Riveroaks Health Campus
Inspection history, citations, penalties and survey trends for this long-term care facility in Princeton, Indiana.
- Location
- 1244 Vail St, Princeton, Indiana 47670
- CMS Provider Number
- 155732
- Inspections on file
- 24
- Latest survey
- October 23, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Riveroaks Health Campus during CMS and state inspections, most recent first.
The facility did not designate a certified Infection Preventionist (IP) for its infection prevention and control program. The ADON, who was responsible for the program, began her role as IP without specialized training and was only able to dedicate limited hours to the program. This resulted in the failure to implement Enhanced Barrier Precautions, potentially affecting all residents.
The facility failed to implement Enhanced Barrier Precautions (EBP) for six residents, as EBP signs were not posted, and staff did not consistently wear gowns during high-contact activities. Residents with conditions such as anemia, COPD, pressure ulcers, and urinary catheters were affected. Observations revealed a lack of EBP signs and protective equipment, despite physician orders and care plans indicating the need for such precautions.
A facility failed to properly document and notify a resident's transfer to the hospital. The resident, who was moderately cognitively intact and diagnosed with encephalopathy, was transferred for an appointment after oral surgery. The transfer paperwork was incomplete, missing resident information and the reason for transfer, contrary to the facility's guidelines requiring such documentation.
A facility failed to obtain immediate doctor's orders for an indwelling urinary catheter for a newly admitted resident with significant medical conditions, including facial/skull fracture and brain hemorrhages. The resident was observed with a catheter, but their clinical record lacked corresponding orders. The facility's policy requires assessment for catheter removal unless clinically necessary, but orders and care plans were delayed to allow physician assessment.
A facility failed to revise a care plan quarterly for a resident with major depressive disorder and mild cognitive impairment. The care plan indicated a risk for adverse consequences from a hypnotic medication, but the resident's record showed no order for such medication, and the MDS assessment confirmed no hypnotic use. The MDS Coordinator acknowledged the need for care plan updates when medications are discontinued, which was not done, violating the facility's policy.
A facility failed to follow professional standards for a resident's PICC line care. The resident had a PICC line for osteomyelitis, but physician orders for care were not followed, and no care plan was developed. The resident's clinical record did not reflect IV access, and there was no documentation of refusal to remove the line or education provided. Observations showed the insertion site was red with purulent drainage, and the facility lacked a policy for IV care.
A medication error rate of 5.71% was identified when a nurse administered discontinued famotidine to a resident via gastric tube and incorrectly applied eye drops. The resident, with a history of colon cancer and duodenal ulcer, was not assessed for cognitive ability. Facility policies on medication administration and disposal were not followed.
A facility failed to document neurological checks for a resident with a history of falls and cognitive impairment after three unwitnessed falls. Despite the facility's policy requiring neuro-checks for 24 hours post-fall, no documentation or order sets were initiated for these checks. The Regional Support Nurse confirmed the lack of documentation and adherence to the policy.
The facility failed to provide adequate assistance with bathing and oral hygiene for four residents, as documented in the report. Residents with various medical conditions, including cognitive impairments and mobility issues, did not receive scheduled showers or daily mouth care. The facility's grievance log showed multiple complaints about inadequate assistance, and staff interviews revealed that short-staffing often prevented scheduled care. Facility policies requiring regular bathing and documentation were not consistently followed.
The facility failed to provide adequate nursing staff, resulting in delayed responses to call lights and incomplete ADLs for residents. Observations and interviews revealed that residents experienced long wait times for assistance, with some waiting up to an hour and a half. The grievance log showed multiple complaints about call light delays, and staffing patterns indicated inconsistencies in meeting the facility's scheduling standards.
Failure to Designate Certified Infection Preventionist
Penalty
Summary
The facility failed to ensure the designation of a certified Infection Preventionist (IP) responsible for the infection prevention and control program. The Assistant Director of Nursing (ADON) was assigned the role of IP without having received specialized training in infection prevention and control at the time of her appointment. She began her role as IP on June 4, 2024, and obtained her IP certification on June 17, 2024. Subsequently, on July 17, 2024, she was promoted to ADON. The ADON indicated that she could only dedicate approximately 5-10 hours per week to the infection control program. This lack of a dedicated IP led to the failure in implementing Enhanced Barrier Precautions, potentially affecting all 56 residents in the facility.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement infection control practices for six residents who required Enhanced Barrier Precautions (EBP). Observations revealed that EBP signs were not posted on the doors of residents who required them, and staff did not consistently wear gowns during high-contact activities. For instance, Resident L, who had diagnoses including anemia and COPD, did not have an EBP sign on their door despite physician orders and care plans indicating the need for EBP. Similarly, Resident W, who had a neuromuscular dysfunction of the bladder and a malignant neoplasm of the colon, also lacked an EBP sign, and staff were not observed wearing gowns during care. Resident V, who had a stage four pressure ulcer, did not have an EBP sign until after the survey began, and there were no prior physician orders for EBP. Resident D, who had a urinary catheter, was observed being transferred without staff wearing protective gowns, and there was no EBP sign on their door. The clinical record for Resident D lacked an order for EBP, and there was confusion among staff regarding the reason for the precautions. Residents S and T also did not have EBP signs or carts with gowns and gloves near their rooms, despite having conditions that required such precautions. Resident S had severe cognitive impairment and an unhealed wound, while Resident T had obstructive and reflux uropathy with a urinary catheter. The facility's inconsistency in implementing EBP was acknowledged by Regional Clinical Support, and the facility's standard operating procedure indicated that EBP should be in place for residents with chronic wounds and indwelling medical devices.
Failure to Document and Notify Resident Transfer
Penalty
Summary
The facility failed to ensure proper notification and documentation for a resident's transfer to the hospital. Resident 21, who was moderately cognitively intact and diagnosed with encephalopathy, was transferred for an appointment following oral surgery. However, the transfer discharge paperwork provided by the facility was incomplete, lacking resident information and the reason for the transfer. Additionally, the facility's guidelines required documentation of the reason, effective date, and location of the transfer or discharge, which was not adhered to in this instance.
Failure to Obtain Immediate Orders for Indwelling Urinary Catheter
Penalty
Summary
The facility failed to ensure that a newly admitted resident, identified as Resident D, had immediate doctor's orders for an indwelling urinary catheter. On September 30, 2024, staff observed Resident D being transferred with a urinary catheter. However, a review of Resident D's clinical record on October 1, 2024, revealed that there were no orders for the indwelling urinary catheter or catheter care, despite the resident's diagnoses of facial/skull fracture, subdural hemorrhage, and subarachnoid hemorrhage. Further review on October 3, 2024, indicated that a nursing assessment dated October 2, 2024, noted the absence of an indwelling urinary catheter. The Regional Support RN explained that catheters are assessed during the initial admission nursing assessment, but orders and care plans are not always immediately implemented as the facility allows time for physicians to assess the medical necessity of the catheter. The facility's policy on indwelling catheter use states that residents with a catheter should be assessed for removal unless clinically necessary.
Failure to Revise Care Plan for Discontinued Medication
Penalty
Summary
The facility failed to ensure that care plans were revised quarterly for a resident reviewed for unnecessary medications. Resident 36, who had diagnoses including major depressive disorder, restlessness and agitation, and mild cognitive impairment, was found to have a care plan indicating a risk for adverse consequences related to receiving a hypnotic medication for insomnia. However, the resident's current clinical record, reviewed on 10/2/24, showed no order for a hypnotic medication, and the Annual MDS assessment indicated that the resident did not receive hypnotic medications during the assessment period. Despite this, the care plan had not been updated to reflect the discontinuation of the medication, as confirmed by the MDS Coordinator during an interview. The facility's policy requires comprehensive care plans to be reviewed at least quarterly and revised to reflect changes in the resident's condition, which was not adhered to in this case.
Failure to Implement Professional Standards for PICC Line Care
Penalty
Summary
The facility failed to ensure professional standards of practice were implemented for a resident with a PICC line. The resident, identified as Resident T, had a PICC line inserted for osteomyelitis treatment but was unsure of its purpose. The clinical record review revealed that physician orders for the PICC line care, such as changing end caps, monitoring for infiltration, flushing with normal saline, and changing the dressing, were not followed. Additionally, there was no care plan developed for the PICC line, and the resident was not marked as having IV access on the MDS assessment. The deficiency was further highlighted by the lack of documentation regarding the resident's refusal to remove the PICC line, the education provided after the refusal, and the failure to follow the physician's order for removal. Observations noted the PICC line insertion site was red and had purulent drainage, indicating potential complications. Despite requests, the facility did not provide a policy related to IV care or a PICC line care skills check-off, indicating a lack of proper procedural documentation and oversight.
Medication Error Rate Exceeds 5% Due to Administration Errors
Penalty
Summary
The facility failed to ensure a medication error rate below 5 percent, resulting in a rate of 5.71 percent. This deficiency was identified during an observation of a registered nurse administering medication to a resident. The nurse administered 2.5 milliliters of liquid famotidine via the resident's gastric tube, despite the medication having been discontinued on 9/24/24. Additionally, the nurse administered carboxymethylcellulose eye drops incorrectly by lifting the upper eyelids instead of pulling down the lower eyelids to form a pouch, as per the facility's policy. The resident involved had a history of malignant neoplasm of the colon and chronic duodenal ulcer with hemorrhage, and was not assessed for cognitive ability due to rarely or never being understood. The facility's policies on medication administration and disposal were not followed, as the discontinued famotidine was not removed from the medication cart. The Director of Nursing and Regional Support staff confirmed the discontinuation of the medication and the correct procedure for administering eye drops, highlighting the failure to adhere to established protocols.
Failure to Document Neurological Checks After Falls
Penalty
Summary
The facility failed to ensure that clinical records were accurate and complete for a resident who was reviewed for falls. The resident, who had a history of unsteadiness on feet, abnormalities of gait and mobility, and previous falls, was identified as mildly cognitively impaired and required substantial assistance with transfers and hygiene. Despite these conditions, neurological checks were not documented following three separate unwitnessed falls on 7/31/24, 8/11/24, and 8/25/24. During an interview, the Regional Support Nurse confirmed the absence of documented neurological checks after the fall on 7/31/24 and noted that no order sets for neurological checks were initiated for any of the falls. The facility's policy, revised on 12/31/23, required neuro-checks to be completed within the Fall Event Form for 24 hours, which was not adhered to in these instances.
Failure to Provide Adequate Assistance with ADLs
Penalty
Summary
The facility failed to provide adequate assistance with bathing and oral hygiene for four residents, as observed and documented in the report. Resident F, with diagnoses including heart failure and reduced mobility, did not receive any documented showers or complete bed baths, nor daily mouth care, despite being dependent on staff for these activities. Similarly, Resident G, who had severe cognitive impairment and was dependent for oral hygiene and bathing, also did not receive any documented showers or complete bed baths, nor daily mouth care during their stay. Resident H, with severe cognitive impairment and a history of falls, received only three showers over a period of several weeks, with no documentation of daily mouth care. Resident J, who required assistance for bathing, reported not receiving the scheduled showers or complete bed baths, with only one shower documented over several weeks. The facility's grievance log revealed multiple complaints from residents about not receiving timely assistance with showers and toileting, and not being offered necessary items like razors for personal grooming. Interviews with staff indicated that the inability to provide scheduled care was often due to being short-staffed. The facility's policies required bathing at least twice a week and documentation of ADL services by CNAs, but these were not consistently followed, leading to the deficiencies noted in the report.
Insufficient Nursing Staff Leads to Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, as evidenced by observations, interviews, and record reviews conducted during the survey. On two consecutive days, it was noted that the facility was short-staffed, leading to delays in responding to call lights and completing residents' activities of daily living (ADLs). Residents reported waiting for extended periods, sometimes up to an hour and a half, for assistance with basic needs such as standing up or using the restroom. One resident recounted an incident where she turned on her call light at 2:45 A.M. and did not receive assistance until 5:00 A.M., resulting in missed showers and meal trays left in rooms overnight. The facility's grievance log revealed multiple complaints from residents about long wait times for call lights to be answered, with some residents experiencing accidents due to the delays. The grievances spanned several weeks, indicating a persistent issue with staffing levels. Observations during the survey confirmed that call lights were frequently left unanswered, and meal trays were not cleared in a timely manner, further highlighting the staffing inadequacies. A review of the facility's staffing patterns showed inconsistencies in the number of licensed nursing staff and nurse aides scheduled for each shift. The facility's policy on scheduling standards emphasized the need for adequate staffing to meet resident needs, yet the actual staffing levels fell short of these standards. This deficiency in staffing resulted in a lack of ADL services, including bathing and oral care, for the residents.
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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