Rolling Hills Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in New Albany, Indiana.
- Location
- 3625 St Joseph Rd, New Albany, Indiana 47150
- CMS Provider Number
- 155488
- Inspections on file
- 48
- Latest survey
- February 23, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Rolling Hills Healthcare Center during CMS and state inspections, most recent first.
A resident with hypotension had a physician order for Midodrine with instructions to hold the dose if systolic BP exceeded a specified parameter. Review of the MAR showed the medication was administered multiple times despite systolic BP readings above the ordered threshold. An RN acknowledged that BP medications should not be given outside ordered parameters, and the facility’s medication administration policy requires medications to be given only as prescribed.
A resident with COPD and emphysema received multiple ordered Yupelri nebulizer treatments, but the clinical record lacked documentation of required pre- and post-treatment respiratory assessments and cleaning of the nebulizer equipment after each use. Facility policy and an RN interview confirmed that respirations, pulse, oxygen saturation, lung sounds, and proper rinsing and drying of the nebulizer were required with each treatment, yet these actions were not documented for the resident’s 16 recorded doses.
The facility did not ensure hot water temperatures in resident rooms and bathrooms were maintained between 100 and 120°F, with some areas having no hot water or temperatures as low as 88°F. Multiple residents and staff reported that hot water was often unavailable or took up to 10 minutes to warm up, particularly in rooms farther from the boilers. The Maintenance Director and Executive Director confirmed these issues during interviews and observations.
A resident with diabetes and moderate cognitive impairment did not have several scheduled doses of Lantus insulin documented as administered in the EMAR, and there was no record of the resident being absent or any explanation for the missing documentation. Nursing staff confirmed that all medication administrations and omissions should be recorded, in accordance with facility policy.
Two residents requiring IV antibiotics for post-surgical infections received their medications late on multiple occasions, with no documentation provided to explain the delays. Staff interviews confirmed that timely administration and proper documentation were expected but not followed in these instances.
Surveyors found expired and improperly labeled food items, lack of internal refrigerator thermometers, and maintenance issues such as dusty and loose vents and a grease-laden drip pan. Staff attempted to use expired milk in food preparation, and some food items were not properly dated or disposed of. Facility policies for food safety and kitchen maintenance were not consistently followed.
A resident with multiple complex medical conditions and severe cognitive impairment refused several critical medications, including blood pressure, cardiac, and blood thinner drugs, due to not wanting them crushed. Additionally, long-acting insulin was held on multiple occasions based on blood glucose readings, but there was no documentation of physician notification or established parameters for holding the insulin. Facility policy and care plans required physician notification and documentation for such events, but these actions were not taken.
A resident with diabetes and sepsis experienced multiple episodes of extremely high blood sugar, but staff did not consistently recheck blood sugar within 30 minutes after insulin administration or promptly notify the physician or NP as ordered. Documentation was incomplete, and required follow-up actions were delayed, contrary to facility policy and physician instructions.
A resident with diabetes and hyperglycemia experienced multiple elevated blood sugar readings above 400 mg/dL, but staff failed to document timely rechecks, physician or NP notification, and verbal orders in the clinical record as required by facility policy. Nursing notes showed attempts to contact providers and instructions to administer insulin, but the necessary follow-up and documentation were missing.
A resident with multiple medical conditions and pressure ulcers did not consistently receive or have documented vital sign monitoring, wound care, or daily wound assessments as ordered. Staff continued to document checks of a low air loss mattress after it was removed at the resident's request, and care plans were not updated to reflect this change. Wound dressings were not dated during care, and no wound care policy was provided by the facility.
An LPN in a facility signed out narcotic medications for seven residents before the scheduled administration times, contrary to facility policy. The residents had various conditions requiring pain management, and the facility's policy mandates that narcotics be signed out at the time of administration.
The facility failed to document the administration of narcotic medications for four residents, despite records indicating the medications were given. Residents with conditions such as a stage 4 pressure ulcer, diabetes, and depression had physician orders for narcotics, but the MAR lacked documentation of administration on several occasions. This discrepancy was confirmed by staff interviews and a review of the facility's medication administration policy.
A facility failed to implement indwelling catheter care orders for a resident with a stage 4 sacral pressure ulcer. The resident's care plan required catheter care every shift, but there was no documentation of this care being provided. A staff member confirmed that catheter care orders should be implemented upon admission, but this was not reflected in the records. The facility's policy required catheter care twice daily, which was not followed.
The facility failed to document the administration of medications for three residents, including anti-psychotic and narcotic medications, leading to discrepancies in the MAR and controlled drug records. A QMA confirmed the requirement for proper documentation.
The facility failed to care plan and monitor behaviors for residents with mental disorders. A resident with dementia and schizoaffective disorder sought out another resident without a care plan addressing this behavior. Another resident with dementia and behavioral disturbances also lacked a care plan for similar behavior. Additionally, behavior monitoring logs for a resident with alcohol-induced dementia were incomplete, despite facility policy requiring documentation and management of behaviors.
A facility failed to manage a resident with dementia who exhibited sexually inappropriate behaviors. Despite being on one-on-one supervision, the resident continued to engage in inappropriate actions with female residents. Staff intervened by separating the resident and reporting incidents, but the behaviors persisted. The care plan included interventions like encouraging group interactions and keeping the resident within eyesight of staff, but these measures were insufficient. Interviews with staff confirmed the ongoing issues, highlighting a failure in effectively managing the resident's behaviors.
A facility failed to implement fall prevention measures for a resident with Parkinson's disease and epilepsy. The care plan required non-skid strips on the bed, but they were not in place during an observation with the DON. The DON acknowledged that care plan interventions should be implemented. The facility's fall prevention policy was undated.
The facility failed to ensure call lights were within reach for 10 residents, compromising their ability to communicate needs. Observations showed call lights on the floor or out of reach, with no staff present. Residents affected had various medical conditions, including cognitive impairments and mobility issues, necessitating assistance. Interviews confirmed call lights should be accessible, but this standard was not met, violating the facility's policy on resident-centered care.
The facility failed to address resident concerns during Resident Council meetings over a year, with issues such as nursing shortages, improper meal handling, and laundry problems remaining unresolved. Residents reported verbal abuse, medication errors, and inadequate response times to call lights, with management often brushing aside their grievances.
The facility failed to ensure CNAs were tested for licensure within 120 days of employment, resulting in six CNAs working beyond this period without certification. The oversight was due to a lack of dedicated HR personnel, leading to a lapse in monitoring staff licensure.
The facility failed to ensure meals were served at appropriate temperatures and were palatable, affecting most residents. Observations during meal test trays showed inconsistencies in food temperatures, with some items being bland or requiring additional seasoning. Residents expressed dissatisfaction with food quality, temperature, and presentation, with some reporting weight loss and unappetizing meals. The Dietary Manager noted menu changes for nursing home week, approved by the dietician.
The facility failed to maintain a clean and well-repaired kitchen, with issues such as a malfunctioning dishwasher, flaking ceiling plaster, grease-covered vents, and a significant wall opening behind the garbage disposal. The Dietary Manager acknowledged the kitchen's age and maintenance issues, while the Executive Director presented a roofing quote without a repair date. The facility's policies on maintaining clean food preparation areas and proper dishwashing procedures were not followed.
A resident with multiple health issues, including hemiplegia and dementia, developed a Stage 3 pressure ulcer on the right heel that was not identified until it became an open blister. Despite a care plan for skin integrity, the ulcer was overlooked during routine assessments. The facility's policy for weekly skin evaluations and daily monitoring was not effectively followed, resulting in the deficiency.
Failure to Follow Blood Pressure Parameters for Midodrine Administration
Penalty
Summary
The deficiency involves the facility’s failure to follow a physician’s ordered blood pressure parameters for administration of Midodrine for a resident diagnosed with hypotension. The physician’s order dated 2/6/26 directed that the resident receive Midodrine HCl 2.5 mg three times daily at 8:00 a.m., 12:00 p.m., and 4:00 p.m., with instructions to hold the medication if the resident’s systolic blood pressure was above 130. Review of the February 2026 MAR showed that the medication was administered despite systolic blood pressures above the ordered threshold on multiple occasions. Specifically, the MAR indicated that Midodrine was given on 2/07/26 at 4:00 p.m. when the resident’s systolic blood pressure was 132, and on 2/17/26 at 8:00 a.m., 12:00 p.m., and 4:00 p.m. when the systolic blood pressure was 138 at each of those times. During an interview, an RN stated that blood pressure medication should not be administered when a resident’s blood pressure is outside the parameters set by the physician. The facility’s Medication Administration policy, provided by the Regional Director of Clinical Operations, stated that medications are to be administered only as prescribed by the provider and identified the MAR as the legal documentation for medication administration, while emphasizing resident safety and resident-centered care.
Failure to Perform and Document Required Assessments for Nebulizer Treatments
Penalty
Summary
The facility failed to ensure required respiratory assessments and equipment care were provided and documented for a resident receiving nebulizer treatments. Resident B, who had diagnoses including COPD and emphysema, had a physician’s order dated 2/6/26 for Yupelri 175 mcg, 3 ml once daily via nebulizer at 9:00 a.m. for 20 days. Observation on 2/23/26 showed the resident with a nebulizer machine at the bedside. Review of the February 2026 MAR indicated the resident received 16 doses of Yupelri between 2/6/26 and 2/23/26. The clinical record lacked documentation of pre- and post-treatment respiratory assessments and cleaning of the nebulizer equipment after each administration. Facility policy titled “Nebulizer Treatments,” provided by the Regional Director of Clinical Operations, required collection of respirations, pulse, oxygen saturation, and lung sounds before treatment, repetition of this data collection after treatment, and rinsing the nebulizer with sterile water and allowing it to air dry. In an interview, an RN confirmed that a respiratory assessment should be completed before and after each nebulizer treatment, but such assessments and equipment cleaning were not documented for this resident’s treatments.
Failure to Maintain Adequate Hot Water Temperatures
Penalty
Summary
The facility failed to maintain hot water temperatures between 100 and 120 degrees Fahrenheit, as required, throughout resident rooms and bathrooms. Observations revealed that some rooms had hot water temperatures as low as 88.0 and 93.6 degrees Fahrenheit, while at least one room had no hot water at all. Multiple residents reported ongoing issues with the availability and consistency of hot water, with some stating that it took up to 10 minutes for the water to warm up, and others indicating that they often had to use cold water for handwashing due to the delay. The Maintenance Director confirmed these issues during observations and interviews, acknowledging that certain rooms lacked hot water and that a valve replacement was needed in at least one case. Staff interviews corroborated the residents' complaints, with a CNA noting that hot water in resident rooms and the shower room could take 5 to 10 minutes to warm up, especially in rooms farther from the boilers. The Executive Director also confirmed that staff had reported the lack of hot water and that the issue was more pronounced in rooms located farther from the decentralized boilers. The facility's practice of flushing the system each morning did not resolve the problem, and the Maintenance Director had not received formal complaints from residents prior to the survey. The deficiency had the potential to affect all 82 residents in the facility.
Failure to Document Insulin Administration in EMAR
Penalty
Summary
The facility failed to document the administration of Lantus (insulin) for one resident who was moderately cognitively impaired and had diagnoses including diabetes, hypertension, non-Alzheimer's dementia, anxiety, and depression. The resident had a physician's order for Lantus, 30 units, to be administered twice daily. Review of the electronic medication administration record (EMAR) for August and September showed missing documentation for several morning doses, with no indication that the resident was out of the building or that the medication was withheld for a documented reason. Interviews with nursing staff confirmed that all medications should be documented in the EMAR, and if not administered, a progress note should explain the omission. The facility's policy requires that medications be charted when given and that any refusals or omissions be documented. The lack of documentation for the specified dates and times was not explained by any changes in the medication order or resident absence, resulting in a deficiency related to pharmaceutical services and medication administration documentation.
Failure to Administer IV Antibiotics Timely and Document Delays
Penalty
Summary
The facility failed to ensure timely administration of intravenous (IV) antibiotics for two residents who required these medications for post-surgical infections. For one resident with a dehisced surgical wound and infection following a craniotomy, physician orders specified Ceftriaxone Sodium 2 grams IV twice daily and at bedtime for specified durations. The Medication Administration Record (MAR) showed that the resident’s evening doses were administered late on multiple occasions, with some doses given several hours past the scheduled time. There was no documentation in the clinical record explaining the reasons for the late administration or any comments regarding the delays. Similarly, another resident with an infection and inflammatory reaction due to a hip prosthesis had physician orders for Ceftriaxone Sodium Solution 2 grams IV at bedtime. The MAR indicated that several doses were administered late, including one instance where the dose was given several hours after the scheduled time. Again, the clinical record lacked any documentation explaining the late administration. Interviews with the Director of Nursing and a registered nurse confirmed that medications should be given on time and that any late administration should be documented with a reason, but this was not done in these cases.
Deficient Food Storage, Labeling, and Kitchen Maintenance
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's food storage, preparation, and kitchen maintenance practices. During kitchen tours, several refrigerators lacked internal thermometers, and one refrigerator displayed an external temperature of 50°F. Expired food items, such as whole milk and leftover fish, were found in the refrigerators, and some containers lacked proper labeling or use-by dates. Lettuce with brown edges and undated containers were also present. A staff member was seen attempting to use expired milk in food preparation before being stopped. Additionally, prepared drinks and desserts were stored without clear dating, and some items were disposed of only after being identified as expired or undated. The kitchen environment also showed maintenance issues, including dust accumulation on vents, a vent partially detached from the ceiling, and a drip pan under the cooktop with significant food debris and grease buildup. The Dietary Manager acknowledged responsibility for monitoring expiration dates, while the Maintenance Director was responsible for cleaning and repairs. The facility's policies required proper labeling, dating, and preventive maintenance, but these were not consistently followed, as evidenced by the observations and staff interviews.
Failure to Notify Physician of Medication Refusals and Held Insulin
Penalty
Summary
The facility failed to ensure that a physician was notified when a resident refused multiple critical medications and when long-acting insulin was held on several occasions. The resident in question had significant medical conditions, including type 2 diabetes mellitus with chronic kidney disease, a history of cerebral events, atrial fibrillation, congestive heart failure, hemiplegia, and hypertension. The resident also had severe cognitive impairment, as documented in the most recent assessment. On several documented dates, the resident refused to take all morning medications, including blood pressure, cardiac, and blood thinner medications, due to not wanting the medications crushed. There was no documentation that the physician was notified of these refusals. Additionally, the resident's long-acting insulin (Tresiba) was held multiple times due to varying blood glucose levels, but the medical record did not contain documentation of physician notification or clear parameters for when the insulin should be held. The facility's care plans required that medications be administered as ordered and that abnormal findings or refusals be reported to the medical provider, resident, or representative. Interviews with facility leadership confirmed that there should have been parameters for holding medications and that the physician should have been notified of both the medication refusals and the holding of long-acting insulin. The facility's policy also required notification of the physician and resident representative when there was a need to alter treatment, such as discontinuing or holding medications. The lack of documentation and notification in these instances constituted a failure to follow both physician orders and facility policy.
Failure to Provide Timely Diabetes Care and Monitoring
Penalty
Summary
A resident with diagnoses including type 2 diabetes mellitus with diabetic peripheral angiopathy, sepsis due to methicillin susceptible staphylococcus aureus, and hyperglycemia did not receive timely treatment and care as ordered. The resident had physician orders for multiple diabetes medications, including Lispro insulin on a sliding scale, Metformin, and Tresiba. The orders specified that staff should notify the physician if the resident's blood sugar was less than 70 or greater than 400 mg/dL, and to recheck blood sugar 30 minutes after administering insulin if levels exceeded 400 mg/dL. Over several days, the resident's blood sugar readings were repeatedly above 400 mg/dL, with values as high as 502 mg/dL. Despite these elevated readings, documentation showed that blood sugar was not rechecked within the required 30-minute window after insulin administration, and there was a lack of timely notification to the physician or nurse practitioner as ordered. Nursing notes indicated that the nurse attempted to contact the physician and left a message, and was instructed by the DON to administer insulin and notify the nurse practitioner. However, the clinical record lacked documentation that the nurse practitioner was notified at the time of the high blood sugar readings, and blood sugar rechecks were delayed, sometimes not occurring until many hours later. Interviews with facility leadership confirmed these documentation gaps and delays in following the physician's orders for monitoring and notification. The facility's policy required timely and accurate documentation of resident information, which was not met in this instance.
Failure to Document Blood Sugar Rechecks and Physician Notification for Diabetic Resident
Penalty
Summary
A deficiency occurred when the facility failed to ensure that sufficient information related to a resident's blood sugar was rechecked and that physician notification and verbal orders were properly documented in the clinical record. The resident in question had diagnoses including type 2 diabetes mellitus, sepsis, and hyperglycemia, and was on a sliding scale insulin regimen with specific instructions to notify the physician and recheck blood sugar if levels exceeded 400 mg/dL. On multiple occasions, the resident's blood sugar readings were above 400 mg/dL, but the clinical record lacked documentation of a timely recheck, confirmation that the physician or nurse practitioner was notified, or that verbal orders were received and recorded as required. Nursing notes indicated attempts to contact the physician and nurse practitioner, as well as instructions from the DON to administer insulin and recheck the blood sugar. However, there was no documentation in the medical record confirming that the nurse practitioner was notified, that a recheck was performed, or that a verbal order was received and documented. Interviews with staff confirmed these documentation gaps, and the facility's policy required real-time charting and documentation of resident status and changes, which was not followed in this instance.
Failure to Complete and Document Pressure Ulcer Interventions and Assessments
Penalty
Summary
The facility failed to ensure that interventions and treatments for pressure ulcers were completed for a resident with significant medical conditions, including type 2 diabetes mellitus, morbid obesity, osteomyelitis, and chronic embolism. The resident had a stage 4 pressure ulcer to the sacrum and a pressure injury to the right hip, with care plans and physician orders specifying interventions such as vital sign monitoring, use of a low air loss mattress, regular wound assessments, and specific wound care treatments. However, the record lacked documentation that vital signs were consistently obtained as ordered, with the last recorded blood pressure noted several months prior, despite vital sign monitoring being a care plan intervention for both skin impairment and osteomyelitis. There were multiple instances where wound care and daily wound assessments were not documented for both the sacrum and right thigh wounds on specified dates. Additionally, the care plan intervention for a low air loss mattress remained active in the resident's record and was documented as checked by staff every shift, even after the mattress had been removed at the resident's request. This discrepancy indicated that staff continued to document compliance with an intervention that was no longer in place, and the care plan was not updated to reflect the change. Furthermore, wound care and dressing changes were not consistently documented as completed according to physician orders. Observations also revealed that wound dressings were not dated during wound care procedures, and there was no wound care policy provided by the facility. Interviews with staff confirmed that the resident refused the low air loss mattress due to discomfort, but the care plan and electronic records were not updated accordingly. The lack of documentation and failure to follow through with ordered interventions and assessments contributed to the deficiency in providing appropriate pressure ulcer care and prevention.
Narcotic Medications Signed Out Prematurely
Penalty
Summary
The facility failed to ensure that narcotic medications were not signed out prior to administration times for seven residents. During an observation, it was noted that an LPN had signed out narcotic medications for the 1:00 p.m. and 2:00 p.m. administration times but had not yet administered them. The LPN acknowledged awareness that medications should not be signed out ahead of time. This practice was contrary to the facility's policy, which requires that narcotics be signed out at the time of administration. The residents involved had various medical conditions requiring pain management, including major depressive disorder, amputations, pressure ulcers, diabetes with neuropathy, rheumatoid arthritis, malignant neoplasms, and peripheral vascular disease. Physician orders for these residents specified the administration of medications such as Hydrocodone-Acetaminophen and Oxycodone HCl at specific intervals for pain management. The facility's policy documents, including the Chain of Custody for Controlled Substances and Medication Administration, were reviewed and indicated that narcotics should be signed out when given, highlighting a deviation from established procedures.
Failure to Document Narcotic Medication Administration
Penalty
Summary
The facility failed to ensure that medication administration records (MAR) accurately reflected the administration of narcotic medications for four residents. Resident M, diagnosed with a stage 4 sacral pressure ulcer, had a physician's order for Oxycodone to be administered every four hours as needed for pain. However, the MAR lacked documentation of the medication administration on several dates, despite records indicating the medication was given. Similarly, Resident N, with diagnoses including diabetes and arthritis, had a physician's order for Oxycodone every eight hours as needed, but the MAR did not document the administration of the medication on specific dates. Resident O, diagnosed with depression, was prescribed Morphine Sulfate every four hours as needed for pain or shortness of air, yet the MAR did not reflect the administration of the medication on certain dates. Resident V, with conditions including a left femur fracture and diabetes, was ordered Norco every six hours as needed for pain, but the MAR also lacked documentation of the medication administration on multiple occasions. The facility's policy requires that medications be charted when given, but this was not adhered to, as confirmed by staff interviews and the review of the facility's medication administration policy.
Failure to Implement Indwelling Catheter Care Orders
Penalty
Summary
The facility failed to implement indwelling catheter care orders for a resident with a stage 4 sacral pressure ulcer. The resident was observed with an indwelling catheter in place, but the clinical record lacked documentation of any catheter care being provided. The care plan, dated earlier in the month, indicated that catheter care should be provided every shift. However, there was no evidence that this care was documented or performed. During an interview, a staff member indicated that catheter care orders should be implemented upon admission, but this was not reflected in the resident's records. The facility's policy stated that catheter care should be performed twice daily for residents with indwelling catheters, but this was not adhered to in the case of the resident in question.
Medication Administration Documentation Deficiencies
Penalty
Summary
The facility failed to ensure proper documentation of medication administration for three residents, leading to deficiencies in maintaining accurate medical records. Resident G, diagnosed with dementia with behavioral disturbance, had multiple instances where the administration of Divalproex Sodium was not documented in the medication administration record (MAR) for both November and December 2024. The medication was not signed out as given on several scheduled administration times, indicating a lapse in documentation practices. Similarly, Resident C, who was prescribed Hydrocodone-Acetaminophen for pain, had a missing entry in the October 2024 MAR despite the controlled drug record indicating administration. Resident E, with diagnoses of pain and anxiety, also had discrepancies in the documentation of Lorazepam and Morphine Sulfate administration in both the controlled drug record and the MAR. These documentation failures were confirmed during an interview with a Qualified Medication Aide, who acknowledged that the MAR and controlled drug record should be signed off to confirm medication administration.
Failure to Care Plan and Monitor Resident Behaviors
Penalty
Summary
The facility failed to ensure that behaviors were care planned and monitored for several residents with mental disorders or psychosocial adjustment difficulties. Resident B, diagnosed with dementia with agitation and schizoaffective disorder, was observed to actively seek out another resident, Resident C, but lacked a care plan addressing this behavior. Similarly, Resident D, with dementia and behavioral disturbances, also sought out Resident C without a corresponding care plan. The Director of Nursing noted inappropriate interactions between Residents B and D in Resident C's room, which were not addressed in their care plans. Resident G, diagnosed with alcohol-induced persisting dementia and dementia with behavioral disturbance, had a care plan indicating behavior problems such as inappropriate bowel movements and verbal aggression. However, the behavior tracking logs for November and December 2024 lacked documentation of behavior monitoring on several days. A Qualified Medication Aide confirmed that all behaviors should be documented, but this was not consistently done. The facility's policy required a resident-centered behavior management care plan and documentation of behavior assessments, which were not adequately implemented for these residents.
Inadequate Management of Resident's Inappropriate Behaviors
Penalty
Summary
The facility failed to implement effective interventions for a resident diagnosed with dementia and exhibiting sexually inappropriate behaviors. Resident C, who has a history of sexually acting out, was placed on one-on-one supervision due to these behaviors. Despite this measure, the resident continued to engage in inappropriate actions, such as attempting to touch and kiss female residents. Staff members frequently intervened by separating Resident C from others and reporting incidents, but the behaviors persisted. The care plan for Resident C included interventions like encouraging interactions in group settings and keeping the resident within eyesight of staff, but these measures were insufficient in preventing the inappropriate behaviors. Interviews with staff members revealed that Resident C was known to be overly affectionate, often rubbing the backs of female residents and attempting to kiss them. The Memory Care Unit Manager and Social Services staff acknowledged the resident's behaviors, noting that they were not consistent but still problematic. Despite the ongoing one-on-one supervision, Resident C continued to seek out female company and engage in inappropriate actions, indicating a failure in the facility's approach to managing the resident's behaviors effectively. The facility's policy emphasized resident-centered care and safety, but the interventions in place did not adequately protect the rights and safety of other residents.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure that fall prevention interventions were in place for a resident identified as being at risk for falls. The clinical record for the resident, who had diagnoses including Parkinson's disease and epilepsy, indicated a care plan dated March 4, 2022, which required the application of non-skid strips to the left side of the bed to mitigate fall risks. However, during an observation conducted with the Director of Nursing (DON), it was noted that the non-skid strips were not in place as per the care plan. The DON confirmed that interventions listed in a resident's care plan should be implemented. Additionally, the facility's policy on Fall Prevention and Management, which emphasizes resident-centered care and fall risk management, was provided but did not have a date.
Deficiency in Call Light Accessibility for Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for 10 residents, leading to a deficiency in meeting the needs and preferences of each resident. Observations revealed that call lights were often found on the floor, under beds, or otherwise out of reach, with no staff present in the rooms. This was noted for residents with various medical conditions, including cognitive impairments, mobility issues, and other health concerns that necessitate assistance with personal care. Resident 20, for example, had a call light on the floor beneath the bed, despite having conditions such as COPD, dementia, and difficulty walking, which require frequent assistance. Similarly, Resident 77's call light was found on the floor and under pillows, out of reach, while the resident was severely cognitively impaired and needed a wheelchair for mobility. These observations were consistent across multiple residents, including those with severe cognitive impairments, functional limitations, and other significant health issues. Interviews with CNAs confirmed that call lights should always be within reach of residents, yet this standard was not met. The facility's policy on resident rights emphasizes the importance of providing resident-centered care and ensuring safety, including having a method for residents to communicate their needs. However, the repeated observations of inaccessible call lights indicate a failure to adhere to this policy, compromising the ability of residents to communicate their needs effectively.
Facility Fails to Address Resident Concerns
Penalty
Summary
The facility failed to ensure that the administration was taking resident concerns seriously or being visible to the residents during Resident Council meetings. Over a period spanning from March 2023 to May 2024, residents repeatedly voiced concerns that were not resolved or acted upon. These concerns included issues with administration's responsiveness, nursing staff shortages, improper handling of meals, and laundry problems. Residents reported that their concerns were often met with excuses, and there was a lack of visible action from the administration to address these issues. Specific grievances included nursing staff walking past rooms without assisting residents, meals not being served according to dietary needs, and laundry not returning clothes to the correct residents. Additionally, residents complained about the lack of cleanliness in their living areas, with housekeeping failing to mop floors or clean restrooms. The documentation from these meetings often lacked responses from the responsible department heads, indicating a systemic issue in addressing and resolving resident grievances. The report also highlighted instances of verbal abuse by staff, medication errors, and inadequate response times to call lights. Residents expressed dissatisfaction with the management's handling of their concerns, feeling that their issues were brushed aside without resolution. The facility's policies on resident grievances and council meetings were not effectively implemented, as evidenced by the ongoing unresolved issues and lack of corrective actions documented in response to the residents' complaints.
Failure to Ensure Timely CNA Licensure Testing
Penalty
Summary
The facility failed to ensure that Certified Nurse Aides (CNAs) were tested for their licensure within 120 days of employment, resulting in six CNAs working beyond this period without proper certification. The CNAs in question were identified during a review of employee records, which revealed that they had been employed for more than 120 days without having taken their licensure test. Specifically, CNAs 13, 14, 16, 15, 19, and 17 continued to work past their 120th day of employment without being certified, with some working significantly beyond this timeframe. The Executive Director (ED) acknowledged the oversight, noting that there was no dedicated Human Resources (HR) personnel until April 5, 2024, which contributed to the lapse in monitoring staff licensure. The ED discovered that eight staff members, who were licensed in Kentucky, had not taken their CNA licensure test within the required 120 days in Indiana. Consequently, these staff members were removed from the work schedule until they passed their licensure test. The deficiency was identified as part of a complaint investigation, highlighting a systemic issue in the facility's process for monitoring CNA licensure compliance.
Deficiency in Meal Temperature and Palatability
Penalty
Summary
The facility failed to ensure that meals were served at appropriate temperatures and were palatable for residents, as observed during three meal test trays. The baked ziti served during the 100 Hall lunch test tray was at 145 degrees Fahrenheit, which was palatable but bland, requiring additional salt for flavor. The Caesar salad was at 65.6 degrees Fahrenheit, which was appetizing. During the 400 Hall lunch test tray, the baked ziti was at 135 degrees Fahrenheit, and the Caesar salad was at 63.5 degrees Fahrenheit. In the 200 Hall lunch test tray, the pepperoni pizza was at 168.8 degrees Fahrenheit and was appetizing, while the baked ziti was at 131.5 degrees Fahrenheit and palatable. The side salad with mushrooms was at 48.7 degrees Fahrenheit and appealing, and the mixed fruit was at 74.7 degrees Fahrenheit, served at room temperature. Interviews with residents revealed dissatisfaction with the food quality and temperature. One resident mentioned the food could be better, often requesting a cheeseburger due to the poor quality. Another resident complained about cold breakfast and bad food quality. A resident expressed that the food was unappealing and that their likes and dislikes were not considered, leading to weight loss. Another resident noted that food was always cold and unappetizing, and staff delayed addressing food issues. A resident showed a picture of a meal where the sloppy joe bun was soggy due to the placement of vegetables on the plate. The Dietary Manager explained that menu changes were made for nursing home week, approved by the dietician, and that the regular menu would resume the following day.
Kitchen Maintenance and Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain a clean and well-repaired kitchen environment, as observed during multiple inspections. On one occasion, the dishwasher was initially not working but was later observed to be functioning with a wash cycle temperature of 145 degrees F and a rinse cycle temperature of 170 degrees F. The kitchen ceiling had flaking plaster around a vent, brown stains, and grease-covered vents. The stove's back panel had brown grease streaks, and the ceiling around another vent was cracked. On another occasion, the dishwasher's wash and rinse temperatures were recorded at 150 degrees F and 187 degrees F, respectively, with a leak previously repaired. Grease was noted on the wall behind the dishwasher, and a significant wall opening was observed behind the garbage disposal, with water dripping from the sink. The Dietary Manager acknowledged the kitchen's age and maintenance issues, including a stuck drip pan and grease behind the dishwasher. The dishwasher's temperature logs showed consistent readings of 160 degrees F for the wash cycle and 180 degrees F for the rinse cycle, despite observed fluctuations. The Executive Director presented a roofing company quote for roof repairs, but the kitchen ceiling was not included, and the repair date was uncertain. The facility's policies required maintaining clean and sanitary food preparation areas and proper dishwashing procedures, which were not adhered to, leading to the observed deficiencies.
Failure to Identify and Manage Pressure Ulcer
Penalty
Summary
The facility failed to identify a pressure ulcer on a resident's right heel before it developed into an open blister. The resident, who had multiple diagnoses including hemiplegia, dementia, and difficulty walking, required substantial assistance with activities of daily living. Despite having a care plan in place that included interventions for impaired skin integrity, such as applying barrier creams and conducting weekly skin checks, the pressure ulcer was not detected until it had progressed to a blister that no longer held fluid. The CNA shower records from late April to early May indicated no new skin issues, suggesting a lack of thorough skin assessments. On May 7, the wound was identified during wound rounds as a pressure ulcer on the right heel, measuring 5.0 cm by 4.0 cm with a depth of 0.1 cm. The wound was classified as a Stage 3 pressure ulcer, indicating full-thickness skin loss. The wound care nurse confirmed that the ulcer began as a blister that had popped, revealing the wound bed. The facility's policy required weekly skin evaluations and daily monitoring of existing wounds, but these measures were not effectively implemented, leading to the oversight of the resident's pressure ulcer development.
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Surveyors observed that dietary staff repeatedly worked in kitchen and meal service areas with uncovered facial hair, despite facility policy and state sanitation requirements mandating effective hair restraints. Two dietary aides with short beards or mustaches were seen walking through food preparation areas, taking food temperatures, handling food, and plating meals at steamtables in dining rooms without any facial hair coverings, while the current policy required all hair, including facial hair, to be restrained to prevent contamination.
The facility failed to consistently provide and document required bed-hold policy notices when several residents were transferred to the hospital. In multiple cases, residents with dementia, psychotic disorders, COPD, chronic respiratory failure, altered mental status, and cerebral infarction were sent out for acute changes in condition, and while transfer notes reflected physician and family notifications, they lacked documentation that the bed-hold policy was discussed with the resident or responsible party. Notices of Transfer or Discharge often indicated a copy of the bed-hold policy was sent with the resident, but the records did not show signed and dated acknowledgment by the resident or appropriate representative, including in situations where a resident had moderate cognitive impairment, short-term memory issues, or a documented need for a proxy and a financial POA authorizing an agent for health care decisions.
Surveyors found that the facility failed to provide trauma‑informed and culturally competent care by not incorporating two residents’ extensive trauma histories and specific behavioral triggers into their care plans. One resident with documented homelessness, polysubstance abuse, severe accidents with multiple fractures, viral encephalitis with coma, physical and sexual abuse, loss of family contact, and a past suicide attempt had multiple behavior‑focused care plans that referenced identifying triggers but listed none and did not mention their physical, sexual, medical, or psychosocial trauma. Another resident with TBI from being struck by a truck, an 11‑month coma, long‑term state hospital residence, alleged shooting of a parent, and diagnoses including intermittent explosive disorder and borderline personality disorder had a PASRR identifying a specific trigger and notes of inappropriate sexual behavior, yet their care plans omitted these traumatic events, the identified trigger, and the sexual behavior. Staff interviews confirmed that residents were screened for trauma, but the trauma histories and triggers were not reflected in the individualized plans of care.
A resident with schizophrenia, post‑stroke hemiparesis, and mild cognitive impairment expressed feeling down and wanting to kill himself, but staff did not document asking about a specific plan, did not notify the physician or psychiatric NP as expected, and did not develop or update a care plan addressing depression or suicidal ideation. The SSD documented offering support and initiating 15‑minute checks once, but there was no further follow‑up or documentation of interventions after subsequent suicidal statements made in a care plan meeting with the resident’s father. The DON and Administrator reported that facility policy requires immediate notification of key staff, assessment for a plan and means of self‑harm, and thorough documentation, which were not carried out or reflected in the medical record for this resident.
A resident with schizophrenia, post-stroke hemiparesis, and mild cognitive impairment verbalized suicidal ideation, but the care plan did not address depression or suicidal thoughts, and required assessments and services were not accurately or timely documented. An SSD note recorded the resident saying he wanted to kill himself and referenced 15‑minute checks and a care plan update, yet the active care plan lacked depression/suicidal ideation interventions. Multiple late-entry Social Services notes were later added, describing follow-up visits and the resident denying suicidal ideation, but the SSD later reported she did not typically ask about a suicide plan and did not personally provide individual follow-up visits as described. These practices conflicted with the facility’s policy requiring factual, first-hand, and timely documentation of assessments and services.
A resident was observed with an Albuterol inhaler on an overbed table and later reported keeping the inhaler in a nightstand drawer, with no staff present during these observations. Record review showed the resident had no cognitive impairment on the admission MDS but lacked any documented self-medication administration assessment. The DON acknowledged that the required assessment had not been completed, despite facility policy requiring staff and the practitioner to evaluate each resident’s mental and physical abilities before allowing self-administration of medications.
Surveyors found that the facility submitted inaccurate direct care staffing data to CMS through the PBJ system over multiple days in a quarter. CASPER reports showed apparent gaps in 24-hour licensed nurse coverage, low weekend staffing, and a 1-star staffing rating, while internal staffing sheets documented that licensed nurses were present and the facility was fully staffed on those days. The Administrator reported that the discrepancies were due to PBJ data entry errors, despite a facility policy requiring all PBJ entries to be accurate, auditable, and verifiable against payroll, invoices, or contracts.
Surveyors found that the facility did not provide or document required written transfer/discharge notices and bed-hold policy information for four residents who were sent to the hospital, including individuals with conditions such as dementia, CHF, chronic respiratory failure, and CKD. In each case, progress notes showed that the resident was transferred for acute issues, but the clinical records lacked evidence that written notices were given to the residents or their representatives, and in one case lacked documentation that required information was sent to the receiving provider. Facility leadership, including the ADON, DON, and Administrator, acknowledged that the records did not contain the required documentation, despite a written policy requiring such notices and information exchange.
A resident with Alzheimer’s disease and depression, previously on an antidepressant, exhibited intermittent refusals of medications and care, occasional yelling at staff, and reports of unusual perceptions, such as believing men were in or near her room. Nursing notes over several months documented these refusals and complaints but did not show that the behaviors were evaluated or recorded as dangerous, non-redirectable, or causing significant distress, nor did they document specific non-pharmacological interventions attempted or their outcomes. Despite this, a psychiatric NP later added new diagnoses of schizoaffective disorder, borderline personality disorder, and delusional disorder and ordered an antipsychotic (Seroquel) without a comprehensive evaluation in the record to support these diagnoses. The facility’s psychotropic medication policy, which requires identification and documentation of target behaviors, use of nonpharmacological interventions, and ongoing behavior monitoring, was not followed for this resident.
The facility failed to keep PASARR Level I screenings accurate and current for three residents when new mental health diagnoses and psychoactive medications were initiated. One resident’s PASARR omitted a PTSD diagnosis and an added antidepressant, despite documentation of PTSD on the MDS and care plan and a physician order for Pristiq. Another resident’s PASARR listed only depression and dementia, even after additional diagnoses such as borderline personality disorder, delusional disorder, and schizoaffective disorder were added and an antipsychotic (quetiapine) was ordered, with the MDS later reflecting psychotic disorder, schizophrenia, and depression with antipsychotic and antidepressant use. A third resident’s PASARR did not include a depression diagnosis or newly ordered escitalopram and lorazepam, although the admission MDS documented depression with antianxiety and antidepressant use. These omissions occurred despite facility policy requiring a new Level I review after significant mental status changes, including new mental health diagnoses or new psychotropic medications.
Uncovered Facial Hair During Food Preparation and Meal Service
Penalty
Summary
The deficiency involves the facility’s failure to ensure that food was served in a sanitary and safe manner in accordance with professional standards and facility policy during multiple kitchen and meal service observations. During an initial kitchen observation, two dietary aides were seen walking through the kitchen food preparation area with uncovered facial hair. One aide had facial hair above and below the lip and along the jaw line, approximately one-fourth inch in length, and the other had a mustache of similar length; neither used any facial hair covering. These observations occurred while staff were present in the kitchen area where food was stored and prepared. During subsequent observations on the same day, the same two dietary aides were again observed with uncovered facial hair while directly involved in meal preparation and service. One aide walked through the kitchen while the noon meal was being prepared and placed into a transport cart for service in the south dining room, and later was observed plating the noon meal at the steamtable in that dining room, still without a facial hair covering. The other aide walked through the kitchen while the noon meal was being prepared and placed into the steamtable for the north dining room, took food temperatures, assisted with plating meals at the steamtable, and retrieved food items and supplies from the kitchen, all while having an uncovered mustache approximately one-fourth inch in length. The Dietary Manager stated that staff hair was to be covered when in the kitchen and during meal service, and the facility’s written policy and the cited Indiana Food Establishment Sanitation Requirements both required effective hair restraints, including for facial hair, to prevent contamination of food, equipment, and utensils.
Failure to Provide and Document Bed-Hold Policy at Time of Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure that required bed-hold policy information was provided and documented for four residents transferred to the hospital. For a resident with dementia, psychotic disorder, and autistic disorder who had a BIMS score of 0 indicating severe cognitive impairment, progress notes documented physician notification and guardian notification when the resident was sent to the hospital, but there was no documentation that the bed-hold policy was provided to the responsible party. A Notice of Transfer or Discharge later indicated a copy of the bed-hold policy was sent with the resident. Another resident with COPD and chronic respiratory failure, cognitively intact with a BIMS score of 13, experienced a decline in condition and was transferred to the hospital by ambulance; progress notes documented family notification but did not document any discussion of the bed-hold policy, although a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident. A third resident with altered mental status and cerebral infarction, with a BIMS score of 10 indicating moderate cognitive impairment and documented short-term memory impairment, experienced changes in condition and was transferred to the hospital. Progress notes stated the resident was their own responsible party and that no other notification was completed, and transfer documentation did not include the bed-hold policy, although an untimed Notice of Transfer or Discharge indicated a copy of the bed-hold policy was signed by the resident. A financial power of attorney document in the record showed the resident had designated an agent to act in consent or refusal of health care. For a fourth resident with dementia and osteomyelitis, transfer documentation and a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident, and the transfer form noted the resident required a proxy for decision making. The facility’s policy required that at the time of transfer to a hospital, written notice specifying the duration of the bed-hold policy and information on return to the next available bed be provided, and that a signed and dated copy of the bed-hold notice given to the resident or representative be kept in the resident file, which was not consistently documented for these residents.
Failure to Integrate Trauma Histories and Behavioral Triggers Into Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to identify and incorporate residents’ trauma histories and specific behavioral triggers into their care plans, despite documented histories of significant trauma and behavioral health issues. For one resident, extensive social service and progress notes documented homelessness, polysubstance abuse, major depressive and anxiety disorders, chronic pain, a history of severe car accidents with multiple fractures, viral encephalitis resulting in a three‑month coma, loss of child custody, multiple divorces, physical abuse by a spouse, the death of a fiancé who was struck by a car while in a wheelchair, lack of family contact, and a past suicide attempt by Valium overdose. Additional documentation noted a history of rape by a brother at age eight and prior placement under direct supervision and 15‑minute checks related to suicidal ideation. Despite these documented traumatic events and behavioral health concerns, the resident’s care plans did not identify a history of physical trauma, sexual trauma, homelessness, substance abuse, medical trauma, or attempted suicide. For this same resident, the MDS showed no cognitive deficit and identified behaviors such as verbal aggression and rejection of care, along with diagnoses including seizure disorder, depression, chronic pain syndrome, homelessness, and anxiety disorder. Multiple care plans addressed behaviors such as drug‑seeking, pretending to have seizures for attention or medication, making false allegations, verbal aggression when unable to smoke, and a desire for intimate relationships with consenting male residents. These care plans referenced goals such as effective coping skills, seeking staff support, and compliance with the smoking policy, and they called for identification and reduction of behavioral triggers. However, none of these care plans actually listed any specific triggers. The care plan addressing the resident’s right to consensual intimate relationships focused on assessment and education regarding consent but did not integrate the resident’s extensive trauma history. Staff interviews indicated the resident had displayed sexual behaviors since admission, including an incident where the resident expressed anger at another resident for not buying a soda after engaging in sexual acts. A second resident with a documented history of traumatic brain injury (TBI), dementia, seizure disorder, borderline personality disorder, anxiety, intermittent explosive disorder, tobacco use, and other behavioral/emotional disorders was also affected by the same deficiency. Social history and progress notes documented that this resident sustained a TBI after being hit by a semi‑truck while riding a bicycle at age 18, resulting in an 11‑month coma, followed by 13 years in a state hospital and subsequent residence in a group home. Additional documentation indicated the resident allegedly shot their father at age 26 after being sworn at and had a PASRR identifying TBI, intermittent explosive disorder, and borderline personality disorder, with a specific trigger of hearing the name of the current U.S. President. Progress notes also described inappropriate sexual behavior toward staff, including touching themselves intimately during personal care and refusing to stop when redirected. Despite this, the resident’s care plans, which addressed explosive disorder and history of altercations, risk for decreased psychosocial well‑being, and refusal to bathe or shower, did not list any specific behavioral triggers, did not reference the traumatic events such as being hit by a truck or shooting their father, and did not document the inappropriate sexual behavior. The Administrator and Social Service Director acknowledged that residents were to be screened for trauma and that trauma responses and PTSD should be added to care plans, but the specific trauma histories and triggers for these two residents were not incorporated into their plans of care.
Failure to Assess and Care Plan for Resident Suicidal Ideation
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess, investigate, and care plan for a resident’s suicidal ideation in accordance with its own policy and staff expectations. The resident had diagnoses including schizophrenia, cerebral edema, and hemiparesis/hemiplegia following a cerebral infarction, and a current MDS showed mild cognitive impairment (BIMS score 12). A progress note documented that the resident told the Social Services Director (SSD) he was feeling down and wanted to kill himself; the SSD offered assistance, activities, and initiated 15‑minute checks, and the note stated the care plan was updated. However, the note did not indicate that the SSD asked whether the resident had a plan to kill himself, and there were no additional notes regarding suicidal ideation or follow‑up. Review of the current care plan showed no problem, goal, or interventions addressing depression or suicidal ideation, and progress notes over the following month contained no documentation of physician notification related to the suicidal statement. Further record and interview evidence showed that the care plan conference summary did not document interventions for suicidal ideation, and the SSD acknowledged she did not normally ask residents expressing suicidal ideation if they had a plan. The SSD reported that the resident had admission paperwork mentioning suicidal ideation related to depression after a stroke and that the resident again vocalized suicidal ideation during a care plan meeting with his father, after which emotional support was offered and the father took the resident out on a leave of absence; no further visits or follow‑up were done. The DON stated that, upon notification of suicidal verbalization, staff should assess the resident, ask if there is a plan, remove potential means of self‑harm, immediately notify the psychiatric NP, and document the occurrence, and that a detailed progress note and updated care plan were expected but not present for this resident. The Administrator similarly stated that staff should ask about a plan, document interventions, notify the physician and family, and update the care plan, and indicated the resident should have had a care plan addressing depression with suicidal ideation. The facility’s written policy required immediate notification of the DON, SSD, and physician, an interview including asking about a plan and assessing mood and means for self‑harm, and thorough documentation of mood, behavior, and all actions taken, which were not reflected in the resident’s record.
Incomplete and Inaccurate Documentation of Suicidal Ideation and Follow-Up
Penalty
Summary
The facility failed to ensure accurate, complete, and timely documentation of assessments and services for a resident who verbalized suicidal ideation. Resident 6, who had schizophrenia, cerebral edema, and right-sided hemiparesis/hemiplegia following a cerebral infarction, had a BIMS score of 12 indicating mild cognitive impairment. The resident’s admission paperwork mentioned suicidal ideation related to depression after a stroke, and a Social Services note on 3/11/2026 documented that the resident was feeling down and said he wanted to kill himself. The Social Services Director (SSD) documented that she talked with the resident, coordinated with Activities, advised the resident to contact SSD or nursing if he wanted to talk, and that the resident was scheduled for 15-minute checks and the care plan was updated. However, the current care plan initiated on 2/26/2026 did not address depression or suicidal ideation. Multiple Social Services progress notes were later entered as late entries in April, with effective dates in March, stating that the resident had no plan and no longer had suicidal ideation, that he felt much better after 1:1 time, and that he continued his daily routine and therapy. These late entries described follow-up visits and reassessments of suicidal ideation on several consecutive days, but in interviews the SSD stated she did not normally ask residents about having a plan when they verbalized suicidal ideation and did not recall any other occurrences beyond the initial event. She further indicated she did not personally provide individual follow-up visits with this resident regarding suicidal ideation, despite the late-entry notes describing such visits. The DON acknowledged that late entries had been added to address concern about suicidal verbalization, and the Administrator stated that upon suicidal statements staff should ask about a plan, notify the physician and family, and update the care plan, and that this resident should have had a care plan addressing depression with suicidal ideation. The facility’s documentation policy required factual, first-hand, timely documentation, which was not followed in this case.
Failure to Complete Required Self-Administration Assessment for Inhaler Kept at Bedside
Penalty
Summary
Surveyors identified that a resident was allowed to keep and access an Albuterol inhaler without the facility completing the required self-administration medication assessment. During an initial tour, the resident was observed sitting in a wheelchair with a handheld Albuterol inhaler on the overbed table and no staff present in the room or hallway. On a subsequent observation, the resident again was in a wheelchair and reported that the Albuterol inhaler was stored in the top drawer of the nightstand, where it was found. Review of the clinical record showed an admission MDS indicating no cognitive impairment, but there was no documentation of a self-medication administration assessment. In an interview, the DON confirmed that the resident did not have the required self-medication assessment, despite the facility’s policy stating that staff and the practitioner must assess each resident’s mental and physical abilities to determine whether self-administering medications is clinically appropriate. This failure to complete and document a self-administration medication assessment for a resident who had an Albuterol inhaler kept at bedside constituted noncompliance with the facility’s own policy and with 410 IAC 16.2-3.1-11(a).
Inaccurate PBJ Staffing Data Submission to CMS
Penalty
Summary
The deficiency involves the facility’s failure to electronically submit complete and accurate direct care staffing information to CMS through the Payroll-Based Journal (PBJ) system for 22 days in a fiscal quarter. A CASPER report review on 4/6/26 showed that, according to PBJ data, the facility did not have licensed nursing coverage 24 hours per day on multiple specific dates across three months, had low weekend staffing, and held a 1-star staffing rating. However, review of the facility’s internal staffing sheets for that quarter indicated the facility was fully staffed and had licensed nurse coverage on all of the dates in question. During an interview, the Administrator stated that the PBJ information must have contained data entry errors, as she had verified licensed staff coverage on the timesheets. The facility’s PBJ policy in effect stated that all staffing data entered into the PBJ system would be auditable and verifiable through payroll, invoices, or contracts, but the submitted PBJ data did not accurately reflect the facility’s actual licensed nurse staffing as documented on internal records. No specific residents or clinical conditions were mentioned in the report, and the deficiency centers solely on inaccurate staffing data submission rather than direct resident care events.
Failure to Provide and Document Required Transfer/Discharge and Bed-Hold Notices
Penalty
Summary
The deficiency involves the facility’s failure to provide and document required written notices of transfer/discharge and bed-hold policies, as well as required information to receiving providers, for four residents who were transferred or discharged to the hospital. For a resident with generalized anxiety disorder, major depressive disorder, and dementia, progress notes showed that the resident was sent to the hospital via 911 for chest pain, lower back pain, and shortness of breath and later returned to the facility, but the clinical record lacked documentation that a written Notice of Transfer/Discharge and the bed-hold policy were provided to the resident or representative, and lacked documentation that required information was conveyed to the receiving facility. The ADON and the Administrator both confirmed there was no documentation that these written notices were provided. For a resident with congestive heart failure and muscle weakness who was sent to the emergency room for painful urination and bloody urine, the clinical record lacked documentation that a Notice of Transfer/Discharge or bed-hold policy was given to the resident or representative, which the DON confirmed. Another resident with chronic respiratory failure and diabetes was discharged to the hospital for respiratory failure, and a resident with chronic kidney disease and dementia was discharged to the hospital, but in both cases there was no documentation that a written notice of transfer/discharge or bed-hold policy was provided to the residents or their representatives. Review of the facility’s Transfer and Discharge policy, dated 1/15/26, showed that the policy required the facility to provide written transfer/discharge notices and bed-hold information to residents and representatives and to provide specified information to receiving providers, but the records for these four residents did not contain the required documentation.
Failure to Document Target Behaviors and Non-Pharmacological Interventions Before Initiating Antipsychotic
Penalty
Summary
The deficiency involves the facility’s failure to document how a resident’s behaviors presented danger or distress to self or others, and failure to document non-pharmacological interventions attempted prior to initiating an antipsychotic medication. Resident 6 had documented diagnoses of Alzheimer’s disease, depression, and severe cognitive impairment, and was receiving sertraline for depression. A PASSAR identified only depression and dementia, and the admission MDS listed Alzheimer’s disease and depression as active diagnoses. Over several months, nursing progress notes documented that the resident intermittently reported unusual perceptions, such as believing there were men causing trouble, a man in her room, or a man wanting to marry her and yelling through the walls, but there was no documentation that these episodes caused danger to the resident or others or that they resulted in unmanageable distress. From late April through mid-July, nursing notes primarily described the resident’s frequent refusals of evening and morning medications, blood sugar checks, blood pressure checks, insulin administration, hygiene care, and showers. Staff documented that the resident sometimes yelled at staff, said “Get out!”, was visibly upset by a room move, was leery of staff and asked to see name badges, and became upset about a pillow under her head until it was removed, after which she calmed down. The notes also recorded instances where the resident believed housekeeping had not cleaned her room or that she had not received medications when she had. However, there were no progress notes or assessments indicating that these behaviors were evaluated as dangerous, non-redirectable, or causing significant distress or functional impairment, and no detailed behavior monitoring logs were present as required by facility policy. On a psychiatric NP visit for initial psychotropic medication management, new mental health diagnoses of schizoaffective disorder, borderline personality disorder, and delusional disorder were added, and Seroquel 25 mg, an antipsychotic, was ordered. The clinical record did not contain a comprehensive evaluation to support these new diagnoses, and there was no documentation of target behaviors meeting the facility’s policy criteria for psychotropic use, such as behaviors representing danger to self or others, causing distress and impairment in functional abilities, or clearly attributable to psychosis or mania. The resident’s representative reported that the resident had no prior history of mental health disorders or psychiatric hospitalization and was unaware of the new diagnoses. The facility’s own psychotropic medication policy required identification and documentation of specific target behaviors, use and documentation of nonpharmacological interventions, and ongoing monitoring of behaviors and interventions, which were not reflected in the record for this resident.
Failure to Update PASARR Screens for New Mental Health Diagnoses and Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that Preadmission Screening and Resident Review (PASARR) Level I screenings were accurate and updated when new mental health diagnoses and psychoactive medications were initiated for multiple residents. For one resident with dementia, anxiety, depression, and post-traumatic stress disorder (PTSD), the PASARR completed on admission listed anxiety, depression, and dementia with sertraline and quetiapine, but did not include the PTSD diagnosis or the antidepressant Pristiq, despite the admission MDS and care plan documenting PTSD and a subsequent physician’s order for Pristiq. For another resident with Alzheimer’s disease, borderline personality disorder, delusional disorder, schizoaffective disorder, and depression, the PASARR only reflected depression and dementia with sertraline, even though additional mental health diagnoses were added later and an antipsychotic (quetiapine) was ordered for borderline personality disorder, and the quarterly MDS documented psychotic disorder, schizophrenia, and depression with antipsychotic and antidepressant use. A third resident had diagnoses including Alzheimer’s disease, depression, anxiety disorder, irritability and anger, and nonrheumatic aortic valve stenosis. The PASARR for this resident listed dementia and anxiety with Risperdal but omitted the diagnosis of depression and the medications escitalopram and lorazepam, although physician’s orders were in place for escitalopram for depression and lorazepam for anxiety, and the admission MDS documented depression with antianxiety and antidepressant use. Interviews with the Assistant Director of Nursing confirmed that new Level I PASARR screens should have been completed when new mental health diagnoses and psychoactive medications were added, and that the PASARR for one resident, completed prior to arrival, should have included all mental health diagnoses and medications. The facility’s own policy required notification of the state mental health authority within 14 days after a significant change in mental condition and specified that a new Level I screen is required for new mental health diagnoses or newly prescribed psychotropic medications, which was not followed in these cases.
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