Springs Of Richmond, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Richmond, Indiana.
- Location
- 400 Industries Road, Richmond, Indiana 47374
- CMS Provider Number
- 155843
- Inspections on file
- 40
- Latest survey
- February 13, 2026
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Springs Of Richmond, The during CMS and state inspections, most recent first.
Surveyors found that the facility failed to ensure bedside fluids for three residents who were care planned as at risk for dehydration. A resident with stroke, CKD, and UTI, and another with CHF and anemia, both cognitively intact, reported that fluids were only provided with meal trays or that they sometimes had to ask for water, with observations showing minimal or delayed water provision. A third, moderately cognitively impaired resident with severe sepsis, septic shock, and acute respiratory failure was repeatedly observed with an empty, undated Styrofoam cup and stated she always had to request water and that water had not been passed with her lunch. The Administrator reported there was no hydration policy and that water cups were only passed once per shift.
A resident, cognitively intact per MDS, developed a large, worsening bruise on the back that was documented in progress notes and led to an internal event and NP notification, but there was no documentation that the responsible party was informed. The family only became aware of the bruise and the resident’s report of a prior fall during a transfer when the resident was later hospitalized. This failure to notify occurred despite a facility policy requiring immediate notification of the responsible party for changes in condition.
A resident with a history of stroke was admitted from the hospital with a large traumatic wound on the right side of the back, described as purple, red, and erythematous. Facility documentation later noted that dark areas on the back were worsening, darkening, and increasing in size, and an internal event was opened and an NP notified, but no further assessments of the back or bruise were documented in the wound management record. The DON explained that events in the EHR became internal incident reports, yet no additional assessment notes were available despite a bruising policy requiring a bruise incident and assessment progress note. The resident reported having fallen during a staff-assisted transfer and hitting the bed, and the family stated they were not informed of either the large bruise or the fall.
A resident with multiple chronic conditions was given another resident's medications in error and later transferred to a hospital. The facility did not inform the hospital of the medication error at the time of transfer, and the hospital only learned of the incident after the resident's family provided the information. Staff interviews confirmed the expectation to report such errors, but no policy existed to guide this process.
A resident with complex medical needs, including end-stage renal disease and a history of medication allergies, was given another resident's morning medications in error. The resident did not receive their own prescribed medications, and the error was confirmed by staff and family interviews. The facility's medication administration policy, which requires verification of the five rights and resident identification, was not followed, leading to the error.
A resident with cancer and cognitive impairment did not receive timely follow-up after a hemolyzed CBC sample was reported, resulting in a missed critical lab value and subsequent hospitalization for acute on chronic anemia requiring transfusions. The facility lacked documentation of redraw or provider notification, and staff interviews revealed no clear policy for handling hemolyzed labs.
Two residents experienced significant delays in call light response, with one waiting up to 45 minutes and another waiting over two hours for assistance, leading to discomfort and feelings of helplessness. A staff member confirmed that inadequate staffing contributed to the inability to provide timely care and respond to residents' needs, resulting in a failure to promote resident dignity.
A resident with a knee infection was allowed to self-administer home medications, including narcotics, after admission when the facility did not have the prescribed drugs available. Nursing staff witnessed the resident and his son handling and taking medications from an unlabeled container, but did not complete the required self-administration assessment or obtain a physician order, contrary to facility policy.
A resident with multiple medical conditions did not receive her scheduled morning medications, including antihypertensives and other critical prescriptions, because she was marked as unavailable. The missed administration was not identified or reported by staff until several days later, and appropriate notifications to supervisors and providers were not made at the time.
A resident with a left knee infection was reported by multiple staff to have exhibited verbally aggressive behaviors and refused care, including wound dressing changes and urinal emptying. Despite these incidents, the medical record did not reflect any documentation of the refusals or behaviors, and staff confirmed there was no specific policy for documenting such events, resulting in incomplete medical records.
A facility failed to assess a resident's ability to self-administer a nebulizer medication. An LPN allowed the resident, who had a right arm sling due to a humerus fracture, to self-administer the nebulizer without documented assessment or care plan. The facility's policy required an assessment and return demonstration, which was not documented.
A facility failed to provide a homelike environment for a resident with acute respiratory disease, heart failure, and obesity. Observations revealed that the corner molding in the resident's room was detached, exposing drywall, and there were areas with missing paint. The Executive Director was unaware of these issues, which were attributed to the resident's use of a motorized wheelchair. The facility's expectation was to ensure a safe, clean, and homelike environment for all residents.
A facility failed to document and follow up on a resident's bowel movements, leading to inadequate constipation management. The resident, who was cognitively intact and continent, went 13 days without a bowel movement after admission. The facility lacked a policy for monitoring bowel movements, resulting in multiple undocumented periods of constipation.
A facility failed to administer g-tube feeding and water flushes as ordered for a resident with severe sepsis and dysphagia. The resident's feeding pump was observed running at outdated settings due to a communication lapse by the ADHS, who did not ensure nursing staff were informed of the updated physician's orders. This failure was contrary to the facility's policy requiring regular assessment and monitoring by a Registered Dietitian.
A facility failed to date oxygen tubing for a resident with acute kidney failure and falls, who required continuous oxygen. Observations over several days showed the tubing was not dated, contrary to the facility's policy. The ADHS noted that dates rubbed off, and labels were ordered to resolve the issue.
A resident with chronic pain conditions did not receive effective pain management despite reporting moderate pain. An LPN failed to administer or offer pain relief after the resident reported a pain level of 5 out of 10. The facility's policy on pain management was not followed, as no follow-up or documentation was completed.
The facility failed to administer medications as ordered for three residents, leading to deficiencies in pharmaceutical services. A resident with a UTI received an antibiotic for longer than prescribed, another resident did not receive several medications during a respite stay, and a third resident was given a higher dose of Ambien than ordered. The facility did not notify physicians or the pharmacy about these discrepancies.
The facility failed to provide a clinical rationale for denying a gradual dose reduction of antidepressant and antianxiety medications for two residents. One resident, with no documented anxious behaviors, was prescribed clonazepam, and despite recommendations for dose reduction, the physician denied changes without initial rationale. Another resident, receiving two antidepressants, had dose reduction evaluations denied without specific justification until later documentation cited severe depression. The facility's policy requires documented medical necessity for psychotropic medications, which was not initially met.
A facility failed to follow Enhanced Barrier Precautions (EBP) during care for a resident with a feeding tube. Despite a sign indicating the need for gloves and gowns during high-contact activities, two CRCAs provided perineal care without gowns. The Director of Health Services acknowledged the oversight, which violated the facility's infection control policy.
A resident with a pressure ulcer did not receive consistent wound assessments and documentation as required. The wound nurse failed to enter handwritten notes into the EHR, and the attending physician was not informed of the ulcer until weeks later. The care plan included weekly assessments, but these were not consistently documented, and discrepancies were found in the records of dressing changes and wound assessments.
The facility failed to document meal intakes for three residents with nutritional concerns, leading to a deficiency. A resident with multiple health issues had difficulty chewing and inconsistent meal documentation. Another resident with a history of rhabdomyolysis and heart conditions had missing meal records despite weight monitoring. A third resident with malnutrition and pressure ulcers also had incomplete meal documentation, despite interventions. The facility's policy required meal intakes to be recorded, which was not consistently followed.
Failure to Ensure Bedside Hydration for Residents at Risk of Dehydration
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate residents’ hydration needs and preferences by not ensuring fluids were available at bedside for three residents assessed as at risk for dehydration. One resident with diagnoses including stroke, chronic kidney disease, and UTI, and care plans identifying risk for dehydration, diuretic use, and constipation with interventions to encourage and offer fluids, reported only receiving fluids with meal trays. The resident’s family member, who visited daily, stated the resident never had fluids in the room and that the family had to provide fluids every day. Another resident, cognitively intact with diagnoses including CHF and iron deficiency anemia and a care plan indicating risk for dehydration with an intervention to offer fluids, was observed in the morning with a Styrofoam cup containing only a small amount of water and reported that no water had been brought that day and that sometimes he had to ask for it. Later that day, he reported receiving fresh water for the first time about twenty minutes prior. A third resident, moderately cognitively impaired with diagnoses including severe sepsis with septic shock and acute respiratory failure with hypoxia, and care planned as at risk for dehydration with an intervention to offer fluids, was twice observed with an empty Styrofoam cup without a date, first stating she always had to ask for water and later indicating the empty cup with ice came on her lunch tray and that water had still not been passed. The Administrator stated there was no facility hydration policy and that water cups were passed once per shift.
Failure to Notify Family of Resident’s Significant Bruising and Possible Fall
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s family of a significant change in condition, specifically the development and worsening of a large bruised area on the resident’s back. A family member reported that they first observed the large bruise when the resident was admitted to the hospital on 12/21/25 and stated they had not been informed of the bruise or of any fall. The resident told the family member that about a week prior to the hospital admission, she had a fall during a transfer with staff. Review of the clinical record showed no documentation that the resident had a fall. The resident’s admission MDS, dated 9/24/25, indicated the resident was cognitively intact and able to make consistent and reasonable daily decisions. A progress note dated 12/21/25 at 2:23 p.m. documented that dark areas on the resident’s back had worsened, were getting darker, and had increased in size. An event was opened to ensure the wound nurse was aware, and the Nurse Practitioner was notified. However, the documentation did not show that the resident’s family had been notified of this change in condition. During an interview, the DNS explained that when an event was created in the computer, it was turned into an internal incident report, and no further information or documentation of family notification was provided. The facility’s notification policy stated that the resident’s responsible party would be notified immediately of a change in condition, but this was not reflected in the record for this resident.
Failure to Assess and Document Large Back Bruise and Notify Family
Penalty
Summary
The deficiency involves the facility’s failure to complete a thorough and accurate assessment of a large bruised area on a resident’s back and to document ongoing evaluation of the condition. Hospital documentation dated 1/21/26 indicated that the resident had a traumatic wound on admission to the right side of the back measuring 22 cm by 9 cm, described as purple and red with erythema. The resident’s diagnoses included stroke, and the clinical record did not indicate that the resident had a fall. A progress note dated 12/21/25 at 2:23 p.m. documented that dark areas on the resident’s back had worsened, were getting darker, and increasing in size, and that an event was opened to ensure the wound nurse was aware and the Nurse Practitioner was notified. However, there were no further assessments of the back area documented after this note. Review of the wound management record on 1/28/26 showed no bruising assessment for the resident’s back or any other assessment of the back. During interview, the DNS stated that when an event was created in the computer it was turned into an internal incident report, and no additional documentation or assessments were provided to surveyors. The facility’s bruising policy required completion of a bruise incident in the electronic health record along with a template/assessment progress note, but such documentation was not present. In addition, during an interview, the resident’s family member reported they were not notified of a large bruise on the resident’s back. The resident reported having had a fall during a transfer with staff and hitting the side of the bed, and the family member was not aware of either the fall or the bruising.
Failure to Notify Hospital of Medication Error During Resident Transfer
Penalty
Summary
A resident with multiple complex medical conditions, including chronic pain, diabetes, stage 5 chronic kidney disease, heart failure, dependence on renal dialysis, and pulmonary edema, received another resident's morning medications in error. The incident was immediately reported to the nursing supervisor, Director of Health Services (DHS), and Nurse Practitioner (NP), who assessed the resident and implemented orders to monitor for potential side effects. The resident was made aware of the error, and an attempt was made to notify his wife. The resident was subsequently transferred to a local hospital. Upon transfer, the facility failed to notify the receiving hospital that the resident had received the wrong medications prior to admission. There was no documentation provided to the hospital regarding the medication error, and the hospital only became aware of the incident after the resident's family member obtained and delivered the information. Interviews with facility staff confirmed that it was expected for the nurse transferring the resident to report such incidents, but there was no policy in place outlining what should be communicated to the hospital during transfers.
Resident Received Another Resident's Medications Due to Medication Administration Error
Penalty
Summary
A resident with multiple complex medical conditions, including chronic pain, diabetes, stage 5 chronic kidney disease, heart failure, and dependence on renal dialysis, was administered another resident's morning medications in error. The resident's care plan included interventions to administer medications as ordered, and the resident was identified as being at risk for dehydration, fluid imbalance, and pain related to several chronic conditions. On the day of the incident, the resident did not receive their scheduled morning medications and instead received a full set of medications intended for another resident. The medications administered in error included several drugs with significant potential side effects, such as amlodipine, atorvastatin, duloxetine, Eliquis, furosemide, gabapentin, potassium chloride, sotalol, and atenolol. The resident had a documented allergy to atorvastatin, with previous reactions of dizziness and rash. At the time of the incident, the resident was assessed and found to have no immediate signs or symptoms of adverse effects, and no rash was present. The resident was later sent to the hospital due to symptomatic bradycardia and ongoing concerns related to his medical history, including orthostatic hypotension and dialysis needs. Interviews with facility staff, the resident's family member, and the nurse practitioner confirmed that the resident received the wrong medications and did not receive his own scheduled medications. The facility's medication administration policy required verification of the five rights of medication administration, including resident identification, but this process was not followed, resulting in the medication error.
Failure to Follow Up on Hemolyzed Lab Results Leads to Hospitalization
Penalty
Summary
The facility failed to timely follow up on hemolyzed laboratory results for a resident with a history of malignant melanoma and encephalopathy, who was at risk for complications related to cancer. The resident had physician orders for weekly complete blood count (CBC) tests, with results to be faxed to the oncologist. On one occasion, a CBC drawn was found to be hemolyzed and the laboratory requested a new order and recollection, but there was no documentation in the progress notes that the lab was redrawn or that the provider was notified. The resident's care plan included monitoring laboratory results as ordered, but this was not followed. Subsequently, several days later, the resident exhibited confusion and a new CBC was obtained, revealing a critically low hemoglobin level. The resident was then transferred to the emergency room and hospitalized for acute on chronic anemia, requiring multiple blood transfusions. Interviews with family and the oncologist's office confirmed that no CBC results were received during the period in question, and facility staff were unable to explain why the labs were not redrawn or the provider notified. There was no specific policy in place for handling hemolyzed samples.
Failure to Ensure Timely Call Light Response and Resident Dignity
Penalty
Summary
The facility failed to honor residents' rights to a dignified existence and timely assistance, as evidenced by prolonged call light response times for two residents. One resident, who was cognitively intact and had diagnoses including aftercare following joint replacement surgery and hypertensive heart disease, reported that call light response times varied from a few minutes to as long as 45 minutes, with waits usually exceeding 15 minutes. She expressed discomfort and distress due to the delays, particularly when needing immediate assistance to use the bathroom. The facility's policy required call lights to be answered as quickly as possible, but this standard was not met. Another resident, alert and oriented with a diagnosis of infection related to an internal prosthetic, reported waiting over two hours for assistance after initially requesting help, and an additional 45 minutes after a second request. This resident described feeling helpless due to the repeated and prolonged waits. A Certified Resident Care Associate confirmed that staffing levels were inadequate, often leaving her responsible for 37 patients and unable to provide routine care or respond to call lights promptly. She acknowledged that residents sometimes waited 30 minutes or more for assistance, especially when she required help from a nurse for certain residents, leaving no one available to respond to other needs.
Failure to Assess Resident for Safe Self-Administration of Medication
Penalty
Summary
A resident with a medical history of a left knee infection related to an internal prosthetic was admitted to the facility and was alert and oriented upon admission. On the night of admission, the resident's son brought in home medications, including narcotics, because the facility did not have the resident's prescribed medications available. The resident and his son administered the medications, and the resident confirmed taking his own oxycodone. Nursing staff, including two LPNs, were aware that the resident was using medications brought from home, some of which were in an unlabeled container. One LPN attempted to verify the medications verbally with the resident but did not complete a self-administration of medication assessment and was unfamiliar with the facility's policy on self-administration. The other LPN, who admitted the resident, also did not complete the required assessment. Review of the clinical record revealed there was no documentation of a Self-Administration of Medication assessment or a physician order authorizing self-administration. Facility policy required an assessment to be completed for any resident requesting or engaging in self-administration of medication. The failure to assess the resident's ability to safely self-administer medications and to follow policy regarding verification and documentation led to the deficiency.
Failure to Administer Prescribed Medications as Ordered
Penalty
Summary
A resident with diagnoses including aftercare following joint replacement surgery, cerebral ischemia, and hypertensive heart disease did not receive her prescribed morning medications on a specific date. The medications missed included antihypertensives, an antiplatelet, a supplement, an antidepressant, an antianginal, and an antidiabetic agent. The medication administration record indicated these medications were not administered because the resident was marked as unavailable. The resident later reported feeling dizzy that afternoon and realized she had not received her morning medications. She did not inform facility staff of the missed dose at the time. The facility only became aware of the missed medication administration several days later, on the resident's discharge date, when the issue was brought to their attention. The nurse responsible was a relatively new staff member and had not communicated any difficulties in locating the resident, despite being checked on multiple times by supervisory staff. Documentation showed that the nurse practitioner was informed of the missed dose, but no new orders were received. The facility's process for notifying supervisors, providers, and the resident or responsible party was not followed at the time of the incident.
Failure to Document Resident Refusals and Aggressive Behaviors
Penalty
Summary
The facility failed to accurately document the behaviors and refusals of care for a resident with a medical diagnosis of a left knee infection related to an internal prosthetic. The resident was alert and oriented upon admission. Multiple staff interviews revealed that the resident exhibited verbally aggressive behaviors, including cussing at staff, refusing care such as wound dressing changes and urinal emptying, and expressing intentions to leave the facility against medical advice. Staff described the resident as agitated, frustrated, and resistive to assistance, with specific incidents where the resident verbally abused staff and refused interventions. Despite these reported behaviors and refusals, a review of the resident's medical record showed no documentation of these events. The facility did not have a specific policy for documenting behaviors, but the expectation was that refusals of care would be recorded in the chart. The lack of documentation was confirmed during interviews with staff and the corporate nurse, indicating a failure to maintain accurate and complete medical records in accordance with accepted professional standards.
Failure to Assess Resident's Ability to Self-Administer Nebulizer
Penalty
Summary
The facility failed to ensure that a resident was clinically assessed and deemed appropriate to self-administer a nebulizer medication. During an observation of medication administration, an LPN prepared and handed a nebulizer face mask to a resident who then self-administered the medication. The LPN left the room while the resident continued the nebulizer treatment. The resident had a sling on her right arm due to a humerus fracture, and the nebulizer machine was placed on the right side of her bed, which could have posed a challenge for her to manage the equipment safely. The resident's clinical record indicated a recent orthopedic appointment where she was advised to be non-weight bearing on her right upper extremity. Although the resident expressed a desire to self-administer medications, there was no documented assessment or care plan in the electronic health record to confirm her capability to safely self-administer the nebulizer treatment. The facility's policy required an assessment and return demonstration to ensure safety, which was not documented in this case.
Failure to Maintain Homelike Environment for Resident
Penalty
Summary
The facility failed to provide a homelike environment for a resident, identified as Resident 14, who was reviewed for homelike environment. The resident's clinical record indicated diagnoses including acute respiratory disease, heart failure, and obesity. During observations, it was noted that the corner molding in Resident 14's room was detached from the wall, exposing the drywall where it connected at the corner. The molding was found leaning against the opposite wall, and there were areas where paint was missing on the wall behind the head of the bed. These observations were made on multiple occasions. During a tour, the Executive Director stated he was unaware of the molding issue and missing paint, acknowledging that this had been a recurring problem due to the resident's use of a motorized wheelchair. The facility's expectation was to maintain a safe, clean, and homelike environment for all residents.
Failure to Document and Follow Up on Resident's Bowel Movements
Penalty
Summary
The facility failed to ensure proper documentation and follow-up for a resident's bowel movements, leading to a deficiency in care for constipation management. Resident G, who was cognitively intact and always continent of bowel, was admitted with a diagnosis that included constipation. Despite having a bowel and bladder care plan in place, which required notifying the charge nurse of changes in bowel patterns, the facility did not document or follow up on the resident's bowel movements adequately. The resident went 13 days without a bowel movement after admission, as reported by a family member. The electronic health record showed multiple instances where Resident G went several days without a documented bowel movement, including periods of up to six days without any record. The Executive Director confirmed that there was no facility policy regarding the monitoring of bowel movements. This lack of documentation and follow-up is contrary to the guidelines from the National Library of Medicine, which defines constipation as having three or fewer bowel movements per week.
Failure to Administer G-Tube Feeding as Ordered
Penalty
Summary
The facility failed to administer gastric tube (g-tube) feeding and water flushes as ordered by the physician for Resident 299, who was reviewed for nutrition. Resident 299 had a medical history that included severe sepsis with septic shock, dysphagia, and was receiving orthopedic aftercare following surgical amputation. The care plan for tube feeding, initiated and revised in February 2025, required adherence to specific feeding and flushing orders. However, observations on two separate occasions revealed that the feeding pump was running at the previous order's settings, which had been discontinued, rather than the updated physician's orders. The discrepancy arose because the Assistant Director of Health Services (ADHS) entered the new order for the g-tube feedings and flushes but failed to ensure that the nursing staff was informed of the change. The Director of Health Services (DHS) confirmed this lapse in communication during an interview. The facility's policy on tube feedings, which was revised in May 2024, mandates that residents requiring tube feeding be assessed by a Registered Dietitian or Nutrition & Dietetics Technician, Registered, with monthly monitoring. This policy was not effectively followed, leading to the deficiency in care for Resident 299.
Failure to Date Oxygen Tubing for Resident
Penalty
Summary
The facility failed to properly date oxygen tubing for a resident requiring respiratory care. Resident 253, who has diagnoses including acute kidney failure and falls, was observed on multiple occasions with oxygen tubing that was not dated. A physician's order required the resident to be on continuous oxygen at two to three liters per minute. Observations on three separate days revealed that the oxygen tubing at the resident's bedside was not dated as per the facility's policy. The Assistant Director of Health Services acknowledged the issue, noting that the dates rubbed off the tubing, and indicated that labels had been ordered to address the problem. The facility's Administration of Oxygen Policy mandates that tubing be dated when initiated and changed monthly or as needed.
Failure to Provide Effective Pain Management
Penalty
Summary
The facility failed to provide effective pain management for Resident 251, who had diagnoses including Alzheimer's disease, chronic back pain, and chronic vertebral fractures due to osteoporosis. A physician's order required monitoring of the resident's pain three times a day for seventy-two hours, and a pain medication order allowed for morphine concentrate solution to be administered every four hours as needed. Despite the resident rating her pain as a 5 out of 10, indicating moderate pain, on 2/12/25, no pain medication was administered, and no follow-up was documented in the electronic health record (EHR). During an interview, an LPN admitted to not providing any pharmacological or non-pharmacological interventions after the resident reported her pain level. The LPN acknowledged forgetting to check if there was an order for pain medication. Additionally, the resident's daughter reported that the resident experienced discomfort during care activities. A progress note later indicated that the resident was resting without outward signs of pain, but the facility's policy required evaluation and documentation of pain management effectiveness, which was not adhered to in this case.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to administer medications according to physician orders for three residents, leading to deficiencies in pharmaceutical services. Resident G, diagnosed with sepsis and a urinary tract infection (UTI), was prescribed cefdinir 300 mg twice a day for seven days. However, the medication administration record (MAR) indicated that the antibiotic was administered for eight days on two separate occasions, contrary to the physician's orders. This discrepancy in medication administration was not addressed or corrected by the facility. Resident C, admitted for a respite stay, did not receive several medications as they were listed as unavailable in the MAR. These included Depakote, ropinirole, Rytary, and trazodone. There was no documentation indicating that the physician was notified of the missed doses or that the pharmacy was contacted to ensure medication delivery. Additionally, Resident 40, who had orders for Ambien 5 mg for insomnia, was incorrectly administered 10 mg on multiple occasions, as documented in the controlled drug use record. The Director of Health Services confirmed that medications should be administered as ordered, highlighting a failure in the facility's medication management processes.
Failure to Provide Rationale for Denial of Gradual Dose Reduction
Penalty
Summary
The facility failed to ensure a clinical rationale was provided for the denial of a gradual dose reduction (GDR) of antidepressant and antianxiety medications for two residents. Resident 30, diagnosed with conditions including major depressive disorder and agoraphobia with panic disorder, was prescribed clonazepam. Despite a lack of documented anxious behaviors and multiple pharmacist recommendations for a GDR, the physician repeatedly denied the reduction without providing a specific rationale. It was only after a recent fall that the physician noted the resident's seizure disorder and risk of breakthrough seizures as reasons for maintaining the current dosage. Resident 26, who was cognitively intact and exhibited no behaviors, was receiving two antidepressants: venlafaxine and Wellbutrin. The facility's care plan required attempts at GDR unless clinically contraindicated. However, despite pharmacy recommendations for dose reduction evaluations, the physician denied changes without initially providing a specific rationale. It was later documented that the resident's severe depression related to recent illness and overall decline justified the continuation of the current dosages. The facility's policy on psychotropic medication usage and GDRs mandates that residents receive such medications only if medically necessary, with documented justification. The policy also requires ongoing efforts to reduce dosages unless contraindicated. In both cases, the facility did not initially provide adequate documentation or rationale for the continued use of the medications at their current dosages, leading to the identified deficiency.
Failure to Adhere to Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to maintain proper infection control practices by not adhering to Enhanced Barrier Precautions (EBP) during the provision of activities of daily living (ADL) care for a resident. Resident 299, who had a history of severe sepsis with septic shock, dysphagia, and was receiving tube feeding, was observed in a room with a sign indicating the need for EBP. The sign instructed that gloves and gowns should be worn for high-contact care activities, such as providing hygiene and toileting assistance. However, during an observation, two Certified Resident Care Associates (CRCAs) were seen providing perineal care to the resident without wearing gowns, although gloves were used. A cart with the necessary personal protective equipment (PPE) was available in the room. The Director of Health Services confirmed that the CRCAs should have been wearing the appropriate PPE, as outlined in the facility's Enhanced Barrier Precautions Standard Operating Procedure. This policy mandates the use of gloves and gowns during high-contact care activities for residents with indwelling medical devices, such as feeding tubes, which was applicable to Resident 299. The failure to adhere to these precautions during the care of Resident 299 represents a deficiency in the facility's infection control practices.
Inadequate Wound Care Documentation and Assessment
Penalty
Summary
The facility failed to ensure routine and timely wound assessments for a resident with a pressure ulcer. Resident B, who was admitted with an unstageable pressure ulcer, did not receive consistent weekly wound assessments and documentation as required. The initial wound assessment was incomplete, lacking details such as the stage of the wound, drainage, color, odor, wound margins, surrounding tissue, and presence of tunneling or undermining. The wound nurse admitted to not entering the handwritten notes into the electronic health record (EHR), and the attending physician was not informed of the pressure ulcer until several weeks after admission. The care plan for Resident B included weekly skin assessments and wound measurements, but these were not consistently documented. The wound nurse acknowledged being overwhelmed with responsibilities, which contributed to the lack of documentation. The facility's records showed discrepancies in the documentation of dressing changes and wound assessments, with only one dressing change recorded in the Treatment Administration Record (TAR) for May 2024, despite orders for daily changes. Additionally, the application of a foam dressing was not documented in the EHR. Interviews with facility staff revealed that the wound nurse did not document the application of a foam dressing or enter specific care orders into the EHR. The facility's policy required weekly documentation of wound measurements and conditions, but this was not adhered to until later in May 2024. The lack of consistent documentation and communication regarding Resident B's pressure ulcer care led to a deficiency in the facility's wound care practices.
Failure to Document Meal Intakes for Residents with Nutritional Concerns
Penalty
Summary
The facility failed to routinely document meal intakes for three residents with nutritional concerns, leading to a deficiency in maintaining adequate nutrition records. Resident B, who had multiple health issues including a heart attack, diabetes, and obesity, was noted to have difficulty chewing due to not wearing dentures. Despite a family member's request for a nutritionist, there was no follow-up, and meal intakes were not consistently documented. The Registered Dietitian (RD) recommended dietary supplements and monitoring, but several meals were not recorded, indicating a lapse in documentation. Resident C, with a history of rhabdomyolysis, sepsis, and heart conditions, was on a mechanical soft diet. The RD noted significant weight gain, which was considered beneficial, and planned to monitor weights and intakes. However, meal documentation was missing for several meals in June, indicating a failure to consistently record meal intakes as per the facility's policy. Resident D, who had malnutrition and pressure ulcers, was closely monitored by the RD due to significant weight loss. Despite interventions like a liberalized diet and nutritional supplements, meal intakes were not consistently documented. The RD noted a recent weight gain, but the lack of meal documentation on specific dates highlights a deficiency in maintaining accurate nutritional records. The facility's policy required meal intakes to be recorded in the electronic health record, which was not adhered to, leading to this deficiency.
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Surveyors observed that dietary staff repeatedly worked in kitchen and meal service areas with uncovered facial hair, despite facility policy and state sanitation requirements mandating effective hair restraints. Two dietary aides with short beards or mustaches were seen walking through food preparation areas, taking food temperatures, handling food, and plating meals at steamtables in dining rooms without any facial hair coverings, while the current policy required all hair, including facial hair, to be restrained to prevent contamination.
The facility failed to consistently provide and document required bed-hold policy notices when several residents were transferred to the hospital. In multiple cases, residents with dementia, psychotic disorders, COPD, chronic respiratory failure, altered mental status, and cerebral infarction were sent out for acute changes in condition, and while transfer notes reflected physician and family notifications, they lacked documentation that the bed-hold policy was discussed with the resident or responsible party. Notices of Transfer or Discharge often indicated a copy of the bed-hold policy was sent with the resident, but the records did not show signed and dated acknowledgment by the resident or appropriate representative, including in situations where a resident had moderate cognitive impairment, short-term memory issues, or a documented need for a proxy and a financial POA authorizing an agent for health care decisions.
Surveyors found that the facility failed to provide trauma‑informed and culturally competent care by not incorporating two residents’ extensive trauma histories and specific behavioral triggers into their care plans. One resident with documented homelessness, polysubstance abuse, severe accidents with multiple fractures, viral encephalitis with coma, physical and sexual abuse, loss of family contact, and a past suicide attempt had multiple behavior‑focused care plans that referenced identifying triggers but listed none and did not mention their physical, sexual, medical, or psychosocial trauma. Another resident with TBI from being struck by a truck, an 11‑month coma, long‑term state hospital residence, alleged shooting of a parent, and diagnoses including intermittent explosive disorder and borderline personality disorder had a PASRR identifying a specific trigger and notes of inappropriate sexual behavior, yet their care plans omitted these traumatic events, the identified trigger, and the sexual behavior. Staff interviews confirmed that residents were screened for trauma, but the trauma histories and triggers were not reflected in the individualized plans of care.
A resident with schizophrenia, post‑stroke hemiparesis, and mild cognitive impairment expressed feeling down and wanting to kill himself, but staff did not document asking about a specific plan, did not notify the physician or psychiatric NP as expected, and did not develop or update a care plan addressing depression or suicidal ideation. The SSD documented offering support and initiating 15‑minute checks once, but there was no further follow‑up or documentation of interventions after subsequent suicidal statements made in a care plan meeting with the resident’s father. The DON and Administrator reported that facility policy requires immediate notification of key staff, assessment for a plan and means of self‑harm, and thorough documentation, which were not carried out or reflected in the medical record for this resident.
A resident with schizophrenia, post-stroke hemiparesis, and mild cognitive impairment verbalized suicidal ideation, but the care plan did not address depression or suicidal thoughts, and required assessments and services were not accurately or timely documented. An SSD note recorded the resident saying he wanted to kill himself and referenced 15‑minute checks and a care plan update, yet the active care plan lacked depression/suicidal ideation interventions. Multiple late-entry Social Services notes were later added, describing follow-up visits and the resident denying suicidal ideation, but the SSD later reported she did not typically ask about a suicide plan and did not personally provide individual follow-up visits as described. These practices conflicted with the facility’s policy requiring factual, first-hand, and timely documentation of assessments and services.
A resident was observed with an Albuterol inhaler on an overbed table and later reported keeping the inhaler in a nightstand drawer, with no staff present during these observations. Record review showed the resident had no cognitive impairment on the admission MDS but lacked any documented self-medication administration assessment. The DON acknowledged that the required assessment had not been completed, despite facility policy requiring staff and the practitioner to evaluate each resident’s mental and physical abilities before allowing self-administration of medications.
Surveyors found that the facility submitted inaccurate direct care staffing data to CMS through the PBJ system over multiple days in a quarter. CASPER reports showed apparent gaps in 24-hour licensed nurse coverage, low weekend staffing, and a 1-star staffing rating, while internal staffing sheets documented that licensed nurses were present and the facility was fully staffed on those days. The Administrator reported that the discrepancies were due to PBJ data entry errors, despite a facility policy requiring all PBJ entries to be accurate, auditable, and verifiable against payroll, invoices, or contracts.
Surveyors found that the facility did not provide or document required written transfer/discharge notices and bed-hold policy information for four residents who were sent to the hospital, including individuals with conditions such as dementia, CHF, chronic respiratory failure, and CKD. In each case, progress notes showed that the resident was transferred for acute issues, but the clinical records lacked evidence that written notices were given to the residents or their representatives, and in one case lacked documentation that required information was sent to the receiving provider. Facility leadership, including the ADON, DON, and Administrator, acknowledged that the records did not contain the required documentation, despite a written policy requiring such notices and information exchange.
A resident with Alzheimer’s disease and depression, previously on an antidepressant, exhibited intermittent refusals of medications and care, occasional yelling at staff, and reports of unusual perceptions, such as believing men were in or near her room. Nursing notes over several months documented these refusals and complaints but did not show that the behaviors were evaluated or recorded as dangerous, non-redirectable, or causing significant distress, nor did they document specific non-pharmacological interventions attempted or their outcomes. Despite this, a psychiatric NP later added new diagnoses of schizoaffective disorder, borderline personality disorder, and delusional disorder and ordered an antipsychotic (Seroquel) without a comprehensive evaluation in the record to support these diagnoses. The facility’s psychotropic medication policy, which requires identification and documentation of target behaviors, use of nonpharmacological interventions, and ongoing behavior monitoring, was not followed for this resident.
The facility failed to keep PASARR Level I screenings accurate and current for three residents when new mental health diagnoses and psychoactive medications were initiated. One resident’s PASARR omitted a PTSD diagnosis and an added antidepressant, despite documentation of PTSD on the MDS and care plan and a physician order for Pristiq. Another resident’s PASARR listed only depression and dementia, even after additional diagnoses such as borderline personality disorder, delusional disorder, and schizoaffective disorder were added and an antipsychotic (quetiapine) was ordered, with the MDS later reflecting psychotic disorder, schizophrenia, and depression with antipsychotic and antidepressant use. A third resident’s PASARR did not include a depression diagnosis or newly ordered escitalopram and lorazepam, although the admission MDS documented depression with antianxiety and antidepressant use. These omissions occurred despite facility policy requiring a new Level I review after significant mental status changes, including new mental health diagnoses or new psychotropic medications.
Uncovered Facial Hair During Food Preparation and Meal Service
Penalty
Summary
The deficiency involves the facility’s failure to ensure that food was served in a sanitary and safe manner in accordance with professional standards and facility policy during multiple kitchen and meal service observations. During an initial kitchen observation, two dietary aides were seen walking through the kitchen food preparation area with uncovered facial hair. One aide had facial hair above and below the lip and along the jaw line, approximately one-fourth inch in length, and the other had a mustache of similar length; neither used any facial hair covering. These observations occurred while staff were present in the kitchen area where food was stored and prepared. During subsequent observations on the same day, the same two dietary aides were again observed with uncovered facial hair while directly involved in meal preparation and service. One aide walked through the kitchen while the noon meal was being prepared and placed into a transport cart for service in the south dining room, and later was observed plating the noon meal at the steamtable in that dining room, still without a facial hair covering. The other aide walked through the kitchen while the noon meal was being prepared and placed into the steamtable for the north dining room, took food temperatures, assisted with plating meals at the steamtable, and retrieved food items and supplies from the kitchen, all while having an uncovered mustache approximately one-fourth inch in length. The Dietary Manager stated that staff hair was to be covered when in the kitchen and during meal service, and the facility’s written policy and the cited Indiana Food Establishment Sanitation Requirements both required effective hair restraints, including for facial hair, to prevent contamination of food, equipment, and utensils.
Failure to Provide and Document Bed-Hold Policy at Time of Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure that required bed-hold policy information was provided and documented for four residents transferred to the hospital. For a resident with dementia, psychotic disorder, and autistic disorder who had a BIMS score of 0 indicating severe cognitive impairment, progress notes documented physician notification and guardian notification when the resident was sent to the hospital, but there was no documentation that the bed-hold policy was provided to the responsible party. A Notice of Transfer or Discharge later indicated a copy of the bed-hold policy was sent with the resident. Another resident with COPD and chronic respiratory failure, cognitively intact with a BIMS score of 13, experienced a decline in condition and was transferred to the hospital by ambulance; progress notes documented family notification but did not document any discussion of the bed-hold policy, although a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident. A third resident with altered mental status and cerebral infarction, with a BIMS score of 10 indicating moderate cognitive impairment and documented short-term memory impairment, experienced changes in condition and was transferred to the hospital. Progress notes stated the resident was their own responsible party and that no other notification was completed, and transfer documentation did not include the bed-hold policy, although an untimed Notice of Transfer or Discharge indicated a copy of the bed-hold policy was signed by the resident. A financial power of attorney document in the record showed the resident had designated an agent to act in consent or refusal of health care. For a fourth resident with dementia and osteomyelitis, transfer documentation and a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident, and the transfer form noted the resident required a proxy for decision making. The facility’s policy required that at the time of transfer to a hospital, written notice specifying the duration of the bed-hold policy and information on return to the next available bed be provided, and that a signed and dated copy of the bed-hold notice given to the resident or representative be kept in the resident file, which was not consistently documented for these residents.
Failure to Integrate Trauma Histories and Behavioral Triggers Into Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to identify and incorporate residents’ trauma histories and specific behavioral triggers into their care plans, despite documented histories of significant trauma and behavioral health issues. For one resident, extensive social service and progress notes documented homelessness, polysubstance abuse, major depressive and anxiety disorders, chronic pain, a history of severe car accidents with multiple fractures, viral encephalitis resulting in a three‑month coma, loss of child custody, multiple divorces, physical abuse by a spouse, the death of a fiancé who was struck by a car while in a wheelchair, lack of family contact, and a past suicide attempt by Valium overdose. Additional documentation noted a history of rape by a brother at age eight and prior placement under direct supervision and 15‑minute checks related to suicidal ideation. Despite these documented traumatic events and behavioral health concerns, the resident’s care plans did not identify a history of physical trauma, sexual trauma, homelessness, substance abuse, medical trauma, or attempted suicide. For this same resident, the MDS showed no cognitive deficit and identified behaviors such as verbal aggression and rejection of care, along with diagnoses including seizure disorder, depression, chronic pain syndrome, homelessness, and anxiety disorder. Multiple care plans addressed behaviors such as drug‑seeking, pretending to have seizures for attention or medication, making false allegations, verbal aggression when unable to smoke, and a desire for intimate relationships with consenting male residents. These care plans referenced goals such as effective coping skills, seeking staff support, and compliance with the smoking policy, and they called for identification and reduction of behavioral triggers. However, none of these care plans actually listed any specific triggers. The care plan addressing the resident’s right to consensual intimate relationships focused on assessment and education regarding consent but did not integrate the resident’s extensive trauma history. Staff interviews indicated the resident had displayed sexual behaviors since admission, including an incident where the resident expressed anger at another resident for not buying a soda after engaging in sexual acts. A second resident with a documented history of traumatic brain injury (TBI), dementia, seizure disorder, borderline personality disorder, anxiety, intermittent explosive disorder, tobacco use, and other behavioral/emotional disorders was also affected by the same deficiency. Social history and progress notes documented that this resident sustained a TBI after being hit by a semi‑truck while riding a bicycle at age 18, resulting in an 11‑month coma, followed by 13 years in a state hospital and subsequent residence in a group home. Additional documentation indicated the resident allegedly shot their father at age 26 after being sworn at and had a PASRR identifying TBI, intermittent explosive disorder, and borderline personality disorder, with a specific trigger of hearing the name of the current U.S. President. Progress notes also described inappropriate sexual behavior toward staff, including touching themselves intimately during personal care and refusing to stop when redirected. Despite this, the resident’s care plans, which addressed explosive disorder and history of altercations, risk for decreased psychosocial well‑being, and refusal to bathe or shower, did not list any specific behavioral triggers, did not reference the traumatic events such as being hit by a truck or shooting their father, and did not document the inappropriate sexual behavior. The Administrator and Social Service Director acknowledged that residents were to be screened for trauma and that trauma responses and PTSD should be added to care plans, but the specific trauma histories and triggers for these two residents were not incorporated into their plans of care.
Failure to Assess and Care Plan for Resident Suicidal Ideation
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess, investigate, and care plan for a resident’s suicidal ideation in accordance with its own policy and staff expectations. The resident had diagnoses including schizophrenia, cerebral edema, and hemiparesis/hemiplegia following a cerebral infarction, and a current MDS showed mild cognitive impairment (BIMS score 12). A progress note documented that the resident told the Social Services Director (SSD) he was feeling down and wanted to kill himself; the SSD offered assistance, activities, and initiated 15‑minute checks, and the note stated the care plan was updated. However, the note did not indicate that the SSD asked whether the resident had a plan to kill himself, and there were no additional notes regarding suicidal ideation or follow‑up. Review of the current care plan showed no problem, goal, or interventions addressing depression or suicidal ideation, and progress notes over the following month contained no documentation of physician notification related to the suicidal statement. Further record and interview evidence showed that the care plan conference summary did not document interventions for suicidal ideation, and the SSD acknowledged she did not normally ask residents expressing suicidal ideation if they had a plan. The SSD reported that the resident had admission paperwork mentioning suicidal ideation related to depression after a stroke and that the resident again vocalized suicidal ideation during a care plan meeting with his father, after which emotional support was offered and the father took the resident out on a leave of absence; no further visits or follow‑up were done. The DON stated that, upon notification of suicidal verbalization, staff should assess the resident, ask if there is a plan, remove potential means of self‑harm, immediately notify the psychiatric NP, and document the occurrence, and that a detailed progress note and updated care plan were expected but not present for this resident. The Administrator similarly stated that staff should ask about a plan, document interventions, notify the physician and family, and update the care plan, and indicated the resident should have had a care plan addressing depression with suicidal ideation. The facility’s written policy required immediate notification of the DON, SSD, and physician, an interview including asking about a plan and assessing mood and means for self‑harm, and thorough documentation of mood, behavior, and all actions taken, which were not reflected in the resident’s record.
Incomplete and Inaccurate Documentation of Suicidal Ideation and Follow-Up
Penalty
Summary
The facility failed to ensure accurate, complete, and timely documentation of assessments and services for a resident who verbalized suicidal ideation. Resident 6, who had schizophrenia, cerebral edema, and right-sided hemiparesis/hemiplegia following a cerebral infarction, had a BIMS score of 12 indicating mild cognitive impairment. The resident’s admission paperwork mentioned suicidal ideation related to depression after a stroke, and a Social Services note on 3/11/2026 documented that the resident was feeling down and said he wanted to kill himself. The Social Services Director (SSD) documented that she talked with the resident, coordinated with Activities, advised the resident to contact SSD or nursing if he wanted to talk, and that the resident was scheduled for 15-minute checks and the care plan was updated. However, the current care plan initiated on 2/26/2026 did not address depression or suicidal ideation. Multiple Social Services progress notes were later entered as late entries in April, with effective dates in March, stating that the resident had no plan and no longer had suicidal ideation, that he felt much better after 1:1 time, and that he continued his daily routine and therapy. These late entries described follow-up visits and reassessments of suicidal ideation on several consecutive days, but in interviews the SSD stated she did not normally ask residents about having a plan when they verbalized suicidal ideation and did not recall any other occurrences beyond the initial event. She further indicated she did not personally provide individual follow-up visits with this resident regarding suicidal ideation, despite the late-entry notes describing such visits. The DON acknowledged that late entries had been added to address concern about suicidal verbalization, and the Administrator stated that upon suicidal statements staff should ask about a plan, notify the physician and family, and update the care plan, and that this resident should have had a care plan addressing depression with suicidal ideation. The facility’s documentation policy required factual, first-hand, timely documentation, which was not followed in this case.
Failure to Complete Required Self-Administration Assessment for Inhaler Kept at Bedside
Penalty
Summary
Surveyors identified that a resident was allowed to keep and access an Albuterol inhaler without the facility completing the required self-administration medication assessment. During an initial tour, the resident was observed sitting in a wheelchair with a handheld Albuterol inhaler on the overbed table and no staff present in the room or hallway. On a subsequent observation, the resident again was in a wheelchair and reported that the Albuterol inhaler was stored in the top drawer of the nightstand, where it was found. Review of the clinical record showed an admission MDS indicating no cognitive impairment, but there was no documentation of a self-medication administration assessment. In an interview, the DON confirmed that the resident did not have the required self-medication assessment, despite the facility’s policy stating that staff and the practitioner must assess each resident’s mental and physical abilities to determine whether self-administering medications is clinically appropriate. This failure to complete and document a self-administration medication assessment for a resident who had an Albuterol inhaler kept at bedside constituted noncompliance with the facility’s own policy and with 410 IAC 16.2-3.1-11(a).
Inaccurate PBJ Staffing Data Submission to CMS
Penalty
Summary
The deficiency involves the facility’s failure to electronically submit complete and accurate direct care staffing information to CMS through the Payroll-Based Journal (PBJ) system for 22 days in a fiscal quarter. A CASPER report review on 4/6/26 showed that, according to PBJ data, the facility did not have licensed nursing coverage 24 hours per day on multiple specific dates across three months, had low weekend staffing, and held a 1-star staffing rating. However, review of the facility’s internal staffing sheets for that quarter indicated the facility was fully staffed and had licensed nurse coverage on all of the dates in question. During an interview, the Administrator stated that the PBJ information must have contained data entry errors, as she had verified licensed staff coverage on the timesheets. The facility’s PBJ policy in effect stated that all staffing data entered into the PBJ system would be auditable and verifiable through payroll, invoices, or contracts, but the submitted PBJ data did not accurately reflect the facility’s actual licensed nurse staffing as documented on internal records. No specific residents or clinical conditions were mentioned in the report, and the deficiency centers solely on inaccurate staffing data submission rather than direct resident care events.
Failure to Provide and Document Required Transfer/Discharge and Bed-Hold Notices
Penalty
Summary
The deficiency involves the facility’s failure to provide and document required written notices of transfer/discharge and bed-hold policies, as well as required information to receiving providers, for four residents who were transferred or discharged to the hospital. For a resident with generalized anxiety disorder, major depressive disorder, and dementia, progress notes showed that the resident was sent to the hospital via 911 for chest pain, lower back pain, and shortness of breath and later returned to the facility, but the clinical record lacked documentation that a written Notice of Transfer/Discharge and the bed-hold policy were provided to the resident or representative, and lacked documentation that required information was conveyed to the receiving facility. The ADON and the Administrator both confirmed there was no documentation that these written notices were provided. For a resident with congestive heart failure and muscle weakness who was sent to the emergency room for painful urination and bloody urine, the clinical record lacked documentation that a Notice of Transfer/Discharge or bed-hold policy was given to the resident or representative, which the DON confirmed. Another resident with chronic respiratory failure and diabetes was discharged to the hospital for respiratory failure, and a resident with chronic kidney disease and dementia was discharged to the hospital, but in both cases there was no documentation that a written notice of transfer/discharge or bed-hold policy was provided to the residents or their representatives. Review of the facility’s Transfer and Discharge policy, dated 1/15/26, showed that the policy required the facility to provide written transfer/discharge notices and bed-hold information to residents and representatives and to provide specified information to receiving providers, but the records for these four residents did not contain the required documentation.
Failure to Document Target Behaviors and Non-Pharmacological Interventions Before Initiating Antipsychotic
Penalty
Summary
The deficiency involves the facility’s failure to document how a resident’s behaviors presented danger or distress to self or others, and failure to document non-pharmacological interventions attempted prior to initiating an antipsychotic medication. Resident 6 had documented diagnoses of Alzheimer’s disease, depression, and severe cognitive impairment, and was receiving sertraline for depression. A PASSAR identified only depression and dementia, and the admission MDS listed Alzheimer’s disease and depression as active diagnoses. Over several months, nursing progress notes documented that the resident intermittently reported unusual perceptions, such as believing there were men causing trouble, a man in her room, or a man wanting to marry her and yelling through the walls, but there was no documentation that these episodes caused danger to the resident or others or that they resulted in unmanageable distress. From late April through mid-July, nursing notes primarily described the resident’s frequent refusals of evening and morning medications, blood sugar checks, blood pressure checks, insulin administration, hygiene care, and showers. Staff documented that the resident sometimes yelled at staff, said “Get out!”, was visibly upset by a room move, was leery of staff and asked to see name badges, and became upset about a pillow under her head until it was removed, after which she calmed down. The notes also recorded instances where the resident believed housekeeping had not cleaned her room or that she had not received medications when she had. However, there were no progress notes or assessments indicating that these behaviors were evaluated as dangerous, non-redirectable, or causing significant distress or functional impairment, and no detailed behavior monitoring logs were present as required by facility policy. On a psychiatric NP visit for initial psychotropic medication management, new mental health diagnoses of schizoaffective disorder, borderline personality disorder, and delusional disorder were added, and Seroquel 25 mg, an antipsychotic, was ordered. The clinical record did not contain a comprehensive evaluation to support these new diagnoses, and there was no documentation of target behaviors meeting the facility’s policy criteria for psychotropic use, such as behaviors representing danger to self or others, causing distress and impairment in functional abilities, or clearly attributable to psychosis or mania. The resident’s representative reported that the resident had no prior history of mental health disorders or psychiatric hospitalization and was unaware of the new diagnoses. The facility’s own psychotropic medication policy required identification and documentation of specific target behaviors, use and documentation of nonpharmacological interventions, and ongoing monitoring of behaviors and interventions, which were not reflected in the record for this resident.
Failure to Update PASARR Screens for New Mental Health Diagnoses and Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that Preadmission Screening and Resident Review (PASARR) Level I screenings were accurate and updated when new mental health diagnoses and psychoactive medications were initiated for multiple residents. For one resident with dementia, anxiety, depression, and post-traumatic stress disorder (PTSD), the PASARR completed on admission listed anxiety, depression, and dementia with sertraline and quetiapine, but did not include the PTSD diagnosis or the antidepressant Pristiq, despite the admission MDS and care plan documenting PTSD and a subsequent physician’s order for Pristiq. For another resident with Alzheimer’s disease, borderline personality disorder, delusional disorder, schizoaffective disorder, and depression, the PASARR only reflected depression and dementia with sertraline, even though additional mental health diagnoses were added later and an antipsychotic (quetiapine) was ordered for borderline personality disorder, and the quarterly MDS documented psychotic disorder, schizophrenia, and depression with antipsychotic and antidepressant use. A third resident had diagnoses including Alzheimer’s disease, depression, anxiety disorder, irritability and anger, and nonrheumatic aortic valve stenosis. The PASARR for this resident listed dementia and anxiety with Risperdal but omitted the diagnosis of depression and the medications escitalopram and lorazepam, although physician’s orders were in place for escitalopram for depression and lorazepam for anxiety, and the admission MDS documented depression with antianxiety and antidepressant use. Interviews with the Assistant Director of Nursing confirmed that new Level I PASARR screens should have been completed when new mental health diagnoses and psychoactive medications were added, and that the PASARR for one resident, completed prior to arrival, should have included all mental health diagnoses and medications. The facility’s own policy required notification of the state mental health authority within 14 days after a significant change in mental condition and specified that a new Level I screen is required for new mental health diagnoses or newly prescribed psychotropic medications, which was not followed in these cases.
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