River Bend Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Evansville, Indiana.
- Location
- 3400 Stocker Dr, Evansville, Indiana 47720
- CMS Provider Number
- 155621
- Inspections on file
- 37
- Latest survey
- January 30, 2026
- Citations (last 12 mo.)
- 22
Citation history
Health deficiencies cited at River Bend Nursing And Rehabilitation during CMS and state inspections, most recent first.
The facility failed to maintain complete and timely documentation for several residents, including missing or retroactively entered care conference notes for a resident with multiple sclerosis and another with severe cognitive impairment, where quarterly care plan conferences were not documented until much later. A resident with chronic kidney disease and diabetes had large gaps in recorded weights despite orders for monthly and then weekly weights, and the DON reported the resident refused weights but staff did not document refusals. For a resident with COPD and an indwelling catheter, the eMAR/eTAR showed multiple undocumented administrations of Lyrica, blood glucose checks, BIPAP care, and ordered small frequent meals, with the DON stating staff said they provided the care but failed to chart it. Another resident with congestive heart failure and an insulin lispro sliding scale had numerous early-morning insulin doses not documented as given, with the DON indicating that insulin administration at breakfast was sometimes missed in documentation.
Surveyors identified a failure to maintain a safe, sanitary environment when strong, persistent odors were observed in multiple common areas and units, including hallways, the main lobby, and an area outside a conference room. Odors noted included urine, sewer gas, and bowel movement smells. During an interview, the Administrator stated that odors should be controlled through routine cleaning and increased cleaning in odor-prone areas. The facility’s Environmental policy requires staff and management to promote pleasant, neutral scents and minimize institutional odors, but the observed conditions did not meet these standards.
Surveyors found that the facility failed to consistently implement care plan interventions for two residents, one at high risk for falls and one with a pressure ulcer and continuous tube feeding. A resident with cognitive impairment and a history of multiple falls was observed without required nonskid socks and with the call light out of reach, while the wheelchair was placed in the resident’s line of sight despite prior falls during self-transfer attempts. Another resident with a coccyx wound and PEG tube feeding did not receive wound care as ordered, as an RN applied triad and collagen without cleansing the area first and laid the resident flat without pausing continuous tube feeding, contrary to care plan aspiration precautions requiring head-of-bed elevation during feedings.
A resident receiving O2 therapy was observed with undated O2 tubing, water bottle, and nebulizer equipment, and without an “Oxygen in Use” sign posted on the room door. On another observation, the resident was in bed without O2, and the nebulizer mask was on the floor with undated tubing. Record review showed no physician order for O2 and no care plan addressing O2 use. In interviews, a hospice provider and an RN stated that residents on O2 should have an order with the facility, and the facility’s O2 administration policy requires a physician’s order, review of the care plan, and an O2-in-use sign, which were not in place for this resident.
Surveyors observed failures in infection prevention practices, including a glucometer on the insulin cart with visible blood spots that had not been cleaned between uses, and improper PPE and hand hygiene during tracheostomy suctioning for a resident on Enhanced Barrier Protocol. An RN did not perform hand hygiene before donning gloves, did not wear a gown, used the same gloves to open a trach care kit and sterile water, contaminated a sterile glove by touching the trach collar, and then handled the suction catheter without changing gloves or re-washing hands, while two CNAs assisted in the room without gowns. Staff interviews confirmed that gowns should have been worn for EBP, gloves changed when moving from dirty to clean tasks, and glucometers cleaned after each use, consistent with facility policies on hand hygiene, PPE, and glucometer disinfection.
The facility failed to notify residents or their representatives of the bed hold policy during hospital transfers. A resident with a fractured neck, another with multiple hospitalizations, and others requiring substantial assistance were not provided with the necessary documentation. The DON confirmed the absence of transfer paperwork and bed hold policies.
The facility failed to properly store medications, as loose pills were found in medication carts across three halls. Despite a policy requiring drugs to be stored in their original packaging, numerous loose pills with various markings were observed. An RN noted that carts are cleaned bi-weekly, but the presence of loose pills indicates non-compliance with the storage policy.
The facility failed to serve food at appropriate temperatures, with a test tray showing a grilled cheese at 117°F and fruit cocktail at 60.2°F, both cooler than required. Residents reported the food as unappetizing and repetitive, and the Ombudsman noted several complaints. The facility's policy requires hot food to be at least 135°F and cold food at or below 41°F.
The facility failed to properly store, label, and date food items, as observed during multiple kitchen inspections. Items such as onions, lettuce, tea, and various sauces were found without proper dates, and temperature logs were incomplete. The Interim Dietary Manager confirmed that open lettuce should be dated and temperatures recorded twice daily. Further inspections revealed additional items without dates, and inconsistencies in temperature logs were noted, with housekeeping responsible for checks.
The facility was found to have a persistent urine odor in several areas, including hallways and a conference room, over six days. Staff interviews confirmed awareness of the issue, attributing it to a resident urinating on the floor. Additionally, air conditioning units in resident rooms were observed with flaking paint and rust, indicating poor maintenance. The facility's maintenance policy requires documentation of compliance, but the observed conditions suggest non-adherence.
The facility failed to provide SNF-ABN and NOMNC forms to two residents who remained in the facility after their Medicare services ended. One resident did not receive a SNF-ABN form despite being notified of the end of coverage, while another did not receive either form due to a discharge from therapy. The Social Services Director acknowledged the oversight and a lack of understanding of the Medicare coverage process.
A facility failed to provide necessary transfer documentation for a resident who was emergently sent to the hospital after a fall resulting in a fractured neck. The resident's clinical record lacked any transfer paperwork, which was confirmed by the DON during interviews. The DON acknowledged that essential documents like the face sheet and bed hold policy should have been sent with the resident.
A facility failed to notify the Ombudsman office about an emergency hospital transfer of a resident with a fractured neck. The resident, who is moderately cognitively impaired, was transferred without the necessary paperwork or notification to the Ombudsman. Interviews revealed that the required transfer forms were missing, and the Social Service Director acknowledged the oversight.
The facility failed to develop comprehensive care plans for three residents, leading to deficiencies in addressing behaviors, accidents, and nutrition. A resident with dementia was observed eating non-food items without a behavior-focused care plan. Another resident involved in an altercation lacked documentation and a care plan for the incident. A third resident experienced significant weight loss without an updated intervention plan, despite being on nutritional supplements.
The facility failed to conduct quarterly care plan conferences for two residents, one with dementia and anxiety, and another with multiple sclerosis and other conditions. Both residents were dependent on staff for daily activities, and the required care plan conferences were not held within the specified periods. The Social Services Director and DON confirmed the necessity of these quarterly reviews.
A facility failed to provide person-centered activities for a resident with dementia and anxiety. The resident was often positioned in a way that obstructed her view of the television and was not invited to group activities. Despite a care plan emphasizing engagement, there was no documentation of activity participation, and a CNA noted restrictions in assisting residents to activities.
A resident with multiple sclerosis and vision impairments was not assessed by vision services for over a year, despite wearing cloudy glasses and having difficulty with her prescription. The facility's policy requires assistance in arranging such services, but the resident's clinical record lacked documentation of evaluations or transportation offers since April 2023. Interviews revealed a gap in the process for arranging vision services.
A resident with a suprapubic catheter experienced infections due to inadequate care and maintenance by the facility. The catheter was not changed or documented as required, and staff failed to follow enhanced barrier precautions. Observations showed improper placement of the catheter bag and lack of training for CNAs on catheter care. Interviews revealed confusion among staff about care responsibilities, contributing to the resident's infections.
A facility failed to provide sufficient fluid intake to a resident, who was found with an empty cup and an unreachable call light. The resident, dependent on staff for daily activities and on diuretic medication, expressed concerns about inadequate fluid intake. Despite being at risk for dehydration due to medical conditions and diuretic use, the facility did not closely monitor fluid intake, contrary to their hydration policy.
The facility failed to provide and dispense medications as ordered for two residents. A resident did not receive their prescribed ProStat supplement due to unavailability, and another resident's ProStat AWC SF was inconsistently administered, with doses missed or incorrectly given. The facility's medication management practices were inadequate, impacting residents with significant medical needs.
The facility exceeded the acceptable medication error rate with an 8% error rate during a medication pass. An LPN failed to prime insulin pens before administering insulin to two residents, contrary to manufacturer instructions. This resulted in incorrect dosing for both residents, as the facility's policy requiring adherence to manufacturer guidelines was not followed.
A facility failed to consistently document wound care treatments for a resident with pressure injuries on the right buttock and heel. Despite specific orders for wound care, records showed incomplete documentation on several dates. The DON could not explain the inconsistency, and the staff nurse's job description included responsibilities for ensuring proper care and treatment administration.
The facility failed to follow infection control practices for three residents, including improper use of mechanical lift slings, inadequate hand hygiene during incontinence care, and inconsistent use of gowns and masks during catheter care. These actions were contrary to the facility's infection control policies.
The facility failed to maintain a pest-free environment, with flies and gnats observed in a resident's room and the Second Floor Nurse's Station. A resident reported previous pest issues, and the Administrator was unaware of the problem. The facility's pest control policy requires a clean environment and an active pest control contract.
A resident sustained fractures to both ankles due to inadequate safety measures during transport. In one incident, the resident's foot was caught under the wheelchair due to missing footrests, and in another, the resident slid out of the wheelchair because the seatbelt was not properly secured. The resident, who had a history of mobility issues, required medical intervention for her injuries.
The facility failed to properly dispose of and store medications for discharged and deceased residents, with controlled medications not double locked and improper temperature controls. Medications for residents who had expired or been discharged were not disposed of timely, and there was inadequate documentation for non-narcotic medication disposition.
The facility failed to develop and implement a timely care plan for a resident with an enteral feeding tube. Despite physician orders, the care plan did not include a focus on the feeding tube until much later, and observations revealed that the enteral feeding pump was not running as ordered. Staff interviews and record reviews indicated a lack of documentation and adherence to facility policies.
A resident with a history of inappropriate sexual behavior inappropriately touched another resident, who has a history of mental health issues, in a common area of the facility. The incident was observed by staff, and the residents were separated immediately. Despite the facility's awareness of the perpetrator's behavior, the incident occurred, indicating a failure in monitoring or intervention strategies.
Incomplete and Late Clinical Documentation for Care Conferences, Weights, and Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate clinical documentation and care conference records for multiple residents. For one resident with multiple sclerosis and quadriplegia who was cognitively intact and dependent on staff for all ADLs, the record showed the most recent completed care conference on one date, with a later care conference note marked as “in progress” and not completed. The Social Services Director later produced several care conference notes for this resident that were all created and signed in the EHR on the same later date, despite being dated for earlier months, and stated she took notes in a notebook and entered them into the EHR whenever she had the chance, acknowledging she had fallen behind on documentation. Another resident with congestive heart failure and severe cognitive impairment had no quarterly care plan conferences documented since admission, and the record later showed multiple quarterly care plan conferences that were all created on the same later date, although they were dated for earlier months. The facility also failed to accurately document weights and refusals for a resident with chronic kidney disease and diabetes mellitus who was cognitively intact and dependent on staff for toileting. The care plan included monitoring weight and intake and educating and documenting refusals, and physician orders required monthly weights and then weekly weights. The weight summary showed only a single weight in October and then weights in January, with a significant decrease, and an IDT note referenced a three percent weight decrease and missing weights from October to January. The TAR for November and December had blank monthly weight entries with no staff signatures, and the DON reported the resident was noncompliant and refused to be weighed in those months, but staff did not document the refusals. Additional documentation deficiencies were identified in medication and treatment administration records for residents with chronic obstructive pulmonary disease and congestive heart failure who required insulin and other treatments. For one resident with COPD, oxygen therapy, and an indwelling catheter, the eMAR/eTAR showed multiple dates when Lyrica, blood sugar checks, BIPAP-related tasks, and ordered small frequent meals were not documented as administered or refused; the DON reported that staff working those shifts stated they had provided the medications and treatments but missed the documentation. For another resident with congestive heart failure and an insulin lispro sliding scale order, the eMAR showed numerous early-morning doses not administered, and the DON explained that night shift nurses obtained blood sugars and relayed results to day shift nurses, who then gave insulin at breakfast, but documentation sometimes was missed.
Failure to Maintain Odor-Free, Sanitary Environment in Common Areas and Units
Penalty
Summary
The facility failed to provide a safe and sanitary environment by not maintaining pleasant, neutral scents and minimizing institutional odors as required by its Environmental policy. During multiple observations, surveyors noted strong, persistent odors in several areas of the building. On 1/22/26 at 9:40 A.M., the hallways on Stocker Unit 1 and Stocker Unit 2 had a strong smell of urine. On 1/23/26 at 8:56 A.M., the main lobby, Stocker Unit 1, and Stocker Unit 2 had a strong, pungent odor consistent with sewer gas. On 1/28/26 at 9:05 A.M., the hallway outside of the conference room had an odor consistent with bowel movement. In an interview, the Administrator stated that odors in the facility should be controlled by general routine cleaning and that staff should increase cleaning in areas prone to odors. The facility’s written Environmental policy, dated 5/17 and provided by the Administrator, states that staff and management shall maximize pleasant, neutral scents and minimize institutional odors, but the observed conditions did not align with these policy expectations. No specific residents or their medical conditions were identified in the report; the deficiency was based on environmental observations in common areas and units accessible to residents, staff, and the public.
Failure to Implement Care Plan Interventions for Falls and Pressure Ulcer Management
Penalty
Summary
Surveyors identified that the facility did not fully implement and maintain care plan interventions for a resident at high risk for falls. One resident with senile degeneration of the brain, muscle weakness, impaired cognition, and a documented high fall risk had a care plan that required a safe environment, call light within reach, and nonskid socks at all times as the resident allowed. Despite multiple prior falls related to self-transfers and added interventions such as nonskid socks, alarms, and safe storage of assistive devices, the resident was observed sitting in a wheelchair wearing plain white socks without nonskid tread. On another occasion, the resident was observed in bed with the call light under the bed and the wheelchair positioned in the resident’s line of sight, contrary to staff’s stated practice of storing the wheelchair out of sight to reduce self-transfer attempts. Surveyors also found that the facility failed to follow physician orders for wound care for a resident with a coccyx wound. The resident, who had chronic respiratory failure, was rarely or never understood, and was dependent on staff for all ADLs, had a physician order directing staff to cleanse the coccyx wound with wound cleanser, pat dry, then apply a mixture of triad and collagen particles to the wound bed and leave it open to air once per day on the day shift. During an observed treatment, an RN entered the room, turned the resident, laid the bed down, removed existing paste from the coccyx area using the pad under the resident, changed gloves, and applied a mixture of collagen and triad with a cotton swab. The RN did not cleanse the wound area before applying the new paste, contrary to the physician’s order. In addition, the facility did not adhere to care plan interventions related to aspiration precautions for the same resident receiving continuous tube feeding. The resident’s care plan required keeping the head of the bed elevated 45 degrees during tube feeding and for one hour after completion. During the observed wound treatment, the RN used the bed remote to lay the bed down without pausing the resident’s continuous PEG tube feeding. The Infection Prevention Nurse later stated that a resident receiving continuous tube feeding should not be laid flat and that staff should follow treatment orders as written by the physician. These observations demonstrated that care plan and physician-ordered interventions for both fall prevention and pressure ulcer management were not consistently implemented as planned.
Failure to Ensure Ordered and Properly Managed Oxygen Therapy
Penalty
Summary
The deficiency involves the facility’s failure to provide safe and appropriate respiratory care for a resident receiving oxygen therapy by not ensuring required orders, care planning, equipment dating, and signage were in place. During an observation, the resident was found in bed with oxygen tubing connected to a concentrator, but the tubing and water bottle, as well as the nebulizer, were not dated, and there was no oxygen administration sign posted on the door. On a later observation, the same resident was in bed without oxygen in use, and the nebulizer face mask was on the floor with tubing that also lacked a date. Review of the physician orders showed there was no documented order for oxygen, and the clinical record did not contain a care plan addressing oxygen use. In interviews, a hospice provider stated that residents on oxygen should have an order with the facility, and an RN confirmed there should be an oxygen order for anyone utilizing it. The facility’s own oxygen administration policy, provided by the Administrator, requires verification of a physician’s order, review of the resident’s care plan for special needs, and placement of an “Oxygen in Use” sign on the room entrance door, all of which were not followed for this resident.
Failure to Follow Infection Control Practices for Tracheostomy Care and Glucometer Cleaning
Penalty
Summary
Surveyors identified a failure to follow infection prevention and control practices related to glucometer cleaning and use of personal protective equipment (PPE) and hand hygiene. During a random observation of the insulin cart, a glucometer was found with two visible spots of blood on the machine, despite facility policy stating that glucometers must be cleaned and disinfected after each use on each patient. In an interview, a registered nurse confirmed there should be no blood on glucometers and that they are to be cleaned between each use. In a separate observation of tracheal suctioning for a resident on Enhanced Barrier Protocol (EBP) due to a tracheostomy, multiple infection control breaches were observed. The RN performing the procedure did not wash hands before donning gloves and did not wear a gown, and two CNAs who entered the room to assist with repositioning the resident also did not don gowns, although they wore gloves. The RN used the same gloves to open the tracheostomy care kit and sterile water, then removed gloves and washed hands before donning a single sterile glove on the right hand. The RN then touched the trach collar with the sterile gloved hand, did not remove the glove or perform hand hygiene, and subsequently touched the suction catheter with a now-contaminated glove without changing to a new sterile glove or washing hands. The RN proceeded to perform multiple suction passes, cleared the catheter with sterile water, placed the catheter into a container uncurled, reattached the trach collar, and then removed gloves and discarded the suction catheter. In interviews, the RN, CNAs, and Infection Preventionist acknowledged that gowns should have been worn for EBP and that gloves should be changed when moving from dirty to clean tasks, and that glucometers should be cleaned after each use. Facility policies on hand hygiene, PPE, and glucometer cleaning supported these requirements.
Failure to Provide Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide notification of transfer and bed hold policy to residents or their representatives in cases of hospitalization. This deficiency was identified in the records of four residents who were reviewed for hospitalizations. Resident 7, who was moderately cognitively impaired, was emergently transferred to the hospital after a fall resulting in a fractured neck, but the clinical record lacked any transfer paperwork and bed hold policy. The Director of Nursing (DON) confirmed the absence of these documents during an interview. Similarly, Resident 51, who was cognitively intact and had multiple hospitalizations, did not receive a bed hold policy for any of the transfers. Resident 53, who required substantial assistance and had been hospitalized twice, also lacked documentation of a bed hold policy. Lastly, Resident 57, who was not cognitively intact and under hospice care, was hospitalized without receiving a bed hold policy. The facility's policy on changes in resident condition or status was provided by the DON, but it was non-dated and did not ensure compliance with the notification requirements.
Improper Storage of Medications in Facility
Penalty
Summary
The facility failed to ensure proper storage of medications, as evidenced by the presence of loose pills in the medication carts across three different halls. On November 7, 2024, during a review of the medication cart for rooms 310 to 317, several loose pills were found in the bottom of the drawers, including a blue oval capsule, red circle pills, light blue circle pills, and others with various markings. Similar observations were made in the 400 hall medication cart and the upstairs medication cart, where numerous loose pills with different markings were found scattered in the drawers. Registered Nurse 5 indicated that medication carts were cleaned out every two weeks during the night shift, and loose pills were disposed of in the drug buster or sharps container. The facility's current Storage of Medications policy, revised in April 2007, states that drugs and biologicals should be stored in the packaging, containers, or other dispensing systems in which they are received. However, the presence of loose pills in the medication carts indicates a failure to adhere to this policy, leading to the deficiency noted in the report.
Deficiency in Food Temperature and Palatability
Penalty
Summary
The facility failed to ensure that food was served at palatable temperatures and taste, as evidenced by a test tray from the 200 Hall. The grilled cheese sandwich was served at 117 degrees Fahrenheit, and the fruit cocktail was at 60.2 degrees Fahrenheit, both of which were cool to taste. According to the Interim Dietary Manager, hot food should be served at a minimum of 155 degrees Fahrenheit, and cold food should be served at a minimum of 41 degrees Fahrenheit. Additionally, Resident 6 expressed that the food was not appetizing and often repetitive, while Resident 15 mentioned receiving a lot of sandwiches. The Ombudsman reported several anonymous complaints about food and meals after a resident council meeting. The facility's current policy, dated July 2023, states that foods should be transported and delivered to maintain temperatures at or below 41 degrees Fahrenheit for cold items and at or above 135 degrees Fahrenheit for hot items.
Deficiencies in Food Storage and Labeling Practices
Penalty
Summary
The facility failed to ensure proper storage, labeling, and dating of food items in accordance with professional standards during multiple kitchen observations. During an initial tour of the kitchen, several items were found improperly stored or labeled, including a box of onions with a sprouted onion, bags of lettuce, pitchers of tea, and various other food items without dates. The temperature log for the drink refrigerator was incomplete, missing entries for specific shifts. The Interim Dietary Manager acknowledged that open lettuce should be dated and is typically good for only three days, and that temperatures should be recorded twice daily. Further observations revealed additional issues, such as an open bag of biscuits without an open date, and spices and sauces without proper labeling. A second walkthrough found more items without dates, including Worcestershire sauce and cottage cheese. The kitchenette nutrition refrigerator on the first floor lacked a temperature log and contained several items without names or open dates. The administrator indicated that housekeeping was responsible for temperature checks, but inconsistencies were noted in the logs. The facility's policies on storage and food from outside sources were provided, but no specific policy for the kitchenette refrigerator was produced.
Facility Fails to Maintain Sanitary Environment and Equipment
Penalty
Summary
The facility failed to maintain a safe and sanitary environment for residents, staff, and the public, as evidenced by multiple observations of strong urine odors and deteriorating conditions of air conditioning units. Over a period of six days, surveyors noted a persistent smell of urine in various areas, including the conference room, the 400 Unit Nurse's Station Hallway, and the 400 Unit Hallway. Interviews with staff, including an LPN and the Administrator, confirmed awareness of the odor issue, attributing it to a resident urinating on the floor. Despite this acknowledgment, the problem persisted across multiple days and locations. Additionally, the facility's maintenance of heating and air conditioning units was found lacking, with observations of paint flaking and rust on units in resident rooms. The facility's current maintenance policy, dated March 2015, was provided by the DON, indicating a requirement for documentation of functional compliance for heating and cooling systems. However, the observed conditions suggest a failure to adhere to these standards, contributing to an unsanitary and potentially unsafe environment for residents.
Failure to Provide Required Medicare Coverage Notices
Penalty
Summary
The facility failed to provide the necessary SNF-ABN (Skilled Nursing Facility-Advanced Beneficiary Notice) and NOMNC (Notice of Medicare Non-Coverage) forms to two residents who were discharged from Medicare services but remained in the facility. Resident 9, who began receiving Medicare Part A Skilled Services on August 26, 2024, had her last covered day on October 18, 2024. Although she received a NOMNC form indicating the end of her Medicare coverage, she did not receive the required SNF-ABN form. The Social Services Director confirmed that Resident 9 remained in the facility and acknowledged the oversight in not providing the SNF-ABN form. Similarly, Resident 215, who started receiving Medicare Part A Skilled Services on June 24, 2024, had her last covered day on July 31, 2024. She did not receive either the SNF-ABN or NOMNC forms because she was discharged from therapy before the end of her covered days. The Social Services Director admitted that Resident 215 remained in the facility and had not received the necessary forms since 2022. The Director also indicated a lack of understanding of the Medicare Part A coverage process, which contributed to the failure in providing the required notifications.
Failure to Provide Transfer Documentation for Hospitalized Resident
Penalty
Summary
The facility failed to provide the necessary documentation for a resident who was emergently transferred to the hospital. The incident involved a resident with diagnoses including a fracture of the neck and disorders of bone density. Upon review of the clinical record, it was found that there was no transfer paperwork accompanying the resident when they were sent to the hospital following a fall that resulted in a fractured neck. During interviews, the Director of Nursing (DON) confirmed the absence of transfer forms and acknowledged that documents such as the face sheet and bed hold policy should have been sent with the resident to the hospital.
Failure to Notify Ombudsman of Emergency Hospital Transfer
Penalty
Summary
The facility failed to notify the Ombudsman office regarding the emergency transfer of a resident to the hospital. Resident 7, who is moderately cognitively impaired and has diagnoses including a fracture of the neck and disorders of bone density, was emergently transferred to the hospital after a fall resulting in a fractured neck. The clinical record lacked any transfer paperwork or information sent to the Ombudsman for this hospitalization. Interviews with the Director of Nursing and the Social Service Director revealed that there were no transfer forms located, and the Social Service Director acknowledged the absence of the required notification to the Ombudsman. An email from the Ombudsman Office indicated that information regarding emergency transfers expected to return can be provided in a monthly list to the State LTC Ombudsman portal.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for three residents, leading to deficiencies in addressing behaviors, accidents, and nutrition. Resident 39, who has unspecified dementia and cognitive communication deficits, was observed eating puzzle pieces, indicating a need for a behavior-focused care plan. Despite discussions between the Social Service Director and the family about the resident's behaviors, the care plan lacked specific interventions for these behaviors. Resident 58, diagnosed with dysphagia and PTSD, was involved in an altercation with a roommate, resulting in a room transfer. However, there was no documentation of the incident or a care plan addressing the retaliatory behavior that led to the room change. The Social Services Director acknowledged the oversight in documentation and care planning. Resident 15 experienced significant weight loss, dropping from 200.1 lbs to 164.6 lbs over several months. Despite being on nutritional supplements and having a care plan indicating a risk for weight loss, there was no updated intervention plan to address the ongoing weight loss. The facility's policy required monthly weight monitoring, but the care plan was not revised to reflect the resident's nutritional needs adequately.
Failure to Conduct Quarterly Care Plan Conferences
Penalty
Summary
The facility failed to conduct quarterly care plan conferences for two residents, Resident 13 and Resident 29, as required. Resident 13, who has diagnoses including dementia and anxiety, did not have a quarterly care plan conference between March 20, 2024, and September 25, 2024. A significant change MDS assessment dated October 8, 2024, indicated that Resident 13's cognition level was not assessed due to diminished cognition, and the resident was dependent on staff for toileting, bathing, and transfers. Similarly, Resident 29, diagnosed with multiple sclerosis, involuntary eye movements, and kidney calculus, did not have a quarterly care plan conference between April 4, 2024, and August 21, 2024, through November 14, 2024. An annual MDS assessment dated August 13, 2024, showed that Resident 29 was cognitively intact but dependent on staff for eating, toileting, bathing, and transfers. The Social Services Director confirmed that care plan conferences should occur at least quarterly, and the Director of Nursing provided documentation indicating that the interdisciplinary team must review and update the care plan quarterly in conjunction with the required MDS assessment.
Failure to Provide Person-Centered Activities for Resident with Dementia
Penalty
Summary
The facility failed to provide person-centered engagement activities for a resident with dementia and anxiety. Observations over several days revealed that the resident was consistently positioned in her wheelchair in a way that obstructed her view of the television, either by a large plant or by facing away from the screen. On multiple occasions, the television was on a menu screen, indicating a lack of engagement. Additionally, the resident was not offered the opportunity to attend group activities, such as bingo, despite being in the common area during these events. The resident's care plan emphasized the importance of involving her in daily activities, encouraging socialization, and providing one-on-one conversations. However, there was a lack of documentation in the clinical record regarding invitations to or participation in activities since the last care plan revision. A CNA indicated that the resident would participate in group activities if assisted by staff, but personal restrictions prevented the CNA from bringing residents to activities. The facility's policy required effective communication and documentation of resident participation in activities, which was not adhered to in this case.
Failure to Arrange Vision Services for Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 29, received proper treatment to maintain vision abilities. Resident 29, who has diagnoses including multiple sclerosis, diplopia, and involuntary eye movements, was observed wearing cloudy glasses and reported not having been assessed by vision services in over a year. The resident's clinical record indicated a lack of documentation showing that she had been evaluated by vision services or offered transportation for such services since April 2023, despite care plan interventions requiring consultation with an eye care practitioner and ensuring glasses are in good repair. Interviews with facility staff revealed a gap in the process for arranging vision services. The Social Services Director indicated that residents must request health services like vision screenings, or it should be agreed upon admission and discussed during care plan conferences. However, the facility's policy on the care of visually impaired residents states that it is the facility's responsibility to assist residents in locating resources, scheduling appointments, and arranging transportation for needed services. This discrepancy contributed to the failure in providing necessary vision care for Resident 29.
Inadequate Suprapubic Catheter Care Leads to Infections
Penalty
Summary
The facility failed to provide appropriate care for a resident with a suprapubic catheter, leading to an infection at the catheter insertion site and multiple urinary tract infections. The resident, who had a history of prostate cancer and other medical conditions, was found to have a suprapubic catheter that was not being maintained according to physician orders. The clinical record lacked specific orders for routine catheter care beyond monthly changes, and there were inconsistencies in the documentation of catheter changes in the Medication/Treatment Administration Record. Observations revealed that the resident's catheter bag was improperly placed on the floor, and staff did not adhere to enhanced barrier precautions during care. Certified Nursing Aides (CNAs) were observed using a mechanical lift sling on the resident without washing it between uses, and they did not wear gowns as required for enhanced barrier precautions. Additionally, the facility's policies did not specify the frequency of suprapubic catheter care, and there was a lack of in-service training for CNAs on catheter care. Interviews with staff indicated confusion and lack of clarity regarding the responsibilities for catheter care. The Registered Nurse (RN) and Director of Nursing (DON) acknowledged that the catheter site should be cleansed daily, but this was not consistently documented or performed. The facility's failure to ensure proper catheter care and adherence to infection control protocols contributed to the resident's infections.
Failure to Provide Adequate Hydration to Resident
Penalty
Summary
The facility failed to ensure that a resident was offered sufficient fluid intake to maintain proper hydration and health. During an observation, the resident was found in bed with the call light out of reach and an empty cup labeled from the previous night on the bedside table. The resident expressed that she did not feel she received enough fluids and was unable to call for staff assistance due to her physical condition and the call light being out of reach. The resident's clinical record indicated she was dependent on staff for eating, toileting, bathing, and transfers, and was on diuretic medication, which increases the risk of dehydration. The resident had a history of multiple sclerosis, hydronephrosis, and kidney stones, and had been admitted to the hospital for kidney stones and a urinary tract infection related to sepsis. A nutritional risk assessment indicated the resident was at risk for dehydration due to recurrent infection and diuretic use, requiring an estimated 1600-1900 mL of fluid daily. However, the facility's Director of Nursing indicated that residents were not closely monitored for exact fluid intake unless on a fluid restriction, and nurses were expected to assess for signs of dehydration each shift. The facility's policy on hydration required staff to identify and report individuals with signs of fluid imbalance, but this was not effectively implemented for the resident in question.
Medication Availability and Dispensing Deficiency
Penalty
Summary
The facility failed to ensure that routine medications were available and dispensed according to physician's orders for two residents. For Resident 15, it was observed that the medication cart did not contain ProStat, a protein supplement prescribed to be administered twice daily. The Qualified Medicine Aide (QMA) indicated that the medication was not available and mistakenly believed it could be obtained from medications of discharged residents. Resident 15's medical history included dysphagia and gastro-esophageal reflux disease, necessitating the prescribed supplements. For Resident 47, the facility did not maintain an adequate supply of ProStat AWC SF, a wound healing supplement. The Medication Administration Record indicated multiple instances where the supplement was not administered as ordered, with some doses being missed or incorrectly administered. The Registered Nurse (RN) and Director of Nursing (DON) confirmed the absence of the supplement in the supply room, and it was noted that the resident had been receiving the supplement from a general supply that had run out. Resident 47's medical conditions included pressure ulcers, hemiplegia, cancer, diabetes, and coronary artery disease, highlighting the importance of the prescribed wound healing supplement.
Medication Error Rate Exceeds 5% Due to Improper Insulin Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5 percent, resulting in an observed error rate of 8 percent during a medication pass. This deficiency was identified through the observation of two medication errors out of 25 opportunities for error. Specifically, the errors involved the administration of insulin to two residents. In both cases, the Licensed Practical Nurse (LPN) did not prime the insulin pens before administering the medication, which is a necessary step to ensure accurate dosing as per the manufacturer's instructions. The first incident involved a resident with a blood glucose level of 198 mg/dL, who was administered 3 units of insulin lispro without priming the pen. The second incident involved another resident with a blood glucose level of 145 mg/dL, who was administered 2 units of insulin aspart, again without priming the pen. The facility's insulin administration policy, which requires nursing staff to follow manufacturer instructions for insulin delivery systems, was not adhered to. This oversight was further compounded by a registered nurse's incorrect assertion that priming was unnecessary, despite clear instructions in the insulin pen manuals.
Inconsistent Documentation of Wound Care Treatments
Penalty
Summary
The facility failed to ensure consistent documentation for wound care treatments for a resident with multiple pressure injuries. The resident, who was diagnosed with pressure ulcers on the right buttock and right heel, along with other medical conditions such as hemiplegia, hemiparesis, prostate cancer, diabetes mellitus type 2, coronary artery disease, and peripheral vascular disease, required specific wound care treatments. The clinical records indicated that the resident was mild to moderately cognitively impaired and required extensive assistance from two staff members for bed mobility, transferring, and toileting. Despite having orders for specific wound care treatments, the Medication Administration Record/Treatment Administration Record showed incomplete documentation of these treatments on several dates in October and November 2024. The Director of Nursing was unable to provide an explanation for the inconsistent documentation of the treatments. The job description for the staff nurse indicated responsibilities for receiving and transcribing orders and ensuring the competent administration of care and treatments according to physician orders and facility policy. However, the records revealed that the treatments for the resident's pressure injuries were not consistently documented, leading to a deficiency in the facility's care practices.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to adhere to proper infection prevention and control practices for three residents, leading to deficiencies in care. For Resident 47, who had multiple open wounds and an indwelling suprapubic catheter, CNAs used a mechanical lift sling that had been previously used on another resident without washing it between uses. Additionally, the CNAs did not wear gowns for enhanced barrier precautions during the care of Resident 47. In another instance, CNAs providing incontinence care for Resident 8 did not change gloves or sanitize their hands before placing a new brief on the resident. Furthermore, an LPN changing a dressing on Resident 8's right shoulder did not change gloves or sanitize hands before applying a clean bandage. During catheter care for Resident 29, the resident expressed discomfort with staff wearing gowns and face masks, which was not a usual practice. The facility's policies on infection control and enhanced barrier precautions were not followed, contributing to these deficiencies.
Pest Control Deficiency in Resident Areas
Penalty
Summary
The facility failed to maintain a safe environment free of pests, as evidenced by multiple observations of flies and gnats in resident areas. On three separate occasions, surveyors observed flies and gnats in Resident 15's room and the Second Floor Nurse's Station. Resident 15 reported previous incidents of flies and gnats in their room. During an interview, the Administrator was unaware of the pest issue in the resident's room. The facility's pest control policy, dated August 2011, mandates a clean and sanitary environment free from pests and requires an appropriate pest control contract to be in operation.
Transport Safety Failures Lead to Resident Injuries
Penalty
Summary
The facility failed to ensure adequate safety measures during the transport of a resident, resulting in two separate incidents that led to injuries. In the first incident, the resident was being transported to an appointment when her foot got caught beneath the wheelchair due to the absence of footrests. This resulted in a fracture to her left ankle. The driver, who was aware that footrests should be used, did not attach them because the resident typically self-propelled her wheelchair. However, during this transport, the resident was being pushed, and the lack of footrests led to the injury. In the second incident, the same resident was being transported in the facility van when she slid out of her wheelchair. The driver had not properly secured the seatbelt, which allowed the resident to slide out of the chair, resulting in a fracture to her right ankle. The driver had previously been educated on the proper use of seatbelts but failed to apply this knowledge during the transport. The resident reported that the driver did not buckle her in properly and only secured the legs of the wheelchair, which contributed to her sliding out of the chair. The resident involved in these incidents had a medical history that included fractures to both lower legs, osteoarthritis, diabetes mellitus, and pain. She was dependent on a wheelchair for mobility and required assistance for transfers and other activities of daily living. The facility's failure to adhere to safety protocols during transport directly led to the resident sustaining injuries that required medical intervention.
Medication Disposal and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper disposal and storage of medications for discharged and deceased residents, as well as maintaining appropriate security and temperature controls for medications. Observations revealed that controlled medications were not double locked, and the refrigerator containing these medications was not secured with a locked padlock. Additionally, the refrigerator freezer had a thick layer of ice with unidentifiable medication packages stuck in it, and there was no temperature log sheet for the refrigerator. Medications for residents who had been discharged or had expired were not disposed of in a timely manner, and there was a lack of documentation for the disposition of non-narcotic medications. Specific instances included a bottle of lorazepam intensol for Resident H, whose medication had been discontinued, and a bottle for Resident G, both found in the refrigerator. A bottle of lorazepam intensol with no resident identifier was found in a cup labeled with Resident E's name, who had expired at the facility. Medications for Resident D and Resident J, who had also expired or been discharged, were found improperly stored. The facility's procedure for drug disposition was inadequate, as non-narcotic medications were placed in a tote for pharmacy pickup without proper documentation, contrary to the facility's policy requiring documentation of medication disposal.
Failure to Implement Timely Care Plan for Enteral Feeding
Penalty
Summary
The facility failed to develop and implement a timely care plan for a resident with an enteral feeding tube. The resident, admitted on 3/29/24, had diagnoses including dysphagia, speech and language deficits, and muscle weakness. Despite physician orders for enteral feeding and treatments initiated on 4/30/24, the care plan did not include a focus on the resident's feeding tube until 5/13/24. Observations on 5/13/24 and 5/14/24 revealed that the resident's enteral feeding pump was not running as ordered, and there was a lack of documentation in the medication administration record (MAR) and treatment administration record (TAR) indicating that the physician's orders were followed on multiple occasions. Interviews with staff indicated that the resident's enteral feeding should have been turned on daily at 1:00 P.M., but it was not running during observations. Additionally, the staff failed to document any refusals of the enteral feeding by the resident. The facility's policies on care plans and gastrostomy site care were not adhered to, as evidenced by the lack of a comprehensive, person-centered care plan within 21 days of admission and the failure to follow physician orders for enteral feeding and tube flushing. This deficiency was related to complaint IN00434111.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident from abuse, as evidenced by an incident where Resident D inappropriately touched Resident E. This incident was observed by a staff member, who reported that Resident D had placed his hand down Resident E's pants. The incident occurred in a common area of the facility, and Resident E was visibly upset by the encounter. Despite the immediate separation of the residents and notification of relevant authorities, the incident highlights a lapse in the facility's ability to prevent resident-to-resident abuse. Resident E, who was the victim of the inappropriate touching, has a medical history that includes bipolar disorder, major depressive disorder, Parkinson's disease, generalized anxiety disorder, and unspecified dementia with mood disturbance. At the time of the incident, Resident E's cognition was moderately impaired, which may have affected his ability to fully comprehend or recall the event. Despite this, Resident E reported feelings of trauma related to past abuse, indicating that the incident had a psychological impact. Resident D, the perpetrator, also has a history of mental health issues, including altered mental status, dementia, and anxiety. His care plan noted a tendency for inappropriate sexual behavior, which suggests that the facility was aware of potential risks. However, the incident still occurred, indicating a failure in monitoring or intervention strategies to prevent such behavior. The facility's policy on abuse prevention was not effectively implemented in this case, leading to the deficiency noted in the report.
Latest citations in Indiana
Surveyors observed that dietary staff repeatedly worked in kitchen and meal service areas with uncovered facial hair, despite facility policy and state sanitation requirements mandating effective hair restraints. Two dietary aides with short beards or mustaches were seen walking through food preparation areas, taking food temperatures, handling food, and plating meals at steamtables in dining rooms without any facial hair coverings, while the current policy required all hair, including facial hair, to be restrained to prevent contamination.
The facility failed to consistently provide and document required bed-hold policy notices when several residents were transferred to the hospital. In multiple cases, residents with dementia, psychotic disorders, COPD, chronic respiratory failure, altered mental status, and cerebral infarction were sent out for acute changes in condition, and while transfer notes reflected physician and family notifications, they lacked documentation that the bed-hold policy was discussed with the resident or responsible party. Notices of Transfer or Discharge often indicated a copy of the bed-hold policy was sent with the resident, but the records did not show signed and dated acknowledgment by the resident or appropriate representative, including in situations where a resident had moderate cognitive impairment, short-term memory issues, or a documented need for a proxy and a financial POA authorizing an agent for health care decisions.
Surveyors found that the facility failed to provide trauma‑informed and culturally competent care by not incorporating two residents’ extensive trauma histories and specific behavioral triggers into their care plans. One resident with documented homelessness, polysubstance abuse, severe accidents with multiple fractures, viral encephalitis with coma, physical and sexual abuse, loss of family contact, and a past suicide attempt had multiple behavior‑focused care plans that referenced identifying triggers but listed none and did not mention their physical, sexual, medical, or psychosocial trauma. Another resident with TBI from being struck by a truck, an 11‑month coma, long‑term state hospital residence, alleged shooting of a parent, and diagnoses including intermittent explosive disorder and borderline personality disorder had a PASRR identifying a specific trigger and notes of inappropriate sexual behavior, yet their care plans omitted these traumatic events, the identified trigger, and the sexual behavior. Staff interviews confirmed that residents were screened for trauma, but the trauma histories and triggers were not reflected in the individualized plans of care.
A resident with schizophrenia, post‑stroke hemiparesis, and mild cognitive impairment expressed feeling down and wanting to kill himself, but staff did not document asking about a specific plan, did not notify the physician or psychiatric NP as expected, and did not develop or update a care plan addressing depression or suicidal ideation. The SSD documented offering support and initiating 15‑minute checks once, but there was no further follow‑up or documentation of interventions after subsequent suicidal statements made in a care plan meeting with the resident’s father. The DON and Administrator reported that facility policy requires immediate notification of key staff, assessment for a plan and means of self‑harm, and thorough documentation, which were not carried out or reflected in the medical record for this resident.
A resident with schizophrenia, post-stroke hemiparesis, and mild cognitive impairment verbalized suicidal ideation, but the care plan did not address depression or suicidal thoughts, and required assessments and services were not accurately or timely documented. An SSD note recorded the resident saying he wanted to kill himself and referenced 15‑minute checks and a care plan update, yet the active care plan lacked depression/suicidal ideation interventions. Multiple late-entry Social Services notes were later added, describing follow-up visits and the resident denying suicidal ideation, but the SSD later reported she did not typically ask about a suicide plan and did not personally provide individual follow-up visits as described. These practices conflicted with the facility’s policy requiring factual, first-hand, and timely documentation of assessments and services.
A resident was observed with an Albuterol inhaler on an overbed table and later reported keeping the inhaler in a nightstand drawer, with no staff present during these observations. Record review showed the resident had no cognitive impairment on the admission MDS but lacked any documented self-medication administration assessment. The DON acknowledged that the required assessment had not been completed, despite facility policy requiring staff and the practitioner to evaluate each resident’s mental and physical abilities before allowing self-administration of medications.
Surveyors found that the facility submitted inaccurate direct care staffing data to CMS through the PBJ system over multiple days in a quarter. CASPER reports showed apparent gaps in 24-hour licensed nurse coverage, low weekend staffing, and a 1-star staffing rating, while internal staffing sheets documented that licensed nurses were present and the facility was fully staffed on those days. The Administrator reported that the discrepancies were due to PBJ data entry errors, despite a facility policy requiring all PBJ entries to be accurate, auditable, and verifiable against payroll, invoices, or contracts.
Surveyors found that the facility did not provide or document required written transfer/discharge notices and bed-hold policy information for four residents who were sent to the hospital, including individuals with conditions such as dementia, CHF, chronic respiratory failure, and CKD. In each case, progress notes showed that the resident was transferred for acute issues, but the clinical records lacked evidence that written notices were given to the residents or their representatives, and in one case lacked documentation that required information was sent to the receiving provider. Facility leadership, including the ADON, DON, and Administrator, acknowledged that the records did not contain the required documentation, despite a written policy requiring such notices and information exchange.
A resident with Alzheimer’s disease and depression, previously on an antidepressant, exhibited intermittent refusals of medications and care, occasional yelling at staff, and reports of unusual perceptions, such as believing men were in or near her room. Nursing notes over several months documented these refusals and complaints but did not show that the behaviors were evaluated or recorded as dangerous, non-redirectable, or causing significant distress, nor did they document specific non-pharmacological interventions attempted or their outcomes. Despite this, a psychiatric NP later added new diagnoses of schizoaffective disorder, borderline personality disorder, and delusional disorder and ordered an antipsychotic (Seroquel) without a comprehensive evaluation in the record to support these diagnoses. The facility’s psychotropic medication policy, which requires identification and documentation of target behaviors, use of nonpharmacological interventions, and ongoing behavior monitoring, was not followed for this resident.
The facility failed to keep PASARR Level I screenings accurate and current for three residents when new mental health diagnoses and psychoactive medications were initiated. One resident’s PASARR omitted a PTSD diagnosis and an added antidepressant, despite documentation of PTSD on the MDS and care plan and a physician order for Pristiq. Another resident’s PASARR listed only depression and dementia, even after additional diagnoses such as borderline personality disorder, delusional disorder, and schizoaffective disorder were added and an antipsychotic (quetiapine) was ordered, with the MDS later reflecting psychotic disorder, schizophrenia, and depression with antipsychotic and antidepressant use. A third resident’s PASARR did not include a depression diagnosis or newly ordered escitalopram and lorazepam, although the admission MDS documented depression with antianxiety and antidepressant use. These omissions occurred despite facility policy requiring a new Level I review after significant mental status changes, including new mental health diagnoses or new psychotropic medications.
Uncovered Facial Hair During Food Preparation and Meal Service
Penalty
Summary
The deficiency involves the facility’s failure to ensure that food was served in a sanitary and safe manner in accordance with professional standards and facility policy during multiple kitchen and meal service observations. During an initial kitchen observation, two dietary aides were seen walking through the kitchen food preparation area with uncovered facial hair. One aide had facial hair above and below the lip and along the jaw line, approximately one-fourth inch in length, and the other had a mustache of similar length; neither used any facial hair covering. These observations occurred while staff were present in the kitchen area where food was stored and prepared. During subsequent observations on the same day, the same two dietary aides were again observed with uncovered facial hair while directly involved in meal preparation and service. One aide walked through the kitchen while the noon meal was being prepared and placed into a transport cart for service in the south dining room, and later was observed plating the noon meal at the steamtable in that dining room, still without a facial hair covering. The other aide walked through the kitchen while the noon meal was being prepared and placed into the steamtable for the north dining room, took food temperatures, assisted with plating meals at the steamtable, and retrieved food items and supplies from the kitchen, all while having an uncovered mustache approximately one-fourth inch in length. The Dietary Manager stated that staff hair was to be covered when in the kitchen and during meal service, and the facility’s written policy and the cited Indiana Food Establishment Sanitation Requirements both required effective hair restraints, including for facial hair, to prevent contamination of food, equipment, and utensils.
Failure to Provide and Document Bed-Hold Policy at Time of Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure that required bed-hold policy information was provided and documented for four residents transferred to the hospital. For a resident with dementia, psychotic disorder, and autistic disorder who had a BIMS score of 0 indicating severe cognitive impairment, progress notes documented physician notification and guardian notification when the resident was sent to the hospital, but there was no documentation that the bed-hold policy was provided to the responsible party. A Notice of Transfer or Discharge later indicated a copy of the bed-hold policy was sent with the resident. Another resident with COPD and chronic respiratory failure, cognitively intact with a BIMS score of 13, experienced a decline in condition and was transferred to the hospital by ambulance; progress notes documented family notification but did not document any discussion of the bed-hold policy, although a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident. A third resident with altered mental status and cerebral infarction, with a BIMS score of 10 indicating moderate cognitive impairment and documented short-term memory impairment, experienced changes in condition and was transferred to the hospital. Progress notes stated the resident was their own responsible party and that no other notification was completed, and transfer documentation did not include the bed-hold policy, although an untimed Notice of Transfer or Discharge indicated a copy of the bed-hold policy was signed by the resident. A financial power of attorney document in the record showed the resident had designated an agent to act in consent or refusal of health care. For a fourth resident with dementia and osteomyelitis, transfer documentation and a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident, and the transfer form noted the resident required a proxy for decision making. The facility’s policy required that at the time of transfer to a hospital, written notice specifying the duration of the bed-hold policy and information on return to the next available bed be provided, and that a signed and dated copy of the bed-hold notice given to the resident or representative be kept in the resident file, which was not consistently documented for these residents.
Failure to Integrate Trauma Histories and Behavioral Triggers Into Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to identify and incorporate residents’ trauma histories and specific behavioral triggers into their care plans, despite documented histories of significant trauma and behavioral health issues. For one resident, extensive social service and progress notes documented homelessness, polysubstance abuse, major depressive and anxiety disorders, chronic pain, a history of severe car accidents with multiple fractures, viral encephalitis resulting in a three‑month coma, loss of child custody, multiple divorces, physical abuse by a spouse, the death of a fiancé who was struck by a car while in a wheelchair, lack of family contact, and a past suicide attempt by Valium overdose. Additional documentation noted a history of rape by a brother at age eight and prior placement under direct supervision and 15‑minute checks related to suicidal ideation. Despite these documented traumatic events and behavioral health concerns, the resident’s care plans did not identify a history of physical trauma, sexual trauma, homelessness, substance abuse, medical trauma, or attempted suicide. For this same resident, the MDS showed no cognitive deficit and identified behaviors such as verbal aggression and rejection of care, along with diagnoses including seizure disorder, depression, chronic pain syndrome, homelessness, and anxiety disorder. Multiple care plans addressed behaviors such as drug‑seeking, pretending to have seizures for attention or medication, making false allegations, verbal aggression when unable to smoke, and a desire for intimate relationships with consenting male residents. These care plans referenced goals such as effective coping skills, seeking staff support, and compliance with the smoking policy, and they called for identification and reduction of behavioral triggers. However, none of these care plans actually listed any specific triggers. The care plan addressing the resident’s right to consensual intimate relationships focused on assessment and education regarding consent but did not integrate the resident’s extensive trauma history. Staff interviews indicated the resident had displayed sexual behaviors since admission, including an incident where the resident expressed anger at another resident for not buying a soda after engaging in sexual acts. A second resident with a documented history of traumatic brain injury (TBI), dementia, seizure disorder, borderline personality disorder, anxiety, intermittent explosive disorder, tobacco use, and other behavioral/emotional disorders was also affected by the same deficiency. Social history and progress notes documented that this resident sustained a TBI after being hit by a semi‑truck while riding a bicycle at age 18, resulting in an 11‑month coma, followed by 13 years in a state hospital and subsequent residence in a group home. Additional documentation indicated the resident allegedly shot their father at age 26 after being sworn at and had a PASRR identifying TBI, intermittent explosive disorder, and borderline personality disorder, with a specific trigger of hearing the name of the current U.S. President. Progress notes also described inappropriate sexual behavior toward staff, including touching themselves intimately during personal care and refusing to stop when redirected. Despite this, the resident’s care plans, which addressed explosive disorder and history of altercations, risk for decreased psychosocial well‑being, and refusal to bathe or shower, did not list any specific behavioral triggers, did not reference the traumatic events such as being hit by a truck or shooting their father, and did not document the inappropriate sexual behavior. The Administrator and Social Service Director acknowledged that residents were to be screened for trauma and that trauma responses and PTSD should be added to care plans, but the specific trauma histories and triggers for these two residents were not incorporated into their plans of care.
Failure to Assess and Care Plan for Resident Suicidal Ideation
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess, investigate, and care plan for a resident’s suicidal ideation in accordance with its own policy and staff expectations. The resident had diagnoses including schizophrenia, cerebral edema, and hemiparesis/hemiplegia following a cerebral infarction, and a current MDS showed mild cognitive impairment (BIMS score 12). A progress note documented that the resident told the Social Services Director (SSD) he was feeling down and wanted to kill himself; the SSD offered assistance, activities, and initiated 15‑minute checks, and the note stated the care plan was updated. However, the note did not indicate that the SSD asked whether the resident had a plan to kill himself, and there were no additional notes regarding suicidal ideation or follow‑up. Review of the current care plan showed no problem, goal, or interventions addressing depression or suicidal ideation, and progress notes over the following month contained no documentation of physician notification related to the suicidal statement. Further record and interview evidence showed that the care plan conference summary did not document interventions for suicidal ideation, and the SSD acknowledged she did not normally ask residents expressing suicidal ideation if they had a plan. The SSD reported that the resident had admission paperwork mentioning suicidal ideation related to depression after a stroke and that the resident again vocalized suicidal ideation during a care plan meeting with his father, after which emotional support was offered and the father took the resident out on a leave of absence; no further visits or follow‑up were done. The DON stated that, upon notification of suicidal verbalization, staff should assess the resident, ask if there is a plan, remove potential means of self‑harm, immediately notify the psychiatric NP, and document the occurrence, and that a detailed progress note and updated care plan were expected but not present for this resident. The Administrator similarly stated that staff should ask about a plan, document interventions, notify the physician and family, and update the care plan, and indicated the resident should have had a care plan addressing depression with suicidal ideation. The facility’s written policy required immediate notification of the DON, SSD, and physician, an interview including asking about a plan and assessing mood and means for self‑harm, and thorough documentation of mood, behavior, and all actions taken, which were not reflected in the resident’s record.
Incomplete and Inaccurate Documentation of Suicidal Ideation and Follow-Up
Penalty
Summary
The facility failed to ensure accurate, complete, and timely documentation of assessments and services for a resident who verbalized suicidal ideation. Resident 6, who had schizophrenia, cerebral edema, and right-sided hemiparesis/hemiplegia following a cerebral infarction, had a BIMS score of 12 indicating mild cognitive impairment. The resident’s admission paperwork mentioned suicidal ideation related to depression after a stroke, and a Social Services note on 3/11/2026 documented that the resident was feeling down and said he wanted to kill himself. The Social Services Director (SSD) documented that she talked with the resident, coordinated with Activities, advised the resident to contact SSD or nursing if he wanted to talk, and that the resident was scheduled for 15-minute checks and the care plan was updated. However, the current care plan initiated on 2/26/2026 did not address depression or suicidal ideation. Multiple Social Services progress notes were later entered as late entries in April, with effective dates in March, stating that the resident had no plan and no longer had suicidal ideation, that he felt much better after 1:1 time, and that he continued his daily routine and therapy. These late entries described follow-up visits and reassessments of suicidal ideation on several consecutive days, but in interviews the SSD stated she did not normally ask residents about having a plan when they verbalized suicidal ideation and did not recall any other occurrences beyond the initial event. She further indicated she did not personally provide individual follow-up visits with this resident regarding suicidal ideation, despite the late-entry notes describing such visits. The DON acknowledged that late entries had been added to address concern about suicidal verbalization, and the Administrator stated that upon suicidal statements staff should ask about a plan, notify the physician and family, and update the care plan, and that this resident should have had a care plan addressing depression with suicidal ideation. The facility’s documentation policy required factual, first-hand, timely documentation, which was not followed in this case.
Failure to Complete Required Self-Administration Assessment for Inhaler Kept at Bedside
Penalty
Summary
Surveyors identified that a resident was allowed to keep and access an Albuterol inhaler without the facility completing the required self-administration medication assessment. During an initial tour, the resident was observed sitting in a wheelchair with a handheld Albuterol inhaler on the overbed table and no staff present in the room or hallway. On a subsequent observation, the resident again was in a wheelchair and reported that the Albuterol inhaler was stored in the top drawer of the nightstand, where it was found. Review of the clinical record showed an admission MDS indicating no cognitive impairment, but there was no documentation of a self-medication administration assessment. In an interview, the DON confirmed that the resident did not have the required self-medication assessment, despite the facility’s policy stating that staff and the practitioner must assess each resident’s mental and physical abilities to determine whether self-administering medications is clinically appropriate. This failure to complete and document a self-administration medication assessment for a resident who had an Albuterol inhaler kept at bedside constituted noncompliance with the facility’s own policy and with 410 IAC 16.2-3.1-11(a).
Inaccurate PBJ Staffing Data Submission to CMS
Penalty
Summary
The deficiency involves the facility’s failure to electronically submit complete and accurate direct care staffing information to CMS through the Payroll-Based Journal (PBJ) system for 22 days in a fiscal quarter. A CASPER report review on 4/6/26 showed that, according to PBJ data, the facility did not have licensed nursing coverage 24 hours per day on multiple specific dates across three months, had low weekend staffing, and held a 1-star staffing rating. However, review of the facility’s internal staffing sheets for that quarter indicated the facility was fully staffed and had licensed nurse coverage on all of the dates in question. During an interview, the Administrator stated that the PBJ information must have contained data entry errors, as she had verified licensed staff coverage on the timesheets. The facility’s PBJ policy in effect stated that all staffing data entered into the PBJ system would be auditable and verifiable through payroll, invoices, or contracts, but the submitted PBJ data did not accurately reflect the facility’s actual licensed nurse staffing as documented on internal records. No specific residents or clinical conditions were mentioned in the report, and the deficiency centers solely on inaccurate staffing data submission rather than direct resident care events.
Failure to Provide and Document Required Transfer/Discharge and Bed-Hold Notices
Penalty
Summary
The deficiency involves the facility’s failure to provide and document required written notices of transfer/discharge and bed-hold policies, as well as required information to receiving providers, for four residents who were transferred or discharged to the hospital. For a resident with generalized anxiety disorder, major depressive disorder, and dementia, progress notes showed that the resident was sent to the hospital via 911 for chest pain, lower back pain, and shortness of breath and later returned to the facility, but the clinical record lacked documentation that a written Notice of Transfer/Discharge and the bed-hold policy were provided to the resident or representative, and lacked documentation that required information was conveyed to the receiving facility. The ADON and the Administrator both confirmed there was no documentation that these written notices were provided. For a resident with congestive heart failure and muscle weakness who was sent to the emergency room for painful urination and bloody urine, the clinical record lacked documentation that a Notice of Transfer/Discharge or bed-hold policy was given to the resident or representative, which the DON confirmed. Another resident with chronic respiratory failure and diabetes was discharged to the hospital for respiratory failure, and a resident with chronic kidney disease and dementia was discharged to the hospital, but in both cases there was no documentation that a written notice of transfer/discharge or bed-hold policy was provided to the residents or their representatives. Review of the facility’s Transfer and Discharge policy, dated 1/15/26, showed that the policy required the facility to provide written transfer/discharge notices and bed-hold information to residents and representatives and to provide specified information to receiving providers, but the records for these four residents did not contain the required documentation.
Failure to Document Target Behaviors and Non-Pharmacological Interventions Before Initiating Antipsychotic
Penalty
Summary
The deficiency involves the facility’s failure to document how a resident’s behaviors presented danger or distress to self or others, and failure to document non-pharmacological interventions attempted prior to initiating an antipsychotic medication. Resident 6 had documented diagnoses of Alzheimer’s disease, depression, and severe cognitive impairment, and was receiving sertraline for depression. A PASSAR identified only depression and dementia, and the admission MDS listed Alzheimer’s disease and depression as active diagnoses. Over several months, nursing progress notes documented that the resident intermittently reported unusual perceptions, such as believing there were men causing trouble, a man in her room, or a man wanting to marry her and yelling through the walls, but there was no documentation that these episodes caused danger to the resident or others or that they resulted in unmanageable distress. From late April through mid-July, nursing notes primarily described the resident’s frequent refusals of evening and morning medications, blood sugar checks, blood pressure checks, insulin administration, hygiene care, and showers. Staff documented that the resident sometimes yelled at staff, said “Get out!”, was visibly upset by a room move, was leery of staff and asked to see name badges, and became upset about a pillow under her head until it was removed, after which she calmed down. The notes also recorded instances where the resident believed housekeeping had not cleaned her room or that she had not received medications when she had. However, there were no progress notes or assessments indicating that these behaviors were evaluated as dangerous, non-redirectable, or causing significant distress or functional impairment, and no detailed behavior monitoring logs were present as required by facility policy. On a psychiatric NP visit for initial psychotropic medication management, new mental health diagnoses of schizoaffective disorder, borderline personality disorder, and delusional disorder were added, and Seroquel 25 mg, an antipsychotic, was ordered. The clinical record did not contain a comprehensive evaluation to support these new diagnoses, and there was no documentation of target behaviors meeting the facility’s policy criteria for psychotropic use, such as behaviors representing danger to self or others, causing distress and impairment in functional abilities, or clearly attributable to psychosis or mania. The resident’s representative reported that the resident had no prior history of mental health disorders or psychiatric hospitalization and was unaware of the new diagnoses. The facility’s own psychotropic medication policy required identification and documentation of specific target behaviors, use and documentation of nonpharmacological interventions, and ongoing monitoring of behaviors and interventions, which were not reflected in the record for this resident.
Failure to Update PASARR Screens for New Mental Health Diagnoses and Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that Preadmission Screening and Resident Review (PASARR) Level I screenings were accurate and updated when new mental health diagnoses and psychoactive medications were initiated for multiple residents. For one resident with dementia, anxiety, depression, and post-traumatic stress disorder (PTSD), the PASARR completed on admission listed anxiety, depression, and dementia with sertraline and quetiapine, but did not include the PTSD diagnosis or the antidepressant Pristiq, despite the admission MDS and care plan documenting PTSD and a subsequent physician’s order for Pristiq. For another resident with Alzheimer’s disease, borderline personality disorder, delusional disorder, schizoaffective disorder, and depression, the PASARR only reflected depression and dementia with sertraline, even though additional mental health diagnoses were added later and an antipsychotic (quetiapine) was ordered for borderline personality disorder, and the quarterly MDS documented psychotic disorder, schizophrenia, and depression with antipsychotic and antidepressant use. A third resident had diagnoses including Alzheimer’s disease, depression, anxiety disorder, irritability and anger, and nonrheumatic aortic valve stenosis. The PASARR for this resident listed dementia and anxiety with Risperdal but omitted the diagnosis of depression and the medications escitalopram and lorazepam, although physician’s orders were in place for escitalopram for depression and lorazepam for anxiety, and the admission MDS documented depression with antianxiety and antidepressant use. Interviews with the Assistant Director of Nursing confirmed that new Level I PASARR screens should have been completed when new mental health diagnoses and psychoactive medications were added, and that the PASARR for one resident, completed prior to arrival, should have included all mental health diagnoses and medications. The facility’s own policy required notification of the state mental health authority within 14 days after a significant change in mental condition and specified that a new Level I screen is required for new mental health diagnoses or newly prescribed psychotropic medications, which was not followed in these cases.
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