Serenity Spring Senior Living At Northwood
Inspection history, citations, penalties and survey trends for this long-term care facility in Jasper, Indiana.
- Location
- 2515 Newton St, Jasper, Indiana 47547
- CMS Provider Number
- 155282
- Inspections on file
- 28
- Latest survey
- June 30, 2025
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Serenity Spring Senior Living At Northwood during CMS and state inspections, most recent first.
The facility did not hold or document required care plan conferences for four residents with various diagnoses, including anxiety, depression, dementia, and neurological disorders. Despite being cognitively intact in most cases, these residents' records showed significant gaps in care plan conference documentation over the past year, contrary to facility policy and staff expectations.
The facility did not document notification to family or resident representatives after falls involving several residents with severe cognitive impairments and complex medical histories. Despite policy requiring such notifications, clinical records and IDT notes lacked evidence that families or representatives were informed following these incidents.
Several residents with severe cognitive and physical impairments experienced repeated falls, and the facility did not consistently perform thorough post-fall assessments, update care plans, or implement timely interventions. Documentation often lacked neurological checks and falls assessments, and staff did not always follow care plan interventions or ensure assistive devices were accessible. Facility policies for post-fall care and care plan updates were not consistently followed.
A resident was discharged from Medicare services with benefit days remaining, but the facility did not have documentation showing that the required Notice of Medicare Non-Coverage (NOMNC) was provided prior to discharge. The Social Service Director reported that the notice was given, but no record of this was found in the clinical file, contrary to facility guidelines.
Two residents were affected by failures in medication management: one was given an antipsychotic injection without a current physician order, and another continued to receive antipsychotic and antianxiety medications without documented attempts at gradual dose reduction or physician-documented contraindications, contrary to facility policy and regulatory requirements.
Staff did not follow infection prevention protocols during incontinence care, including inadequate hand hygiene, improper glove changes, and incorrect handling of incontinence pads. Residents were not offered hand hygiene after toileting, and soiled briefs were not always changed, contrary to facility policy.
The facility failed to provide transfer or discharge notices to five residents or their representatives during hospitalizations. Clinical records lacked documentation of these notices, and the Administrator indicated that staff were not retaining copies in the records.
The facility failed to provide bed hold forms and policies to residents or their representatives during hospitalizations. This deficiency was identified for five residents, whose clinical records lacked documentation of receiving the necessary information. The Administrator acknowledged that staff might not be making copies of the forms for the records.
The facility failed to ensure the accuracy of MDS Assessments for 14 out of 26 resident records reviewed. Several residents were observed without bed rails, despite their assessments indicating daily use of bed rails as restraints. The MDS Coordinator admitted to errors in coding and training, leading to discrepancies between the residents' actual conditions and their documented assessments.
The facility failed to develop comprehensive person-centered care plans for four residents, including those on hospice care and those receiving specific medications. This oversight was confirmed by the MDS Coordinator and the DON, leading to deficiencies in addressing the residents' specific needs.
The facility failed to update care plans and conduct timely care plan conferences for several residents. One resident's care plan was not revised after moving from a locked dementia unit, and another resident's care plan was not updated after a change in sleep medication. Additionally, two residents did not receive care plan conferences within the required timeframe.
The facility failed to ensure residents were free from unnecessary medications, with five residents receiving psychotropic medications without proper diagnoses or exceeding the 14-day limit for PRN orders without documented rationale for extension. The facility's Psychotropic Medication Use Policy was not adhered to in these cases.
The facility failed to maintain safe and secure storage of medications in three medication carts and one medication storage room. Loose pills were found in the carts, and temperature logs for the refrigerators were incomplete. LPNs indicated inconsistencies in cleaning schedules, and medications for a discharged resident were improperly stored.
The facility failed to adhere to food service safety standards as staff were observed handling food and utensils with bare hands during meal services, contrary to the facility's policy requiring the use of gloves.
The facility failed to document influenza and pneumococcal vaccines being offered to three residents. Clinical records lacked consent/refusal dates, reasons for refusal, and dates education was provided. The Infection Preventionist acknowledged the documentation lapses, despite the facility's policy requiring such records.
The facility failed to ensure a safe, functional, sanitary, and comfortable environment for residents, with issues such as dusty vents, unlabeled personal care items, scuffed doors, sticky floors, loose grab bars, and exposed wires in the common area. Observations on two separate dates confirmed these issues were not addressed.
The facility failed to treat two residents with respect and dignity. A CNA was observed standing while assisting a resident with feeding, contrary to policy. Additionally, an LPN left a resident with a visible urine spot under her wheelchair without providing immediate care, violating the facility's dignity policy.
The facility failed to provide ice water to a resident when requested, despite the resident being cognitively intact and requiring extensive assistance. The facility's policies on hydration and accommodation of needs were not followed, as ice water was not routinely passed, and residents had to ask for it.
The facility failed to clarify a resident's code status, resulting in a discrepancy between the resident's DNR order and the physician's orders, which indicated CPR. Interviews confirmed the inconsistency, and the facility's policy was not followed.
The facility failed to ensure a resident's right to be free from physical restraints, as bed rails were used without proper documentation, informed consent, or evidence that the resident could remove the restraint herself. Staff interviews and observations confirmed the inappropriate use of bed rails to prevent falls, contrary to the facility's policy.
A resident reported that a CNA physically removed her fingers from a lift, but the facility failed to document or report the allegation immediately as required by their policy. The DON was aware but did not report it, and the CNA had a prior battery charge.
A facility failed to properly investigate an abuse allegation involving a resident who reported that a CNA physically removed her fingers from a sit-to-stand lift. The incident was not documented or followed up on, and the CNA had a prior battery charge. The facility's policy on abuse reporting and investigation was not followed.
The facility failed to ensure adequate supervision to prevent accidents for two residents reviewed for falls. Non-skid strips were not placed, care plans were not updated, and neurological checks were not consistently completed. The facility did not follow its policies on falls and neurological assessments, leading to multiple falls and injuries.
The facility failed to ensure a resident received appropriate care to prevent and treat UTIs, leading to recurrent infections, cognitive decline, and multiple falls. Delays in obtaining and processing urinalysis orders, misinterpretation of results, and inadequate infection control practices during incontinence care were observed.
The facility failed to provide consistent respiratory care for three residents, with observations of incorrect oxygen settings, uncleaned oxygen concentrator filters, and lack of adherence to physician orders and care plans. The DON confirmed that staff were not following the facility's policy on cleaning filters weekly.
The facility failed to follow proper infection control practices during incontinence care and blood glucose monitoring for three residents. Staff did not perform hand hygiene between glove changes and did not adequately clean a glucometer between uses, contrary to facility policies and expected protocols.
The facility did not post nurse staffing sheets daily during the survey period, missing updates on two specific days. The DON confirmed that the night shift is responsible for this task, and the facility's policy requires daily postings.
Failure to Hold and Document Required Care Plan Conferences
Penalty
Summary
The facility failed to ensure that care plan conferences were held and documented for four out of five residents reviewed for unnecessary medications. For each of these residents, clinical record reviews revealed significant gaps in the documentation of care plan conferences within the past year. Specifically, one resident with diagnoses including anxiety, osteoporosis, depression, and early-onset cerebellar ataxia, who was cognitively intact, had no documented care plan conference between May 2024 and February 2025. Another resident with anxiety, depression, and dementia with behaviors, also cognitively intact, lacked documentation of a care plan conference between August 2024 and May 2025. A third resident with dementia without behaviors, depression, epilepsy, and anxiety, who was severely cognitively impaired, had no documented care plan conference after September 2024. The fourth resident, diagnosed with psychotic disorder with hallucinations, vascular dementia with behaviors, and stroke, and who was cognitively intact, had no documented care plan conference after August 2024. Interviews with facility staff confirmed that care plan conferences are expected to occur quarterly and as needed, with documentation required in the clinical record. The facility's own Comprehensive Care Plan Policy, revised in March 2022, also specifies that care plan meetings should take place according to state regulations, including at admission, with changes in condition, quarterly, annually, or as requested by the resident, POA, or facility. Despite these requirements, the records for the identified residents did not contain evidence of timely care plan conferences, resulting in a failure to allow residents to participate in the development and implementation of their person-centered care plans.
Failure to Notify Family/Representatives After Resident Falls
Penalty
Summary
The facility failed to ensure timely notification of family members or resident representatives following a change in condition, specifically after resident falls, for four out of five residents reviewed. In each case, clinical records and interdisciplinary team notes documented the occurrence of falls, but lacked evidence that the family or resident representative was informed. The residents involved had significant cognitive impairments or diagnoses such as Parkinson's disease, dementia, Alzheimer's disease, schizophrenia, seizure disorder, and depression. Falls were documented in the residents' health status notes and reviewed by the interdisciplinary team, but there was no documentation of required notifications to families or representatives. The facility's policy, last revised in 2018, requires that both the physician and family be notified when a resident falls, and that this notification be recorded in the medical record. Despite this policy, the records for the affected residents did not include documentation of such notifications. The Assistant Director of Nursing confirmed that all provided information was part of the clinical record and that any additional internal documents were not included in the clinical record reviewed.
Failure to Provide Adequate Supervision and Post-Fall Assessment
Penalty
Summary
The facility failed to ensure adequate supervision and the use of assistive devices to prevent accidents for four out of five residents reviewed for falls. Multiple residents with significant cognitive and physical impairments experienced repeated falls, and the facility did not consistently perform thorough post-fall assessments, update care plans with each incident, or implement timely interventions. For example, one resident with Parkinson's disease and dementia had at least eight falls, with records frequently lacking post-fall neurological checks and falls assessments. Interventions such as anti-rollbacks for wheelchairs and reminders for staff to use gait belts were often delayed in being added to care plans, and some interventions were not implemented at the time of the falls. Another resident, who was legally blind and had a seizure disorder, experienced several falls, including unwitnessed incidents resulting in head injuries. Documentation showed that neurological checks were incomplete or missing after some falls, and falls assessments were not performed. Observations revealed that staff did not always follow care plan interventions, such as ensuring the call light was clipped to the resident's clothing for safety. Transfers were sometimes performed by a single staff member despite care plan requirements for two-person assistance. Additional residents with diagnoses such as Alzheimer's disease, dementia, and schizophrenia also experienced multiple falls. In several cases, the facility did not document interdisciplinary team reviews or update care plans with new interventions after falls. Neurological checks were inconsistently performed or not documented, and falls risk assessments were often omitted following incidents. Observations further indicated that assistive devices, such as call lights, were not always accessible to residents as required by their care plans. Facility policies required neurological assessments and care plan updates after falls, but these were not consistently followed.
Failure to Provide Required Medicare Non-Coverage Notice at Discharge
Penalty
Summary
The facility failed to provide the required Notice of Medicare Non-Coverage (NOMNC) to a resident who was being discharged from Medicare services, despite the resident having Medicare benefit days remaining at the time of discharge. Record review showed that there was no documentation in the clinical record indicating that the resident was notified of the end of Medicare coverage prior to discharge. During interviews, the Social Service Director stated that the NOMNC notice was given to the resident, but was unable to provide documentation to support this. Facility guidelines indicated that a NOMNC should have been issued in this scenario, but no such documentation was available in the resident's record.
Failure to Prevent Unnecessary Psychotropic Medication Use and Ensure Proper Documentation
Penalty
Summary
The facility failed to ensure that residents' drug regimens were free from unnecessary psychotropic medications, resulting in two deficiencies involving two residents. In the first case, a resident with diagnoses including Parkinson's disease, dementia, anxiety, depression, and psychotic disorder was administered an antipsychotic medication (Haldol) via injection after the physician's order for the medication had already been discontinued earlier that day. Documentation in the clinical record confirmed the administration of the medication without a current physician's order, and the Medication Administration Record did not reflect that the medication was given on that date. Interviews with staff revealed a lack of recall regarding the incident and a delay in follow-up after the medication was administered. In the second case, another resident with anxiety, osteoporosis, depression, and early-onset cerebellar ataxia was receiving both an antipsychotic and an antianxiety medication. The clinical record showed ongoing administration of these medications, with care plans indicating the need to consult with the healthcare provider for possible dosage reduction. However, there was no documentation of a contraindication for a gradual dose reduction (GDR) or a rationale from the prescribing practitioner to continue the medications at the current dose. The facility's policy required attempts at GDR unless clinically contraindicated and documented by the physician, but such documentation was not present in the resident's record. Facility policies reviewed included requirements to verify physician orders before administering intramuscular injections and to attempt GDRs for psychotropic medications unless contraindicated and documented. Staff interviews confirmed that orders should be obtained and documented for such medications, and that the required documentation for GDR contraindications was not available in the clinical record for the resident in question.
Infection Control Lapses During Incontinence Care
Penalty
Summary
Staff failed to maintain a sanitary environment and adhere to infection prevention and control protocols during incontinence care for three residents. Observations revealed that hand hygiene was not performed correctly, with staff washing hands for less than the required 15 seconds and failing to perform hand hygiene between glove changes. In several instances, staff handled soiled incontinence pads improperly, such as holding a clean pad against their scrub pants and leaving a visibly soiled pad on a resident after toileting. Additionally, residents were not offered the opportunity to wash their hands after toileting, and staff did not always assess or change soiled briefs as needed. Interviews with staff and review of facility policies confirmed that proper hand hygiene should include at least 20 seconds of scrubbing, and gloves should be changed with hand hygiene performed between tasks. The facility's policy also specified that gloves do not replace handwashing and that hand hygiene is the final step after removing personal protective equipment. Despite these guidelines, staff actions did not align with policy requirements, resulting in multiple breaches of infection control practices during resident care.
Failure to Provide Transfer or Discharge Notices
Penalty
Summary
The facility failed to ensure that a notice of transfer or discharge was given to residents or their representatives for five residents who were hospitalized. The clinical records for these residents lacked documentation of the transfer or discharge notice, and the facility did not make copies of the forms to keep in the residents' clinical records. The Administrator indicated that staff were filling out the forms and sending them with the residents but were not retaining copies in the clinical records. Resident 38, who had severe cognitive impairment, was sent to the emergency room after a fall, but there was no documentation of a transfer notice. Resident 52, with unspecified intellectual disabilities, was sent to the hospital after a fall, but again, no transfer notice was documented. Resident 43, who was cognitively intact, was hospitalized for vomiting, but neither the resident nor the representative received a transfer notice. Resident 15, with moderate cognitive impairment, was hospitalized for hypotension and lethargy, but the transfer form provided later lacked essential information. Resident 46 was hospitalized and returned the next day, but there was no transfer notice documented in the clinical record.
Failure to Provide Bed Hold Information During Hospitalizations
Penalty
Summary
The facility failed to ensure that a bed hold form and policy were provided to residents or their representatives during hospitalizations. This deficiency was identified for five residents who were hospitalized. The clinical records for these residents lacked documentation that the bed hold form and policy were given at the time of hospitalization. For instance, Resident 38, who had severe cognitive impairment, was sent to the emergency room after a fall, but there was no documentation that the representative received the bed hold form and policy. Similarly, Resident 52, who had severe intellectual disabilities, was sent to the hospital after a fall, and the clinical record also lacked documentation of the representative receiving the bed hold form and policy. Resident 43, who was cognitively intact, was sent to the emergency room due to vomiting, but neither the resident nor the representative received the bed hold form and policy. Resident 46 was discharged to the hospital and returned the next day, but there was no documentation that bed hold information was provided. During an interview, the Administrator indicated that staff were likely filling out bed hold forms and giving them to residents but were not making copies to keep in the clinical records. The Director of Nursing provided a current Bed-Holds and Returns policy, which stated that all residents or their representatives should receive written information about the facility's bed-hold policies at least twice, including well in advance of any transfer and at the time of transfer. However, this policy was not followed, leading to the deficiency.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure the accuracy of assessments for 14 out of 26 resident records reviewed during the survey. The Minimum Data Set (MDS) Assessments did not accurately reflect the resident status. For instance, Resident 36's clinical record indicated the use of physical restraints in the form of bed rails, but there was no current physician order or care plan related to bed rails. Similarly, Resident 14's MDS Assessment indicated the use of an anticoagulant medication, but the clinical record lacked a current physician's order for such medication, while it did include orders for antiplatelet medications instead. Several residents were observed without bed rails, despite their MDS Assessments indicating daily use of bed rails as restraints. For example, Resident 48's clinical record lacked an order and care plan related to bed rails, and Resident 19's MDS Assessment incorrectly marked the presence of pneumonia and the use of bed rails. The MDS Coordinator admitted that pneumonia was marked in error and should have been removed from the assessment. Additionally, Resident 17, Resident 52, Resident 38, and Resident 41 were all observed without bed rails, contradicting their MDS Assessments which indicated daily use of bed rails as restraints. The MDS Coordinator acknowledged errors in coding and training, stating that bed rails were not used as physical restraints and that the assessments were marked incorrectly. The facility lacked a policy for MDS Assessments and relied on the Resident Assessment Instrument (RAI) Manual. The inaccuracies in the MDS Assessments were attributed to incorrect training and misunderstanding of the use of bed rails and physical restraints, leading to discrepancies between the residents' actual conditions and their documented assessments.
Failure to Develop Comprehensive Care Plans
Penalty
Summary
The facility failed to develop comprehensive person-centered care plans for four residents, leading to deficiencies in addressing their specific needs. Resident 19, who was on hospice care due to atherosclerotic heart disease, did not have a hospice care plan in their clinical record. This oversight was confirmed by both the MDS Coordinator and the Director of Nursing (DON), who acknowledged that a hospice care plan should have been in place following the physician's order for hospice care. Additionally, Resident 48, who was receiving antianxiety and antidepressant medications, lacked care plans for these medications, which was also confirmed by the DON as a requirement that should have been fulfilled by the MDS Coordinator. Resident 5, diagnosed with Alzheimer's disease, bipolar disorder, and other conditions, was taking multiple medications, including antipsychotic, antianxiety, hypnotic, anticoagulant, antibiotic, and diuretic medications. However, the clinical records did not include care plans for the diuretic and anticoagulant use. The MDS Coordinator admitted that care plans, especially for medications with black box warnings like anticoagulants, should have been developed. Furthermore, Resident 45, who was on hospice and used a bedside table in the dining room, did not have care plans for hospice care or the use of the bedside table. The resident was observed eating alone at a bedside table, and the CNA indicated that this arrangement was due to the resident's preference and visual impairment. The facility's policy, as provided by the Dementia Care Coordinator, mandates the development and implementation of comprehensive, person-centered care plans with measurable objectives and timetables to meet each resident's needs. The DON confirmed that it is the facility's policy to follow physician's orders and care plan interventions. Despite this policy, the facility failed to ensure that care plans were developed and implemented for the residents reviewed, leading to deficiencies in their care.
Failure to Update Care Plans and Conduct Timely Care Plan Conferences
Penalty
Summary
The facility failed to ensure that residents had timely care plan conferences and that care plans were revised appropriately. Resident 38, who was diagnosed with dementia and had severe cognitive impairment, was moved from a locked dementia unit to another hall, but her care plan was not updated to reflect this change. The Director of Nursing acknowledged that the care plan should have been revised. Additionally, Resident 12, who had moderate cognitive impairment and multiple diagnoses including hypertension and diabetes, did not receive a care plan conference after a significant period. Similarly, Resident 48, who had dysphagia and muscle weakness, did not receive a care plan conference within the required timeframe, as confirmed by the Social Services Director (SSD) and facility policy, which mandates quarterly care plan conferences. Furthermore, Resident 5, who had Alzheimer's disease and other significant health issues, had a change in sleep medication from Ambien to Belsomra, but the care plan was not updated to reflect this change. The Director of Nursing indicated that care plans should be revised immediately after any changes occur. The facility's policy on comprehensive person-centered care plans, revised in March 2022, states that care plans should be revised as information about the residents and their conditions change. These deficiencies were identified through observations, interviews, and record reviews conducted by the surveyors.
Failure to Ensure Residents Were Free from Unnecessary Medications
Penalty
Summary
The facility failed to ensure residents were free from unnecessary medications for five of six residents reviewed. Resident 48 was prescribed an antipsychotic medication, Seroquel, for dementia without behavioral, psychotic, mood, or anxiety disturbances, which is not an acceptable diagnosis for such medication. The Director of Nursing confirmed that dementia alone is not a valid reason for prescribing antipsychotics. Resident 12 had an as-needed order for Lorazepam, an anti-anxiety medication, which was prescribed for restlessness and had been in place since November 2022. The medication was administered on multiple occasions in April and May 2024, exceeding the 14-day limit for PRN orders without documented rationale for extension. Similarly, Resident 14 had an as-needed order for Ativan, another anti-anxiety medication, without a stop date, and it was prescribed for increased anxiety. Resident 3 and Resident 45 also had PRN orders for Lorazepam for anxiety and pain/restlessness, respectively, with no documented rationale for extending the use beyond 14 days. Resident 19, who was cognitively intact, had a PRN order for Lorazepam for anxiety, which was administered multiple times in April and May 2024. The facility's Psychotropic Medication Use Policy, revised in July 2022, states that PRN orders for psychotropic medications should be limited to 14 days unless a documented rationale for extension is provided, which was not adhered to in these cases.
Medication Storage and Temperature Log Deficiencies
Penalty
Summary
The facility failed to maintain safe and secure storage of medications in three out of four medication carts and one out of three medication storage rooms observed. Loose pills were found in the drawers of the medication carts on the PARF Hall, 300 Hall, and 200 Hall. Licensed Practical Nurses (LPNs) indicated that the night shift was responsible for cleaning the medication carts, but there was inconsistency in the cleaning process. Additionally, the pharmacy reviewed the carts only once a month. Specific loose pills were identified in each cart, including small oval white pills, oblong white pills, and round red pills with various imprints. The LPNs were unsure about the cleaning schedule and the process for maintaining the carts' cleanliness. In the medication room on the 300 Hall, the temperature logs for the supplement and medication refrigerators were incomplete for several days. Medications for a discharged resident were found sitting on the counter, and the LPN was unsure why they were there, indicating they needed to be destroyed. The facility's policies on medication storage and refrigerator temperature tracking were not followed, as evidenced by the missing temperature logs and the presence of loose pills in the medication carts. The Director of Nursing (DON) and Clinical Care Leader provided policies that were not adhered to, highlighting a lapse in maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.
Failure to Adhere to Food Service Safety Standards
Penalty
Summary
The facility failed to ensure food distribution and service were provided in accordance with professional standards for food service safety. During a lunch observation, a Qualified Medication Aide (QMA) and a Certified Nurse Aide (CNA) were seen handling cookies with bare hands before serving them to residents. In a separate meal service observation in the kitchen, a Dietary Aide was observed transferring coffee mugs and touching the inside lids of handled cups with bare hands. Additionally, during a breakfast observation, the same QMA was seen touching toast with bare hands while applying jelly. The Kitchen Manager confirmed that staff should not handle food or utensils with bare hands, and the facility's Food Preparation and Service policy prohibits bare hand contact with food, requiring gloves to be worn and changed between tasks.
Failure to Document Influenza and Pneumococcal Vaccinations
Penalty
Summary
The facility failed to properly document influenza and pneumococcal vaccines being offered to residents for three of five residents reviewed. Clinical records for these residents lacked the vaccine consent/refusal date, the reason for refusal, and the date education was provided to the resident and/or resident representative. Specifically, Resident 19's record lacked documentation for the influenza vaccine, Resident 4's record lacked documentation for the pneumococcal vaccines, and Resident 36's record lacked documentation for both the influenza and pneumococcal vaccines. All three residents were cognitively intact and had various diagnoses, including anxiety, atherosclerotic heart disease, depression, and Parkinson's disease. During interviews, the Infection Preventionist (IP) indicated that newly admitted residents should be offered the vaccines at admission, and other residents should be offered them annually before the influenza season. The IP acknowledged that the residents had refused the vaccines, but the reasons and education provided were not clearly documented. The facility's current Resident Immunizations Policy requires documentation of education, consent, and screening prior to vaccine administration, but this was not followed in these cases.
Facility Fails to Maintain Safe and Sanitary Environment
Penalty
Summary
The facility failed to ensure a safe, functional, sanitary, and comfortable environment for residents in two of the five halls observed and one common area. Specific deficiencies included bathroom vents caked with dust, unlabeled personal care items, scuff marks, and chipping on doors, sticky floors, loose grab bars, and exposed wires in the common area. Additionally, there were issues with call lights, with one room having only one call light cord wrapped around a bed and no call light for the other side of the room. Uncovered briefs and personal care items were also found inappropriately stored in bathrooms. The observations were made on two separate dates, confirming that the issues were not addressed in the interim. The Maintenance Director indicated that staff should report environmental issues or submit a work order, but the repeated observations suggest this process was not effectively followed. The facility's Homelike Environment policy, revised in February 2021, states that residents should be provided with a safe, clean, and comfortable environment, which was not upheld in these instances.
Failure to Ensure Resident Dignity and Proper Care
Penalty
Summary
The facility failed to ensure residents were treated with respect and dignity, as evidenced by two specific observations. In the first instance, a Certified Nurse Aide (CNA) was observed standing while assisting Resident 27 with feeding, which is against the facility's policy that requires staff to sit next to residents during meal assistance. This policy is intended to ensure residents are fed with attention to safety, comfort, and dignity. The CNA's action of standing while feeding the resident did not align with these standards and compromised the resident's dignified dining experience. In the second instance, Resident 48 was observed with a large wet spot, identified as urine, under her wheelchair while eating in the dining room. A Licensed Practical Nurse (LPN) placed the resident's meal tray in front of her and walked away without addressing the wet spot. The Director of Nursing (DON) later indicated that staff are expected to bring residents back to their rooms and provide care if such a situation is observed, and then clean the wet spot and the chair. The failure to address the resident's condition promptly and appropriately also violated the facility's dignity policy, which emphasizes caring for residents in a manner that promotes their well-being and self-esteem.
Failure to Provide Requested Ice Water to Resident
Penalty
Summary
The facility failed to provide services based on resident preferences for one of the five residents reviewed. Specifically, the facility did not provide ice water to Resident 45 when requested. During an interview, Resident 45 indicated that she did not receive water unless she asked for it. On a subsequent observation, a CNA assisted Resident 45 and noted that her water cup had only a small amount of water, asking if she would like it filled. Despite Resident 45's affirmative response, the water cup was not filled upon a later observation. Resident 45's clinical records indicated she was cognitively intact and required extensive assistance for various activities, including bed mobility, transfers, and toilet use. She also used oxygen and was on hospice care. Further interviews revealed that ice water was not routinely passed to residents, and they had to request it. The LPN mentioned that she would fill up an empty cup if she saw one in a resident's room. The facility's current Resident Hydration and Prevention of Dehydration policy, revised in October 2017, stated that the facility would strive to provide adequate hydration and prevent dehydration. Additionally, the Accommodation of Needs policy, revised in March 2021, indicated that residents' individual needs and preferences should be accommodated to the extent possible, except when it would endanger the health and safety of the individual or other residents.
Failure to Clarify Resident's Code Status
Penalty
Summary
The facility failed to clarify a resident's code status, leading to a discrepancy between the resident's documented wishes and the physician's orders. Resident 18, who had diagnoses including end-stage renal disease and diabetes mellitus, was cognitively intact and had a signed Do Not Resuscitate (DNR) order dated [DATE]. However, the current physician's orders indicated that the resident was to be resuscitated (CPR). Additionally, the resident's care plans were inconsistent, with one indicating a DNR status and another indicating a CPR status. During interviews, an LPN confirmed that the computer system showed the resident's code status as CPR, and the Director of Nursing acknowledged that the resident should have been listed as DNR. The facility's Advance Directives policy stated that the plan of care should be consistent with the resident's documented treatment preferences, which was not the case for Resident 18. This inconsistency in the resident's code status could lead to actions contrary to the resident's wishes in an emergency situation.
Failure to Ensure Resident's Right to be Free from Physical Restraints
Penalty
Summary
The facility failed to ensure the resident's right to be free of physical restraints for one resident who was observed with bed rails used as a physical restraint. During multiple observations, the resident was seen with bed rails up, and both the resident and her family member indicated that the bed rails were used to prevent falls. The resident's clinical record lacked an order for the bed rails, documentation of informed consent, and evidence that the resident could remove the restraint herself. Additionally, there was no documentation of the restraint being removed every two hours as required. Interviews with staff revealed that the bed rails were used for mobility and to prevent the resident from climbing out of bed. The Director of Nursing and other staff members indicated that evaluations for restraints should be completed quarterly, but the clinical record lacked a restraint evaluation after a specific date. The facility's policy on the use of restraints, which was provided by the Dementia Care Director, indicated that restraints should only be used to treat medical symptoms and not for the prevention of falls, and that a pre-restraining assessment and written order from a physician are required. The facility did not adhere to these policies in the case of this resident.
Failure to Report Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident who claimed that a CNA physically removed her fingers and hand from a sit-to-stand lift. The resident, who has diagnoses including anxiety and depression and is cognitively intact, reported the incident to surveyors. The resident's clinical record lacked documentation of the allegation, an assessment of her hand/fingers, and any follow-up actions. The facility's policy requires immediate reporting of suspected abuse, but this was not adhered to in this case. Interviews revealed that the Director of Nursing (DON) was aware of the situation but did not report it immediately. The Administrator confirmed that the allegation should have been reported as soon as it was discovered. Additionally, the CNA involved had a prior battery charge, which was known to the facility. The facility's policy on abuse, neglect, exploitation, or misappropriation, revised in September 2022, mandates that suspicions of abuse be reported immediately, defined as within 24 hours of the allegation.
Failure to Investigate Abuse Allegation
Penalty
Summary
The facility failed to properly investigate an allegation of abuse involving a resident who reported that a Certified Nurse Aide (CNA) physically removed her fingers and hand from a sit-to-stand lift. The resident, who has diagnoses including anxiety and depression and is cognitively intact, indicated that the CNA used an abusive tone and pulled her fingers one by one off the lift. The clinical record lacked documentation of the allegation, assessment of the resident's hand/fingers, and any follow-up to the allegation. The facility's policy requires immediate reporting and thorough investigation of abuse allegations, which was not followed in this case. The Director of Nursing (DON) was aware of the situation but did not inform the Administrator when it happened. The Administrator later indicated that the allegation should have been properly investigated and the CNA should have been suspended. Additionally, the CNA had a prior battery charge on their criminal background check. The facility's failure to investigate the abuse allegation promptly and thoroughly constitutes a deficiency in their handling of abuse reports.
Failure to Prevent Falls and Ensure Adequate Supervision
Penalty
Summary
The facility failed to ensure adequate supervision to prevent accidents for two residents reviewed for falls. For Resident 38, non-skid strips were not observed on the floor in front of the toilet in her bathroom, and her care plan was not updated with new interventions after falls. Neurological checks were not consistently completed after her falls, and interventions such as keeping Dycem in her chair and ensuring she wore appropriate footwear were not followed. Despite having multiple falls, her care plan was not adequately revised to address her high fall risk, and necessary safety measures were not implemented in her new room after she moved from the locked dementia unit to the 300 Hall. For Resident 52, the facility failed to lock his Broda chair, which led to multiple incidents where he attempted to scoot out of the chair, causing it to roll. His care plan included interventions such as placing a soft mat on the wall side of his bed and providing diversional activities, but these were not consistently followed. Neurological checks were not performed after some falls, and his care plan was not updated with new interventions after each fall. Despite being identified as a high fall risk, the facility did not adequately supervise him or ensure that his care plan was followed. The Director of Nursing (DON) acknowledged that both residents were high fall risks and that there should have been interdisciplinary team (IDT) meetings, new interventions placed, and care plans revised after each fall. The facility's policies on falls and neurological assessments were not consistently followed, leading to multiple falls and injuries for both residents. The DON also indicated that there was no specific policy for following orders and interventions, but it was expected that staff would do so.
Failure to Prevent and Treat UTIs and Maintain Infection Control
Penalty
Summary
The facility failed to ensure a resident received appropriate care to prevent and treat urinary tract infections (UTIs). Resident 36, who had diagnoses including Parkinson's Disease and dementia, experienced recurrent UTIs and exhibited cognitive changes and behavioral issues. Despite these symptoms, there were significant delays in obtaining and processing urinalysis orders, and the clinical record lacked timely documentation and follow-up from the physician. For instance, a urinalysis ordered on 1/23/24 was not obtained until 1/24/24 and not sent to the hospital until 1/25/24. Additionally, there were inconsistencies in the interpretation of urinalysis results, leading to inappropriate antibiotic treatments and further confusion about the resident's condition. The resident experienced multiple falls and increased confusion, which were often linked to UTIs. Despite these indicators, the facility's response was delayed and inadequate. For example, after a fall on 3/10/24, a urinalysis was not collected until 3/11/24, and the results were misinterpreted as clear despite the presence of bacteria. This led to further delays in appropriate treatment. The resident's condition continued to deteriorate, with increased confusion, hallucinations, and aggressive behavior, eventually leading to a diagnosis of dementia and relocation to a secured unit. In addition to the delays and mismanagement of UTIs, the facility also failed to maintain proper infection control practices during incontinence care. On 5/20/24, two CNAs were observed assisting the resident with toileting but did not follow proper hand hygiene protocols. They failed to wash their hands adequately, did not change gloves appropriately, and contaminated clean items with soiled gloves. These lapses in infection control practices further compromised the resident's care and increased the risk of infection.
Failure to Provide Consistent Respiratory Care
Penalty
Summary
The facility failed to ensure respiratory care was provided consistent with the residents' orders and care plans. Resident 14 was observed with oxygen set incorrectly at 2.5 liters per minute (lpm) instead of the ordered 3 lpm. Additionally, the oxygen concentrator filter was caked with dust and had not been cleaned as required. The Director of Nursing (DON) indicated that the order to change the filter was not properly integrated into the system, leading to the oversight. Furthermore, Resident 14 was seen without oxygen on another occasion, despite having a portable oxygen tank available, and later with oxygen set between 3.5 and 4 lpm, which was not in accordance with the physician's orders. The oxygen concentrator had not been serviced since 8/16/23, and staff were unsure about the cleaning responsibilities for the filters. Resident 28's oxygen filter was also observed to be caked with dust on multiple occasions, and the resident was using oxygen at 2 lpm. The clinical records indicated that the filter should be cleaned weekly, but this was not being done. The DON confirmed that the company servicing the oxygen machines had shown staff how to clean the filters, but the task was not being performed as required. Resident 45 was observed with oxygen set at 3.5 lpm, and the filter on the oxygen machine was similarly caked with dust. The humidification bottle was dated 4/29/24, and there were no orders in the clinical records to change the oxygen tubing or humidification bottle. The DON indicated that the company serviced the oxygen machines weekly and had instructed staff on cleaning the filters, but the filters remained uncleaned. The facility's policy on respiratory therapy and infection prevention, which required washing filters every seven days, was not being followed.
Infection Control Deficiencies in Incontinence Care and Blood Glucose Monitoring
Penalty
Summary
The facility failed to ensure proper infection control practices during incontinence care and blood glucose monitoring for three residents. During an observation, a Qualified Medication Aide (QMA) did not adequately clean a glucometer after obtaining a blood glucose level for a resident, wiping it for less than two seconds before placing it back in the medication cart. The QMA indicated that the glucometer should air dry for at least two minutes, which was not followed. Additionally, during incontinence care for two residents, Certified Nurse Aides (CNAs) did not perform hand hygiene between glove changes. One CNA removed soiled briefs and applied cream without sanitizing hands between glove changes, while another CNA also failed to sanitize hands between glove changes during the incontinence care process. Interviews with the Infection Preventionist (IP) and Licensed Practical Nurse (LPN) confirmed that the expected protocol was not followed. The IP indicated that staff should sanitize their hands between glove changes during incontinence care. The LPN and QMA both confirmed that the glucometer should be cleaned thoroughly and allowed to air dry for at least two minutes between uses. The facility's policies on hand hygiene and blood glucose monitoring were not adhered to, leading to these deficiencies.
Failure to Post Daily Nurse Staffing Sheets
Penalty
Summary
The facility failed to ensure that nurse staffing sheets were posted daily during the survey period, specifically on May 18 and May 19. On May 20, it was observed that the posted nurse staffing sheet in the main lobby was dated May 17, indicating that the sheets were not updated over the weekend. During an interview, the Director of Nursing (DON) confirmed that the night shift is responsible for posting the nurse staffing sheet daily, including weekends. The facility's policy, revised in July 2016, mandates daily posting of staffing numbers for each shift.
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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