Transcendent Healthcare Of Owensville
Inspection history, citations, penalties and survey trends for this long-term care facility in Owensville, Indiana.
- Location
- 7336 W State Road 165, Owensville, Indiana 47665
- CMS Provider Number
- 155502
- Inspections on file
- 30
- Latest survey
- January 8, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Transcendent Healthcare Of Owensville during CMS and state inspections, most recent first.
Surveyors found that a resident on enhanced barrier precautions for a Foley catheter had catheter tubing repeatedly observed resting on the floor in both the room and dining area after a CNA emptied the drainage bag, contrary to facility expectations for catheter care and use of PPE. Another resident receiving toileting assistance had a soiled brief removed by a CNA who then changed gloves without performing required hand hygiene between glove changes, despite facility policy that hand hygiene be performed after glove removal and before applying new gloves.
Surveyors found that the facility failed to offer and document annual influenza (flu) vaccinations for two residents who had signed consent forms to receive the vaccine. Record reviews showed that each resident’s last documented flu shot was several years prior, and there was no documentation that the vaccine was administered, refused, or medically contraindicated during the most recent flu season. Facility policy required that all residents be offered vaccines unless medically contraindicated or already vaccinated, and the ICP and RN staff confirmed that there were no records indicating the flu vaccine had been offered or given to these residents as required.
The facility did not ensure that the Food Services Director possessed the required qualifications, as the director began the role before enrolling in and completing a necessary food service manager course, and lacked the documented competencies outlined in the job description.
Four residents at risk for falls did not consistently receive required fall prevention interventions, including missing nonskid strips, absent motion sensor night lights, residents left unattended in wheelchairs, and failure to maintain beds in the lowest position or post safety signage, as observed and confirmed by staff.
Surveyors found that food items, including spices, oils, dry goods, and frozen foods, were not properly labeled or dated in the kitchen. Staff confirmed that items should be dated when opened, and facility policy requires all stored foods to be labeled and dated, but these procedures were not followed.
A resident with severe cognitive impairment, bladder incontinence, and on a daily diuretic requested to use the bathroom during a meal but was denied by a CNA, who told her she had to eat instead. This action did not promote dignity or respect the resident's rights, as required by facility policy.
The facility did not complete or properly document quarterly care plan conferences for two residents with COPD and moderate cognitive impairment, resulting in missed opportunities for resident and representative participation in person-centered care planning as required by facility policy.
A resident with multiple medical conditions was repeatedly observed with Tums at the bedside, despite lacking a physician order, a care plan for self-administration, or documentation authorizing self-administration. Facility policy requires assessment and documentation for self-administration, but these steps were not completed, and the resident's assessment indicated they did not wish to self-administer medications.
A resident with chronic wounds did not receive wound care and antibiotic treatment as ordered by the physician. Wound care orders were not consistently followed, unna boots were continued after discontinuation, and a skin culture was not obtained before starting antibiotics, contrary to facility policy. Documentation of antibiotic duration was inconsistent.
A resident with non-pressure wounds on both feet was observed with bandaged feet resting directly on the floor during wound care. The wound nurse removed dressings, cleansed one foot, and after the foot made contact with the floor, applied new dressings without re-cleansing. Facility policy required a barrier under the wound, which was not used, and the Infection Preventionist confirmed this as an infection control concern.
A room housing multiple residents was found to provide only 70.29 square feet per resident, falling short of the required 80 square feet. The facility had applied for but not received a variance waiver, and did not have a room variance policy in place. This deficiency was confirmed through interviews and documentation review.
A resident with severe cognitive impairment was involved in an incident where they mistakenly believed a CNA was a man and attempted to hit the CNA, resulting in skin tears. The resident's family alleged that the CNA may have exposed her breasts during the incident. The facility investigated and suspended the CNA but did not report the allegation to the state agency, contrary to their policy.
The facility failed to prevent and manage pressure injuries for two residents, leading to the development and worsening of pressure ulcers. Inconsistent and incomplete documentation and assessment contributed to the deterioration of the residents' conditions, resulting in hospitalization and severe complications.
The facility failed to provide adequate nutritional care for a resident, resulting in a 20% weight loss, a stage two pressure ulcer that worsened to an infected unstageable pressure injury, and hospitalization for sepsis, dehydration, and malnutrition. The facility did not have a care plan addressing the resident's nutritional needs, and there was a lack of timely notification to the physician, RD, or family about the resident's poor food intake and significant weight loss.
The facility failed to submit required direct care staffing information to CMS for the first fiscal quarter. The PBJ Staffing Data Report review revealed missing data for the specified quarter. The BOM indicated that outside staff are responsible for timely submission, but the facility's policy requiring quarterly submissions was not followed.
The facility failed to ensure accurate MDS assessments for four residents, leading to inconsistencies in documenting conditions such as pressure ulcers, tube feedings, edentulous status, and hallucinations. These inaccuracies were confirmed by the MDS Coordinator.
The facility failed to conduct timely care plan conferences and revisions for 9 of 12 residents, including those with cognitive impairments and significant weight loss. The facility's policies on care planning and weight assessment were not followed, leading to deficiencies in resident care.
The facility failed to ensure proper handling of tableware and hand hygiene during dining services. A staff member placed their thumb inside a resident's coffee mug while refilling it and did not perform hand hygiene after coming into contact with multiple residents. This was against the facility's policy and professional standards.
The facility failed to notify the physician and resident representative of significant weight loss and pressure ulcers for two residents. One resident experienced severe weight loss and developed a stage 4 pressure ulcer, while another resident had a 15.89% weight loss over six months without receiving the full prescribed enteral feeding. The facility did not follow its policies on weight assessment and condition changes.
The facility failed to provide a resident with restorative therapy services to prevent avoidable decline in range of motion and muscle atrophy. The resident, who had multiple severe diagnoses and was totally dependent on staff, showed no documentation of receiving restorative therapy during the current year. Staff interviews confirmed the resident should have been receiving these services but was removed from the program due to COPD, despite no observed shortness of breath during exercises.
The facility failed to provide adequate supervision and assistive devices to prevent falls for a resident with dementia and chronic instability, resulting in 14 falls over several months. Care plans were not consistently revised with effective interventions following each fall, contributing to repeated injuries.
The facility failed to maintain a medication error rate below 5 percent, as an RN crushed and administered extended-release medications to a resident, contrary to guidelines. This resulted in a medication error rate of 7.41 percent.
The facility failed to ensure complete and accurate records for two residents. One resident had inconsistent weight measurements and improper skin assessments, while another resident frequently lost dentures with no documented communication between the facility and the family.
The facility failed to provide the required minimum square footage per resident in a specific room. Despite having a waiver to accommodate three residents, an observation revealed that the room only provided 71.25 square feet per resident, falling short of the required 80 square feet per resident in double occupancy rooms and 100 square feet in single occupancy rooms. This measurement was verified by Maintenance.
The facility failed to ensure the resident call system was functioning in three of eleven room call systems observed. A resident's restroom call system was not functioning, and another room's call system pull cord was broken. Maintenance staff indicated that call system checks were not completed routinely and relied on staff to report malfunctions.
The facility failed to ensure at least 8 consecutive hours of RN coverage on three specific days within a review period. The DON confirmed the absence of RN coverage on these dates, and the facility's policy mandates RN services for at least eight consecutive hours every 24 hours, seven days a week.
Infection Control Lapses in Catheter Management and Hand Hygiene
Penalty
Summary
Surveyors identified failures in the facility’s infection prevention and control practices involving residents with Foley catheters and during personal care. For one resident on enhanced barrier precautions (EBP) due to a Foley catheter, signage outside the room indicated EBP was required. During observations, the resident’s catheter drainage bag was clipped to the wheelchair with the catheter tubing resting on the floor in the room and later in the dining room. A CNA emptied the catheter drainage bag while wearing gloves but left the catheter tubing dragging on the floor when exiting the room. Record review showed the resident had neuromuscular dysfunction of the bladder and prostatic hyperplasia, with physician orders for catheter care every shift and EBP due to the Foley catheter. Facility policy for emptying Foley catheters required standard precautions and aseptic technique, and the isolation policy required that protective equipment be maintained near the resident’s room for use when transmission-based precautions are implemented. The Infection Control Preventionist stated that catheter tubing should be kept off the floor whenever possible and that staff should don gloves and a gown when providing catheter care for residents on EBP due to a Foley catheter. In a separate observation involving another resident, a CNA assisted the resident to the restroom and removed a soiled brief while the resident was on the commode. After disposing of the soiled brief, the CNA removed their gloves and donned a new pair of gloves from a container without performing hand hygiene in between glove changes. The facility’s hand hygiene policy stated that hand hygiene is the primary means to prevent the spread of infections and required the use of alcohol-based hand rub or soap and water after removing gloves, as well as performing hand hygiene before applying non-sterile gloves. The Infection Control Preventionist confirmed that staff should perform hand hygiene before donning new gloves and between glove changes.
Failure to Offer and Document Annual Influenza Vaccinations
Penalty
Summary
The deficiency involves the facility’s failure to ensure that annual influenza immunizations were offered and documented for two residents who had provided consent. For Resident D, record review showed an immunization consent form signed and dated 7/16/25 indicating consent to receive the influenza vaccine. The immunization history showed the last influenza vaccine was administered on 10/27/21. There was no documentation in Resident D’s record that the influenza vaccine was administered, refused, or medically contraindicated during 2025. For Resident G, record review showed an immunization consent form signed and dated 10/30/25 indicating consent to receive the influenza vaccine. The immunization history showed the last influenza vaccine was administered on 10/7/19. Resident G’s record contained no indication that the influenza vaccine was administered, refused, or medically contraindicated during 2025. The facility’s policy stated that all residents would be offered vaccines unless medically contraindicated or already vaccinated, and that influenza vaccines could be administered per physician-approved protocol after assessment for contraindications. The ICP stated that, after consent, a physician’s order should be obtained and documentation of administration or refusal should appear in the record, and RN 7 reported there was no record that the influenza vaccine was offered to these two residents.
Unqualified Food Services Director
Penalty
Summary
The facility failed to ensure that the Food Services Director (FSD) met the required qualifications for the position. The FSD began her role on 6/30/24 but did not enroll in a food service manager course until September 2024, several months after starting the position. During interviews, the FSD stated she delayed enrollment because she was unsure which course to take. Documentation provided by the FSD confirmed that the required course had not yet been completed. The job description for the Director of Food Services, provided by the Regional Consultant Nurse, specified that the director should possess administrative and supervisory skills essential for the department, which the FSD had not yet demonstrated through completion of the required training.
Failure to Consistently Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to consistently implement fall prevention interventions for four residents identified as being at risk for falls. For one resident with a history of falls and a recent wrist fracture, the care plan required nonskid strips at the bedside, but these were not present during observation. The absence of this intervention was confirmed by both facility staff and a regional consultant. This resident's care plan also included other interventions such as ensuring the call light was within reach and the use of appropriate footwear, but the specific intervention added after the most recent fall was not in place. Another resident with dementia and repeated falls was care planned to have a motion sensor night light in the room to provide adequate nighttime lighting. However, during observation, the night light was not present, and this was confirmed by a qualified medication aide. The care plan for this resident had been recently revised following a fall, and the intervention was specifically identified as necessary by the interdisciplinary team. A third resident, who was moderately cognitively impaired and dependent on staff for transfers, was not to be left unattended in a wheelchair in the room, according to the care plan. Despite this, the resident was observed alone in the room in a wheelchair on multiple occasions. Staff confirmed that the resident should not have been left unattended. For a fourth resident with severe cognitive impairment and a history of falls, the care plan required the bed to be in the lowest position and a "call don't fall" sign in the bathroom. Observations revealed the bed was not in the lowest position and the sign was missing. Staff and a family member confirmed the bed was not kept in the lowest position, and documentation showed the sign was not in place.
Failure to Properly Label and Date Food Items in Kitchen Storage
Penalty
Summary
During a kitchen inspection, surveyors observed multiple food storage violations. In the reach-in freezer, a container of butter oil and four premade lunches were found without open or preparation dates. The spice cabinet contained numerous containers of spices and oils, all lacking open dates. In the dry storage area, a bin of flour, a bin of sugar, and a bag of panko breadcrumbs were also missing open dates. Additionally, in the walk-in freezer, an open bag of waffles was found exposed to air and not dated. An interview with a staff member confirmed that spices should be dated when opened. Review of the facility's current food receiving and storage policy indicated that all foods stored in refrigerators or freezers must be covered, labeled, and dated, and that dry foods stored in bins should be labeled and dated after removal from original packaging. These observations demonstrated that the facility failed to follow its own policy and professional standards for food storage, labeling, and dating.
Resident Denied Timely Toileting Assistance During Meal
Penalty
Summary
A resident with severe cognitive impairment and a history of bladder incontinence, who required substantial assistance for toileting and was prescribed a daily diuretic (Lasix), requested to use the bathroom during a dining observation. The certified nurse aide (CNA) present denied the resident's request, instructing her that she could not go to the bathroom because she had to eat. This interaction was directly observed by surveyors. Review of the resident's clinical record confirmed her diagnoses, care needs, and medication regimen, all of which increased her likelihood of needing prompt toileting assistance. Facility policy on dignity emphasized that residents should be treated with respect and allowed to exercise their rights, including prompt response to toileting requests. The staff's failure to allow the resident to use the bathroom as requested did not align with these expectations and resulted in a deficiency related to resident dignity and rights.
Failure to Complete and Document Quarterly Care Plan Conferences
Penalty
Summary
The facility failed to ensure that care plan conferences were completed quarterly and that residents and their representatives were included in the development and implementation of person-centered care plans. For one resident with chronic obstructive pulmonary disease (COPD) who was moderately cognitively impaired and required substantial assistance with activities of daily living, the clinical record did not show evidence of a care plan conference since January, despite a quarterly MDS assessment in March. Although documentation was later provided indicating a care plan conference in April, the resident's power of attorney reported not being invited or included since January. Similarly, another resident with COPD and moderate cognitive impairment, who required supervision for daily activities, had no record of a care plan conference since November of the previous year, despite a quarterly MDS assessment in February. Documentation for a care plan conference in February was provided after the fact, and the Social Services Director acknowledged that care plan conferences should occur every three months and be documented in the clinical record, but in these cases, conferences had been backdated or documented late. Facility policy requires quarterly review and resident participation in care planning, which was not followed for these residents.
Failure to Assess and Authorize Self-Administration of Medication
Penalty
Summary
A resident was observed on multiple occasions with a bottle of Tums at their bedside, indicating self-administration of medication. The clinical record review showed that the resident had diagnoses including cellulitis, diabetes mellitus, and obesity. The resident's Admission MDS assessment was incomplete, with sections on medication and functional abilities not filled out, though the resident was noted to be cognitively intact. There was no physician order for Tums or for self-administration of medication, and the comprehensive care plan did not address self-administration. A Self-Administration of Medication Assessment completed prior to these observations indicated that the resident did not wish to self-administer medications. The DON confirmed that no residents in the facility were authorized to self-administer medications. The facility's policy requires documentation and care planning for any resident deemed safe to self-administer medications, and mandates that unauthorized medications found at the bedside be removed. Despite these requirements, the resident continued to have access to Tums at the bedside without proper assessment, documentation, or authorization.
Failure to Follow Physician Orders for Wound Care and Antibiotic Administration
Penalty
Summary
The facility failed to ensure that physician orders were followed for wound treatment and antibiotic administration for a resident with chronic obstructive pulmonary disease and non-pressure wounds on both feet. Observations showed the resident with both feet wrapped in bandages and directly on the ground. Review of clinical records revealed that physician orders for wound care, including cleansing, application of oil emulsion, and specific wrapping techniques, were not consistently followed. Documentation indicated that unna boots were continued after the order for their use had been discontinued, and the prescribed wound care regimen was not administered as ordered on at least one occasion. Additionally, the facility did not obtain a skin culture prior to starting the resident on Cefdinir, an antibiotic, contrary to facility policy. The antibiotic was ordered for a specific duration, but there was inconsistency in documentation regarding the length of therapy, with no clear record of changes to the duration. The facility's policy required medication orders to be accurate and timely, but these standards were not met in this case.
Infection Control Lapse During Wound Care
Penalty
Summary
During wound care for a resident with chronic obstructive pulmonary disease and non-pressure wounds on both feet, infection control practices were not followed. The resident, who was moderately cognitively impaired and required staff supervision for daily activities, was observed with both feet wrapped in bandages and resting directly on the floor without shoes or socks. Physician orders specified daily wound care, including cleansing the lower extremities, applying oil emulsion, and wrapping with gauze, as well as the use of enhanced barrier precautions due to the wounds. During a wound care observation, the wound nurse removed the dressings from both feet, cleansed the left foot, and then performed hand hygiene while the resident's left foot, now undressed, rested directly on the floor. The nurse then applied new dressings to the left foot without re-cleansing it after it had made contact with the floor. The facility's policy required placing a disposable cloth under the wound to serve as a barrier, but this was not done. The Infection Preventionist confirmed that allowing the resident's feet, covered only with absorbent dressings, to be in direct contact with the floor was an infection control concern.
Room Size Deficiency for Multiple Occupancy
Penalty
Summary
The facility failed to provide the required minimum of 80 square feet per resident in a multiple occupancy room, as identified in one of the 34 rooms reviewed. During the entrance conference, the Administrator in Training acknowledged that the room in question required a variance waiver to accommodate three residents, but the waiver had been applied for and not granted. Documentation provided by a Registered Nurse confirmed that the room measured only 70.29 square feet per resident. Additionally, the Regional Consultant stated that the facility did not have a room variance policy and was following federal regulations.
Failure to Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse to the state agency after being made aware of the incident involving a resident. The resident, who had severe cognitive impairment and diagnoses including anxiety, bipolar disorder, and dementia with agitation, was involved in an incident where they mistakenly believed a CNA was a man and attempted to hit the CNA. The resident sustained skin tears to both hands during the altercation. The family of the resident alleged that the CNA may have exposed her breasts to the resident during the incident. The facility conducted an investigation and issued a 3-day suspension to the CNA involved, noting the complaint of alleged abuse from a family member. However, the Director of Nursing indicated that the allegation was found to be unfounded and was not reported to the state agency. The facility's policy requires all reports of resident abuse, neglect, exploitation, or theft to be reported to local, state, and federal agencies and thoroughly investigated, but this procedure was not followed in this case.
Failure to Prevent and Manage Pressure Injuries
Penalty
Summary
The facility failed to provide effective services to prevent the development of facility-acquired stage two pressure injuries for two residents, Resident 46 and Resident 9, who were admitted without pressure injuries but were identified as being at risk. Resident 46 developed a stage two pressure injury on the coccyx that deteriorated to an unstageable pressure injury with infection, requiring hospitalization for intravenous antibiotic therapy and surgical debridement. The facility's documentation and assessment of the pressure injury were insufficient, with gaps in daily assessments and progress notes, leading to the worsening of the injury and subsequent hospitalization for severe sepsis and other complications. Resident 9, who had diagnoses including type II diabetes, dementia, heart failure, and chronic kidney disease, developed a facility-acquired stage two pressure ulcer on the left heel that deteriorated to a stage three pressure injury. The facility's records showed inconsistent and incomplete documentation of the wound's characteristics and measurements, indicating a lack of effective assessment and management of the pressure injury. Despite physician orders and care plans, the facility failed to adequately monitor and document the wound's progression, leading to its deterioration. The facility's policies on pressure ulcer treatment and documentation were not followed, as evidenced by the lack of complete and accurate records of the residents' conditions and wound assessments. The Director of Nursing acknowledged the deficiencies in documentation and assessment, noting that some evaluations were likely copied and pasted. The facility's failure to adhere to its own policies and provide consistent and thorough care contributed to the development and worsening of pressure injuries in both residents.
Failure to Provide Adequate Nutritional Care
Penalty
Summary
The facility failed to provide adequate nutritional care and services for Resident 46, who experienced a significant weight loss of 20% over 35 days. The resident's clinical record indicated severe cognitive impairment and a high risk for dehydration and malnutrition. Despite these risks, the facility did not have a care plan addressing the resident's nutritional needs, and there was a lack of timely notification to the physician, Registered Dietitian (RD), or family about the resident's poor food intake and significant weight loss. The resident's weight was not consistently monitored, and there were errors in data entry that further complicated the situation. The facility also failed to conduct necessary nutritional risk assessments upon the resident's re-admission after hospitalization for psychiatric treatment. The resident's poor appetite and food intake were documented, but no effective interventions were implemented to address these issues. The resident developed a stage two pressure ulcer that worsened to an infected unstageable pressure injury, leading to hospitalization for sepsis, dehydration, and malnutrition. The facility's documentation and communication failures contributed to the resident's deteriorating condition, ultimately resulting in severe health complications and hospitalization.
Failure to Submit Direct Care Staffing Information to CMS
Penalty
Summary
The facility failed to electronically submit required direct care staffing information to CMS for the first fiscal quarter from 10/1/23 through 12/31/23. During a review of the facility's PBJ Staffing Data Report on 3/25/24, it was found that the data for the specified quarter was not submitted. In an interview on 3/28/24, the Business Office Manager (BOM) indicated that the responsibility for ensuring the timely submission of payroll-based journal information lies with outside staff. The facility's policy on reporting direct care staffing information states that staffing data should be submitted no less frequently than quarterly and no later than 45 days after the end of the reporting quarter. However, this policy was not adhered to, resulting in the deficiency.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure the MDS (Minimum Data Set) Assessment was completed accurately for four residents. Resident 46's assessments contained multiple inaccuracies, including incorrect height measurements and inconsistent documentation of pressure ulcer risk and presence. Despite having a stage 4 pressure ulcer and undergoing surgical debridement, the resident's MDS assessments did not accurately reflect these conditions. Additionally, the resident experienced significant weight fluctuations that were not consistently documented in the MDS assessments. Resident 22's MDS assessment inaccurately indicated that the resident was receiving tube feedings, which was confirmed to be incorrect by the MDS Coordinator. Resident 5's MDS assessment failed to document that the resident was edentulous, despite observations confirming the resident had no teeth. The MDS Coordinator acknowledged this error during an interview. Resident 45's MDS assessment incorrectly stated that the resident had not experienced hallucinations, despite care plans and progress notes indicating otherwise. The MDS Coordinator confirmed that the resident did experience hallucinations, and this was documented in the care plan. These inaccuracies in the MDS assessments highlight a failure to ensure accurate and consistent resident assessments, which is critical for providing appropriate care and treatment.
Failure to Conduct Timely Care Plan Conferences and Revisions
Penalty
Summary
The facility failed to ensure care plan conferences were conducted in a timely manner every 3 months and revised with changes for 9 of 12 residents. Resident 8's clinical record showed a missed care plan conference in January 2024, despite being mildly cognitively impaired and requiring extensive assistance with transfer and mobility. The MDS coordinator confirmed the missed conference, and the DON indicated that care plan conferences should occur upon admission and with quarterly assessments. The facility's policy on care planning was provided but not followed as per the documented timeframes based on resident assessments. Resident 41's clinical record indicated care conferences were held on 4/12/23, 1/22/24, and 3/27/24, showing a gap in the quarterly schedule. Similarly, Resident 5's record showed only one care conference on 3/15/23 for the past year, despite moderate cognitive impairment and requiring extensive assistance. Resident 45's record also lacked timely care conferences, with the last one documented on 12/6/23. Resident 22's care conferences were held on 4/3/23, 10/20/23, and 3/27/24, indicating irregular intervals. Resident 4's clinical record lacked documented care plan conferences after 11/15/23, and Resident 34's record showed a gap between 9/26/23 and 3/20/24. Resident 46's record lacked care plan conferences after 10/16/23, and Resident 49's care plan was not revised despite significant weight loss and new orders. The DON confirmed that significant weight loss should be added to the care plan once identified. The facility's policies on weight assessment and care planning were provided but not adhered to, leading to deficiencies in timely and appropriate care plan revisions for the residents involved.
Failure to Ensure Proper Hand Hygiene and Tableware Handling
Penalty
Summary
The facility failed to ensure proper handling of tableware and hand hygiene during dining services. During an observation, a staff member was seen placing their thumb inside the rim of a resident's coffee mug while refilling it. Additionally, the same staff member did not perform hand hygiene after coming into contact with multiple residents while providing dining services. This included touching residents' shoulders, adjusting oxygen tubing, and serving meals without washing hands in between these tasks. During an interview, a registered nurse indicated that staff should not touch utensils or cups where a resident's mouth may come in contact and should perform hand hygiene after direct contact with residents or after passing every third tray. The facility's policy on preventing foodborne illness also mandates that hands be washed after direct contact with residents. The observations and interviews indicate a failure to adhere to these hygiene and sanitary practices, leading to the deficiency.
Failure to Notify Physician and Family of Significant Weight Loss and Pressure Ulcers
Penalty
Summary
The facility failed to notify the physician and resident representative of changes in a resident's medical status for two residents reviewed for weight loss. One resident, who had severe cognitive impairment and a stage 4 pressure ulcer, experienced significant weight loss over several months. Despite documented poor appetite and food intake, the clinical record lacked notification to the physician, Registered Dietitian (RD), or family about the weight loss. Additionally, a new stage 2 pressure ulcer was identified, but the family was not informed until the resident was hospitalized for sepsis due to the ulcer. The resident was later discharged back to the facility and admitted to hospice care. Another resident, who was moderately cognitively impaired and dependent on staff for eating and other activities, experienced a significant weight loss of 15.89% over six months. The resident did not receive the full amount of prescribed enteral feeding on multiple occasions, and there was no documentation of notification to the dietitian or physician. The Director of Nursing (DON) confirmed that families should be notified of significant weight loss and that such notifications should be documented, but this was not done in this case. The facility's policies on weight assessment and intervention, as well as changes in a resident's condition or status, were not followed. These policies require immediate notification to the dietitian and physician for significant weight changes and prompt notification to the resident's representative for significant changes in the resident's condition. The failure to adhere to these policies resulted in a lack of timely medical intervention and family awareness of the residents' deteriorating conditions.
Failure to Provide Restorative Therapy Services
Penalty
Summary
The facility failed to ensure that a resident was provided with restorative therapy services to prevent avoidable decline in range of motion and progression of muscle atrophy. Resident 41, who had diagnoses including anoxic brain damage, rheumatoid arthritis, and multiple sclerosis, was totally dependent on two staff members for transfers, mobility, eating, and toileting. The resident's clinical record indicated limitations in range of motion and impairments in both upper and lower extremities but showed no documentation of restorative therapy services provided during the current year. Observations revealed that the resident had contracted hands and feet, and interviews with staff confirmed that the resident should have been receiving restorative nursing for range of motion but was removed from the program in December due to COPD, despite no observed shortness of breath during exercises. The facility's policy on Restorative Nursing Services, provided by the Director of Nursing, indicated that restorative goals and objectives should be individualized and resident-centered, but there was no evidence that these services were being provided to Resident 41. The lack of restorative therapy services and range of motion exercises for Resident 41 was a clear deficiency in the care provided, as it failed to prevent the avoidable decline in the resident's physical condition.
Failure to Prevent Falls and Update Care Plans
Penalty
Summary
The facility failed to provide adequate supervision and assistive devices to prevent falls for a resident with a history of dementia, chronic instability of the knee, and repeated falls. The resident experienced 14 falls over a period of several months, with varying degrees of injury. Despite the high fall risk identified in the resident's assessments, the care plans were not consistently revised with effective interventions following each fall. For instance, after the resident's fall on 9/11/23, the care plan was updated to encourage the resident to ask for assistance with getting items out of the closet, but no interdisciplinary team (IDT) note was made. Similarly, after a fall on 10/19/23, non-skid strips were added to the care plan, but again, no IDT note was recorded. This pattern of inadequate and inconsistent care plan updates continued throughout the resident's stay, contributing to repeated falls and injuries. The facility's Director of Nursing (DON) indicated that IDT meetings were held each business day to review falls and update care plans, but the documentation and implementation of these interventions were insufficient. The facility's policy on comprehensive person-centered care plans stated that assessments and care plans should be revised as residents' conditions change, but this was not effectively carried out for the resident in question.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to ensure it was free of a medication error rate of greater than 5 percent, as observed during a medication pass for one of five residents. Specifically, two medication errors were observed during 27 opportunities for error, resulting in a medication error rate of 7.41 percent. During an observation, an RN crushed and administered Divalproex sodium ER and Gabapentin tablets to a resident, despite these medications being on the facility's 'do not crush' list due to their extended-release properties. The MDS nurse confirmed that extended-release medications and Gabapentin tablets should not be crushed because it affects how the medication is absorbed by the body. The director of nursing provided a 'do not crush' list from the facility pharmacy, which included both Divalproex ER and Gabapentin as medications that should not be altered. This oversight in medication administration led to the identified deficiency.
Incomplete and Inaccurate Resident Records
Penalty
Summary
The facility failed to ensure resident records were complete and accurate for two residents. For Resident 46, who had diagnoses including Alzheimer's Disease and a stage 4 pressure ulcer, the clinical record showed inconsistencies in weight measurements and skin assessments. The resident's weight was recorded while they were on hospital leave, and the Director of Nursing (DON) indicated these were likely data entry errors. Additionally, the resident developed a pressure ulcer that worsened over time, but the Nursing Skilled Evaluations and weekly skin assessments documented no skin issues, suggesting that the assessments were copied and pasted from one shift to the next without proper evaluation. For Resident 5, who had aphasia and required extensive assistance for daily activities, the clinical record indicated the resident had dentures but often lost them. During an observation, the resident was found without dentures and stated they could not eat well without them. The Social Services Director confirmed that the resident had been taken to get dentures multiple times but often lost them, and there was no documented communication between the facility and the resident's family regarding the lost dentures. The facility's Charting and Documentation policy required documentation to be objective, complete, and accurate, which was not adhered to in these cases.
Failure to Provide Minimum Square Footage per Resident
Penalty
Summary
The facility failed to provide the required minimum square footage per resident in room [ROOM NUMBER]. During an entrance conference interview, the Director of Nursing (DON) indicated that the facility had a room size waiver for this room to accommodate three residents. However, an observation on 3/27/24 revealed that the room, which measured 15 feet 10 inches long by 13 feet 6 inches wide, only provided 71.25 square feet per resident for three residents, falling short of the required 80 square feet per resident in double occupancy rooms and 100 square feet in single occupancy rooms. This measurement was verified by Maintenance on the same day.
Resident Call System Malfunction
Penalty
Summary
The facility failed to ensure the resident call system was functioning in three of eleven room call systems observed. Specifically, Resident 21's restroom call system was not functioning, and a sign was placed by the restroom door reminding the resident to call for assistance. Additionally, the call system in another room's restroom was not functioning, and the pull cord in a third room's restroom was broken. Maintenance staff indicated that call system checks were not completed routinely and relied on staff to report malfunctions. During interviews, it was revealed that Resident 21 occasionally transfers herself to the restroom, and Resident 152 had difficulty reaching the call system switch due to the broken pull cord. The facility's policy stated that the resident call system should remain functional at all times and be routinely maintained and tested by the maintenance department. However, this policy was not adhered to, leading to the deficiencies observed.
Failure to Ensure RN Coverage for 8 Consecutive Hours
Penalty
Summary
The facility failed to ensure at least 8 consecutive hours of registered nurse (RN) coverage during three days in the review period from 10/1/23 to 12/31/23. Specifically, RN coverage was lacking on weekends, as evidenced by the facility's daily staffing reports reviewed on 4/1/24, which showed no RN coverage on 10/1/23, 10/29/23, and 12/30/23. During an interview on 4/1/24, the Director of Nursing (DON) confirmed the absence of RN coverage on these dates and was unable to provide any proof of RN presence. Additionally, the Business Office Manager (BOM) provided an undated facility policy that mandates RN services for at least eight consecutive hours every 24 hours, seven days a week, which the facility failed to meet.
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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