Signature Healthcare Of Bremen
Inspection history, citations, penalties and survey trends for this long-term care facility in Bremen, Indiana.
- Location
- 316 Woodies Lane, Bremen, Indiana 46506
- CMS Provider Number
- 155474
- Inspections on file
- 26
- Latest survey
- October 10, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Signature Healthcare Of Bremen during CMS and state inspections, most recent first.
A resident with dementia and a documented tomato allergy was served ketchup on a hotdog, despite care plan and physician orders prohibiting tomato products. The CNA provided the food after the resident requested it, only noticing the allergy after the resident had eaten several bites. This failure to follow the care plan was documented in progress notes and led to a family grievance.
A resident with a Stage 2 pressure ulcer did not receive daily wound care as ordered by the physician, with staff documenting completion of dressing changes that were not actually performed. The issue was identified when the resident's family noticed the dressing had not been changed for two days, leading to confirmation that required wound care was missed and not in accordance with facility policy.
An LPN failed to follow infection control procedures during a medication pass for two residents. The LPN broke tablets with bare hands, coughed into her hand, and administered an insulin injection without sanitizing hands or wearing gloves. The DON confirmed that gloves should have been worn, as per facility policy.
The facility failed to maintain sanitary conditions in its kitchen and nutrition pantries, affecting meal safety for residents. Observations revealed unsealed and expired food, dirty equipment, and improper storage practices. The Dietary Manager and Corporate Dietician acknowledged these issues, which were not in compliance with the facility's food handling and ware washing policies.
A facility failed to ensure an advance directive was completed upon admission for a resident with significantly impaired cognition. Although a Physician's Order indicated a Do Not Resuscitate (DNR) status, there was no documentation of a completed DNR form signed by the resident or their representative. The Administrator acknowledged the oversight, and the facility's policy required determining advance directive status during admission.
A facility failed to notify the Ombudsman of hospital transfers for a resident with severe cognitive impairment and an indwelling urinary catheter. The resident was transferred to a neuropsychological hospital and later returned, but was not listed in the facility's transfer and discharge records. The DON confirmed the Ombudsman should have been notified, as per the facility's policy.
A facility failed to accurately complete the MDS assessment for a resident with multiple falls. The resident, with conditions such as COPD and diabetes, reported several falls, but only two were documented in the clinical record. These falls were not included in the Quarterly MDS assessment. The MDS Nurse admitted the oversight, and the facility lacked a specific policy for MDS completion, relying on the RAI Manual.
The facility failed to create comprehensive care plans for three residents, leading to unaddressed skin issues and behavioral problems. A resident with cancerous skin areas lacked a care plan for her condition and behavior of picking at her face. Another resident had bruises from medical procedures without a care plan for skin assessment or aspirin use. A third resident with cognitive impairment and a history of aggression lacked a behavioral care plan to address physical altercations.
Two residents in an LTC facility did not receive scheduled showers as required for their ADL care. One resident with dementia and diabetes was observed with greasy hair, and documentation showed infrequent showers without recorded refusals. Another resident with hemiplegia and aphasia had long fingernails, indicating neglect in personal care, with significant gaps in shower documentation. Staff interviews revealed inconsistencies in documentation practices.
A facility failed to assess a resident for new and existing skin issues after returning from a hospital stay. The resident, with multiple health conditions, was observed with numerous bruises on their arms and hands, but the clinical record lacked proper documentation. Despite policy requirements for weekly skin assessments and documentation of new impairments, no skin event form was completed, and assessments were not conducted on shower days.
A resident with severe cognitive impairment and multiple psychiatric diagnoses was involved in repeated physical altercations with other residents. Despite being on psychiatric medications and having physician orders for behavior monitoring, the facility failed to implement a behavioral care plan with preventative interventions. The facility also lacked a behavior management policy, contributing to the recurrence of these incidents.
The facility failed to provide adequate showering assistance to eight residents who required help with ADLs. Observations and record reviews revealed that these residents received fewer showers than the facility's standard of two per week. Interviews with staff highlighted inconsistencies in documentation and understanding of the electronic medical record system, contributing to the deficiency.
The facility failed to administer physician-ordered medications to two residents, resulting in missed doses of Hydrocodone and Lyrica. The administrator confirmed the residents should have received their medications as per orders, but no policy for following physician orders was provided.
The facility failed to ensure medications were available and administered as ordered for three residents. A resident with Alzheimer's and acute kidney failure missed multiple doses of Mupirocin and Clonazepam due to unavailability. Another resident with chronic headaches had discrepancies in Lyrica administration, including missed and extra doses. A third resident with dementia did not receive Valsartan as prescribed. The facility lacked a policy for handling unavailable medications, and the Administrator acknowledged the need for proper medication management.
A resident with multiple diagnoses, including Alzheimer's and depression, was administered Clonazepam without a stop date, leading to continuous use throughout October. The facility's policy limits PRN orders for psychotropic drugs to 14 days, but this was not followed. The resident also received Ativan on several occasions, and the Administrator confirmed the use of both medications due to behavioral issues.
A resident with severe cognitive disabilities and epilepsy experienced significant medication errors, including missed doses and incorrect administration of antiseizure medications over several months. Facility staff failed to communicate effectively with the pharmacy and physician, leading to ongoing medication administration issues.
A resident with a history of Parkinson's disease, dementia, neurogenic bladder, and diabetes was observed multiple times with their urinary catheter equipment improperly positioned on the floor, despite physician orders and care plans indicating the need for proper catheter management. Interviews confirmed that the catheter tubing and drainage bag should not be on the floor, highlighting a failure in maintaining sanitary conditions.
A resident in a reclining chair requested assistance for toileting multiple times but was not promptly assisted by staff, resulting in an incontinence episode. Despite visible distress and repeated requests, the staff prioritized feeding over toileting needs. The resident's care plan indicated a risk for urinary incontinence, but interventions were not followed, and the facility's policy on resident rights was not upheld.
The facility failed to notify the physician of significant changes in the conditions of two residents. One resident with atrial fibrillation experienced elevated heart rates without physician notification, while another resident with Lennox-Gastaut syndrome missed multiple doses of anti-seizure medication, leading to seizures, without the physician being informed. The facility did not adhere to its policy requiring notification of significant changes in resident status.
A facility failed to develop a care plan for a resident with a seizure disorder, despite the resident's complex medical history and frequent seizure activity. The resident, diagnosed with Lennox-Gastaut syndrome and other conditions, experienced numerous seizures, as documented in nursing progress notes. Despite being prescribed multiple medications, there was no care plan in place to address the resident's seizures, and the facility did not provide a policy regarding care plans before the survey exit.
The facility failed to notify the physician about the removal of a PICC line and discharge of a resident, as well as a low blood glucose level in another resident. The first resident had a PICC line removed without physician notification and was discharged without informing the physician. The second resident experienced a low blood sugar reading, but there was no documentation of physician notification, despite the care plan requiring monitoring for hypo/hyperglycemia.
A facility failed to provide a transfer/discharge form for a resident during two hospital transfers. The resident, with multiple diagnoses including diabetes and fractures, was first transferred after being found unresponsive with low blood sugar. Later, the resident was transferred again due to abdominal swelling and bruising, requiring surgery for a hematoma. In both cases, the required documentation was not provided, contrary to facility policy.
A resident with multiple medical conditions was transferred to the hospital for emergency treatment and surgery, but the facility failed to provide a bed hold form as required by their policy. The Director of Nursing confirmed that such documentation should have been included, and the facility's policy mandates notification of the bed-hold policy during hospital transfers.
The facility failed to manage a diabetic resident's care, resulting in a critical hypoglycemic event without proper physician orders for emergency transfer or blood sugar monitoring. Additionally, another resident was discharged without notifying the physician or documenting the removal of a PICC line, contrary to facility policy.
A facility failed to provide timely dressing changes for a PICC line for a resident with multiple health issues, including osteomyelitis and MRSA infection. The resident was admitted with a PICC line, and physician orders required weekly dressing changes. However, the first documented change occurred over a week after admission. The DON confirmed the lack of documentation for dressing changes during this period, despite the facility's policy outlining the procedure.
A resident with multiple medical conditions, including a right hip fracture, was not transferred according to physician orders, which required a mechanical lift. A CNA attempted to transfer the resident without the lift, resulting in the resident being lowered to the floor. The CNA was unaware of the updated transfer requirements due to not reviewing the electronic tablet with care instructions.
Failure to Follow Care Plan for Food Allergy
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including dementia, feeding difficulties, and a documented allergy to tomatoes, was served food containing tomato despite clear care plan instructions and physician orders indicating the allergy. The resident's care plan specifically stated that tomato should not be served at meals, and the dietary order reinforced this restriction. However, the resident was given ketchup on a hotdog, which was delivered from the kitchen on the resident's tray. The incident was documented in nursing progress notes and led to a grievance filed by the resident's family. A CNA reported offering ketchup and mustard to the resident, who accepted, and only realized the tomato allergy after the resident had consumed several bites. The facility's policy required implementation of a comprehensive, person-centered care plan, but in this instance, the care plan related to the resident's food allergy was not followed.
Failure to Follow Physician Orders for Pressure Ulcer Care
Penalty
Summary
A resident with multiple complex medical conditions, including chronic obstructive pulmonary disease, vascular dementia, and muscle wasting, developed a Stage 2 pressure ulcer on the right heel. Physician orders were in place to cleanse the wound, apply calcium alginate, and cover it with ABD and rolled gauze daily. However, documentation and interviews revealed that the dressing was not changed as ordered on two consecutive days. The treatment administration record showed that staff had signed off on the dressing changes, but the dressing remained unchanged and was still dated from two days prior. This discrepancy was brought to staff attention by the resident's family, who noticed the outdated dressing. Further investigation confirmed that the responsible LPN had not performed the dressing changes on the specified dates and had mistakenly documented completion in the electronic charting system. Facility policy required that residents with impaired skin integrity receive necessary treatment and services to promote healing, and that neglect, defined as failure to provide necessary services to avoid physical harm, be prevented. The facility was unable to provide a specific policy regarding pressure wound care upon request.
Infection Control Breach During Medication Pass
Penalty
Summary
The facility failed to adhere to infection control procedures during a medication pass for two residents. An LPN was observed breaking potassium chloride tablets with bare hands, despite having sanitized her hands prior to medication preparation. Additionally, the LPN coughed into her bare hand while at the medication cart. Furthermore, the LPN prepared and administered an insulin injection to another resident without sanitizing her hands or wearing gloves. The Director of Nursing confirmed that gloves should have been worn during these procedures, as per the facility's medication administration policy.
Sanitation Deficiencies in Kitchen and Nutrition Pantries
Penalty
Summary
The facility failed to maintain sanitary conditions in its kitchen and nutrition pantries, potentially affecting 59 of 61 residents who received meals from the kitchen. During an initial tour, surveyors observed several issues in the kitchen, including an opened and unsealed bag of chicken pieces in the walk-in freezer, food debris on the floor, and expired or improperly labeled food items in the walk-in cooler. Additionally, the dry storage area contained an opened bag of graham cracker crumbs that were not sealed tightly. The Dietary Manager acknowledged these issues, indicating that expired foods should have been removed, opened foods sealed tightly, and liquids dated when opened. Further observations revealed additional deficiencies, such as skillets with missing Teflon and rust-colored areas, steam table pans with dried food substances, and improperly sealed food items. The Corporate Dietician confirmed these items should not have been used or stored in their current condition. In the nutrition pantries, issues included a dirty microwave, a broken refrigerator seal, and a lack of a thermometer. The Director of Nursing acknowledged these problems, indicating that the microwave should have been cleaned, the refrigerator seal fixed, and staff items should not have been in the resident's refrigerators. The facility's policies on food handling and ware washing were not adhered to, contributing to these deficiencies.
Failure to Complete Advance Directive Upon Admission
Penalty
Summary
The facility failed to ensure that an advance directive was completed upon admission for a resident with significantly impaired cognition. The resident was admitted to the facility, and a review of their records revealed a Physician's Order indicating a Do Not Resuscitate (DNR) status. However, there was no documentation of a completed DNR form signed by the resident or their representative. During an interview, the Administrator acknowledged that the resident should have had a signed DNR form upon admission. The facility's policy on advance directives, which was provided by the Administrator, stated that the facility would attempt to determine whether a resident has an advance directive during the admission process and, if not, whether the resident wishes to formulate one.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to notify the Ombudsman of hospital transfers for a resident, identified as Resident 52, who was reviewed for hospitalizations. Resident 52 had diagnoses including Alzheimer's disease, delusional disorder, neuromuscular dysfunction of the bladder, and obstructive and reflux uropathy. The resident had severe cognitive impairment and an indwelling urinary catheter as indicated in a Quarterly Minimum Data Set (MDS) assessment. On September 7, 2024, Resident 52 was transferred to a neuropsychological hospital, and on September 23, 2024, the resident returned to the facility. Another transfer occurred, and the resident returned from the hospital on October 2, 2025, with a replaced urinary catheter. A review of the facility's transfer and discharge list for September and October revealed that Resident 52 was not listed as a transfer from the facility, indicating a failure to notify the Ombudsman. During an interview, the Director of Nursing confirmed that the Ombudsman should have been notified of the transfers. The facility's current policy, titled 'Transfer/Discharge Notice,' mandates that a copy of the notice of transfer or discharge must be sent to the representative of the Office of the State Long-Term Care Ombudsman, which was not adhered to in this case.
Inaccurate MDS Assessment for Resident with Falls
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessment for a resident reviewed for accidents. The resident, who had diagnoses including chronic obstructive pulmonary disease, type 2 diabetes mellitus, chronic bronchitis, and generalized anxiety disorder, reported having fallen about five times in recent months without major injuries. A review of the resident's clinical records revealed two falls in January, which were not documented in the Quarterly MDS assessment dated February 10, 2025. The MDS Nurse, who participated in follow-up Interdisciplinary Team Meetings after falls, acknowledged that the falls should have been recorded in the MDS assessment. The Executive Director indicated that the facility did not have a specific policy for completing MDS assessments, instead following the Resident Assessment Instrument (RAI) Manual.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents, leading to deficiencies in addressing their specific needs. Resident 5 had a history of picking at cancerous areas on her face, yet her care plan lacked any mention of these behaviors or the skin condition. Despite having a physician's order for topical treatment, there was no care plan to manage her skin issues or her behavior of picking at her face. The administrator acknowledged the absence of a care plan for these issues. Resident 38 was observed with numerous bruises on his arms and hands upon readmission from a hospital stay, attributed to IVs and blood draws. However, the facility did not complete a skin event assessment or develop a care plan to address the bruising or the use of aspirin, which could exacerbate the condition. Resident 52, who had severe cognitive impairment and a history of physical altercations with other residents, also lacked a behavioral care plan to address these issues. Despite multiple incidents of aggression, the facility only had a plan to monitor her behavior of pointing fingers at others, failing to address her physical altercations.
Failure to Provide Scheduled Showers for Residents
Penalty
Summary
The facility failed to ensure that two residents received their scheduled showers, as required for their activities of daily living (ADL) care. Resident 57, who has diagnoses including dementia and diabetes mellitus type 2, was observed multiple times with greasy and disheveled hair, indicating a lack of proper hygiene care. Despite having a physician's order for showers on specific days, documentation showed that Resident 57 received showers infrequently, with no records of refusals or reasons for missed showers. Interviews with staff revealed inconsistencies in documentation practices, with no refusals noted in the Medication Administration Record. Similarly, Resident 48, who requires substantial assistance for showers due to conditions such as hemiplegia and aphasia, was observed with long fingernails, suggesting neglect in personal care. The resident's care plan indicated a need for assistance with ADLs, yet documentation showed significant gaps in showering, with no recorded refusals in the Nursing Progress Notes. Staff interviews confirmed that shower documentation was only completed electronically, which may have contributed to the oversight in care.
Failure to Conduct Proper Skin Assessments for Returning Resident
Penalty
Summary
The facility failed to ensure a resident who returned from a hospital stay was properly assessed for new and existing skin issues. Resident 38, who had diagnoses including congestive heart failure, diabetes, renal disease, and hypertension, was observed with numerous purple areas on both arms and hands. Despite a Nursing Progress Note indicating the presence of bruises related to IVs and blood draws upon the resident's return on 2/3/2025, the clinical record lacked a skin event form and documentation of these bruised areas. A Weekly Skin Assessment completed on 2/8/2025 noted existing impaired skin but did not specify the location or description of the impairment. Interviews with the Director of Nursing and the Administrator revealed that skin assessments should be conducted weekly, and no skin event form was completed for Resident 38 upon their return from the hospital. The resident reported that skin assessments were not conducted on their shower days, and they identified areas of skin impairment from both the hospital stay and an incident involving a wheelchair. The facility's policy on Skin Integrity, dated 1/31/2025, requires initial skin checks upon admission and ongoing observation by licensed nursing staff, with documentation initiated for new impairments. However, no further wound or skin assessments were provided before the survey exit.
Failure to Implement Effective Behavior Monitoring
Penalty
Summary
The facility failed to implement effective behavior monitoring to prevent resident-to-resident altercations from recurring. Resident 52, who has diagnoses including Alzheimer's disease, dementia with agitation, major depressive disorder, post-traumatic stress disorder, and delusional disorder, was involved in multiple incidents of physical altercations with other residents. Despite being on antipsychotic, antianxiety, and antidepressant medications, Resident 52 exhibited behaviors such as pointing fingers at other residents, taking off clothing, and exit-seeking. These behaviors were noted in physician orders and psychiatric consults, yet the facility did not have a behavioral care plan in place with preventative interventions to address these physical altercations. The report details several incidents involving Resident 52, including poking another resident, being unkind, and making physical contact with others. Despite these incidents, the facility did not have a policy for behavior management available when requested. The Executive Director indicated that behaviors were discussed regularly with various staff members, and interventions were supposed to be care planned, but this was not effectively implemented. The lack of a behavioral care plan and preventative interventions contributed to the recurrence of altercations involving Resident 52.
Failure to Provide Adequate Showering Assistance
Penalty
Summary
The facility failed to ensure that showers were provided for eight residents who required assistance with activities of daily living (ADLs). These residents, identified as H, J, L, C, N, P, M, and Q, were observed and documented to have received fewer showers than the facility's standard of two showers per week. The deficiency was identified through a combination of record reviews, interviews, and observations conducted by surveyors. Resident H, diagnosed with dementia and anxiety, was documented to have received only two showers in October 2024, despite being dependent on staff for personal care. Similarly, Resident J, who has Parkinson's disease and dementia, received only one shower in the same month. Resident L, with Alzheimer's disease, was also found to have received fewer showers than required, with documentation showing only five showers over two months. Observations of Resident C revealed greasy hair, and records indicated inconsistent showering, with only a few documented showers in October 2024. Other residents, such as N, P, M, and Q, also experienced similar deficiencies in showering assistance. Resident N's records lacked documentation of showers or refusals, while Resident P's records showed only one documented refusal and no showers. Resident M received only two showers in October 2024, and Resident Q had only one documented shower. Interviews with staff, including CNAs and the Director of Nursing, revealed inconsistencies in shower documentation and a lack of understanding of the electronic medical record system, contributing to the deficiency in providing adequate care.
Failure to Administer Physician-Ordered Medications
Penalty
Summary
The facility failed to administer physician-ordered medications to two residents, resulting in a deficiency. Resident J, diagnosed with Parkinson's disease, dementia, neurogenic bladder, diabetes, and joint pain, did not receive four scheduled doses of Hydrocodone on a specific date and the midnight dose the following day. The facility's administrator confirmed that the resident should have received the medication as per the physician's orders. Similarly, Resident L, who has Alzheimer's disease, hypertension, depression, dementia, and chronic cluster headaches, missed several doses of Lyrica, a controlled pain medication, on multiple occasions. The facility's administrator acknowledged that the resident should have received these medications. The facility's policy on controlled medication administration was reviewed, but no policy for following physician orders was provided. This deficiency was related to a specific complaint.
Medication Availability and Administration Deficiencies
Penalty
Summary
The facility failed to ensure that routine medications were available and dispensed according to physician's orders for three residents. Resident M, diagnosed with multiple conditions including Alzheimer's disease and acute kidney failure, did not receive Mupirocin ointment and Clonazepam as ordered on several occasions due to the medications being unavailable. The October Medication Administration Record (MAR) indicated multiple missed doses for both medications over a span of days. During an interview, a Qualified Medication Aide (QMA) confirmed that medications should always be double-checked with the MAR prior to administration. Resident L, with diagnoses including Alzheimer's disease and chronic cluster headaches, had discrepancies in the administration of Lyrica, a controlled medication. The Controlled Drug Record showed missed doses and extra doses administered on different dates. The MAR indicated that Lyrica was not available on certain days, and the Administrator acknowledged that the resident should not have received extra doses. Resident C, diagnosed with dementia and chronic kidney disease, did not receive Valsartan as ordered due to the medication being unavailable on multiple occasions. The Administrator noted that medications should have been obtained from the Pyxis or through a STAT delivery from the pharmacy, and there was no existing policy for handling unavailable medications.
Excessive Duration of Antianxiety Medication Administration
Penalty
Summary
The facility failed to ensure that an antianxiety drug was not administered for an excessive duration for a resident, identified as Resident M. The medical record review revealed that Resident M had multiple diagnoses, including Alzheimer's disease, acute kidney failure, and depression, among others. Physician's orders indicated that Resident M was prescribed Ativan, an antianxiety medication, to be taken as needed, and Clonazepam, another antianxiety medication, to be taken twice daily. However, the Clonazepam prescription did not have a stop date, and the resident received the medication continuously throughout October. The facility's current Care Plan for Resident M, reviewed in mid-October, noted the risk of drug-related side effects due to psychotropic medication. Despite this, the October Medication Administration Record showed that Resident M received both Clonazepam and Ativan on multiple occasions. During an interview, the Administrator acknowledged that Resident M was on both medications due to behavioral issues. The facility's policy on psychotropic medications, which was provided by the Administrator, stated that PRN orders for such drugs are limited to 14 days and should include documentation of the rationale and duration in the resident's medical record. This policy was not adhered to in Resident M's case, leading to the deficiency.
Significant Medication Errors in Antiseizure Medication Administration
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically related to the administration of antiseizure medications. The resident, who had severe cognitive disabilities and multiple diagnoses including Lennox-Gastaut syndrome and epilepsy, experienced numerous medication errors over several months. These errors included missed doses, overdosing, and underdosing of medications such as Clobazam, Fycompa, and Clonazepam. The narcotic signature sheets for August, September, and October 2024 revealed multiple instances where the resident either missed doses or received incorrect dosages of these medications. Interviews with facility staff and pharmacy personnel indicated a lack of communication and follow-up regarding the medication errors. The pharmacy was contacted multiple times about the missing medications, but there were delays in delivery, and the facility staff failed to notify the physician about the missed doses. Additionally, there was confusion among the nursing staff regarding the correct administration schedule for Clobazam. The facility was unable to provide a policy on medication errors when requested during the survey, highlighting a gap in their procedures for managing medication administration errors.
Improper Maintenance of Urinary Catheter Equipment
Penalty
Summary
The facility failed to maintain urinary catheter equipment in a sanitary manner for Resident J, who was observed multiple times with the catheter tubing and urine collection bag lying on the floor. This was first noted during an observation on October 30, 2024, at 11:41 A.M., when Resident J's catheter equipment was found on the floor under his wheelchair. Subsequent observations on October 31 and November 1, 2024, confirmed that the urine collection bag continued to be improperly positioned on the floor, including when Resident J was in the dining room. Interviews with CNA 11 corroborated that the catheter tubing and drainage bag should not be on the floor, indicating a lapse in adherence to proper catheter management protocols. Resident J's medical record revealed a history of Parkinson's disease, dementia, neurogenic bladder, and diabetes, with a documented use of an indwelling catheter. A physician's order from August 21, 2024, specified the use of a Foley/Supra-pubic catheter with a privacy bag, and another order from August 29, 2024, required the catheter bag to be secured with a Tube Tie adhesive holder every shift. Despite these orders, the facility did not provide a policy for catheter use when requested on October 31, 2024. Resident J's care plan, revised on October 10, 2024, indicated a risk for complications related to the catheter, including a urinary tract infection, but failed to ensure proper catheter care and positioning, leading to the observed deficiencies.
Failure to Provide Timely Toileting Assistance
Penalty
Summary
The facility failed to provide timely assistance for toileting to Resident C, a continent resident, resulting in an incontinence episode. On the observed date, Resident C was in a small dining room and requested assistance from CNA 10 to go to the bathroom. Despite her repeated requests and visible distress, including moaning and banging her hand on the armrest, CNA 10 did not assist her immediately. Instead, CNA 10 left the dining room and later returned with the resident's lunch tray, prioritizing feeding over addressing the resident's toileting needs. After the meal, Resident C was moved to the nurse's desk, where she continued to request help for toileting, but was again not assisted promptly. Resident C was eventually taken to her room, where it was discovered that her pants were wet, indicating an incontinence episode. Despite the resident's requests and the visible signs of distress, the staff, including LPN 9, did not offer a bed pan or take her to the bathroom in a timely manner. The care plan for Resident C indicated she was at risk for complications associated with urinary incontinence, yet the interventions outlined were not followed. The facility's policy on resident rights emphasized treating residents with respect, kindness, and dignity, which was not upheld in this instance.
Failure to Notify Physician of Significant Changes in Resident Conditions
Penalty
Summary
The facility failed to notify the physician of significant changes in the condition of two residents, leading to deficiencies in care. Resident N, who has a history of atrial fibrillation, experienced elevated heart rates ranging from 176 to 211 beats per minute over a period of time. Despite the care plan's directive to report such changes, there was no documentation indicating that the physician was notified of these elevated heart rates. Interviews with nursing staff confirmed that changes in vital signs should prompt notification to the physician, but this protocol was not followed in Resident N's case. Resident E, diagnosed with Lennox-Gastaut syndrome and other severe cognitive disabilities, experienced multiple missed doses of the anti-seizure medication Fycompa over several months. The missed doses coincided with numerous documented seizure activities, yet there was no evidence that the physician was informed of the missed medication or the seizure occurrences. Nursing staff admitted to not notifying the physician about the missed doses or the seizure activity, which is contrary to the facility's policy on notifying changes in a resident's condition. The facility's policy requires that significant changes in a resident's physical, mental, or psychosocial status be communicated to the resident, their representative, and the physician. However, in both cases, the facility did not adhere to this policy, resulting in a failure to provide timely medical intervention for the residents. The lack of documentation and communication with the physician represents a significant oversight in the care provided to these residents.
Failure to Develop Seizure Care Plan for Resident
Penalty
Summary
The facility failed to develop a care plan for a resident with a seizure disorder, despite the resident's complex medical history and frequent seizure activity. The resident, diagnosed with Lennox-Gastaut syndrome, severe intellectual disabilities, autistic disorder, and schizophreniform disorder, was admitted to the facility and had an active diagnosis of seizure disorder. The resident was prescribed multiple medications to manage seizures, including Clobazam, Fycompa, Lamotrigine, Rufinamide, and Clonazepam. Despite these prescriptions, the resident experienced numerous seizures, as documented in nursing progress notes, with episodes occurring on multiple occasions and varying in duration and severity. Observations and interviews revealed that the resident continued to have seizures, including an incident witnessed by a surveyor. Despite the frequent seizure activity and the need for consistent medication administration, there was no current care plan in place to address the resident's seizures. The Executive Director acknowledged that the resident should have uninterrupted administration of seizure medications. However, the facility did not provide a policy regarding care plans before the survey exit, indicating a lack of formalized planning for the resident's seizure management.
Failure to Notify Physician of Critical Changes in Resident Condition
Penalty
Summary
The facility failed to notify the physician regarding the removal of a PICC line and the discharge of Resident B. Resident B, who had multiple diagnoses including diabetes and an infection of the left lower stump, had a PICC line inserted for intravenous antibiotics. On one occasion, the PICC line was found to be out of place, and nursing staff removed it without notifying the physician. Additionally, the resident was discharged from the facility without the physician being informed, as documented in the nursing progress notes. For Resident C, the facility did not notify the physician of a low blood glucose level. Resident C, diagnosed with diabetes mellitus and multiple fractures, had a recorded low blood sugar reading, but there was no documentation of physician notification. The resident's care plan included monitoring for signs of hypo/hyperglycemia, but there were no physician orders for treating hypoglycemia or parameters for notifying the physician about abnormal blood sugar levels. The facility's policy required notifying the physician of significant changes in a resident's condition, but this was not adhered to in these cases.
Failure to Provide Transfer/Discharge Form for Resident Transfers
Penalty
Summary
The facility failed to provide a transfer/discharge form for a resident, identified as Resident C, during two separate hospital transfers. Resident C, who had diagnoses including diabetes mellitus type 2 and fractures of the neck, lumbar and thoracic vertebra, and right humerus, was first transferred to a local hospital after being found unresponsive with symptoms such as cold, clammy skin, non-reactive pupils, labored breathing, and weak hand grips. The resident's blood sugar was recorded at 49 mg/dL. The resident returned from the hospital the same day. On a subsequent occasion, Resident C was transferred to the emergency department due to a swollen and firm left abdomen, bruising on the right arm, and increased pain and swelling. The resident was admitted to the hospital and later transferred to another hospital for surgery due to a large hematoma. In both instances, there was no documentation that a transfer/discharge form was provided, as confirmed by the Director of Nursing. The facility's policy requires that appropriate notice be provided to the resident and/or their representative, which was not adhered to in these cases.
Failure to Provide Bed Hold Form During Hospital Transfer
Penalty
Summary
The facility failed to provide a bed hold form for a resident who was transferred to the hospital, which is a requirement under their policy. The resident, who had diagnoses including diabetes mellitus type 2 and fractures of the neck, lumbar and thoracic vertebra, and right humerus, was transferred to the emergency department due to a swollen and bruised left abdomen and increased pain and swelling in the right arm. The resident was subsequently admitted to the hospital and then transferred to another hospital for surgery due to a large hematoma. Despite these transfers, there was no documentation that a bed hold form was sent to the hospital or provided to the resident's Power of Attorney. The Director of Nursing confirmed that transfer documentation should include a bed hold form, and the facility's policy mandates notifying the resident or their representative of the bed-hold policy at admission and during any hospital transfer or therapeutic leave.
Deficiencies in Diabetes Management and Discharge Procedures
Penalty
Summary
The facility failed to properly manage the care of a resident with diabetes, leading to a critical incident where the resident was found unresponsive with hypoglycemia. The resident, who had a history of diabetes, was discovered by a CNA in a state of unresponsiveness, with symptoms including cold and clammy skin, non-reactive pupils, labored breathing, and weak hand grips. The resident's blood sugar was critically low at 49 mg/dL, and despite administering sugar, it only increased to 56 mg/dL. The facility did not have a physician's order to send the resident to the emergency room, nor were there adequate orders for managing hypoglycemia or parameters for notifying the physician of abnormal blood sugar levels. Additionally, blood sugar monitoring was not conducted routinely or as needed, particularly before administering bedtime insulin. In another instance, the facility failed to notify the physician of a resident's discharge and the removal of a PICC line. The resident, who had multiple diagnoses including diabetes and an infection requiring IV antibiotics, was discharged without proper documentation of physician notification. The resident was informed about the importance of completing her IV antibiotic treatment, but she chose to leave the facility. The facility's policy required physician orders to be followed and the physician to be notified of any concerns or changes, but this was not adhered to in the case of the resident's discharge and PICC line removal.
Failure to Provide Timely PICC Line Dressing Changes
Penalty
Summary
The facility failed to provide timely dressing changes for a PICC line for Resident D, as required by physician orders. Resident D, who had a history of osteomyelitis, alcohol abuse with withdrawal, psychoactive substance abuse, malnutrition, MRSA infection, and patient non-compliance, was admitted to the facility with a PICC line in place. The physician orders specified that the PICC line dressing should be changed weekly. However, the clinical record showed that the first documented dressing change occurred on 5/17/2024, despite the resident being admitted on 5/8/2024. The Director of Nursing confirmed during an interview that there was no documentation of a PICC line dressing change between the resident's admission and 5/17/2024. The facility's policy on vascular access devices and infusion therapy procedures, which was provided by the DON, outlined the steps for dressing changes, including performing hand hygiene, assessing the site, cleaning an area larger than the dressing to be applied, and applying a transparent dressing. This deficiency was identified during a complaint investigation.
Failure to Follow Transfer Orders for Resident
Penalty
Summary
The facility failed to ensure that a resident was transferred according to the physician's orders, leading to a deficiency. Resident C, who had multiple medical conditions including heart failure, end-stage renal disease, and a right hip fracture, was ordered to be non-weight bearing and required a mechanical lift for transfers. However, on one occasion, a CNA attempted to transfer the resident from the bed to a wheelchair without using the mechanical lift, resulting in the resident being lowered to the floor. The CNA was unaware of the updated transfer requirements as she had not reviewed the electronic tablet that contained the resident's care instructions. The incident occurred despite the facility's policy that physician orders should be followed and discussed with staff. The CNA involved had not worked after the new order was received and was not informed of the change in the resident's transfer procedure. The facility's policies on physician orders and fall prevention were not effectively implemented, as evidenced by the CNA's lack of awareness and the absence of a proper transfer method, which contributed to the resident being lowered to the floor during the transfer.
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Surveyors observed that dietary staff repeatedly worked in kitchen and meal service areas with uncovered facial hair, despite facility policy and state sanitation requirements mandating effective hair restraints. Two dietary aides with short beards or mustaches were seen walking through food preparation areas, taking food temperatures, handling food, and plating meals at steamtables in dining rooms without any facial hair coverings, while the current policy required all hair, including facial hair, to be restrained to prevent contamination.
The facility failed to consistently provide and document required bed-hold policy notices when several residents were transferred to the hospital. In multiple cases, residents with dementia, psychotic disorders, COPD, chronic respiratory failure, altered mental status, and cerebral infarction were sent out for acute changes in condition, and while transfer notes reflected physician and family notifications, they lacked documentation that the bed-hold policy was discussed with the resident or responsible party. Notices of Transfer or Discharge often indicated a copy of the bed-hold policy was sent with the resident, but the records did not show signed and dated acknowledgment by the resident or appropriate representative, including in situations where a resident had moderate cognitive impairment, short-term memory issues, or a documented need for a proxy and a financial POA authorizing an agent for health care decisions.
Surveyors found that the facility failed to provide trauma‑informed and culturally competent care by not incorporating two residents’ extensive trauma histories and specific behavioral triggers into their care plans. One resident with documented homelessness, polysubstance abuse, severe accidents with multiple fractures, viral encephalitis with coma, physical and sexual abuse, loss of family contact, and a past suicide attempt had multiple behavior‑focused care plans that referenced identifying triggers but listed none and did not mention their physical, sexual, medical, or psychosocial trauma. Another resident with TBI from being struck by a truck, an 11‑month coma, long‑term state hospital residence, alleged shooting of a parent, and diagnoses including intermittent explosive disorder and borderline personality disorder had a PASRR identifying a specific trigger and notes of inappropriate sexual behavior, yet their care plans omitted these traumatic events, the identified trigger, and the sexual behavior. Staff interviews confirmed that residents were screened for trauma, but the trauma histories and triggers were not reflected in the individualized plans of care.
A resident with schizophrenia, post‑stroke hemiparesis, and mild cognitive impairment expressed feeling down and wanting to kill himself, but staff did not document asking about a specific plan, did not notify the physician or psychiatric NP as expected, and did not develop or update a care plan addressing depression or suicidal ideation. The SSD documented offering support and initiating 15‑minute checks once, but there was no further follow‑up or documentation of interventions after subsequent suicidal statements made in a care plan meeting with the resident’s father. The DON and Administrator reported that facility policy requires immediate notification of key staff, assessment for a plan and means of self‑harm, and thorough documentation, which were not carried out or reflected in the medical record for this resident.
A resident with schizophrenia, post-stroke hemiparesis, and mild cognitive impairment verbalized suicidal ideation, but the care plan did not address depression or suicidal thoughts, and required assessments and services were not accurately or timely documented. An SSD note recorded the resident saying he wanted to kill himself and referenced 15‑minute checks and a care plan update, yet the active care plan lacked depression/suicidal ideation interventions. Multiple late-entry Social Services notes were later added, describing follow-up visits and the resident denying suicidal ideation, but the SSD later reported she did not typically ask about a suicide plan and did not personally provide individual follow-up visits as described. These practices conflicted with the facility’s policy requiring factual, first-hand, and timely documentation of assessments and services.
A resident was observed with an Albuterol inhaler on an overbed table and later reported keeping the inhaler in a nightstand drawer, with no staff present during these observations. Record review showed the resident had no cognitive impairment on the admission MDS but lacked any documented self-medication administration assessment. The DON acknowledged that the required assessment had not been completed, despite facility policy requiring staff and the practitioner to evaluate each resident’s mental and physical abilities before allowing self-administration of medications.
Surveyors found that the facility submitted inaccurate direct care staffing data to CMS through the PBJ system over multiple days in a quarter. CASPER reports showed apparent gaps in 24-hour licensed nurse coverage, low weekend staffing, and a 1-star staffing rating, while internal staffing sheets documented that licensed nurses were present and the facility was fully staffed on those days. The Administrator reported that the discrepancies were due to PBJ data entry errors, despite a facility policy requiring all PBJ entries to be accurate, auditable, and verifiable against payroll, invoices, or contracts.
Surveyors found that the facility did not provide or document required written transfer/discharge notices and bed-hold policy information for four residents who were sent to the hospital, including individuals with conditions such as dementia, CHF, chronic respiratory failure, and CKD. In each case, progress notes showed that the resident was transferred for acute issues, but the clinical records lacked evidence that written notices were given to the residents or their representatives, and in one case lacked documentation that required information was sent to the receiving provider. Facility leadership, including the ADON, DON, and Administrator, acknowledged that the records did not contain the required documentation, despite a written policy requiring such notices and information exchange.
The facility failed to ensure timely electronic transmission of MDS assessment data to CMS for a resident. Record review showed an annual MDS that was more than 120 days overdue for submission. The MDS coordinator reported that two care area assessments on the annual MDS had remained incomplete until just before surveyor review, at which time the MDS was finished and submitted. The Administrator acknowledged there was no facility policy in place governing MDS transmissions.
Surveyors found that MDS assessments were inaccurately coded for two residents. One resident with a prior Level II PASARR for serious mental illness was incorrectly coded on the Annual MDS as not having a serious mental illness or related condition. Another resident with generalized anxiety disorder, major depressive disorder, and dementia, who was receiving Lorazepam for anxiety, was not coded with an active anxiety disorder diagnosis on the Quarterly MDS, despite active orders documented on the MAR. The MDS coordinator acknowledged both coding errors, and leadership reported there was no facility-specific MDS policy, relying instead on the RAI manual.
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 Timely Transmit MDS Assessment Data to CMS
Penalty
Summary
The facility failed to ensure timely electronic transmission of MDS (Minimum Data Set) assessment data to the CMS system for one resident. Review of the clinical record for Resident 36 on 4/9/26 showed an annual MDS assessment dated 2/23/26 that was more than 120 days overdue for submission to CMS. During an interview on 4/10/26 at 11:22 a.m., the MDS coordinator stated she still had two care area assessments left to complete on the annual MDS assessment and that she had just finished them and submitted the MDS to CMS, indicating the assessment had not been completed and transmitted within the required timeframe. In a separate interview on 4/10/26 at 12:05 p.m., the Administrator reported that the facility did not have a policy regarding MDS transmissions, further demonstrating the lack of an established process to ensure that MDS data were encoded and transmitted to the State and CMS within the required time limits.
Inaccurate MDS Coding for Mental Health and PASARR Status
Penalty
Summary
The deficiency involves the facility’s failure to ensure that MDS assessments accurately reflected residents’ clinical status for two residents. For one resident with diagnoses including bipolar disorder and anxiety, the Annual MDS dated 3/11/26 indicated the resident was not considered by the state Level II PASARR process to have a serious mental illness or intellectual disability/related condition, despite a Level II PASARR having been completed on 3/31/23. This discrepancy was identified through record review and confirmed in an interview with the MDS coordinator, who acknowledged that the MDS assessment did not accurately reflect the existing Level II PASARR information. For another resident with generalized anxiety disorder, major depressive disorder, and dementia, the Quarterly MDS dated 3/30/26 did not code anxiety as an active diagnosis. However, review of the MAR showed active orders as of 2/27/26 for Lorazepam, prescribed for generalized anxiety disorder, and the RAI manual specifies that active diagnoses should be identified using sources such as medication sheets and physician orders during the 7-day look-back period. In an interview, the MDS coordinator confirmed that the resident did have an active anxiety disorder diagnosis and that the MDS should have been coded “yes” for anxiety disorder but was incorrectly coded “no.” The Administrator and MDS coordinator also stated the facility did not have an MDS policy and relied on the RAI manual for completing assessments.
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