coordination and communication between the nursing home and the dialysis facility, including the completion of documentation to ensure treatments were provided as ordered. The lack of completed forms on several dates indicates a failure in adhering to these documentation and communication protocols.
Failure to Monitor Medication Side Effects and Consider Pharmacy Recommendations
Penalty
Summary
The facility failed to properly monitor medication side effects and consider pharmacy recommendations for a resident with multiple diagnoses, including Alzheimer's Disease, anxiety, major depressive disorder, and visual/auditory hallucinations. The resident was on a regimen of psychotropic medications, including antipsychotics, antidepressants, and opioids, without adequate monitoring for side effects or effectiveness. Despite pharmacy recommendations for a gradual dose reduction (GDR) and concerns about drug interactions, the facility did not implement these suggestions, and the resident continued to experience adverse symptoms such as lethargy, pacing, hallucinations, and tearfulness. The resident's medication regimen included Lorazepam, Morphine Sulfate, Olanzapine, Mirtazapine, Sertraline, and Haloperidol, with documented drug-to-drug interactions that could lead to severe conditions like serotonin syndrome and neuroleptic malignant syndrome. Despite these warnings, the facility increased dosages and added new medications without proper documentation of side effect monitoring. The resident exhibited symptoms such as drooling, hallucinations, and nonsensical speech, which were not adequately assessed or addressed in the clinical records. Interviews with facility staff revealed that pharmacy recommendations for GDR were not consistently documented or signed by the physician, and the resident had not received psychiatric services since admission, despite consent from the resident's POA. The facility's policy required monitoring for side effects and complications related to psychoactive medications, but this was not effectively implemented, leading to a deficiency in the care provided to the resident.
Failure to Administer IV Antibiotic Leads to Re-hospitalization
Penalty
Summary
The facility failed to administer an intravenous (IV) antibiotic to a resident in accordance with physician orders, resulting in the resident being re-hospitalized. The resident, who had diagnoses including congestive heart failure, diabetes mellitus, and bacteremia, was initially sent to the hospital for pneumonia evaluation and treatment. Upon returning to the facility, the resident had no antibiotic orders, and subsequent blood culture results indicating bacteremia were not communicated to the physician by the staff. A physician's order for the antibiotic ertapenem sodium was entered with a start date that was delayed, and there were no orders for IV placement, maintenance, flushing, or dressing change. The resident's midline IV was placed, but there was a lack of documentation regarding its assessment and monitoring for signs of bacteremia. The antibiotic was not delivered to the facility as expected, and there was no evidence that staff notified the physician or communicated with the pharmacy about the missing medication. The resident was eventually transported to the hospital for IV antibiotic treatment after the resident's son contacted the physician. The facility's Assistant Director of Nursing (ADON) and Director of Nursing (DON) acknowledged the lack of documentation and communication regarding the antibiotic order and IV care. The facility's policies on IV catheter care, notification of changes, and pharmacy services were not adequately followed, contributing to the deficiency.
Improper Food Storage and Labeling in Kitchen
Penalty
Summary
The facility failed to ensure food was stored and labeled appropriately, and the kitchen areas were free of food and debris. During an initial tour of the kitchen, surveyors observed multiple instances of improperly labeled or unlabeled food items in the walk-in refrigerator, drink refrigerator, spice rack, and dry storage area. Specific observations included undated containers of orange juice, lemonade, milk, cucumbers, garlic, dressings, lemon juice, and various spices. Additionally, food debris and paper were found on the floors of the walk-in freezer, drink refrigerator, and dry storage area. The vent under the hood also had a grease buildup. Interviews with kitchen staff confirmed that food items should be dated when opened or prepared, and crumbs should be stored in closed bins with marked dates. The Administrator, who was temporarily supervising the dietary department, provided outdated policies from 2010 that indicated food should be stored in labeled and dated bins or containers. The deficiency was related to a complaint investigation and highlighted the facility's failure to adhere to proper food storage and labeling standards, as well as maintaining cleanliness in the kitchen areas.
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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.
The facility failed to ensure timely electronic transmission of MDS assessment data to CMS for a resident. Record review showed an annual MDS that was more than 120 days overdue for submission. The MDS coordinator reported that two care area assessments on the annual MDS had remained incomplete until just before surveyor review, at which time the MDS was finished and submitted. The Administrator acknowledged there was no facility policy in place governing MDS transmissions.
Surveyors found that MDS assessments were inaccurately coded for two residents. One resident with a prior Level II PASARR for serious mental illness was incorrectly coded on the Annual MDS as not having a serious mental illness or related condition. Another resident with generalized anxiety disorder, major depressive disorder, and dementia, who was receiving Lorazepam for anxiety, was not coded with an active anxiety disorder diagnosis on the Quarterly MDS, despite active orders documented on the MAR. The MDS coordinator acknowledged both coding errors, and leadership reported there was no facility-specific MDS policy, relying instead on the RAI manual.
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 Timely Transmit MDS Assessment Data to CMS
Penalty
Summary
The facility failed to ensure timely electronic transmission of MDS (Minimum Data Set) assessment data to the CMS system for one resident. Review of the clinical record for Resident 36 on 4/9/26 showed an annual MDS assessment dated 2/23/26 that was more than 120 days overdue for submission to CMS. During an interview on 4/10/26 at 11:22 a.m., the MDS coordinator stated she still had two care area assessments left to complete on the annual MDS assessment and that she had just finished them and submitted the MDS to CMS, indicating the assessment had not been completed and transmitted within the required timeframe. In a separate interview on 4/10/26 at 12:05 p.m., the Administrator reported that the facility did not have a policy regarding MDS transmissions, further demonstrating the lack of an established process to ensure that MDS data were encoded and transmitted to the State and CMS within the required time limits.
Inaccurate MDS Coding for Mental Health and PASARR Status
Penalty
Summary
The deficiency involves the facility’s failure to ensure that MDS assessments accurately reflected residents’ clinical status for two residents. For one resident with diagnoses including bipolar disorder and anxiety, the Annual MDS dated 3/11/26 indicated the resident was not considered by the state Level II PASARR process to have a serious mental illness or intellectual disability/related condition, despite a Level II PASARR having been completed on 3/31/23. This discrepancy was identified through record review and confirmed in an interview with the MDS coordinator, who acknowledged that the MDS assessment did not accurately reflect the existing Level II PASARR information. For another resident with generalized anxiety disorder, major depressive disorder, and dementia, the Quarterly MDS dated 3/30/26 did not code anxiety as an active diagnosis. However, review of the MAR showed active orders as of 2/27/26 for Lorazepam, prescribed for generalized anxiety disorder, and the RAI manual specifies that active diagnoses should be identified using sources such as medication sheets and physician orders during the 7-day look-back period. In an interview, the MDS coordinator confirmed that the resident did have an active anxiety disorder diagnosis and that the MDS should have been coded “yes” for anxiety disorder but was incorrectly coded “no.” The Administrator and MDS coordinator also stated the facility did not have an MDS policy and relied on the RAI manual for completing assessments.
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