Tranquility Nursing And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Indianapolis, Indiana.
- Location
- 3640 N Central Avenue, Indianapolis, Indiana 46205
- CMS Provider Number
- 155857
- Inspections on file
- 29
- Latest survey
- March 25, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Tranquility Nursing And Rehab during CMS and state inspections, most recent first.
The facility did not maintain the required RN coverage of 8 hours a day, 7 days a week, impacting all residents. On multiple occasions, there was insufficient or no RN coverage, as confirmed by the DON and time clock reports. The facility lacked a policy to ensure compliance with RN coverage regulations.
The facility did not implement an effective antibiotic stewardship program, failing to track and monitor infections for antibiotic use from October to December 2024, affecting all 25 residents. The DON provided documentation for January and February 2025 but admitted the absence of records for the previous months. The facility's policy, last revised in 2016, was not followed during this period.
The facility did not address grievances reported by residents during council meetings, particularly regarding untimely medication administration on night shifts. Despite policies requiring investigation and resolution of grievances, there was no documentation of actions taken or communication with residents about their concerns.
A resident with a traumatic brain injury alleged that a nurse scratched his leg, resulting in dried blood. The incident, which occurred in December, was not reported to the IDOH until late February. The DON admitted the incident should have been reported immediately, as per the facility's policy requiring prompt reporting of abuse allegations.
A facility failed to thoroughly investigate an abuse allegation involving a resident with paranoid schizophrenia and another with a traumatic brain injury. The investigation was deemed unsubstantiated but lacked statements from staff on duty during the incident. The facility's abuse policy requires thorough investigation, but critical staff interviews were missing, leading to an incomplete assessment.
The facility failed to invite two residents and/or their representatives to quarterly care plan meetings. One resident with traumatic subarachnoid hemorrhage had no documentation of a meeting, despite a voicemail left for their representative. Another resident with dementia had not had a meeting since the previous year. The DON confirmed that meetings should have been conducted, indicating a lapse in policy adherence.
The facility failed to manage g-tube feedings properly for two residents, resulting in duplicate orders and incorrect feeding pump settings. One resident had conflicting physician orders for different feeding solutions and water flush amounts, while another resident's feeding pump was set to deliver double the prescribed water flushes. The DON acknowledged these issues and made necessary adjustments.
A facility failed to provide a timely psychiatric evaluation for a resident with traumatic brain injury and PTSD after a pharmacy recommended reviewing their medications for potential reductions. The medical provider deferred action pending this evaluation, which had not occurred due to delays in obtaining guardian consent for psychiatric services, as noted by the DON.
A resident with chronic kidney disease received an incorrect dose of potassium due to a medication administration error. An LPN crushed two 20 mEq potassium tablets instead of administering the prescribed 10 mEq capsules, resulting in an excessive dose. The error occurred because the correct medication was not available in the medication cart, despite pharmacy recommendations and a physician's order.
A facility failed to follow up on laboratory tests for a resident with multiple health issues, including chronic respiratory failure and a fistula, increasing the risk of UTIs. Despite physician orders for a urinalysis and sputum culture, the electronic health record lacked results, and no follow-up was documented. An interview with the DON confirmed the absence of these lab results, indicating a failure to provide timely and quality laboratory services.
The facility failed to maintain complete and accurate MAR and TAR records for several residents. A resident with multiple health issues had numerous documentation holes in their TAR, while another resident's MAR and TAR also showed incomplete records. Additionally, a resident on the traumatic brain injury unit had incorrect MAR entries for Depo-Provera injections, which were later confirmed as not administered. The facility's documentation policy was not followed, leading to these deficiencies.
A facility failed to ensure proper infection control during medication administration and room cleaning. An LPN did not wear PPE while administering medications through a gastrostomy tube for a resident on enhanced barrier precautions. Additionally, a housekeeper did not perform hand hygiene before and after cleaning rooms of two residents with chronic conditions. The DON confirmed the requirement for hand hygiene as per policy.
The facility failed to maintain a homelike environment for three residents, with issues such as a broken light fixture, unclean walls, and a non-functioning dishwasher leading to the use of paper products for meals. A resident expressed dissatisfaction with the dining ware, and the facility's policy on resident rights was not upheld.
A resident with multiple medical conditions developed a stage 4 pressure ulcer, and the facility failed to implement the wound provider's recommendations for treatment. Despite a care plan and physician's orders, the facility did not document the use of Santyl ointment and calcium alginate, leading to the resident's hospitalization for a wound infection and subsequent surgical interventions. Interviews revealed a lack of adherence to the wound care policy and documentation issues.
A resident with multiple health conditions, including COPD and intellectual disabilities, was left unsupervised during a shower, contrary to their care plan. The resident experienced shortness of breath, exited the shower room, and slipped on the floor. The CNA had ensured full oxygen tanks but did not remain with the resident, as the resident requested to be left alone. The care plan did not indicate the resident's preference for independent bathing.
A facility failed to ensure a resident received medications as ordered upon discharge, resulting in the resident receiving medications belonging to other residents. The resident, with a history of traumatic brain injury and anxiety disorder, experienced behavioral issues due to missing medications. Additionally, the facility did not properly document the administration of a narcotic medication for the resident, despite records indicating it was signed off as given.
The facility failed to ensure sufficient nursing staff, leaving residents on the ventilator and TBI units without a licensed nurse on duty during critical times. Payroll issues led to staff quitting, worsening the staffing shortage. The DON was overworked, and the facility's assessment was incomplete, failing to address resident care requirements and staff competencies. Immediate Jeopardy was declared due to the absence of licensed nurses for 24 hours a day, posing a risk to all residents.
The facility failed to ensure adequate staffing and supplies for respiratory care, resulting in a resident's death and another's hospitalization. The absence of a respiratory therapist and essential supplies, due to unpaid bills, compromised care for ventilator-dependent residents. Administrative issues, including delayed payroll and inconsistent leadership, contributed to staff turnover and instability.
The facility failed to provide adequate respiratory care for residents with tracheostomies and mechanical ventilation, resulting in one resident's death and another's hospitalization. The absence of a respiratory therapist during critical times and insufficient training of nursing staff in ventilator management contributed to these incidents. Additionally, the facility lacked necessary respiratory care supplies, affecting the quality of care for all residents on the ventilator unit.
The facility failed to conduct a complete assessment of resources needed for residents in the Ventilator and TBI unit. The Director of Operations provided an incomplete assessment lacking details on staffing and resources, despite policies requiring 24-hour respiratory therapy coverage. The assessment also omitted necessary third-party provider contracts, indicating an incomplete evaluation of resident care needs.
The facility failed to maintain a comprehensive QAPI program, with the most recent QAPI Action Plan form lacking essential details such as goals and responsible members. Additionally, there was no ongoing PIP, and audits on critical areas like medication errors and resident call systems were incomplete. The Director of Operations had not attended recent QAPI meetings, indicating a lack of oversight, potentially affecting the care of all 32 residents.
The facility failed to provide two residents access to their personal funds due to issues with the Resident Fund Management Service (RFMS) account. The Business Office Manager (BOM) could not cash checks as they were printed with a former administrator's name, and the petty cash account was nearly depleted. The Director of Operations (DOO) instructed the BOM to contact RFMS to update account authorization, but the residents remained without access to their funds.
A facility failed to input all physician medication orders into the EHR for a newly admitted resident with ventilator status. The resident's hospital discharge report included orders for several medications, but only two were entered into the EHR. The DON noted that the RN on shift had a history of not inputting orders for new admissions, leading to this deficiency.
A facility failed to administer the prescribed feeding rate for a resident with a gastric tube. The resident, who is severely cognitively impaired and ventilator-dependent, was ordered to receive Jevity 1.2 at 65 ml per hour, but observations showed the feeding pump was set to 60 ml per hour. An LPN unfamiliar with the residents initially struggled to access the EHR to verify orders, and despite confirming the correct order later, the feeding rate remained incorrect. The facility did not adhere to its policy on verifying the rate of administration, leading to this deficiency.
A resident with significant medical needs, including a feeding tube and ventilator dependence, fell from bed during ADL care due to inadequate supervision. The care plan required two staff members for assistance, but only one aide was present, leading to the fall and minor bruising. Staffing shortages were cited as a reason for the lack of adherence to the care plan.
A facility failed to administer g-tube feedings per physician orders for a resident discharged from the hospital. The resident, with a history of stroke, diabetes, and dysphagia, was supposed to receive continuous tube feeding at 25 mL/hour, but the facility administered it at 75 mL/hour, leading to vomiting episodes. The facility's policy requires checking the feeding rate against orders, which was not followed.
A resident with traumatic brain injury and generalized anxiety disorder did not receive their prescribed daily dose of lorazepam 0.5 mg at 8:00 a.m. as ordered. Instead, a QMA administered the medication in the evenings without a PRN order, leading to a significant medication error. The error was discovered when the resident ran out of medication prematurely, and an investigation revealed the QMA's misunderstanding of the medication order.
A resident with a traumatic brain injury, requiring substantial assistance for showers, did not receive the mandated twice-weekly showers or bed baths. The facility's documentation was lacking, with only one recorded shower refusal and no evidence of further attempts to provide care. The Nurse Consultant confirmed the absence of proper documentation, indicating a failure to adhere to the facility's bathing procedure.
The facility failed to administer medications and wound treatments as ordered for three residents. A resident with traumatic brain injury did not receive prescribed wound care and insulin doses. Another resident with diabetes missed several doses of Novolog insulin. A third resident with diabetes and a foot ulcer did not receive Exenatide ER and Humalog insulin as prescribed. The facility's documentation policy was not followed, leading to these deficiencies.
A facility failed to document urine outputs for a resident with a urinary catheter, despite a physician's order to record outputs every shift. The resident, with a history of traumatic brain injury and neuromuscular dysfunction of the bladder, had multiple undocumented shifts in September. The Nurse Consultant confirmed the policy to record outputs each shift, yet the treatment administration record showed missing entries, leading to the resident's concerns about catheter care.
The facility failed to document the administration of medical treatments for two residents. A resident with dysphagia did not have documented evidence of receiving prescribed gastric tube feedings, despite stable weight suggesting administration. Another resident with a diabetic foot ulcer lacked documentation of wound treatment, although the wound improved. The Nurse Consultant believed treatments were completed, but staff failed to document them, leading to deficiencies in record-keeping.
The facility did not ensure an RN was on duty for at least 8 hours daily from January to March 2024, affecting all 35 residents. The PBJ Staffing Data Report showed RN absence for 25 days in the quarter. The Executive Director confirmed specific dates without RN coverage, despite the facility's policy requiring sufficient skilled staff.
The facility failed to provide adequate bathing and nail care for several residents, including those with cognitive impairments and physical disabilities. Observations and records indicated that residents did not receive regular showers or nail care as required, leading to poor hygiene and unmet care needs.
The facility failed to ensure proper food storage and dishwashing practices, affecting 30 residents. The dishwasher did not reach required temperatures, and expired food was found in the refrigerator. The Maintenance Director was aware but did not stop dishwasher use, and paper products were used instead. Policies on food storage and dishwashing were not followed.
The facility failed to maintain infection control practices during medication administration and resident care. A QMA used improper techniques, such as placing fingers inside medication cups and not performing hand hygiene. Enhanced barrier precautions were not implemented for residents with internal medical devices, and a glucometer was not disinfected between uses. Additionally, an electric razor was shared between residents, violating the facility's policy on personal care items.
The facility's call light system on the Ventilator unit was inaudible to staff, affecting 11 residents. Observations showed that call lights were lit outside residents' doors, but no sound was heard at the nurse's station. Interviews revealed that the system's inaudibility was a recurring issue, with staff often turning off or lowering the sound. The facility's policy emphasized the importance of an audible call light system for resident assistance.
The facility failed to assess the ability of two residents with traumatic brain injuries to safely self-administer medications. One resident was observed with chlorhexidine mouthwash on his tray without a proper assessment, while another resident with severe cognitive impairment had triamcinolone cream on his nightstand without authorization for self-administration. The facility's policy on self-administration was not followed.
A resident with quadriplegia and a tracheostomy was repeatedly found without access to their breath call light, despite facility policies and care plans requiring it to be within reach. Staff interviews revealed that the call light was often moved during care and not returned to an accessible position, leading to a deficiency in accommodating the resident's needs.
A resident's representative reported missing items, including a diamond earring, clothing, and Xanax, after the resident's discharge. The facility failed to initiate a grievance form as required by policy, and the representative did not receive a follow-up. The resident had a history of traumatic brain injury, anxiety disorder, epilepsy, and paraplegia.
A resident-to-resident altercation occurred on the traumatic brain injury unit involving three cognitively impaired residents. The incident began when a resident in a motorized wheelchair became agitated, leading to an altercation with another resident who attempted to intervene. Staff responded quickly to separate the residents and assess them for injuries, but the facility failed to prevent the physical abuse, highlighting a deficiency in protecting residents.
An LTC facility failed to thoroughly investigate an altercation involving three cognitively impaired residents. The incident, which involved physical contact between two residents, lacked witness statements from key staff members, violating the facility's abuse policy. The investigation was incomplete, highlighting a deficiency in the facility's process.
The facility failed to develop a comprehensive care plan for a resident on Seroquel, lacking non-pharmacological interventions for behavior management. Additionally, the facility did not implement interventions for another resident with a suprapubic catheter, failing to record urine output as required. These deficiencies highlight lapses in adhering to care planning policies.
The facility failed to conduct care plan meetings for two residents, one with paraplegia and another with a brain injury. Despite documented meetings earlier in the year, interviews revealed that no recent meetings had occurred due to the departure of the social services staff responsible for organizing them. The Regional Nurse Consultant acknowledged the oversight.
A facility failed to provide individualized activities for a resident with severe cognitive impairment and other conditions. Despite a care plan emphasizing the importance of daily activity engagement, the resident was observed lying in bed with no engagement in preferred activities. The facility's policy required activities based on resident-centered assessments, which was not followed.
A facility failed to administer medications as ordered for a resident with a chronic UTI, resulting in missed doses of antibiotics. Another resident did not receive proper eye medication administration due to a lack of waiting time between different eye drops. Additionally, a resident with a diabetic ulcer did not receive timely treatment, and the treatment order was incorrectly documented. These deficiencies highlight issues in medication and treatment administration.
A facility failed to complete wound dressings as ordered for a resident with a stage 4 sacral pressure ulcer. Despite a physician's order for twice-daily wound care, records showed multiple instances where treatments were not completed. The resident, who was cognitively intact, confirmed the lapses, and there was no documentation of treatment refusals. The Regional Nurse Consultant noted non-compliance by the resident but acknowledged the lack of documentation.
A resident with a history of respiratory failure, diabetes, and quadriplegia experienced mismanagement of their feeding pump, leading to incorrect infusion rates of Glucerna and water flushes. The pump was set to infuse at higher rates than prescribed, as confirmed by observations and an interview with an RN. The physician's order and care plan specified lower rates, which were not followed, contrary to the facility's policy on tube feeding management.
The facility failed to manage medications properly for several residents, leading to deficiencies in pharmaceutical services. A resident with seizures did not receive his prescribed Depakote due to unavailability. Another resident with diabetes had issues with insulin pump management, resulting in elevated blood sugar levels. A third resident did not receive Xanax as there was no physician's order or record of administration. The facility lacked proper documentation and medication management.
The facility was found to have multiple deficiencies in medication management and storage, including unlocked and unattended medication carts, undated insulin vials, expired medications, and improper storage of food items in the medication refrigerator. Staff interviews confirmed these issues, which were not in compliance with the facility's medication storage policy.
The facility failed to document medication administration accurately for two residents. One resident's MAR showed missing entries for blood glucose checks and insulin administration, with no notes on attempts to administer the medication when the resident was asleep. Another resident's MAR lacked documentation for several medications over two days, with no explanation for the omissions. The facility's policy requires documentation of all administered medications and notes for refusals, which was not followed.
Failure to Ensure RN Coverage
Penalty
Summary
The facility failed to ensure Registered Nurse (RN) coverage for 8 hours a day, 7 days a week, affecting all 25 residents in the facility. The daily nursing schedules provided by the Scheduler revealed that on several dates, including 2/1/25, 2/2/25, 2/15/25, 2/16/25, 2/22/25, and 2/23/25, there was no RN coverage for the required 8 hours. Interviews with the Director of Nursing (DON) confirmed that she was aware of the lack of RN coverage, particularly noting that she was the only RN available for coverage on certain weekends. Time clock reports further corroborated the absence of RN coverage, showing insufficient or no RN hours on the specified dates. The facility did not have a policy in place to ensure RN coverage, although they claimed to follow the regulation regarding RN coverage.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program by not tracking and monitoring infections for antibiotic use from October through December of 2024, potentially affecting all 25 residents. On February 28, 2025, the Director of Nursing (DON) provided documentation for January and February 2025 but admitted the absence of records for the previous months. On March 3, 2025, the DON and Executive Director (ED) presented documentation for September 2024 but confirmed that tracking was not completed for the subsequent three months. The facility's Antibiotic Stewardship Policy, last revised in December 2016, outlines the program's purpose to monitor antibiotic use among residents, which was not adhered to during the specified period.
Failure to Address Resident Grievances in Council Meetings
Penalty
Summary
The facility failed to address grievances reported during resident council meetings, affecting nine residents who attended these meetings. In December 2024 and January 2025, residents expressed concerns about medications not being administered timely, particularly during the night shift. Despite these grievances being documented in the resident council minutes, there was no evidence of resolutions or follow-up actions taken by the facility. The Administrator was unable to provide documentation that these grievances were addressed, indicating a lack of response to the residents' concerns. During a resident council meeting in March 2025, residents reiterated that their grievances had not been addressed, with specific mention of the ongoing issue of untimely medication administration during the night shift. The facility's policies on resident council and grievance handling require that grievances be investigated and resolved, with feedback provided to the complainants. However, the facility did not adhere to these policies, as there was no documentation of corrective actions or communication with the residents regarding the resolution of their grievances.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to timely report an allegation of abuse involving a resident with a traumatic brain injury. On December 10, 2024, a progress note indicated that the resident had dried blood on the front of his leg from scratching, and the resident claimed a nurse was responsible for the injury. However, the incident was not reported to the Indiana Department of Health (IDOH) until February 28, 2025, which was a significant delay. During an interview on the same day, the Director of Nursing (DON) acknowledged that the incident should have been reported immediately. The facility's abuse policy mandates that all reported incidents of alleged abuse, neglect, or misappropriation of resident property be investigated and reported per state and federal law, typically within 24 hours of identification.
Incomplete Investigation of Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident with paranoid schizophrenia, who was moderately cognitively impaired, and another resident with a traumatic brain injury, who was cognitively intact. The incident occurred when the first resident was transported to the hospital with symptoms of lethargy and tremors, and a report was made by the hospital's case manager regarding a possible sexual misappropriation. The facility's investigation deemed the allegation unsubstantiated after interviewing staff and residents, but the investigation file lacked statements from the staff who were on duty the night of the incident. The Director of Nursing and Executive Director were unable to locate the necessary staff interviews from the night of the incident, and the investigation was incomplete as it did not include statements from the staff who worked that night. The facility's abuse policy requires thorough investigation and reporting of all allegations, but the investigation did not adhere to these standards. The failure to include critical staff interviews in the investigation process led to an incomplete assessment of the alleged abuse incident.
Failure to Conduct Quarterly Care Plan Meetings
Penalty
Summary
The facility failed to invite residents and/or their representatives to quarterly care plan meetings for two residents. Resident 3, who has a diagnosis of traumatic subarachnoid hemorrhage and is moderately cognitively impaired, did not have documentation of a quarterly care plan meeting in their clinical record. Although a voicemail was left for Resident 3's representative to schedule a meeting, there was no record of the meeting being conducted. The Director of Nursing (DON) acknowledged that a quarterly care plan meeting should have been held for this resident. Similarly, Resident 23, who has a diagnosis of dementia, did not have a care plan meeting conducted since the last one documented on March 5, 2024. The facility's Care Planning Policy and Procedure requires that residents, their families, and/or representatives be invited to participate in care plan development and revisions, with records of such invitations maintained in the clinical record. The DON confirmed that Resident 23 should have had a care plan meeting completed, indicating a lapse in adherence to the facility's policy.
Improper Management of G-Tube Feedings for Two Residents
Penalty
Summary
The facility failed to ensure proper management of gastrostomy tube (g-tube) feedings for two residents, leading to deficiencies in their care. Resident G had duplicate orders for g-tube feedings and water flushes in their electronic health record. The resident's clinical record showed conflicting physician orders for different types of tube feeding solutions and water flush amounts. An observation confirmed that the incorrect order was being followed, and the Director of Nursing (DON) acknowledged the presence of duplicate orders, which were later clarified. Resident F's care was compromised due to incorrect settings on the feeding pump. The resident's physician order specified a certain amount of water flushes per hour, but observations revealed that the pump was set to deliver double the prescribed amount. The DON confirmed the discrepancy and noted that the feeding pump settings were incorrect, which she subsequently adjusted. Both residents had significant medical conditions, including diabetes, malnutrition, and chronic kidney disease, which necessitated precise management of their nutritional intake through g-tubes.
Delayed Psychiatric Evaluation Following Pharmacy Recommendation
Penalty
Summary
The facility failed to ensure a timely psychiatric evaluation for a resident following a pharmacy recommendation regarding unnecessary medications. The resident, who has a history of traumatic brain injury and post-traumatic stress disorder, was residing in the traumatic brain injury unit. In January 2025, the pharmacy recommended evaluating the resident's medications, which included Zyprexa, trazadone, Zoloft, and Buspar, for potential reductions. Although the medical provider reviewed the recommendation, they deferred action pending a psychiatric evaluation. However, as of early March 2025, the resident had not received the necessary psychiatric evaluation due to delays in obtaining consent from guardians for psychiatric services, as explained by the Director of Nursing.
Medication Administration Error Involving Potassium Dosage
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors during a medication administration observation. A Licensed Practical Nurse (LPN) administered an incorrect dose of potassium to a resident with a feeding tube. The resident, who had diagnoses including congestive heart failure, chronic kidney disease, and gastrostomy status, was supposed to receive potassium chloride extended release (ER) 10 mEq capsules, which could be opened and dissolved for administration. However, the LPN crushed two 20 mEq potassium tablets, resulting in an excessive dose of 40 mEq being administered through the resident's feeding tube. The error was identified during an observation and subsequent review of the resident's clinical record and pharmacy recommendations. The pharmacy had previously recommended changing the resident's medication to 10 mEq capsules to avoid crushing the ER tablets. Despite this recommendation and a physician's order for the correct form and dosage, the LPN proceeded with the incorrect administration due to the absence of the appropriate medication in the medication cart. The facility's policy on medication errors, which aims to prevent significant medication errors, was not adhered to in this instance.
Failure to Follow Up on Laboratory Tests for a Resident
Penalty
Summary
The facility failed to ensure proper follow-up on laboratory tests for a resident, identified as Resident G, who was under review for antibiotic use. Resident G's clinical record revealed multiple diagnoses, including chronic respiratory failure and a fistula of the vagina to the large intestine, which increased the risk of urinary tract infections. A physician's order dated December 18, 2024, indicated that lab draws could be completed on the next available lab day unless specified otherwise. On January 8, 2025, a physician noted elevated white blood cells and worsened lung sounds, leading to orders for an antibiotic, a Foley catheter change, a urinalysis (UA) with culture and sensitivity, and a chest x-ray for possible pneumonia. Despite these orders, the electronic health record (EHR) lacked results for the UA and sputum culture for January 2025, and there was no follow-up documentation regarding these tests. A progress note from January 9, 2025, confirmed the completion of a chest x-ray and the initiation of an antibiotic, but the sputum culture was not documented. On January 15, 2025, a physician noted the replacement of a clogged Foley catheter but had no access to imaging results for the prescribed antibiotic follow-up. An interview with the Director of Nursing on March 3, 2025, confirmed the absence of laboratory results for the UA and sputum culture, indicating a failure to meet the facility's policy for timely and quality laboratory services.
Incomplete Documentation in MAR and TAR Records
Penalty
Summary
The facility failed to ensure complete and accurate documentation in the electronic medication and treatment administration records (MAR and TAR) for several residents. For Resident D, the TAR for January and February 2025 contained numerous holes, indicating missing or incomplete documentation. Resident D had significant medical conditions, including respiratory failure, diabetes, depression, quadriplegia, and stage 4 pressure ulcers, which necessitated precise and thorough record-keeping to manage their care effectively. Similarly, Resident 27's MAR and TAR for February 2025 also showed numerous holes, suggesting incomplete documentation. This resident had diagnoses including respiratory failure, hypertension, diabetes, and a sacral pressure ulcer. Additionally, Resident 8, who resided on the traumatic brain injury unit and had schizophrenia, was supposed to receive Depo-Provera injections weekly. However, the MAR inaccurately documented the administration of these injections on two occasions, which was later confirmed by the Director of Nursing to be incorrect. The facility's documentation policy requires records to be objective, complete, and accurate, which was not adhered to in these cases.
Infection Control Deficiencies in Medication Administration and Room Cleaning
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices during medication administration and room cleaning. Specifically, a Licensed Practical Nurse (LPN) did not don personal protective equipment (PPE) while administering medications through a gastrostomy tube for a resident on enhanced barrier precautions. The resident, identified as Resident F, had diagnoses including congestive heart failure, chronic kidney disease, and gastrostomy status. A physician order required gown and gloves to be worn during feeding tube care, which was not adhered to by the LPN. Additionally, infection control practices were not maintained by a housekeeper who failed to perform hand hygiene before and after cleaning resident rooms. Observations showed that the housekeeper entered and exited the rooms of Resident F and Resident G without performing hand hygiene. Resident F had a tracheostomy and chronic respiratory failure, while Resident G had chronic respiratory failure and diabetes. The Director of Nursing confirmed that housekeeping staff should perform hand hygiene before entering and upon exiting resident rooms, as per the facility's hand hygiene policy.
Failure to Maintain Homelike Environment and Kitchen Equipment
Penalty
Summary
The facility failed to ensure a homelike environment for three residents, as observed during a survey. Resident L's room had a light fixture with no cover and one non-functioning lightbulb, which was noted on multiple occasions without being addressed. Similarly, Resident F's room had a brown substance on the wall near the outlet by the resident's head, which remained uncleaned over several days. These environmental issues were observed repeatedly, indicating a lack of timely maintenance and cleaning. Additionally, the facility's kitchen was found to have a non-functioning dishwasher that did not reach the appropriate temperature, leading to the use of paper products for meal service. Resident E expressed dissatisfaction with the use of Styrofoam cups and paper plates, preferring regular dining ware. The Director of Nursing confirmed the dishwasher issue and the use of a three-compartment sink for washing pots and pans. The facility's policy on resident rights emphasizes the right to a clean, safe, comfortable, and home-like environment, which was not upheld in these instances.
Failure to Implement Wound Care Recommendations
Penalty
Summary
The facility failed to provide thorough and complete wound assessments and implement the wound provider's recommendations for a resident with a pressure ulcer. Resident J, who had multiple medical conditions including diabetes mellitus, quadriplegia, and dependence on a ventilator, developed a stage 4 pressure ulcer. The care plan for Resident J included interventions for skin integrity and pressure ulcer prevention, but these were not adequately followed. Despite a physician's order for Triad Hydrophilic Wound Dress External Paste, the facility did not document the use of Santyl ointment and calcium alginate as recommended by the wound provider. The wound provider's notes indicated an unstageable wound with necrosis, requiring specific dressing treatments and surgical debridement. However, the facility's records did not reflect the implementation of these treatments, and the resident's condition worsened, leading to hospitalization for a wound infection. Interviews with the Interim Director of Nursing revealed a lack of documentation and adherence to the wound care policy. The facility did not follow the wound provider's treatment plan, and there was no evidence of Santyl and calcium alginate being administered as prescribed. The resident's sacral wound developed further complications, resulting in multiple hospitalizations and surgical interventions.
Failure to Supervise Resident During Shower
Penalty
Summary
The facility failed to ensure adequate supervision for a resident during a shower, as outlined in the resident's care plan. Resident B, who had diagnoses including chronic obstructive pulmonary disease, diabetes mellitus, hypertension, obesity, and intellectual disabilities, was cognitively intact and required supervision for tub/shower transfers and walking. The care plan specifically indicated that Resident B was at risk for falls and required supervision during showers. However, on the day of the incident, the resident was left unsupervised in the shower room after instructing the Certified Nurse Aide (CNA) to leave and return in 10 minutes. During the unsupervised period, Resident B experienced shortness of breath and exited the shower room, subsequently slipping on the floor. The CNA had ensured that the oxygen tanks were full before the shower, but the resident still experienced respiratory distress. The incident report and CNA's statement confirmed that the resident was not supervised as required by the care plan, and there were no care plans indicating the resident's preference or ability to bathe independently. The Interim Director of Nursing acknowledged that the care plan should reflect the resident's preferences and be followed as written.
Medication Errors and Discharge Issues
Penalty
Summary
The facility failed to ensure that a discharged resident, identified as Resident C, received medications consistent with physician orders, resulting in the resident receiving medications belonging to two other residents, Resident L and Resident M, upon discharge. Resident C, who had diagnoses including traumatic brain injury, anxiety disorder, and post-traumatic seizures, was discharged without all prescribed medications, leading to behavioral issues. The family member of Resident C reported that upon discharge, medications from other residents were included with Resident C's medications, and not all of Resident C's medications were sent home. The Interim Director of Nursing confirmed that the remaining medications for Resident C were found in the medication cart after the family member reported the issue. Additionally, the facility failed to ensure that narcotic medication was signed off as ordered for Resident C. The controlled drug records indicated multiple instances where lorazepam, a narcotic antianxiety medication prescribed for Resident C, was not administered as per physician orders. Despite this, the medication administration record showed that the medication was signed off as administered daily. The facility's policies on discharge medications and medication administration were not adhered to, contributing to the deficiencies observed.
Staffing Deficiencies and Immediate Jeopardy Due to Lack of Licensed Nurses
Penalty
Summary
The facility failed to ensure sufficient nursing staff was available to provide competent nursing services, as observed during two random observations when no licensed nurse was present at the facility. This deficiency affected all residents on the ventilator unit and those with traumatic brain injuries. On two separate occasions, the only licensed nurse on duty left the facility, leaving no licensed nursing staff available to provide necessary care. This absence of licensed nursing staff was observed on both the ventilator and TBI units, with no administrative staff present during these times. The facility also failed to have a plan for staff call-offs and filling open positions in a timely manner, which had the potential to affect all residents. Interviews revealed that payroll issues led to staff quitting, exacerbating the staffing shortages. The Director of Nursing (DON) was overworked and unable to complete necessary administrative tasks due to the lack of staff. The facility had previously terminated contracts with staffing agencies due to non-payment, further complicating staffing issues. The facility's assessment was incomplete and did not provide sufficient information to determine resident care requirements or necessary staff competencies. The policy on nursing staff competency was not effectively implemented, as evidenced by the lack of orientation and training for agency nurses. The Immediate Jeopardy situation began when the facility had no licensed nurse available for 24 hours a day, posing a risk of serious harm to all residents. Despite notification of the Immediate Jeopardy, the situation was not resolved by the exit date of the survey.
Inadequate Staffing and Supplies Lead to Resident Harm
Penalty
Summary
The facility failed to ensure adequate and competent staff were on duty at all times to provide respiratory services, resulting in significant deficiencies in care. Specifically, the facility did not have a respiratory therapist (RT) available 24 hours a day on the ventilator unit, leading to a situation where a resident experienced respiratory distress and subsequent death, and another resident experienced respiratory distress resulting in hospitalization. Interviews with staff revealed that there was no RT present during a critical period, and the Director of Nursing (DON) was unaware of the absence until the following day. The facility's Director of Operations (DOO) and Administrator were responsible for the RT schedules, but there was a lack of documentation and oversight, leading to gaps in coverage. Additionally, the facility failed to maintain adequate respiratory supplies, such as humidification and moisture exchange (HME) devices, which are crucial for ventilator-dependent residents. The facility was unable to order necessary supplies due to unpaid bills with medical supply companies, resulting in a shortage of essential items. Interviews with RT staff and former employees highlighted the challenges faced in maintaining adequate supplies, with some staff resorting to using inappropriate substitutes, such as bacterial filters, which do not provide the necessary humidification for ventilator patients. The facility also experienced significant administrative issues, including inconsistent leadership and delayed payroll, which contributed to staff turnover and instability. The DOO was heavily involved in day-to-day operations, including hiring and scheduling, but there was a lack of coordination and communication with other administrative staff. The facility's financial difficulties, including unpaid vendor bills and insufficient funds for payroll, further exacerbated the situation, leading to a breakdown in the facility's ability to provide consistent and competent care to its residents.
Inadequate Respiratory Care Leads to Resident Distress and Death
Penalty
Summary
The facility failed to ensure adequate and competent staff were on duty to provide necessary respiratory care and services for residents with tracheostomies and mechanical ventilation. This deficiency resulted in a resident experiencing respiratory distress and subsequent death, and another resident experiencing respiratory distress leading to hospitalization. The facility did not have a respiratory therapist (RT) on duty during critical times, and the nursing staff were not adequately trained to manage the technical aspects of ventilator care, which were typically handled by RTs. Resident B, who was admitted with a tracheostomy and dependent on mechanical ventilation, experienced respiratory distress due to the facility's failure to follow physician orders for respiratory care. The orders included nebulizer treatments, oxygen therapy, suctioning, tracheostomy care, and ventilator maintenance. The electronic health record for Resident B lacked these orders, and there was no care plan for ventilator use. The absence of an RT during a night shift left the nursing staff, who were not fully trained in ventilator management, to handle the situation, leading to Resident B's death. Resident C also suffered due to the lack of RT presence. The resident experienced a mucus plug and respiratory distress, and the nursing staff were unable to change the tracheostomy tube, which was necessary to alleviate the distress. Resident C's mother, who lived nearby, had to come to the facility to change the tube, but the resident still required hospitalization for further treatment. The facility's failure to maintain adequate respiratory care supplies, such as heat and moisture exchange filters, further compounded the issue, affecting the quality of care for all residents on the ventilator unit.
Incomplete Facility Assessment for Ventilator and TBI Unit
Penalty
Summary
The facility failed to conduct a complete and accurate facility-wide assessment to determine the necessary resources for resident care, particularly for those in the Ventilator (Vent) and Traumatic Brain Injury (TBI) unit. During an interview, the Director of Operations (DOO) admitted that the facility assessment was blank and needed to be filled out. The provided assessment document, dated 12/19/24, included basic information such as census data and the presence of a Vent and TBI unit but lacked details on staffing, acuity of care, or resources. A subsequent undated assessment document also failed to reflect the needs of residents on ventilators or the requirement for respiratory therapy staff, despite the presence of nine residents needing tracheostomy care, suctioning, and oxygen therapy. The facility's policies on Ventilator Management and Competency of Nursing Staff were not adequately reflected in the facility assessment. The Ventilator Management policy required 24-hour respiratory therapy coverage for ventilator-dependent residents, but the assessment did not account for this need. Additionally, the Competency of Nursing Staff policy emphasized the necessity for staff to demonstrate competencies and skill sets specific to resident needs, which were not evaluated in the facility assessment. The assessment also lacked information on third-party provider contracts for essential services such as laboratory, radiology, and oxygen vendor services, further indicating an incomplete evaluation of the resources required to meet resident care needs.
Incomplete QAPI Program and Lack of Ongoing PIP
Penalty
Summary
The facility failed to maintain a comprehensive Quality Assurance and Performance Improvement (QAPI) program, which is essential for ensuring the quality of care across all services provided. The QAPI Action Plan form from the most recent meeting on 9/25/24 was incomplete, lacking a defined goal, responsible member, start and completion dates, and comments related to the QAPI plan. This indicates a lack of structured planning and accountability in the QAPI process. Additionally, the facility did not have an ongoing Performance Improvement Project (PIP), which is a critical component of the QAPI program to systematically address and improve care or services. The facility's documentation of audits and performance improvement tools was inconsistent and incomplete. For instance, audits on medication errors, resident call systems, quality of care, resident records, tube feeding management, and accident prevention were not documented for December 2024. Furthermore, the Director of Operations admitted to not attending the last three QAPI meetings, which are held quarterly, and the last meeting was conducted before the departure of the former administrator. This lack of consistent oversight and documentation could potentially affect the quality of care for all 32 residents in the facility.
Failure to Provide Residents Access to Personal Funds
Penalty
Summary
The facility failed to ensure that residents had access to their personal funds, affecting two residents, Resident K and Resident L. The Business Office Manager (BOM), who started employment in October 2024, reported that both residents had been requesting money for the past week. The BOM was unable to cash checks from the residents' Resident Fund Management Service (RFMS) accounts because the checks were printed with the name of a former administrator, who was the only person authorized to cash them. The BOM informed the Director of Operations (DOO) about the issue, and the DOO instructed the BOM to use the petty cash account to provide funds to the residents. However, the petty cash account was nearly depleted, with only $12 remaining. The DOO confirmed that he did not have access to the RFMS accounts and that the BOM could not print checks, which prevented the cashing of checks for the residents. The DOO advised the BOM to contact RFMS to update the account authorization to allow the BOM to print and cash checks. A balance sheet confirmed that both residents had funds available in their RFMS accounts. Additionally, a document titled RESIDENT TRUST PETTY CASH showed that the petty cash fund had been reduced from $360 to $12 due to withdrawals made between November 1 and December 9, 2024, with the last withdrawal being for Resident K. The facility was waiting for RFMS to grant the BOM access to print checks, which left the residents without access to their funds.
Failure to Input Medication Orders for New Admission
Penalty
Summary
The facility failed to ensure that medication orders were properly inputted into the electronic health record (EHR) for a resident who was admitted with a ventilator status. The resident, who had diagnoses including respiratory failure with tracheostomy, hypotension, and anemia, was admitted to the facility with specific physician orders for medications such as acetaminophen, ascorbic acid, guaifenesin, hydroxyzine hydrochloride, melatonin, midodrine, oxycodone, and trazodone. However, upon review, it was found that the EHR did not contain orders for all the medications listed in the hospital discharge report. An interview with the Director of Nursing (DON) revealed that the Registered Nurse (RN) on shift during the resident's admission had a history of not inputting physician orders into the EHR for new admissions. The DON's review of the resident's clinical record showed that only two medications, oxycodone and acetaminophen, were inputted into the EHR and reflected on the electronic medication administration record (EMAR). This deficiency was related to a complaint investigation, indicating a failure in the facility's process for ensuring that all necessary medication orders are accurately recorded and administered as per physician instructions.
Failure to Administer Prescribed Feeding Rate for Resident with Gastric Tube
Penalty
Summary
The facility failed to ensure that a resident with gastric tube feedings received their feedings as ordered by the physician. Resident E, who is severely cognitively impaired and dependent on a ventilator, was prescribed Jevity 1.2 at a continuous rate of 65 ml per hour. However, observations over several days revealed that the feeding pump was set to infuse at a rate of 60 ml per hour, which was not in accordance with the physician's orders. This discrepancy was noted during multiple observations, indicating a consistent failure to administer the prescribed feeding rate. The issue was compounded by the fact that an LPN, who was unfamiliar with the residents and unable to initially access the electronic health record (EHR) system, was responsible for verifying the orders. Once access was obtained, the LPN confirmed the correct order, but the feeding rate remained incorrect. The facility's policy on enteral feedings, which emphasizes verifying the rate of administration against the physician's order, was not adhered to, leading to the deficiency. This citation is related to a specific complaint, indicating a failure in the facility's adherence to its own procedures for safe administration of enteral nutrition.
Inadequate Supervision Leads to Resident Fall
Penalty
Summary
The facility failed to ensure adequate supervision and assistance for a dependent resident, resulting in a fall from bed during activities of daily living (ADLs) care. The resident, who had a gastrostomy, anoxic brain damage, muscle contracture, and was dependent on a ventilator, required two staff members for ADL care and bed mobility. Despite this requirement, the resident experienced a fall from the bed while an aide was providing care alone. The aide, who was relatively new and not usually assigned to the Ventilator Unit, did not call for additional assistance, leading to the resident falling and sustaining minor bruising on the right side of the face. Interviews revealed that the facility typically assigned two staff members for the resident's ADL care, but staffing shortages sometimes led to only one staff member being utilized. The Director of Nursing confirmed that the aide did not request help because they were unable to find another staff member to assist. This incident highlights a failure to adhere to the care plan that required two staff members for the resident's ADL care, contributing to the fall and subsequent injury.
Failure to Administer Correct G-Tube Feeding Rate
Penalty
Summary
The facility failed to administer gastrostomy tube (g-tube) feedings according to physician orders for a resident upon discharge from the hospital. Resident B, who had a history of cerebral infarction, diabetes mellitus, and dysphagia, was discharged from the hospital with instructions for continuous tube feeding at 25 milliliters per hour and a diet of nothing by mouth (NPO). However, the facility continued to administer the tube feeding at 75 milliliters per hour, as per a previous physician order, from the evening of September 15 through the day shift on September 18. This discrepancy in feeding rate led to Resident B experiencing projectile vomiting and several episodes of vomiting, as noted in a progress note dated September 18. The facility's policy on Enteral Nutrition, which was revised in January 2014, requires checking the enteral nutrition label against the order before administration, including the rate of administration. The failure to adhere to the updated hospital discharge instructions resulted in the administration of an incorrect feeding rate, contributing to the resident's adverse symptoms.
Failure to Administer Anti-Anxiety Medication as Ordered
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors by not administering an anti-anxiety medication as ordered by the physician. Resident 8, who had diagnoses including traumatic brain injury and generalized anxiety disorder, was prescribed lorazepam 0.5 mg to be taken daily at 8:00 a.m. However, the clinical record did not contain a physician's order for lorazepam to be administered as needed (PRN). Despite this, the medication was administered in the evenings on several occasions without a proper PRN order. The error was discovered when the Director of Nursing (DON) noted that Resident 8 had run out of lorazepam before it was due for reorder. Upon investigation, it was found that a Qualified Medication Aide (QMA) had been administering the medication in the evenings as a PRN, unaware that there was no PRN order in place. The incident was documented, and the resident was assessed with no adverse reactions noted at the time.
Failure to Provide Regular Showers for Resident
Penalty
Summary
The facility failed to provide adequate personal hygiene care for a resident, identified as Resident D, who was unable to perform activities of daily living independently. Resident D, who had a diagnosis of traumatic brain injury and was moderately cognitively impaired, required substantial assistance from staff for showers. Despite this need, the facility did not ensure that Resident D received a shower or complete bed bath twice weekly as required. On one occasion, Resident D was observed in his room expressing discomfort about not having had a shower or hair wash for some time, indicating his hair felt unclean. The facility's documentation was insufficient, as there was only one record of a shower refusal by Resident D, with no other documentation indicating that additional showers were offered during the month. The Nurse Consultant confirmed the lack of documentation and acknowledged that Resident D should have received regular showers or bed baths. The facility's procedure for bathing, which includes documentation of the date and time of showers and any refusals, was not adequately followed, contributing to the deficiency.
Medication and Treatment Administration Deficiencies
Penalty
Summary
The facility failed to administer medications as ordered for two residents and did not complete a wound treatment as prescribed for another resident. Resident C, who has a diagnosis of traumatic brain injury and hemiplegia, had a physician's order for daily wound treatment that was not completed on multiple days in September 2024. Additionally, Resident C did not receive the prescribed 54 units of Lantus insulin on several occasions, with the reason documented as the resident being asleep. Resident F, diagnosed with diabetes mellitus, was supposed to receive Novolog insulin according to a sliding scale twice daily. However, the medication administration record indicated that the insulin was not administered on several mornings in September 2024. The Nurse Consultant confirmed the lack of documentation for the administration of medications as ordered for both Resident C and Resident F. Resident K, who has diabetes and a diabetic foot ulcer, was prescribed Exenatide ER and Humalog insulin. The medication administration record showed that Exenatide ER was not administered on two occasions, and Humalog was not given at various times on multiple days in September 2024. The Nurse Consultant acknowledged that these medications should have been administered and documented as per the physician's orders. The facility's policy on medication administration documentation was not adhered to, as evidenced by the missing records.
Failure to Document Urine Output for Resident with Catheter
Penalty
Summary
The facility failed to ensure proper documentation of urine outputs for a resident with a urinary catheter. Resident D, who has a history of traumatic brain injury and neuromuscular dysfunction of the bladder, had a physician's order to have his catheter drainage bag emptied and urine output recorded every shift. However, the treatment administration record (TAR) for September 2024 showed multiple instances where the urine output was not documented across various shifts, including both day and night shifts on several days. During an interview, the Nurse Consultant confirmed that the facility's policy required the urinary catheter drainage bags to be emptied each shift and the output recorded. Despite this policy, the documentation was incomplete, as evidenced by the missing entries on the TAR for specific dates. Resident D expressed concerns about the care of his catheter, indicating a lack of confidence in the staff's adherence to proper catheter care protocols.
Deficiency in Documentation of Medical Treatments
Penalty
Summary
The facility failed to accurately document the administration of medical treatments for two residents, leading to deficiencies in record-keeping. Resident E, who had a diagnosis of dysphagia and required gastric tube feedings, did not have documented evidence of receiving Jevity 1.5 as ordered by the physician on multiple occasions in September 2024. Despite the absence of documentation, the Nurse Consultant believed the feedings were administered because Resident E's weight remained stable. However, the nursing staff did not document the completion of these feedings, which is a failure to maintain accurate medical records. Similarly, Resident K, who had a diagnosis of diabetes and a diabetic foot ulcer, did not have documented evidence of receiving Medi honey treatment to the right heel on several days in September 2024, as per the physician's order. The order was discontinued on September 10, 2024, but the treatment administration record lacked documentation for the days prior. The Nurse Consultant believed the treatment was completed because the wound showed improvement, yet the staff failed to document the treatment, resulting in a deficiency in maintaining accurate medical records.
Failure to Maintain RN Coverage
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for a minimum of 8 hours each day during the period from January 1, 2024, to March 31, 2024. This deficiency had the potential to affect all 35 residents residing in the facility. According to the Payroll-Based Journal (PBJ) Staffing Data Report, the facility did not have an RN present for 25 out of the 91 days in the first quarter of 2024. Specific dates without RN coverage included January 27 and 28, February 11, 17, and 18, and March 2, 3, 17, and 30. An interview with the Executive Director on August 8, 2024, confirmed the absence of RNs on these dates. The facility's Staffing Policy, provided by the Regional Nurse Consultant, stated that the facility should have sufficient staff with the necessary skills and competency to provide care and services in accordance with resident care plans and the facility assessment.
Deficiency in Providing ADLs: Bathing and Nail Care
Penalty
Summary
The facility failed to provide adequate care and assistance with activities of daily living (ADLs) for several residents, specifically in the areas of bathing and nail care. Resident 30, who was cognitively impaired and had a skin care plan due to potential skin integrity issues, did not receive regular showers or bed baths over several weeks. Observations revealed that his fingernails and toenails were long and untrimmed, despite the resident indicating that staff had attempted to trim them. The facility's records confirmed the lack of consistent bathing, which was supposed to occur twice weekly. Resident D, who had severe cognitive impairment and required maximal assistance for showers, also did not receive adequate nail care or regular showers. Observations noted a long thumbnail with a brown substance underneath, and documentation showed that nail care was last provided nearly a month prior. The resident did not receive the expected twice-weekly showers for several weeks, as indicated by the facility's records. Resident E, who required supervision for bathing, was observed with greasy hair, indicating a lack of proper hygiene care. The facility's documentation showed that Resident E was not offered or did not receive the expected twice-weekly showers for a period of time. Additionally, Resident B, who was admitted for a respite stay and was totally dependent on staff for bathing, was reported by a representative to have returned home with poor hygiene, suggesting a lack of bathing during his stay. The facility's records could only confirm one instance of a shower being provided during his stay.
Improper Food Storage and Dishwashing Practices
Penalty
Summary
The facility failed to ensure proper food storage and dishwashing practices, which could potentially affect 30 out of 35 residents receiving food from the kitchen. During an initial tour of the kitchen, it was observed that the dishwasher, labeled as a high-temperature machine, did not reach the required rinse temperature of 180 degrees Fahrenheit across multiple cycles. The dishwasher temperature worksheet for the month was blank, indicating a lack of monitoring and documentation. Interviews revealed that the Maintenance Director was aware of the issue but did not instruct staff to stop using the dishwasher, and paper products were used as an alternative. Additionally, the dry storage room had boxes stacked on the floor, and the main refrigerator contained expired and unlabeled food items, including moldy cantaloupe and wilted lettuce. The Dietary Manager confirmed the dishwasher's inconsistent performance and the use of paper products during this period. The Maintenance Director attempted to resolve the issue by ordering a booster heater, but the incorrect part was initially received. The facility's policies on food storage and dishwashing machine use were not adhered to, as evidenced by the improper storage of food items and the failure to maintain required dishwashing temperatures. The Dietary Manager was primarily responsible for checking and auditing food, but expired and unlabeled items were still found in the refrigerator.
Infection Control Deficiencies in Medication Administration and Resident Care
Penalty
Summary
The facility failed to maintain proper infection control practices during medication administration and care for residents. Qualified Medication Assistant (QMA) 7 was observed using improper techniques while preparing medications for multiple residents. She placed her fingers inside medication cups to retrieve them, which is against the facility's protocol. Additionally, QMA 7 did not perform hand hygiene before administering medications after touching various items, such as the computer mouse and medication cart keys. This improper handling was observed during medication administration for several residents. The facility also failed to implement enhanced barrier precautions for residents with internal medical devices. Resident F, who had a Foley catheter, reported that staff only used gloves during care, without additional personal protective equipment (PPE). Furthermore, during blood sugar monitoring, QMA 7 used a glucometer on multiple residents without disinfecting it between uses, contrary to the facility's policy that requires disinfection with germicidal bleach wipes after each use. Additionally, the facility did not ensure that personal care items were not shared between residents. An electric razor was shared between Resident E and his roommate, Resident 23, despite it being a personal item. The facility's policy requires that resident-care equipment be cleaned and disinfected according to CDC recommendations, which was not adhered to in this case. These observations indicate a lack of adherence to infection control protocols, potentially compromising resident safety.
Inaudible Call Light System on Ventilator Unit
Penalty
Summary
The facility failed to ensure that the call light system was audible to staff on the Ventilator unit, affecting 11 of 35 residents. Observations revealed that call lights were lit outside residents' doors, but no sound was heard at the nurse's station, indicating a lack of notification for staff. This issue was noted during random observations on multiple occasions, with specific instances involving residents who required assistance. The Maintenance Director confirmed that the call light system was not audible at the nurse's station during an environmental tour and identified that the audible feature had been manually turned down or off, or disconnected, preventing staff from hearing the call lights. Interviews with the Maintenance Director, Executive Director, and Regional Nurse Consultant highlighted that the call light system's inaudibility was a recurring problem, with staff often turning off or lowering the sound. The Executive Director noted that ventilators were directly connected to the call light system, and any alarms from ventilators should also be heard at the nurse's station. The facility's policy on call lights emphasized the importance of having a readily accessible means for residents to obtain assistance, with the call light system serving as a direct link to a centralized staff location. Despite this policy, the system's inaudibility compromised the ability of residents to receive timely assistance.
Failure to Assess Residents' Ability to Self-Administer Medications
Penalty
Summary
The facility failed to assess and determine if residents on the traumatic brain injury unit were able to safely self-administer their medications. Resident 4, who had a diagnosis of traumatic subarachnoid hemorrhage and was moderately impaired, was observed with a medication cup containing chlorhexidine mouthwash on his breakfast tray. The Qualified Medication Aide indicated that Resident 4 had an order to self-administer the mouthwash after breakfast, but there was no self-administration assessment in the clinical record to confirm his ability to do so safely. The Regional Nurse Consultant was unaware of this practice and confirmed the absence of an assessment. Similarly, Resident 8, who had severe cognitive impairment and required assistance with personal care, was observed with a container of triamcinolone cream on his nightstand on multiple occasions. The resident's care plan indicated the need for topical medication administration due to eczema, but there were no physician orders or assessments authorizing self-administration. The Regional Nurse Consultant confirmed that Resident 8 did not have the ability to self-administer the cream, and the nursing staff had placed it on the nightstand for convenience. The facility's policy on self-administration of medications required proper assessment and secure storage, which was not followed in these cases.
Failure to Provide Consistent Access to Call Light for Resident
Penalty
Summary
The facility failed to consistently provide a resident, who requires a breath call light due to quadriplegia, with access to the call light system. The resident, identified as having respiratory failure with a tracheostomy, diabetes mellitus, and quadriplegia, was observed multiple times without the call light within reach. On several occasions, staff members had to reposition the breath call light to make it accessible to the resident. This issue was noted during observations on two consecutive days, where the call light was found out of reach after staff had assisted the resident. Interviews with staff, including a CNA and an RN, revealed that the call light was often moved out of reach during care activities and not always returned to an accessible position. The care plan for the resident specifically indicated the need for the call light to be within reach, yet this was not consistently adhered to. The facility's policy on call lights, dated June 2021, also emphasized the importance of keeping call lights within reach for residents, including those who require breath call lights. Despite these guidelines, the facility did not ensure compliance, leading to the deficiency.
Failure to Address Resident Grievance on Missing Items
Penalty
Summary
The facility failed to promptly address a grievance from a resident's representative concerning missing items, including a diamond earring, clothing, and Xanax medication, following the resident's discharge. The resident, who had a history of diffuse traumatic brain injury, generalized anxiety disorder, epilepsy, and paraplegia, was admitted for a respite stay and discharged home. The representative reported the missing items to a staff member believed to be the head nurse but did not receive a follow-up from the facility. The Admissions Manager confirmed being contacted by the representative about the missing items but did not complete a grievance form as required by the facility's policy. The Regional Nurse Consultant later indicated that the Admissions Manager should have filled out a grievance form. The facility's grievance policy mandates that a grievance form be initiated when a resident or their representative expresses a desire to file a grievance, and the form should be reviewed, investigated, and resolved by the appropriate department.
Resident-to-Resident Altercation on Traumatic Brain Injury Unit
Penalty
Summary
The facility failed to protect residents from physical abuse during a resident-to-resident altercation on the traumatic brain injury unit. The incident involved three residents, all of whom had cognitive impairments due to traumatic brain injuries. Resident H, who had moderate cognitive impairment, was involved in an altercation with Resident 8, who was also cognitively impaired. The altercation began when Resident 8, sitting in a motorized wheelchair, became agitated and started yelling and banging on the wheelchair arms. Resident C approached to check on Resident 8, who then drove his wheelchair towards Resident C, prompting Resident H to intervene. Resident 8 attempted to kick Resident H, leading to both residents swinging their arms at each other, with Resident H making contact with Resident 8's face. The staff responded quickly to separate the residents and assess them for injuries. Resident 8 was placed on 15-minute checks due to his behavior, and Resident H was taken to a hospital for a psychiatric evaluation. The facility's abuse policy emphasizes maintaining an environment free from abuse, but the incident highlights a failure to prevent resident-to-resident physical abuse. The report indicates that the incident was witnessed by staff members, who acted as quickly as possible, but the altercation occurred rapidly, leading to the deficiency in protecting residents from abuse.
Incomplete Investigation of Resident Altercation
Penalty
Summary
The facility failed to thoroughly investigate a reportable incident involving three residents with cognitive impairments. Resident H, who had a traumatic brain injury, was involved in an altercation with Resident 8, who also had a brain injury and severe cognitive impairment. The incident occurred when Resident 8, in a motorized wheelchair, was yelling and banging on his wheelchair arms. Resident C approached to check on Resident 8, who then drove his wheelchair toward Resident C. Resident C moved away, and Resident H attempted to intervene, leading to a physical altercation between Resident H and Resident 8. Staff intervened, and Resident 8 was assessed with no injuries noted, while Resident H was taken to a hospital for a psychiatric evaluation. The investigation into the incident was incomplete as it lacked statements from two key witnesses, CNA 12 and QMA 11, who observed the altercation. The facility's abuse policy mandates that all reports of abuse, neglect, and injuries of unknown sources be promptly and thoroughly investigated, including interviewing witnesses and documenting their statements. However, the Executive Director acknowledged the absence of statements from the witnesses, which is a violation of the facility's policy. This oversight indicates a deficiency in the facility's investigation process for reportable incidents.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with behaviors, identified as Resident 10, who was prescribed Seroquel for a mood disorder. The care plan, dated April 2, 2024, included interventions related to the administration and monitoring of psychotropic medications but lacked non-pharmacological interventions for behavior management. An interview with the Regional Nurse Consultant confirmed that residents with known behaviors should have non-pharmacological interventions included in their care plans. The facility's Behavior Management policy emphasized the need for appropriate interventions and the use of drug management only after less restrictive interventions have been tried and failed. Additionally, the facility did not implement interventions for Resident B, who had a suprapubic urinary catheter due to a neurogenic bladder. The care plan required monitoring and documenting intake and output as per facility policy, with a physician's order to record urine output every eight hours. However, the Treatment Administration Record for June 2024 showed that the facility failed to record the urine output 8 out of 29 times. The facility's Interdisciplinary Team Care Planning policy outlined the need for comprehensive, person-centered care plans with measurable objectives and timeframes, which were not adhered to in this case.
Failure to Conduct Care Plan Meetings for Residents
Penalty
Summary
The facility failed to conduct care plan meetings for two residents, Resident 15 and Resident 30, as required. Resident 15, who has a diagnosis of paraplegia and is cognitively intact, had a care plan meeting documented on 4/10/24. However, during an interview on 8/5/24, Resident 15 indicated that a care plan meeting had not been conducted for some time due to the departure of the social services staff member responsible for organizing these meetings. Similarly, Resident 30, who has a diagnosis of intracranial injury and is cognitively impaired, had a care plan meeting documented on 3/18/24 with their representative in attendance. However, the representative reported on 8/5/24 that no care plan meetings had been held for a long time. The Regional Nurse Consultant confirmed that care plan meetings should have been conducted for both residents and noted that the Social Services Director had left the facility, which contributed to the lapse in care plan meetings.
Failure to Provide Individualized Activities for a Resident
Penalty
Summary
The facility failed to provide individualized activities for a resident with severe cognitive impairment, traumatic brain injury, major depressive disorder, and anxiety disorder. The resident's care plan, revised in March, indicated the importance of informing the resident of daily activities, encouraging socialization during meals, and inviting the resident to activities of interest. Despite these directives, observations on consecutive days in August revealed the resident lying in bed with eyes open and the television off, indicating a lack of engagement in preferred activities such as going outside, playing BINGO, or watching television. The facility's policy on activities programs, revised in 2018, emphasized the need for activities based on comprehensive resident-centered assessments and preferences, which was not adhered to in this case.
Medication and Treatment Administration Deficiencies
Penalty
Summary
The facility failed to ensure medications were administered as ordered for Resident 30, who was on antibiotic therapy for a chronic urinary tract infection. Despite having a physician order to administer 875-125 milligrams of amoxicillin-pot clavulanate daily, the medication was not given on multiple occasions in July and August 2024. The nursing notes indicated the medication was not administered because it was on order, and the Regional Nurse Consultant was unsure why the medication was unavailable. For Resident J, the facility did not adhere to the proper procedure for administering multiple eye medications. The resident was prescribed several eye drops and ointments, but during an observed medication administration, the nurse did not wait the required five minutes between administering different eye medications. The facility's policy required a five-minute wait between applications to ensure safe and accurate administration, but this was not followed. Resident D, who had a diabetic ulcer on the left heel, did not receive timely treatment. Upon returning from hospitalization, the resident's skin was initially intact, but a diabetic ulcer was noted the following day. However, there were no physician orders for treatment until several days later, and the treatment order incorrectly specified the right heel instead of the left. The facility's policy required immediate treatment orders for new skin impairments, which was not obtained in this case.
Failure to Complete Wound Dressings as Ordered
Penalty
Summary
The facility failed to ensure that wound dressings were completed as ordered for a resident with a stage 4 sacral pressure ulcer. The resident's clinical record indicated a physician's order for wound care, which included cleansing with vashe wound wash, drying the area thoroughly, covering with calcium alginate with silver, and securing with ABD pads and tape. The treatment was to be performed twice daily, once during the day shift and once during the night shift. However, the Medication/Treatment Administration Record (MAR/TAR) showed multiple instances throughout July and August where the wound treatments were not completed as ordered. The resident, who was cognitively intact, confirmed in an interview that the staff did not change the dressings twice daily as required. The clinical record did not document any refusals of treatment by the resident on the days the treatments were missed. An interview with the Regional Nurse Consultant revealed that the resident was not compliant with the wound dressings, but there was a lack of documentation regarding any refusals by the resident.
Feeding Pump Mismanagement for Resident with Feeding Tube
Penalty
Summary
The facility failed to properly manage a feeding pump for a resident, resulting in a miscalculated amount of tube feeding and water flushes. The resident, who had a medical history including respiratory failure with a tracheostomy, diabetes mellitus, and quadriplegia, was observed to have their feeding pump programmed incorrectly. The label on the enteral feeding bag indicated that Glucerna should be infused at 60 ml/hr with a 30 ml/hr water flush, but the pump was set to infuse at 65 ml/hr and 40 ml/hr for water flush. This discrepancy was noted during multiple observations. An interview with RN 9 confirmed that the feeding pump was programmed differently than the label instructions. The physician's order, dated prior to the observations, specified the correct infusion rates as 60 ml/hr for Glucerna and 30 ml/hr for water flush. The care plan also indicated that the resident was dependent on tube feeding and water flushes, with instructions to follow the medical director's orders. The facility's policy on administering tube feeding emphasized the importance of reviewing the individual's tube feeding orders and nutritional care plan, which was not adhered to in this case.
Medication Management Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure the availability and administration of medications for several residents, leading to deficiencies in pharmaceutical services. Resident M, diagnosed with seizures, did not receive his prescribed 375 milligrams of Depakote on a specific date due to the medication not being available. The staff's inconsistent method of removing pills from medication cards made it difficult to track when medications were running low, resulting in a lapse in medication administration. The Regional Nurse Consultant was unable to provide a reason for the unavailability of the medication. Resident C, who had Type 1 diabetes and used an insulin pump, was admitted without proper physician orders for insulin administration. The facility failed to manage the insulin pump effectively, leading to elevated blood sugar levels and alarms from the pump. Despite the resident's representative providing insulin pods and vials, the staff did not replace the insulin pod in the pump, causing concerns about the resident's diabetes management. The representative eventually discharged the resident due to these issues and later returned to collect a medication card of trazadone, which was not properly labeled. Resident B, diagnosed with anxiety and other conditions, was supposed to receive Xanax, but there was no physician's order or record of administration in the facility's documentation. The facility received 18 alprazolam tablets for Resident B, but there was no evidence of their administration or proper disposal upon the resident's discharge. The Regional Nurse Consultant was unable to locate the tablets or provide documentation of their disposition, indicating a lack of proper record-keeping and medication management.
Medication Management and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper medication management and storage practices, as observed during a survey. On the Traumatic Brain Injury (TBI) unit, a medication cart was found unlocked and unattended, with loose pills present in the cart. Additionally, opened vials of Humalog and Humulin R insulin were undated, indicating a lack of adherence to proper labeling protocols. On the Ventilator unit, a container of Miralax was left on top of the medication cart without supervision, and the medication storage room contained expired Clorpactin bladder irrigation without proper labeling or resident identification. Further observations revealed improper storage practices in the medication storage room on the Vent unit, where food items such as applesauce, Jello, and chocolate pudding were stored in the medication refrigerator, contrary to facility policy. Expired enteral feeding products were also found on the storage shelf, and an undated Kwikpen with Humalog insulin was discovered in the medication cart. Interviews with staff, including a Qualified Medication Aide and a Registered Nurse, confirmed these deficiencies, and the facility's policy on medication storage was not followed, as indicated by the Regional Nurse Consultant.
Incomplete MAR Documentation for Two Residents
Penalty
Summary
The facility failed to ensure accurate and complete documentation of the medication administration record (MAR) for two residents, leading to deficiencies in medication management. For Resident D, the MAR for August 2024 showed missing entries for blood glucose checks and administration of Humalog insulin at specified times. Additionally, there were instances where the insulin was not administered because Resident D was sleeping, and no progress notes indicated attempts to reapproach or awaken the resident for medication administration. Resident D's diagnoses included traumatic brain injury, major depressive disorder, and anxiety disorder. For Resident N, the MAR for July 2024 lacked documentation for several medications on two consecutive days, despite the resident's census record not indicating they were out of the facility. The medications not documented included olanzapine, Zoloft, Buspar, and trazodone, among others. An interview with the Regional Nurse Consultant revealed an inability to determine whether Resident N received the medications on those days. Resident N's diagnoses included traumatic brain injury, anxiety disorder, PTSD, major depressive disorder, schizophrenia, and psychotic disorder with delusions. The facility's Medication Administration policy requires documentation of all administered medications and notes for any refusals, which was not adhered to in these cases.
Latest citations in Indiana
Surveyors observed that dietary staff repeatedly worked in kitchen and meal service areas with uncovered facial hair, despite facility policy and state sanitation requirements mandating effective hair restraints. Two dietary aides with short beards or mustaches were seen walking through food preparation areas, taking food temperatures, handling food, and plating meals at steamtables in dining rooms without any facial hair coverings, while the current policy required all hair, including facial hair, to be restrained to prevent contamination.
The facility failed to consistently provide and document required bed-hold policy notices when several residents were transferred to the hospital. In multiple cases, residents with dementia, psychotic disorders, COPD, chronic respiratory failure, altered mental status, and cerebral infarction were sent out for acute changes in condition, and while transfer notes reflected physician and family notifications, they lacked documentation that the bed-hold policy was discussed with the resident or responsible party. Notices of Transfer or Discharge often indicated a copy of the bed-hold policy was sent with the resident, but the records did not show signed and dated acknowledgment by the resident or appropriate representative, including in situations where a resident had moderate cognitive impairment, short-term memory issues, or a documented need for a proxy and a financial POA authorizing an agent for health care decisions.
Surveyors found that the facility failed to provide trauma‑informed and culturally competent care by not incorporating two residents’ extensive trauma histories and specific behavioral triggers into their care plans. One resident with documented homelessness, polysubstance abuse, severe accidents with multiple fractures, viral encephalitis with coma, physical and sexual abuse, loss of family contact, and a past suicide attempt had multiple behavior‑focused care plans that referenced identifying triggers but listed none and did not mention their physical, sexual, medical, or psychosocial trauma. Another resident with TBI from being struck by a truck, an 11‑month coma, long‑term state hospital residence, alleged shooting of a parent, and diagnoses including intermittent explosive disorder and borderline personality disorder had a PASRR identifying a specific trigger and notes of inappropriate sexual behavior, yet their care plans omitted these traumatic events, the identified trigger, and the sexual behavior. Staff interviews confirmed that residents were screened for trauma, but the trauma histories and triggers were not reflected in the individualized plans of care.
A resident with schizophrenia, post‑stroke hemiparesis, and mild cognitive impairment expressed feeling down and wanting to kill himself, but staff did not document asking about a specific plan, did not notify the physician or psychiatric NP as expected, and did not develop or update a care plan addressing depression or suicidal ideation. The SSD documented offering support and initiating 15‑minute checks once, but there was no further follow‑up or documentation of interventions after subsequent suicidal statements made in a care plan meeting with the resident’s father. The DON and Administrator reported that facility policy requires immediate notification of key staff, assessment for a plan and means of self‑harm, and thorough documentation, which were not carried out or reflected in the medical record for this resident.
A resident with schizophrenia, post-stroke hemiparesis, and mild cognitive impairment verbalized suicidal ideation, but the care plan did not address depression or suicidal thoughts, and required assessments and services were not accurately or timely documented. An SSD note recorded the resident saying he wanted to kill himself and referenced 15‑minute checks and a care plan update, yet the active care plan lacked depression/suicidal ideation interventions. Multiple late-entry Social Services notes were later added, describing follow-up visits and the resident denying suicidal ideation, but the SSD later reported she did not typically ask about a suicide plan and did not personally provide individual follow-up visits as described. These practices conflicted with the facility’s policy requiring factual, first-hand, and timely documentation of assessments and services.
A resident was observed with an Albuterol inhaler on an overbed table and later reported keeping the inhaler in a nightstand drawer, with no staff present during these observations. Record review showed the resident had no cognitive impairment on the admission MDS but lacked any documented self-medication administration assessment. The DON acknowledged that the required assessment had not been completed, despite facility policy requiring staff and the practitioner to evaluate each resident’s mental and physical abilities before allowing self-administration of medications.
Surveyors found that the facility submitted inaccurate direct care staffing data to CMS through the PBJ system over multiple days in a quarter. CASPER reports showed apparent gaps in 24-hour licensed nurse coverage, low weekend staffing, and a 1-star staffing rating, while internal staffing sheets documented that licensed nurses were present and the facility was fully staffed on those days. The Administrator reported that the discrepancies were due to PBJ data entry errors, despite a facility policy requiring all PBJ entries to be accurate, auditable, and verifiable against payroll, invoices, or contracts.
Surveyors found that the facility did not provide or document required written transfer/discharge notices and bed-hold policy information for four residents who were sent to the hospital, including individuals with conditions such as dementia, CHF, chronic respiratory failure, and CKD. In each case, progress notes showed that the resident was transferred for acute issues, but the clinical records lacked evidence that written notices were given to the residents or their representatives, and in one case lacked documentation that required information was sent to the receiving provider. Facility leadership, including the ADON, DON, and Administrator, acknowledged that the records did not contain the required documentation, despite a written policy requiring such notices and information exchange.
A resident with Alzheimer’s disease and depression, previously on an antidepressant, exhibited intermittent refusals of medications and care, occasional yelling at staff, and reports of unusual perceptions, such as believing men were in or near her room. Nursing notes over several months documented these refusals and complaints but did not show that the behaviors were evaluated or recorded as dangerous, non-redirectable, or causing significant distress, nor did they document specific non-pharmacological interventions attempted or their outcomes. Despite this, a psychiatric NP later added new diagnoses of schizoaffective disorder, borderline personality disorder, and delusional disorder and ordered an antipsychotic (Seroquel) without a comprehensive evaluation in the record to support these diagnoses. The facility’s psychotropic medication policy, which requires identification and documentation of target behaviors, use of nonpharmacological interventions, and ongoing behavior monitoring, was not followed for this resident.
The facility failed to keep PASARR Level I screenings accurate and current for three residents when new mental health diagnoses and psychoactive medications were initiated. One resident’s PASARR omitted a PTSD diagnosis and an added antidepressant, despite documentation of PTSD on the MDS and care plan and a physician order for Pristiq. Another resident’s PASARR listed only depression and dementia, even after additional diagnoses such as borderline personality disorder, delusional disorder, and schizoaffective disorder were added and an antipsychotic (quetiapine) was ordered, with the MDS later reflecting psychotic disorder, schizophrenia, and depression with antipsychotic and antidepressant use. A third resident’s PASARR did not include a depression diagnosis or newly ordered escitalopram and lorazepam, although the admission MDS documented depression with antianxiety and antidepressant use. These omissions occurred despite facility policy requiring a new Level I review after significant mental status changes, including new mental health diagnoses or new psychotropic medications.
Uncovered Facial Hair During Food Preparation and Meal Service
Penalty
Summary
The deficiency involves the facility’s failure to ensure that food was served in a sanitary and safe manner in accordance with professional standards and facility policy during multiple kitchen and meal service observations. During an initial kitchen observation, two dietary aides were seen walking through the kitchen food preparation area with uncovered facial hair. One aide had facial hair above and below the lip and along the jaw line, approximately one-fourth inch in length, and the other had a mustache of similar length; neither used any facial hair covering. These observations occurred while staff were present in the kitchen area where food was stored and prepared. During subsequent observations on the same day, the same two dietary aides were again observed with uncovered facial hair while directly involved in meal preparation and service. One aide walked through the kitchen while the noon meal was being prepared and placed into a transport cart for service in the south dining room, and later was observed plating the noon meal at the steamtable in that dining room, still without a facial hair covering. The other aide walked through the kitchen while the noon meal was being prepared and placed into the steamtable for the north dining room, took food temperatures, assisted with plating meals at the steamtable, and retrieved food items and supplies from the kitchen, all while having an uncovered mustache approximately one-fourth inch in length. The Dietary Manager stated that staff hair was to be covered when in the kitchen and during meal service, and the facility’s written policy and the cited Indiana Food Establishment Sanitation Requirements both required effective hair restraints, including for facial hair, to prevent contamination of food, equipment, and utensils.
Failure to Provide and Document Bed-Hold Policy at Time of Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure that required bed-hold policy information was provided and documented for four residents transferred to the hospital. For a resident with dementia, psychotic disorder, and autistic disorder who had a BIMS score of 0 indicating severe cognitive impairment, progress notes documented physician notification and guardian notification when the resident was sent to the hospital, but there was no documentation that the bed-hold policy was provided to the responsible party. A Notice of Transfer or Discharge later indicated a copy of the bed-hold policy was sent with the resident. Another resident with COPD and chronic respiratory failure, cognitively intact with a BIMS score of 13, experienced a decline in condition and was transferred to the hospital by ambulance; progress notes documented family notification but did not document any discussion of the bed-hold policy, although a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident. A third resident with altered mental status and cerebral infarction, with a BIMS score of 10 indicating moderate cognitive impairment and documented short-term memory impairment, experienced changes in condition and was transferred to the hospital. Progress notes stated the resident was their own responsible party and that no other notification was completed, and transfer documentation did not include the bed-hold policy, although an untimed Notice of Transfer or Discharge indicated a copy of the bed-hold policy was signed by the resident. A financial power of attorney document in the record showed the resident had designated an agent to act in consent or refusal of health care. For a fourth resident with dementia and osteomyelitis, transfer documentation and a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident, and the transfer form noted the resident required a proxy for decision making. The facility’s policy required that at the time of transfer to a hospital, written notice specifying the duration of the bed-hold policy and information on return to the next available bed be provided, and that a signed and dated copy of the bed-hold notice given to the resident or representative be kept in the resident file, which was not consistently documented for these residents.
Failure to Integrate Trauma Histories and Behavioral Triggers Into Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to identify and incorporate residents’ trauma histories and specific behavioral triggers into their care plans, despite documented histories of significant trauma and behavioral health issues. For one resident, extensive social service and progress notes documented homelessness, polysubstance abuse, major depressive and anxiety disorders, chronic pain, a history of severe car accidents with multiple fractures, viral encephalitis resulting in a three‑month coma, loss of child custody, multiple divorces, physical abuse by a spouse, the death of a fiancé who was struck by a car while in a wheelchair, lack of family contact, and a past suicide attempt by Valium overdose. Additional documentation noted a history of rape by a brother at age eight and prior placement under direct supervision and 15‑minute checks related to suicidal ideation. Despite these documented traumatic events and behavioral health concerns, the resident’s care plans did not identify a history of physical trauma, sexual trauma, homelessness, substance abuse, medical trauma, or attempted suicide. For this same resident, the MDS showed no cognitive deficit and identified behaviors such as verbal aggression and rejection of care, along with diagnoses including seizure disorder, depression, chronic pain syndrome, homelessness, and anxiety disorder. Multiple care plans addressed behaviors such as drug‑seeking, pretending to have seizures for attention or medication, making false allegations, verbal aggression when unable to smoke, and a desire for intimate relationships with consenting male residents. These care plans referenced goals such as effective coping skills, seeking staff support, and compliance with the smoking policy, and they called for identification and reduction of behavioral triggers. However, none of these care plans actually listed any specific triggers. The care plan addressing the resident’s right to consensual intimate relationships focused on assessment and education regarding consent but did not integrate the resident’s extensive trauma history. Staff interviews indicated the resident had displayed sexual behaviors since admission, including an incident where the resident expressed anger at another resident for not buying a soda after engaging in sexual acts. A second resident with a documented history of traumatic brain injury (TBI), dementia, seizure disorder, borderline personality disorder, anxiety, intermittent explosive disorder, tobacco use, and other behavioral/emotional disorders was also affected by the same deficiency. Social history and progress notes documented that this resident sustained a TBI after being hit by a semi‑truck while riding a bicycle at age 18, resulting in an 11‑month coma, followed by 13 years in a state hospital and subsequent residence in a group home. Additional documentation indicated the resident allegedly shot their father at age 26 after being sworn at and had a PASRR identifying TBI, intermittent explosive disorder, and borderline personality disorder, with a specific trigger of hearing the name of the current U.S. President. Progress notes also described inappropriate sexual behavior toward staff, including touching themselves intimately during personal care and refusing to stop when redirected. Despite this, the resident’s care plans, which addressed explosive disorder and history of altercations, risk for decreased psychosocial well‑being, and refusal to bathe or shower, did not list any specific behavioral triggers, did not reference the traumatic events such as being hit by a truck or shooting their father, and did not document the inappropriate sexual behavior. The Administrator and Social Service Director acknowledged that residents were to be screened for trauma and that trauma responses and PTSD should be added to care plans, but the specific trauma histories and triggers for these two residents were not incorporated into their plans of care.
Failure to Assess and Care Plan for Resident Suicidal Ideation
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess, investigate, and care plan for a resident’s suicidal ideation in accordance with its own policy and staff expectations. The resident had diagnoses including schizophrenia, cerebral edema, and hemiparesis/hemiplegia following a cerebral infarction, and a current MDS showed mild cognitive impairment (BIMS score 12). A progress note documented that the resident told the Social Services Director (SSD) he was feeling down and wanted to kill himself; the SSD offered assistance, activities, and initiated 15‑minute checks, and the note stated the care plan was updated. However, the note did not indicate that the SSD asked whether the resident had a plan to kill himself, and there were no additional notes regarding suicidal ideation or follow‑up. Review of the current care plan showed no problem, goal, or interventions addressing depression or suicidal ideation, and progress notes over the following month contained no documentation of physician notification related to the suicidal statement. Further record and interview evidence showed that the care plan conference summary did not document interventions for suicidal ideation, and the SSD acknowledged she did not normally ask residents expressing suicidal ideation if they had a plan. The SSD reported that the resident had admission paperwork mentioning suicidal ideation related to depression after a stroke and that the resident again vocalized suicidal ideation during a care plan meeting with his father, after which emotional support was offered and the father took the resident out on a leave of absence; no further visits or follow‑up were done. The DON stated that, upon notification of suicidal verbalization, staff should assess the resident, ask if there is a plan, remove potential means of self‑harm, immediately notify the psychiatric NP, and document the occurrence, and that a detailed progress note and updated care plan were expected but not present for this resident. The Administrator similarly stated that staff should ask about a plan, document interventions, notify the physician and family, and update the care plan, and indicated the resident should have had a care plan addressing depression with suicidal ideation. The facility’s written policy required immediate notification of the DON, SSD, and physician, an interview including asking about a plan and assessing mood and means for self‑harm, and thorough documentation of mood, behavior, and all actions taken, which were not reflected in the resident’s record.
Incomplete and Inaccurate Documentation of Suicidal Ideation and Follow-Up
Penalty
Summary
The facility failed to ensure accurate, complete, and timely documentation of assessments and services for a resident who verbalized suicidal ideation. Resident 6, who had schizophrenia, cerebral edema, and right-sided hemiparesis/hemiplegia following a cerebral infarction, had a BIMS score of 12 indicating mild cognitive impairment. The resident’s admission paperwork mentioned suicidal ideation related to depression after a stroke, and a Social Services note on 3/11/2026 documented that the resident was feeling down and said he wanted to kill himself. The Social Services Director (SSD) documented that she talked with the resident, coordinated with Activities, advised the resident to contact SSD or nursing if he wanted to talk, and that the resident was scheduled for 15-minute checks and the care plan was updated. However, the current care plan initiated on 2/26/2026 did not address depression or suicidal ideation. Multiple Social Services progress notes were later entered as late entries in April, with effective dates in March, stating that the resident had no plan and no longer had suicidal ideation, that he felt much better after 1:1 time, and that he continued his daily routine and therapy. These late entries described follow-up visits and reassessments of suicidal ideation on several consecutive days, but in interviews the SSD stated she did not normally ask residents about having a plan when they verbalized suicidal ideation and did not recall any other occurrences beyond the initial event. She further indicated she did not personally provide individual follow-up visits with this resident regarding suicidal ideation, despite the late-entry notes describing such visits. The DON acknowledged that late entries had been added to address concern about suicidal verbalization, and the Administrator stated that upon suicidal statements staff should ask about a plan, notify the physician and family, and update the care plan, and that this resident should have had a care plan addressing depression with suicidal ideation. The facility’s documentation policy required factual, first-hand, timely documentation, which was not followed in this case.
Failure to Complete Required Self-Administration Assessment for Inhaler Kept at Bedside
Penalty
Summary
Surveyors identified that a resident was allowed to keep and access an Albuterol inhaler without the facility completing the required self-administration medication assessment. During an initial tour, the resident was observed sitting in a wheelchair with a handheld Albuterol inhaler on the overbed table and no staff present in the room or hallway. On a subsequent observation, the resident again was in a wheelchair and reported that the Albuterol inhaler was stored in the top drawer of the nightstand, where it was found. Review of the clinical record showed an admission MDS indicating no cognitive impairment, but there was no documentation of a self-medication administration assessment. In an interview, the DON confirmed that the resident did not have the required self-medication assessment, despite the facility’s policy stating that staff and the practitioner must assess each resident’s mental and physical abilities to determine whether self-administering medications is clinically appropriate. This failure to complete and document a self-administration medication assessment for a resident who had an Albuterol inhaler kept at bedside constituted noncompliance with the facility’s own policy and with 410 IAC 16.2-3.1-11(a).
Inaccurate PBJ Staffing Data Submission to CMS
Penalty
Summary
The deficiency involves the facility’s failure to electronically submit complete and accurate direct care staffing information to CMS through the Payroll-Based Journal (PBJ) system for 22 days in a fiscal quarter. A CASPER report review on 4/6/26 showed that, according to PBJ data, the facility did not have licensed nursing coverage 24 hours per day on multiple specific dates across three months, had low weekend staffing, and held a 1-star staffing rating. However, review of the facility’s internal staffing sheets for that quarter indicated the facility was fully staffed and had licensed nurse coverage on all of the dates in question. During an interview, the Administrator stated that the PBJ information must have contained data entry errors, as she had verified licensed staff coverage on the timesheets. The facility’s PBJ policy in effect stated that all staffing data entered into the PBJ system would be auditable and verifiable through payroll, invoices, or contracts, but the submitted PBJ data did not accurately reflect the facility’s actual licensed nurse staffing as documented on internal records. No specific residents or clinical conditions were mentioned in the report, and the deficiency centers solely on inaccurate staffing data submission rather than direct resident care events.
Failure to Provide and Document Required Transfer/Discharge and Bed-Hold Notices
Penalty
Summary
The deficiency involves the facility’s failure to provide and document required written notices of transfer/discharge and bed-hold policies, as well as required information to receiving providers, for four residents who were transferred or discharged to the hospital. For a resident with generalized anxiety disorder, major depressive disorder, and dementia, progress notes showed that the resident was sent to the hospital via 911 for chest pain, lower back pain, and shortness of breath and later returned to the facility, but the clinical record lacked documentation that a written Notice of Transfer/Discharge and the bed-hold policy were provided to the resident or representative, and lacked documentation that required information was conveyed to the receiving facility. The ADON and the Administrator both confirmed there was no documentation that these written notices were provided. For a resident with congestive heart failure and muscle weakness who was sent to the emergency room for painful urination and bloody urine, the clinical record lacked documentation that a Notice of Transfer/Discharge or bed-hold policy was given to the resident or representative, which the DON confirmed. Another resident with chronic respiratory failure and diabetes was discharged to the hospital for respiratory failure, and a resident with chronic kidney disease and dementia was discharged to the hospital, but in both cases there was no documentation that a written notice of transfer/discharge or bed-hold policy was provided to the residents or their representatives. Review of the facility’s Transfer and Discharge policy, dated 1/15/26, showed that the policy required the facility to provide written transfer/discharge notices and bed-hold information to residents and representatives and to provide specified information to receiving providers, but the records for these four residents did not contain the required documentation.
Failure to Document Target Behaviors and Non-Pharmacological Interventions Before Initiating Antipsychotic
Penalty
Summary
The deficiency involves the facility’s failure to document how a resident’s behaviors presented danger or distress to self or others, and failure to document non-pharmacological interventions attempted prior to initiating an antipsychotic medication. Resident 6 had documented diagnoses of Alzheimer’s disease, depression, and severe cognitive impairment, and was receiving sertraline for depression. A PASSAR identified only depression and dementia, and the admission MDS listed Alzheimer’s disease and depression as active diagnoses. Over several months, nursing progress notes documented that the resident intermittently reported unusual perceptions, such as believing there were men causing trouble, a man in her room, or a man wanting to marry her and yelling through the walls, but there was no documentation that these episodes caused danger to the resident or others or that they resulted in unmanageable distress. From late April through mid-July, nursing notes primarily described the resident’s frequent refusals of evening and morning medications, blood sugar checks, blood pressure checks, insulin administration, hygiene care, and showers. Staff documented that the resident sometimes yelled at staff, said “Get out!”, was visibly upset by a room move, was leery of staff and asked to see name badges, and became upset about a pillow under her head until it was removed, after which she calmed down. The notes also recorded instances where the resident believed housekeeping had not cleaned her room or that she had not received medications when she had. However, there were no progress notes or assessments indicating that these behaviors were evaluated as dangerous, non-redirectable, or causing significant distress or functional impairment, and no detailed behavior monitoring logs were present as required by facility policy. On a psychiatric NP visit for initial psychotropic medication management, new mental health diagnoses of schizoaffective disorder, borderline personality disorder, and delusional disorder were added, and Seroquel 25 mg, an antipsychotic, was ordered. The clinical record did not contain a comprehensive evaluation to support these new diagnoses, and there was no documentation of target behaviors meeting the facility’s policy criteria for psychotropic use, such as behaviors representing danger to self or others, causing distress and impairment in functional abilities, or clearly attributable to psychosis or mania. The resident’s representative reported that the resident had no prior history of mental health disorders or psychiatric hospitalization and was unaware of the new diagnoses. The facility’s own psychotropic medication policy required identification and documentation of specific target behaviors, use and documentation of nonpharmacological interventions, and ongoing monitoring of behaviors and interventions, which were not reflected in the record for this resident.
Failure to Update PASARR Screens for New Mental Health Diagnoses and Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that Preadmission Screening and Resident Review (PASARR) Level I screenings were accurate and updated when new mental health diagnoses and psychoactive medications were initiated for multiple residents. For one resident with dementia, anxiety, depression, and post-traumatic stress disorder (PTSD), the PASARR completed on admission listed anxiety, depression, and dementia with sertraline and quetiapine, but did not include the PTSD diagnosis or the antidepressant Pristiq, despite the admission MDS and care plan documenting PTSD and a subsequent physician’s order for Pristiq. For another resident with Alzheimer’s disease, borderline personality disorder, delusional disorder, schizoaffective disorder, and depression, the PASARR only reflected depression and dementia with sertraline, even though additional mental health diagnoses were added later and an antipsychotic (quetiapine) was ordered for borderline personality disorder, and the quarterly MDS documented psychotic disorder, schizophrenia, and depression with antipsychotic and antidepressant use. A third resident had diagnoses including Alzheimer’s disease, depression, anxiety disorder, irritability and anger, and nonrheumatic aortic valve stenosis. The PASARR for this resident listed dementia and anxiety with Risperdal but omitted the diagnosis of depression and the medications escitalopram and lorazepam, although physician’s orders were in place for escitalopram for depression and lorazepam for anxiety, and the admission MDS documented depression with antianxiety and antidepressant use. Interviews with the Assistant Director of Nursing confirmed that new Level I PASARR screens should have been completed when new mental health diagnoses and psychoactive medications were added, and that the PASARR for one resident, completed prior to arrival, should have included all mental health diagnoses and medications. The facility’s own policy required notification of the state mental health authority within 14 days after a significant change in mental condition and specified that a new Level I screen is required for new mental health diagnoses or newly prescribed psychotropic medications, which was not followed in these cases.
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