Saint Anthony
Inspection history, citations, penalties and survey trends for this long-term care facility in Crown Point, Indiana.
- Location
- 203 Franciscan Dr, Crown Point, Indiana 46307
- CMS Provider Number
- 155214
- Inspections on file
- 42
- Latest survey
- December 23, 2025
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Saint Anthony during CMS and state inspections, most recent first.
Two residents with diabetes did not receive insulin and blood sugar monitoring as ordered by their physicians. Multiple scheduled doses of insulin, including Lispro, Lantus, and Glargine, were missed or not administered according to sliding scale protocols, and blood sugar checks were not consistently performed. Facility leadership acknowledged the missed doses but provided no further explanation.
A resident with Alzheimer's disease, asthma, and GERD was observed keeping and self-administering Tums and an inhaler at the bedside without documented physician orders for self-administration or completed assessments to determine their ability to do so. The facility did not have a care plan or required documentation in place, despite policy requirements.
Two residents did not have their MDS assessments accurately completed regarding antianxiety and antiplatelet medication use. One resident with psychiatric and neurological diagnoses was documented as not receiving antianxiety medication on the MDS, despite physician orders and MAR showing regular administration of clonazepam. Another resident with cardiovascular and renal conditions was similarly documented as not receiving antiplatelet medication, although ticagrelor was administered as ordered. The MDS Coordinator confirmed both errors.
Two residents who were dependent on staff for ADLs did not consistently receive scheduled showers or nail care. One resident missed several scheduled showers, and another had long toenails with no documentation of nail care, despite both having care plans requiring these services. The DON was unable to provide further documentation for the missed care.
A resident with multiple medical conditions, including dementia and on anticoagulant therapy, was observed with a dark purple discoloration on the hand. Despite care plan interventions to monitor for bruising, there was no documentation of assessment or monitoring of the area, and the wound nurse was unaware of the issue.
Two residents with a history of falls and injuries did not have required fall prevention interventions in place, including accessible call lights, non-skid strips, and Dycem mats, as specified in their care plans. Observations confirmed that these interventions were missing at the time of review, despite recent falls resulting in injuries and hospitalizations.
A resident with severe cognitive impairment and respiratory conditions was observed receiving oxygen at 5 lpm instead of the physician-ordered 3 lpm. The incorrect oxygen flow was identified during observations and confirmed by record review and staff interview.
A QMA left a medication cart drawer partially open and unattended with medications visible while administering medications to a resident. The QMA was unaware the drawer was not fully closed, which was not in accordance with facility policy requiring all medications to be secured in locked storage areas.
A staff member in a Memory Care Unit used foul language in the presence of residents after an altercation with a resident diagnosed with Alzheimer's disease. The employee, Terminated Employee 1, reacted to having her hair pulled by Resident G by yelling profanity, which was heard by other residents. The facility's investigation found no staff-to-resident abuse, but the incident was considered disrespectful and undignified.
A facility failed to implement care-planned fall prevention interventions for a resident with dementia and a history of falls. The resident was observed in a wheelchair without a non-slip pad, and a floor mat was not placed next to the bed as required. Staff were unsure about the interventions, and care cards were not up to date, leading to the deficiency.
The facility did not maintain up-to-date Nurse Staffing information, as observed when the posted information was outdated by several days. The Administrator stated that either the Scheduler or the Nursing Supervisor was responsible for updating this information daily. This issue was linked to specific complaints.
A facility failed to implement fall interventions for a resident with a history of falls. Despite a care plan requiring non-skid strips in the bathroom, they were not in place, increasing the resident's fall risk. The resident, with severe cognitive impairment and a history of self-transferring, was found on the bathroom floor, highlighting the need for the intervention.
The facility failed to document meal consumption for two residents with a history of weight loss. One resident, who was cognitively intact, experienced significant weight loss and had numerous undocumented meals. Another resident, who was cognitively impaired, also had missing meal documentation and experienced weight loss. The DON was unable to provide documentation for the missing records.
A facility failed to monitor a resident's pulse before administering metoprolol succinate, as required by the physician's order. The resident, with multiple health conditions, was given the medication on several occasions without documented pulse checks. The DON confirmed the absence of documentation.
The facility failed to provide adequate ADL care for several residents, including those with cognitive impairments and physical disabilities. Observations revealed issues such as greasy hair, unshaven facial hair, and soiled linens, indicating neglect in personal hygiene and toileting care. Documentation inconsistencies and missing records further highlighted the facility's failure to adhere to care plans requiring scheduled showers and grooming.
The facility failed to properly store medications in four out of five medication carts, with loose pills found scattered in the drawers. Nurses acknowledged their responsibility for cleaning the carts, and the DON confirmed that all nursing staff were accountable for this task.
A resident was observed with a medication cup containing multiple pills, which she stated were left by nurses for her to take after breakfast. Despite an IDT note indicating the resident was capable of self-administering medications, there were no physician orders authorizing this. The resident's diagnoses included dementia, heart disease, and anxiety disorder, and she had been taking various medications, including antidepressants and opioids.
The facility failed to notify families of significant weight loss and new dietary orders for two residents. One resident with dementia lost 12.5% of their weight since admission, and another with Alzheimer's lost 6.45% over four months. Despite these changes, families were not informed, contrary to facility policy.
A facility failed to ensure a clean and homelike environment for a resident, as evidenced by stained and dirty bed linens. The resident was observed with a dark reddish-brown stain on the bottom sheet and a large brown stain on the pillowcase over two days. Despite care being provided, the stains remained until the Administrator acknowledged the issue and changed the linens.
The facility failed to monitor and document skin discolorations for three residents. A resident had scabbed areas and discolorations on his forearms without documentation, despite being at risk for skin breakdown. Another resident had dark purple discolorations on her hands, not documented despite her care plan noting a risk for bruising due to aspirin therapy. A third resident had discolorations on his legs, a reddened neck, and a swollen arm, with no documentation or awareness from the Wound Nurse.
A resident with cognitive impairment and a history of hemiplegia and vascular dementia was observed with broken glasses, which were not addressed in a timely manner. The resident's record lacked documentation of the issue or optometry appointments. A CNA noted the glasses had been broken for several days, but it was unclear if the nurse or Unit Manager had been informed. The Social Service Director was unaware of the problem but planned to investigate.
The facility failed to provide adequate pressure ulcer care for two residents. One resident developed a stage 3 pressure ulcer on the left hip, with a lack of documented treatment orders and a data entry error by the Wound Nurse. Another resident was observed without pressure offloading boots, despite orders for their use, and there was no documentation of refusal or intolerance. These deficiencies highlight a failure in ensuring necessary treatment and preventative care.
The facility failed to apply hand splints as ordered for three residents, affecting their range of motion and mobility. A resident with hemiplegia was observed without a prescribed splint, and staff were unaware of the order. Another resident with severe cognitive impairment and cellulitis was not wearing a required splint, and a third resident with a hand contracture reported not receiving assistance with splint application. There were no care plans or documentation of refusals for the splints.
The facility failed to implement fall interventions for two residents, leading to deficiencies in accident prevention. One resident was observed without prescribed floor mats, and another was without non-skid footwear, both contrary to their care plans. The DON was informed but provided no further information.
A facility failed to document urinary output for a resident with a catheter as per the care plan. The resident, who was cognitively intact and dependent on staff for toileting, reported that staff did not regularly empty the catheter bag. The care plan required documentation of catheter output every shift, but records showed multiple instances of missing documentation. The DON confirmed the requirement for documentation every shift.
The facility failed to implement interventions for residents with significant weight loss and did not complete food consumption logs or weekly weights as ordered. A resident with Lewy body dementia lost 29 pounds without receiving nutritional supplements, and their food intake was not consistently recorded. Another resident with diabetes and osteoarthritis lost significant weight, with numerous undocumented meals despite care plan interventions. A third resident with heart failure and kidney disease experienced weight loss, and weekly weights were not obtained as ordered.
A facility failed to provide appropriate care for a resident with a g-tube by not performing a required 30 ml water flush before administering medication. An RN was observed administering Tylenol via the g-tube without the pre-medication water flush, contrary to the physician's orders. The RN acknowledged forgetting this step during an interview.
A facility failed to provide trauma-informed care for a resident with PTSD, dementia, and other mental health issues. Despite care plans outlining interventions like room visits and relaxation techniques, these were not effectively implemented. Staff interviews revealed a lack of awareness and communication regarding the resident's needs and triggers, contributing to the deficiency.
A facility failed to accurately document the administration of antibiotics for a resident with a history of septicemia and a urinary tract infection. Despite a physician's order for piperacillin-tazobactam to be given intravenously every 8 hours, the MAR showed missing signatures for several doses. The DON confirmed the absence of antibiotics in storage, suggesting they were administered but not recorded.
An RN improperly disposed of a used lancet in a resident's garbage can instead of a sharps container during a blood sugar check, violating the facility's infection control guidelines.
Failure to Administer Insulin and Monitor Blood Sugar as Ordered
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, specifically regarding the administration of insulin and monitoring of blood sugar levels for two residents with diabetes mellitus. For one resident, multiple instances were identified where blood sugar checks were not performed and prescribed insulin doses, including Lispro, Lantus, and Glargine, were not administered as ordered by the physician. Documentation showed missed insulin doses at various scheduled times, and in some cases, insulin was administered even when blood sugar levels were below the threshold specified in the physician's order. The Executive Director acknowledged the missed doses during an interview but provided no further information. For another resident, similar deficiencies were observed, including failure to administer sliding scale Lispro insulin when blood sugar readings indicated it was required, and missed doses of Glargine insulin at bedtime. The resident's care plan and physician's orders clearly outlined the need for insulin administration based on blood sugar results, but the Medication Administration Records revealed several occasions where insulin was not given as ordered. The Administrator confirmed the missed dosages and had no additional information regarding these omissions. The facility's medication administration policy required medications to be given as ordered by the physician.
Failure to Assess and Document Self-Administration of Medications
Penalty
Summary
A resident with diagnoses including Alzheimer's disease, asthma, and gastroesophageal reflux disease (GERD) was observed on multiple occasions with Tums (calcium carbonate) and an inhaler at the bedside. The resident reported self-administering Tums as needed for heartburn, and the inhaler was also kept at the bedside. Review of the resident's medical record showed that while there were physician's orders for the use of albuterol sulfate and calcium carbonate as needed, there were no specific orders permitting self-administration of these medications. Additionally, there was no documented assessment to determine the resident's ability to safely self-administer medications, nor was there a care plan addressing self-administration. The facility's policy required both a clinical assessment and a specific skill assessment to determine appropriateness for self-administration, but these steps were not completed for this resident. The DON was unable to provide further information regarding the lack of documentation.
Inaccurate MDS Assessments for Medication Administration
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were accurately completed for two residents regarding their receipt of antianxiety and antiplatelet medications. For one resident with diagnoses including schizoaffective disorder, general anxiety disorder, and dementia with behavioral disturbance, multiple quarterly MDS assessments indicated that the resident had not received any antianxiety medications. However, the care plan and physician's orders documented ongoing administration of clonazepam, an antianxiety medication, which was also confirmed by the Medication Administration Record (MAR). The MDS Coordinator acknowledged that the medication had been incorrectly coded as an anticonvulsant due to the classification in the computer charting system. For another resident with a history of stroke, congestive heart failure, and chronic kidney disease, the admission MDS assessment indicated no receipt of antiplatelet medications in the past seven days. Contrarily, the physician's order summary and MAR showed that the resident had been receiving ticagrelor, an antiplatelet medication, twice daily. The MDS Coordinator confirmed that the MDS assessment was incorrect and required modification.
Failure to Provide Scheduled Showers and Nail Care for Dependent Residents
Penalty
Summary
The facility failed to ensure that activities of daily living (ADLs) were completed for dependent residents, specifically regarding twice weekly showers and nail care. One resident, who was cognitively intact and dependent on staff for bathing and other ADLs due to conditions including heart failure, chronic kidney disease, and a stage 3 pressure ulcer, reported not always receiving scheduled showers. Record review confirmed missed showers on multiple scheduled dates, and the Director of Nursing was unable to provide documentation for these missed showers. Facility policy required showers to be provided per schedule or resident request, but this was not consistently followed. Another resident, also cognitively intact and dependent on staff for personal hygiene due to diagnoses including edema and type 2 diabetes mellitus, reported that her toenails had not been cut despite requests. Observation confirmed long toenails, and record review showed no documentation of nail care being performed during the review period, despite care plan interventions specifying nail care on bath days and as needed. The Director of Nursing had no additional information regarding the lack of nail care documentation.
Failure to Assess and Monitor Skin Discoloration in Resident on Anticoagulant Therapy
Penalty
Summary
A resident with diagnoses including anemia, atrial fibrillation, heart failure, hypertension, and dementia was observed on two separate occasions to have a dark purple discoloration on the top of his right hand. The resident was cognitively impaired, required substantial assistance with mobility and dressing, and was receiving anticoagulant therapy (Eliquis) for atrial fibrillation. The care plan indicated the resident was at risk for abnormal bleeding due to anticoagulant use and included interventions to inspect the skin for bruising and notify nursing staff of abnormal findings. Despite these interventions, there was no documentation in the medical record that the discoloration had been assessed or monitored. The weekly skin assessment did not note any new skin concerns, and the wound nurse was unaware of the discoloration until interviewed by surveyors. The facility did not provide a policy regarding the assessment or monitoring of skin discolorations.
Failure to Implement Fall Prevention Interventions for Residents with History of Falls
Penalty
Summary
The facility failed to ensure that residents with a history of falls and injuries had appropriate fall prevention interventions in place. One resident, who had diagnoses including Alzheimer's disease and dementia, was observed twice with her call light not within reach, despite her care plan specifying that the call light and personal items should be accessible. This resident had recently fallen while attempting to reach for something from her nightstand, resulting in visible injuries, and was unable to locate her call light during both observations. Documentation confirmed her cognitive intactness and dependence on staff for mobility and transfers. Another resident, with a history of a left humerus fracture and other medical conditions, was observed without required non-skid strips near his recliner and without a Dycem mat in his wheelchair, as ordered in his care plan. The resident had recently fallen while trying to pull up his pants from the recliner, resulting in a fracture and hospitalization. Observations confirmed the absence of these fall prevention interventions, and staff interviews indicated that the resident was frequently noncompliant with the Dycem and that the recliner may have been moved, leading to the non-skid strips not being in the correct location.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
A deficiency occurred when a resident with diagnoses including dementia, asthma, and chronic obstructive respiratory disease did not receive oxygen therapy as ordered by the physician. The resident, who had severe cognitive impairment and was dependent for bed mobility, transfers, and toileting, was observed on two separate occasions with oxygen administered at 5 liters per minute (lpm) via nasal cannula, instead of the prescribed 3 lpm continuously. The discrepancy between the physician's order and the actual oxygen flow rate was confirmed through record review and staff interview.
Medication Cart Left Unsecured While Unattended
Penalty
Summary
A medication cart was observed with a bottom drawer not fully closed and medications visible while unattended. The Qualified Medication Aide (QMA) had prepared medications for a resident, locked the cart, and entered the resident's room, but the drawer remained partially open from 9:12 a.m. to 9:18 a.m. The QMA was unaware that the drawer was not completely closed. The Director of Nursing was informed of the incident, and the facility's policy was reviewed, which requires all medications to be secured in locked storage areas accessible only to authorized personnel.
Staff Use of Foul Language in Memory Care Unit
Penalty
Summary
The facility failed to ensure that residents on the Memory Care Unit were treated with respect and dignity. This deficiency arose from an incident involving a staff member, Terminated Employee 1, who used foul language in the presence of residents. The incident occurred when Resident G, who has a diagnosis of Alzheimer's disease and/or dementia, grabbed the hair of Terminated Employee 1. In response to the pain, the employee began to yell profanity, including calling RN 1 derogatory names when instructed to leave the facility. This altercation was audible to residents in the hallway and common area, potentially affecting all residents on the Memory Care Unit. The facility's investigation into the incident, reported to the Indiana Department of Health, concluded that staff-to-resident abuse had not occurred. However, it was noted that Terminated Employee 1 admitted to using profanity in front of the residents. During interviews, RN 1 confirmed that the employee's reaction was not violent towards the resident but was a response to the situation. Despite this, the use of foul language in a setting with residents who have cognitive impairments was deemed disrespectful and undignified, leading to the deficiency finding.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement care-planned interventions to prevent injuries from falls for a resident with a history of falls and dementia. On multiple observations, the resident was seen sitting in a wheelchair without a non-slip pad, which was a specified intervention in the care plan. Additionally, when the resident was assisted to bed, a floor mat intended to be placed next to the bed was not used, as it was left leaning against the wall. Staff members, including a QMA and a CNA, were unsure about the requirement for the non-slip pad and did not place it under the resident in the wheelchair. During an interview, a CNA indicated that care cards, which contain interventions to prevent falls, were available but not always up to date. A review of the care card confirmed the requirement for a non-slip pad on the wheelchair, but the floor mat was not listed. The resident's care plan, however, included both interventions, with the non-slip pad added in November 2024 and the floor mat in March 2020. The deficiency was identified during a complaint investigation related to the resident's risk for falls and history of falls.
Outdated Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the posted Nurse Staffing information was up-to-date and current, which had the potential to affect all residents in the facility. The Nurse Staffing Information was observed to be outdated, as it was dated 1/8/25, while the observation took place on 1/13/25. During an interview, the Administrator indicated that either the Scheduler or the Nursing Supervisor was responsible for posting the current Nurse Staffing Information daily. This deficiency was related to Complaints IN00449509 and IN00450162.
Failure to Implement Fall Interventions for Resident
Penalty
Summary
The facility failed to implement fall interventions for a resident with a history of falls, identified as Resident D. On October 8, 2024, it was observed that there were no non-skid strips on the bathroom floor of Resident D's room, despite a care plan intervention dated September 23, 2024, which required these strips to be placed near the toilet. Resident D's medical history includes Alzheimer's disease, hypertensive chronic kidney disease, type 2 diabetes mellitus, osteoarthritis, dementia, and repeated falls. The resident was assessed as severely cognitively impaired and required substantial assistance with activities of daily living. The facility's records indicate that Resident D had a history of behaviors such as hitting, punching, and kicking walls, and self-transferring without assistance, which contributed to her fall risk. An incident on September 23, 2024, involved the resident being found on her bathroom floor, prompting the recommendation for non-skid strips. However, these strips were not in place at the time of the survey. Interviews with staff confirmed the absence of the non-skid strips, and the facility's fall management policy required fall risks to be assessed and interventions discussed by the interdisciplinary team after each fall.
Failure to Document Meal Consumption for Residents with Weight Loss
Penalty
Summary
The facility failed to ensure that food consumption logs were completed for residents with a history of weight loss, specifically for Residents F and C. Resident F, who was cognitively intact and required partial assistance with eating, experienced a significant weight loss from 227 pounds to 203 pounds over a short period. The resident's meal intakes had declined due to depression, yet the facility did not document meal consumption for numerous dates across breakfast, lunch, and dinner. The Director of Nursing (DON) was unable to provide any documentation for the missing meal consumption logs. Resident C, who was cognitively impaired and required substantial assistance with eating, also had missing meal consumption documentation. The resident's weight decreased from 170 pounds to 154 pounds, and there were multiple instances where meal consumption was not documented. Despite being informed of the missing documentation, the DON did not provide further information. This deficiency was related to a specific complaint, indicating a failure in maintaining accurate records of food and fluid intake for residents at nutritional risk.
Failure to Monitor Pulse Before Administering Blood Pressure Medication
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was properly managed and monitored, specifically regarding the administration of metoprolol succinate, a blood pressure medication. The deficiency involved not monitoring the resident's pulse as ordered before administering the medication. The resident, who was cognitively intact, had multiple diagnoses including atrial fibrillation, heart failure, hypertension, Cushing's syndrome, diabetes mellitus, and end-stage renal disease. The physician's order required holding the medication if the heart rate was less than 60. However, the medication was administered on multiple dates without any documentation of pulse monitoring prior to administration. The Director of Nursing confirmed the lack of documentation during an interview.
Deficiencies in ADL Care for Residents
Penalty
Summary
The facility failed to provide adequate activities of daily living (ADL) care for several residents, as evidenced by observations, record reviews, and interviews. Resident 76, who has hemiplegia and vascular dementia, was observed with greasy hair and food debris in his beard, indicating a lack of proper hygiene care. The resident's care plan required total assistance for bathing, yet records showed only bed baths were given instead of scheduled showers, with no documentation of refusals on certain dates. Similarly, Resident 121, who requires total assistance for bathing due to dementia, reported not receiving showers as scheduled, with missing documentation for several dates. Resident 52, who is cognitively intact but dependent on staff for personal hygiene, was observed with long facial hair, indicating a lack of grooming care. The care plan required weekly shaving, but staff interviews revealed this was not consistently done. Resident C, who is severely cognitively impaired and dependent on staff for toileting, was found in bed with soiled linens and no brief, suggesting neglect in personal hygiene and toileting care. The documentation for Resident C's showers was incomplete, with refusals noted but no further information provided. Resident 45, who has schizoaffective disorder and requires substantial assistance for showering, reported not receiving showers twice a week as scheduled. Although the shower sheets indicated some showers were given, there were inconsistencies in the documentation. Interviews with the Director of Nursing and other staff members revealed a lack of additional shower sheets and no further information to address the discrepancies. These findings highlight the facility's failure to ensure dependent residents received the necessary ADL care, as required by their care plans.
Improper Medication Storage in Facility
Penalty
Summary
The facility failed to ensure proper storage of medications in four out of five medication carts observed. During observations on May 20, 2024, it was noted that the 1A, 2C, 2B, and 3D Medication Carts contained loose pills of various sizes and colors scattered throughout the bottoms of the drawers. The nurses responsible for these carts acknowledged that it was their duty to ensure the medication carts were cleaned and organized. In an interview conducted on the same day, the Director of Nursing confirmed that all nursing staff were responsible for maintaining the cleanliness and organization of the medication carts. This deficiency indicates a lapse in the facility's adherence to proper medication storage protocols, as required by professional principles and regulations.
Lack of Physician Orders for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident had physician's orders for self-administration of medications. On May 14, 2024, a resident was observed in her room with a medication cup containing multiple pills on the table next to her. The resident stated that nurses routinely left her morning medications for her to take after breakfast. The resident's medical record, reviewed on May 15, 2024, indicated diagnoses including dementia, heart disease, and anxiety disorder. An MDS assessment dated April 5, 2024, showed the resident was cognitively intact for daily decision-making and had been taking various medications, including antidepressants and opioids, in the past week. An IDT note from May 14, 2024, documented that the team determined the resident was capable of self-administering her prescribed medications, which included furosemide, l-methylfolate, levothyroxine, and others. However, there were no physician orders authorizing the resident to self-administer these medications. During an interview on May 16, 2024, the Administrator acknowledged that there should have been an order for self-administration.
Failure to Notify Family of Significant Weight Loss and Dietary Changes
Penalty
Summary
The facility failed to notify the family or representative of significant weight loss and a new nutritional supplement order for two residents. Resident 59, diagnosed with Lewy body dementia, psychotic disorder, depressive disorder, and diabetes mellitus, experienced a significant weight loss of 15 pounds, or 5%, within one month, followed by an additional 14-pound loss, totaling a 12.5% weight loss since admission. Despite these changes, there was no documentation that the family was informed. A family member confirmed they were only notified of the weight loss on 5/16/24, and the Director of Nursing acknowledged the lack of documentation regarding family notification. Similarly, Resident 143, with Alzheimer's dementia, iron deficiency, and chronic lymphocytic leukemia, lost eight pounds, or 6.45%, over four months. A new physician's order for a health shake was issued due to the weight loss, but there was no documentation that the family was informed. A family member was unaware of the weight loss and the new dietary order. The Administrator confirmed the absence of documentation for family notification. The facility's policy requires notifying the resident's physician and family/guardian of any significant weight change, which was not adhered to in these cases.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment for Resident B, as evidenced by stained and dirty bed linens. On two consecutive days, Resident B was observed lying in bed with a dark reddish-brown stain on the bottom sheet and a large brown stain on the pillowcase. Despite care being provided by a CNA, the stains remained on the linens. During an interview, the Administrator acknowledged that the linens were likely already stained when placed on the bed and subsequently changed them. This deficiency was identified during a complaint investigation.
Failure to Monitor and Document Skin Discolorations
Penalty
Summary
The facility failed to ensure that residents received necessary treatment and services related to the monitoring and assessment of skin discolorations. Resident B was observed with scabbed areas and multiple purple discolorations on his forearms, yet the most recent Weekly Nursing Summary indicated no current skin issues. Despite being at risk for skin breakdown, as noted in his care plan, there was no documentation of these skin conditions, and the Director of Nursing indicated that the Wound Nurse would assess the resident's skin, but no further information was provided. Resident 66 was observed with dark purple discolorations on the tops of both hands, which were not documented in the Weekly Nursing Summary. Her care plan noted a risk for increased bruising due to aspirin therapy, but there was no documentation of these findings, and the Administrator was made aware of the discolorations without further action. Resident 10 had discolorations on his lower legs, a reddened area on his neck, and a swollen right arm, but there was no documentation of these conditions in his record. The Wound Nurse was unaware of these issues, indicating a lack of proper monitoring and assessment.
Failure to Address Resident's Broken Glasses
Penalty
Summary
The facility failed to ensure a resident received the necessary assistive device to maintain vision, as evidenced by the broken glasses of a resident not being addressed in a timely manner. The resident, who has a history of hemiplegia, hemiparesis following a cerebral vascular accident, diabetes mellitus, and vascular dementia, was observed on multiple occasions with broken glasses on the overbed table. The resident indicated that the glasses were used for reading. A review of the resident's record showed no documentation regarding the broken glasses or any optometry appointments. A CNA mentioned that the glasses had been broken for several days, but she was unsure if the nurse or Unit Manager had been informed, as she had been off work. The Social Service Director was also unaware of the issue but indicated she would investigate further.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment and services to promote healing for pressure ulcers for two residents. Resident D, who was admitted with a risk for pressure ulcers, developed a stage 3 pressure ulcer on the left hip. Despite a care plan indicating wound treatments as ordered, there was a lack of documented treatment orders for the left hip in the Physician's Orders Summary. The Wound Nurse made a data entry error, incorrectly documenting treatment for the left buttock instead of the left hip, and continued using a previous treatment without documenting the deviation from the Wound Nurse Practitioner's recommendation. Resident E, diagnosed with Alzheimer's disease and type 2 diabetes mellitus, was observed without pressure offloading boots, which were found on the floor behind his recliner. Despite a Physician's Order for bilateral heel offloading boots every shift, the Medication Administration Record indicated the boots were signed off every shift. The Director of Nursing was unable to provide documentation of the resident refusing or not tolerating the boots, highlighting a failure to ensure the resident's preventative care was consistently applied.
Failure to Apply Hand Splints as Ordered
Penalty
Summary
The facility failed to ensure proper positioning and application of hand splints for three residents, leading to deficiencies in maintaining or improving their range of motion and mobility. Resident 76, diagnosed with hemiplegia and hemiparesis following a cerebral vascular accident, was observed multiple times without the prescribed left hand splint, which was ordered to be worn 6-8 hours daily. The Treatment Administration Record did not reflect this order, and staff were unaware of the requirement, resulting in the resident's left hand remaining contracted. Resident 10, with severe cognitive impairment and a diagnosis of cellulitis of the right upper limb, was observed without the necessary right hand splint, despite a physician's order for its use and circulation checks every shift. Similarly, Resident 125, who had a contracture in the left hand, was not provided with a splint as ordered, and there was no care plan addressing the contracture. The resident reported that staff had not assisted with the splint in a long time, and there was no documentation of refusals or care plans related to the splinting device.
Failure to Implement Fall Interventions for Residents
Penalty
Summary
The facility failed to ensure fall interventions were in place for two residents, leading to deficiencies in accident prevention. Resident B was observed on two separate occasions lying in bed without the prescribed floor mats in place, which were instead found leaning against the wall. The resident's care plan, updated in March 2024, indicated the need for a mat beside the bed due to the resident's cognitive impairment and requirement for substantial assistance with mobility. Despite this, the intervention was not implemented, and the Director of Nursing (DON) was made aware of the oversight but provided no further information. Similarly, Resident 91 was observed twice seated in a Broda chair without wearing socks, contrary to the care plan's intervention to encourage and assist the resident in wearing appropriate non-skid footwear. The resident, who was cognitively impaired and had a history of falls, was at risk due to the lack of adherence to the care plan. The DON acknowledged the situation and indicated uncertainty about the resident's preference for not wearing socks, suggesting a potential update to the care plan might be necessary.
Failure to Document Urinary Output for Resident with Catheter
Penalty
Summary
The facility failed to ensure that urinary output was recorded as per the plan of care for a resident with a urinary catheter. Resident 89, who was cognitively intact and dependent on staff for toileting, was observed with a urinary catheter that had not been emptied regularly. The resident reported having to remind staff multiple times a day to empty the catheter bag. A review of the resident's care plan indicated a requirement to document catheter output every shift, but records showed multiple instances where this documentation was missing across various shifts. The Director of Nursing confirmed that staff should have documented the urinary output every shift.
Failure to Monitor and Document Nutritional Intake
Penalty
Summary
The facility failed to implement necessary interventions for residents experiencing significant weight loss and did not complete food consumption logs or weekly weights as ordered. Resident 59, diagnosed with conditions including Lewy body dementia and diabetes mellitus, experienced a weight loss of 29 pounds since admission, with no documentation of interventions or nutritional supplements provided. The resident's food consumption was not consistently recorded, and the significant weight loss was not identified until surveyors pointed it out. Resident 91, with diagnoses including type 2 diabetes mellitus and osteoarthritis, also experienced significant weight loss, dropping from 137 pounds to 119 pounds over a few months. Despite a care plan intervention to serve diet and supplements as ordered and record consumption, there were numerous instances where meal consumption was not documented. The lack of documentation was brought to the attention of the facility's administrator, but no further information was provided. Resident 158, who has congestive heart failure and chronic kidney disease, was also affected by the facility's failure to monitor nutrition properly. The resident's weight dropped from 175 pounds to 162 pounds, and a physician's order for weekly weights was not followed. Additionally, there were multiple instances where the resident's meal consumption was not recorded. The Director of Nursing had no further information to provide regarding these deficiencies.
Failure to Perform Pre-Medication Water Flush for G-Tube Administration
Penalty
Summary
The facility failed to ensure appropriate treatment for a resident with a gastronomy tube (g-tube) during medication administration. On May 16, 2024, RN 1 was observed preparing and administering medication to Resident 115 via a g-tube. The nurse crushed Tylenol 325 mg tablets, mixed them with water, and administered the mixture through the g-tube. However, RN 1 did not perform the required water flush of 30 ml before administering the medication, as ordered by the physician. This omission was confirmed during an interview with RN 1, who acknowledged forgetting to flush the g-tube with water prior to medication administration. The physician's order specifically required a 30 ml water flush before and after medication administration via the g-tube.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care for a resident diagnosed with PTSD, dementia, psychosis, major depressive disorder, and generalized anxiety disorder. The resident, who was severely cognitively impaired, exhibited behaviors such as yelling out, anxiety, restlessness, and irritability. Despite having care plans in place that included interventions like room visits, sensory stimulation, and relaxation techniques, these were not effectively implemented or updated to address the resident's PTSD-related needs. Observations noted the resident yelling out in various settings, indicating a lack of adherence to the care plan interventions designed to manage his symptoms. Interviews with facility staff revealed gaps in the execution of the care plan. The Activity Director was unaware of any one-to-one activities being conducted with the resident, despite care plan requirements. Additionally, the Social Services Director admitted to not reaching out to the resident's family to identify potential triggers for the resident's flashbacks and yelling episodes. The family had been invited to care plan meetings but had not attended, leaving the facility without crucial insights into the resident's needs and triggers. This lack of communication and failure to follow through on care plan interventions contributed to the deficiency in providing appropriate care for the resident's PTSD and related behaviors.
Incomplete Documentation of Antibiotic Administration
Penalty
Summary
The facility failed to ensure that clinical records were complete and accurately documented regarding medication administration for a resident being treated with antibiotics. The resident, who was cognitively intact, had a history of septicemia and a urinary tract infection. A physician's order was in place for the administration of piperacillin-tazobactam intravenously every 8 hours for 7 days to treat sepsis due to pseudomonas. However, the Medication Administration Record (MAR) for the month indicated that the antibiotic was not signed off as administered on several occasions, specifically at 6 a.m. on two dates, 2 p.m. on three dates, and 10 p.m. on one date. During an interview, the Director of Nursing confirmed that there were no antibiotics left in the medication storage room and believed the medication had been administered as ordered but not documented in the MAR.
Improper Disposal of Lancet During Blood Sugar Check
Penalty
Summary
The facility failed to adhere to infection control guidelines during a blood sugar check for a resident. An RN was observed performing a blood sugar test on a resident, during which she followed proper hand hygiene and glove use. However, after obtaining the blood sample, the RN improperly disposed of the used lancet in the resident's garbage can instead of the designated sharps container. This action was contrary to the facility's policy on sharps disposal, which mandates that contaminated sharps be discarded into appropriately labeled or color-coded containers. The RN acknowledged the error during an interview following the observation.
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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