University Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Upland, Indiana.
- Location
- 1564 S University Blvd, Upland, Indiana 46989
- CMS Provider Number
- 155200
- Inspections on file
- 38
- Latest survey
- March 24, 2026
- Citations (last 12 mo.)
- 19 (1 serious)
Citation history
Health deficiencies cited at University Nursing Center during CMS and state inspections, most recent first.
A resident with multiple comorbidities, including prior UTI and hemiplegia, experienced hematuria, altered mental status, low BP, and low‑grade fever, and an NP ordered IV fluids, labs, and a UA with culture. Nursing staff, including the DON and RNs, later stated that for an incontinent resident they would obtain a clean‑catch or straight cath specimen and that a physician’s order was required to insert and anchor a Foley catheter. Despite this, an LPN inserted a catheter for a resident who was normally incontinent, obtained no urine return, and chose to inflate the balloon and leave the Foley in place without a provider order, causing pain. A subsequent RN later deflated the balloon and removed the catheter to obtain the urine sample, after which the resident began bleeding profusely from the urethra and was sent to the hospital, where the resident was admitted with septic shock, UTI, and urosepsis.
A resident with dysphagia, lung disease, and a mechanically altered diet experienced an apparent aspiration during a meal, with coughing, gurgling, low SpO2 on supplemental O2, and congestion observed by CNAs, LPNs, and dietary staff. An NP was notified via secure messaging and ordered a stat CXR and Q4H nebulizer treatments; imaging showed bilateral airspace disease suggestive of pneumonia, and the NP later ordered doxycycline and directed close monitoring of oxygen saturation and respiratory status. The MAR showed missed doses of doxycycline, and the clinical record lacked documentation of reassessments, vital signs, or ongoing monitoring between the initial aspiration and a subsequent decline, despite facility policies and charge nurse duties requiring documentation of nursing actions, assessments, and event follow-up. After a second episode of coughing, drooling, difficulty chewing/swallowing, and low SpO2, the resident was sent to the hospital and diagnosed with aspiration pneumonia and acute hypoxic respiratory failure, with multiple staff and leadership acknowledging that required assessments and documentation were not completed or recorded in the EMR.
A resident with severe vascular dementia, psychotic disorder, depression, anxiety, and hallucinations, who exhibited repetitive requests for food, water, and to lie down, was subjected to raised-voice statements by a CNA in the dementia unit dining room, including being told not to expect help "every four seconds" and that she would not be given ice cream or cookies and must eat her food. The CNA stated she did not view her behavior as abusive and felt she needed to get loud to be heard, while an LPN present acknowledged that yelling at residents with dementia was not an appropriate approach. Another CNA reported that this CNA used raised tones and limiting language such as "That's enough" with residents, and that similar approaches were used by other staff, despite a facility policy prohibiting verbal abuse.
A cognitively impaired female resident with a history of wandering was found on two occasions in a male resident's room, where the male resident, known for sexually inappropriate behaviors, engaged in sexual abuse. Staff failed to implement immediate interventions, did not promptly notify the physician or the resident's representative, and did not complete required assessments or follow abuse reporting protocols, resulting in repeated incidents and severe psychosocial harm to the female resident.
An incident involving possible sexual abuse between two cognitively impaired residents was not reported to the IDOH and law enforcement within the required timeframe. Staff who witnessed the event did not immediately notify management, and there were delays in communication and reporting by the SSD, DON, and Administrator, resulting in a failure to meet the facility's policy for timely reporting of abuse allegations.
A facility failed to promptly and thoroughly investigate an alleged incident of resident-to-resident sexual abuse, delaying full body assessments and safety checks, and omitting key staff statements and documentation from the investigation. Required immediate actions and reporting were not fully implemented, and additional information about the incident was not timely shared with the state health department.
A resident with significant visual impairment and physical dependence requested a hat to cover a bald spot, but a CNA abruptly removed the resident's headband without prior communication and placed a hat on the resident in a rushed and irritated manner. The CNA's actions, observed on video and confirmed by interviews, did not demonstrate respect or sensitivity to the resident's needs, resulting in a deficiency related to dignity and resident rights.
A resident admitted with a right leg immobilizer and at risk for skin breakdown did not receive adequate skin assessments or necessary medical orders, resulting in a severe pressure injury. The facility failed to document skin assessments and obtain orders for the immobilizer, leading to a necrotic wound on the resident's knee, which required hospitalization and amputation.
A facility failed to implement appropriate interventions for a resident's surgical wound care. The resident, with a history of right femur fracture and dementia, was admitted with a surgical dressing and immobilizer, but the facility did not assess the skin under the immobilizer or obtain necessary physician orders. Weekly skin assessments were not documented, and the dressing was not changed as per the surgeon's instructions. Staff interviews revealed a lack of order clarification and adherence to facility policies.
A facility failed to report an alleged abuse incident involving two residents, where one resident entered another's room multiple times, argued, and kicked her. The incident was not documented in the clinical records, and the DON and Administrator were not informed. The facility's policy required immediate reporting of abuse allegations, which was not followed.
The facility failed to reconcile controlled medications for two medication carts, with missing signatures and count completions on the 200 and 300 Unit logs. The 200 Unit log lacked signatures and count completion for several shifts, while the 300 Unit log was missing signatures and reconciliation for multiple shifts. The facility's policy required shift change documentation, which was not followed.
The facility failed to administer medications according to physician orders for two residents, with discrepancies in narcotic counts suggesting possible drug diversion. Additionally, daily weights were not obtained for a resident with congestive heart failure as per physician orders, due to ineffective monitoring processes. Interviews with staff revealed gaps in documentation and adherence to facility policies.
A cognitively impaired resident with a history of falls was not adequately supervised or provided with necessary interventions to prevent falls. Despite having a care plan that included using a walker, the resident frequently ambulated without it, leading to multiple falls. Staff failed to redirect the resident or ensure the use of a walker, and the facility's fall management policy was not effectively followed, resulting in repeated falls and injuries.
A staff member verbally abused a resident by whispering inappropriate language while providing care. The incident was reported by another CNA, leading to the suspension and termination of the offending staff member. The resident, who was on hospice and not alert, did not hear the inappropriate language.
The facility failed to ensure controlled medications were accounted for at the time of administration in the Memory Care Unit. An LPN was observed signing off medications given earlier that morning, and the DON confirmed there was no specific policy for signing off controlled medications, although it was expected to be done at the time of administration.
Foley Catheter Anchored Without Physician Order Leading to Urethral Bleeding and Hospitalization
Penalty
Summary
The deficiency involves the facility’s failure to ensure a nurse obtained a physician’s order prior to inserting and anchoring a urinary (Foley) catheter for a resident who was being evaluated for possible UTI and sepsis. The resident had diagnoses including hypertension, iron deficiency anemia, sequelae of cerebral infarction with hemiplegia, chronic pain syndrome, hypokalemia, prior UTI, and bandemia, and was always incontinent of bowel and bladder. On the day of the incident, staff noted blood in the resident’s urine, burning with urination, altered mental status, low blood pressure, and a low‑grade temperature. The on‑call NP was notified and gave orders for IV fluids, labs, and a urinalysis with culture and sensitivity, but there was no order documented for insertion or anchoring of a Foley catheter. Earlier in the day, the DON started an IV due to the resident’s low blood pressure and change in condition, and staff were instructed to obtain a urine specimen. Multiple nurses, including the DON, RN 21, and LPN 3, later stated that for an incontinent resident they would normally obtain a clean‑catch specimen if possible or perform a straight (in‑and‑out) catheterization for a urinalysis, and that they would not anchor a Foley catheter for this purpose. They also indicated that a physician’s order and an appropriate diagnosis were required before inserting and anchoring a Foley catheter. The Administrator and DON confirmed that nurses needed a physician’s order to anchor a Foley catheter, and the Senior Regional Director of Clinical Services reported there was no policy related to physicians’ orders. Despite this, LPN 13 reported that when she worked with the resident that day, aides told her the resident, who was normally incontinent, had been dry and she believed he was probably dehydrated. She inserted the smallest catheter available but did not obtain urine return, then decided to inflate the 10 cc balloon and leave the catheter in place rather than attempting catheterization again, even though there was no physician’s order for a Foley catheter. The resident, who did not normally have a catheter, was in pain. Later, RN 19 came on duty, found the catheter anchored, and when lab staff arrived he deflated the balloon and removed the catheter to obtain the urine sample. Following removal, the resident began bleeding profusely from the urethra, and the on‑call NP was notified and the resident was sent to the hospital, where he was admitted with septic shock, UTI, and urosepsis and had a 16 French catheter inserted.
Failure to Reassess and Monitor Resident After Aspiration Event
Penalty
Summary
The deficiency involves the facility’s failure to reassess and monitor a resident after a change in condition related to possible aspiration. The resident had diagnoses including pneumonia, other lung disorders, and dysphagia, and was on a mechanically altered, soft bite-sized diet with ground meat and thin liquids per Speech Therapy recommendations. Care plans identified chewing difficulties and risk for impaired gas exchange, with interventions to monitor chewing/eating difficulties and assess vital signs and lung sounds as needed, including oxygen saturation. On the day of the first aspiration event, staff in the dining room observed the resident coughing, gurgling, spitting out mucus and food, and having a wet-like cough. The resident’s oxygen saturation was reported in the 80s on 2 L O2, with low blood pressure, and the NP was notified via secure messaging. The NP ordered a stat chest x-ray and Q4H nebulizer breathing treatments. A mobile chest x-ray was completed and showed patchy bilateral airspace disease, with pneumonia to be considered and follow-up recommended. A late-entry progress note documented that the NP was notified of the x-ray results. However, the clinical record lacked documentation that the resident was reassessed or that vital signs were obtained between the initial notification to the NP and the NP’s progress note the following day. The NP later documented that the resident had an episode of hypoxemia following a choking incident, that lung sounds were clear at the time of her assessment, and that she planned Q4H breathing treatments, close monitoring of oxygen saturation, periodic reassessment of respiratory status, and initiation of doxycycline for suspected pneumonia. The MAR showed that doxycycline doses were missed because the medication was not yet available, and there was no documentation that the antibiotic was administered once it arrived. Nursing staff interviews confirmed that on the day after the first aspiration, one LPN only listened to the resident’s lungs, did not obtain a full set of vitals or oxygen saturation, and did not document a full assessment, despite the resident having had recent respiratory issues. Between the NP’s note and the resident’s subsequent decline, the record contained no documented nursing assessments or vital signs, despite the resident having experienced a significant change in condition and being started on an antibiotic for suspected pneumonia. On the day of the second aspiration event, staff again observed the resident coughing, drooling, having trouble chewing and swallowing, spitting out mucus and food, and sounding congested. The resident’s oxygen saturation was again in the 80s on 2 L O2, and an SBAR event report documented decreased oxygen saturation and increased congestion, leading to the decision to send the resident to the hospital, where he was diagnosed with aspiration pneumonia and acute hypoxic respiratory failure. Multiple LPNs and the DON acknowledged that there were no progress notes, vital signs, or event documentation in the EMR between the two aspiration episodes, despite facility policy requiring documentation of nursing actions, physician contacts, and assessments for acute or life-threatening changes in condition, and job descriptions requiring daily documentation, hot charting, and daily event follow-up. Facility leadership and corporate staff further indicated that a hot charting or infection control event should have been initiated and followed with ongoing documentation of assessments after the resident was started on an antibiotic. Interviews with nursing staff involved in the initial aspiration episode revealed that they did not document vital signs or progress notes related to the event, even though they recognized the resident had possible aspiration and respiratory changes. The DON confirmed that there should have been at least a progress note, SBAR, or documented event following the possible aspiration, and that the next shift’s nurse should have taken vital signs and documented an assessment. The absence of documented reassessments, vital signs, and follow-up monitoring after the resident’s change in condition and initiation of treatment formed the basis of the cited deficiency.
Failure to Protect Resident From Verbal Abuse by CNA
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from verbal abuse by a CNA in the dementia unit dining room. During a random observation, surveyors heard the CNA loudly say to one resident, "If you give me four seconds I will come and get you!" Shortly afterward, in the presence of an LPN and the assistant to the nurse practitioner, the same CNA loudly told another resident who was repeatedly requesting to lie down and asking for help, "If you are going to lay down, then stay down. I can't help you every four seconds. I am not going to give you ice cream, and I am not going to give you cookies. You are going to eat your food!" These statements were made in a raised voice in the dining room setting. In interviews, the CNA stated she did not consider her behavior to be abusive and indicated she had to "talk over" the resident because the resident did not hear her. She reported that the resident would eat many cookies and primarily wanted cookies and ice cream, and she described her own behavior as needing to get loud and that ignoring the resident would be abuse. The LPN present indicated he did not know if what the CNA said was abuse and reported he did not hear exactly what was said, but he acknowledged that yelling at residents was not effective and that he taught staff to use a different vocal approach with residents with dementia. Another CNA reported witnessing the same CNA using raised tones with residents and telling a resident, "That's enough," and stated that she had not reported this because other staff handled the resident in a similar way. The resident subjected to the verbal statements had diagnoses including severe vascular dementia with mood disturbance, psychotic disorder with delusions due to a physiological condition, depression, anxiety, delusional disorders, and hallucinations, with a recent MDS indicating severe cognitive impairment. Her care plan documented increased repetitive behaviors, including repeatedly exiting and re-entering her room, frequently requesting cookies, food, water, and to go to bed, and making repetitive verbal requests such as "I want a drink of water" and "I want to lay down." Interventions in the care plan included reminiscing, one-on-one interactions, offering movies/TV, and calming music to help her self-soothe. Despite this, staff interviews and observations showed that the CNA used raised tones and limiting language toward the resident in the dining room, contrary to the facility’s abuse prohibition policy, which defines verbal abuse as the use of oral or gestured language that includes disparaging or derogatory terms within a resident’s hearing, regardless of their ability to comprehend.
Failure to Protect Resident from Sexual Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident's right to be free from sexual abuse by another resident. A cognitively impaired female resident, diagnosed with Alzheimer's disease and severe cognitive impairment, was observed wandering into a male resident's room on multiple occasions. The male resident, who had a documented history of inappropriate sexual behaviors and a diagnosis of sexual disorder and dementia, was found on two separate occasions in physical contact with the female resident. On the first occasion, the male resident was observed rubbing the female resident's buttocks over her clothing. On the second occasion, the female resident was found lying on the male resident's bed with her pants and brief pulled down, and the male resident's hand was inside her genital area. Both residents were separated and redirected by staff, but no immediate interventions were implemented to prevent recurrence between the two incidents. Staff failed to notify the physician and the female resident's representative immediately after the incidents. The nurse on duty did not complete head-to-toe assessments of either resident following the events, nor were other notifications made in a timely manner. The staff member who witnessed the incidents did not report the inappropriate sexual touching to anyone immediately, instead making a note to chart the behavior and pass it on in shift report. There was a delay in implementing increased supervision and moving the female resident to a different room, as these actions were not taken until several hours after the second incident. Additionally, the facility's abuse investigation and reporting procedures were not followed as required by policy, including immediate assessment, notification, and protection of the residents involved. The male resident had a well-documented pattern of sexually inappropriate behaviors toward female staff prior to the incident, including touching, making sexual comments, and requesting inappropriate actions. Despite these known risks, interventions in place were limited to redirection and assigning male caregivers when available. The female resident was known to wander and had interventions such as stop signs on doors, but these were only somewhat effective. The lack of immediate and effective interventions, failure to follow abuse reporting protocols, and insufficient supervision directly led to the recurrence of resident-to-resident sexual abuse and the resulting severe psychosocial harm to the female resident.
Removal Plan
- Completed abuse training for all staff
- Increased monitoring and surveillance for Resident B and Resident C
- Updated care plans
- Resident C was sent to be evaluated at a psychiatric facility
- Completed physical assessments of residents on the secured dementia care unit
- Developed quality assurance actions for ongoing monitoring
Failure to Timely Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The facility failed to timely report an alleged incident of sexual abuse between two cognitively impaired residents. The incident involved a female resident who wandered into a male resident's room in the memory care unit, where staff observed the male resident's hand near the female resident's private area while she was seated on his bed. There was uncertainty among staff regarding whether the residents were clothed, and the initial staff member who witnessed the event did not immediately report it to management, believing it did not require further attention. The incident occurred in the evening, but the report to the Indiana Department of Health (IDOH) was not made until the following day, exceeding the facility's policy requirement to report within two hours. Multiple staff members, including the Social Services Director (SSD), Director of Nursing (DON), and Administrator, were involved in the communication and investigation process. The SSD was notified by the DON via secure message and subsequently contacted the nurse who witnessed the incident. The SSD advised the nurse to contact the Administrator but did not provide further instructions or come to the facility that night. The Administrator and DON discussed the situation, but the information exchanged was vague, and the DON did not directly contact the nurse who witnessed the event. The SSD and Administrator handled the investigation and notifications, but there were delays in notifying the residents' representatives and law enforcement. Facility policy required immediate reporting of abuse allegations to the Executive Director and the IDOH within two hours, as well as notification to law enforcement and Adult Protective Services. Despite these requirements, the incident was not reported to the appropriate authorities in a timely manner. The delay in reporting and lack of immediate action by staff and management contributed to the deficiency cited in the report.
Failure to Timely and Thoroughly Investigate Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to conduct a timely and thorough investigation into an alleged incident of resident-to-resident sexual abuse involving two residents in the memory care unit. The incident occurred when a female resident wandered into a male resident's room, resulting in potential inappropriate contact. Although the residents were separated and full body assessments were eventually completed, these assessments were not performed immediately after the incident. Additionally, 15-minute safety checks for both residents did not begin until over two hours after the event. The facility's investigation was incomplete, as it did not include statements from all staff present during the incident, such as a CNA and an RN, nor did it incorporate a late entry note detailing the event. Furthermore, the investigation did not collect additional information from key staff or include all relevant documentation. The facility's policy required immediate initiation of the investigation, direct supervision of the resident alleged to have initiated the abuse, and prompt reporting to the state health department. However, the staff member responsible for coordinating the investigation did not provide further instructions or come to the facility on the night of the incident, and did not ensure that all necessary statements were collected. There was also a delay in notifying the nurse practitioner about the incident. Additional information provided by a CNA regarding the nature of the contact was not included in the investigation submitted to the state, and the facility did not ensure that the state was made aware of this information in a timely manner.
Failure to Treat Visually Impaired Resident with Dignity During Assistance
Penalty
Summary
A deficiency was identified when staff failed to treat a physically dependent, visually impaired resident with respect and dignity during an interaction regarding the resident's request for a hat to cover a bald spot. The resident, who had diagnoses including epilepsy, muscle weakness, and significant visual impairment, expressed dissatisfaction with a headband not adequately covering her bald spot and requested a hat. During the incident, a CNA responded by telling the resident she was already wearing a headband and did not need a hat, and then abruptly removed the headband from the resident's head without prior verbalization, despite the resident's visual impairment. The CNA was observed on video removing the headband in an abrupt manner, causing the resident's arm to jerk away as she attempted to fix her hair, and then quickly placing a hat on the resident's head before propelling her to the dining room. Interviews with staff and the resident confirmed that the CNA acted in a rushed and irritated manner, did not communicate her actions to the resident, and handled the resident's request without the expected level of respect and sensitivity, particularly given the resident's visual impairment. The incident was reported by another staff member, and it was noted that the CNA had previously displayed attitude issues toward the resident. The facility's policy defines neglect as the failure to provide necessary goods and services to avoid physical harm, pain, mental anguish, or emotional distress, which was relevant to the observed actions.
Failure to Implement Skin Assessments and Obtain Orders Leads to Severe Pressure Injury
Penalty
Summary
The facility failed to implement adequate skin assessments and obtain necessary medical orders for a resident, leading to the development of a severe pressure injury. Resident B, who was admitted following surgical repair of a right femur fracture, was at risk for skin breakdown due to factors such as weakness, incontinence, and the use of a right leg immobilizer. Despite these risks, the facility did not conduct skin assessments under the immobilizer or obtain orders for its use, which contributed to the development of a necrotic wound on the resident's right knee. The resident's care plan, dated shortly after admission, identified the risk for skin breakdown but lacked specific interventions to manage the immobilizer and prevent pressure injuries. The facility's records showed that skin assessments were not documented, and there was no clarification or documentation of orders for the immobilizer. This oversight was compounded by the lack of communication with the orthopedic surgeon regarding the immobilizer and the absence of timely wound care orders for the knee injury. The deficiency was further highlighted by the progression of the knee wound, which became unstageable and required hospitalization. The wound was initially identified during an orthopedic follow-up, but treatment orders were delayed, and the wound worsened, leading to an above-the-knee amputation. Interviews with facility staff revealed a lack of awareness and documentation regarding the immobilizer and skin assessments, contributing to the deficient practice.
Failure to Implement Surgical Wound Care Interventions
Penalty
Summary
The facility failed to identify and implement appropriate interventions for the care of a surgical wound for a resident who was reviewed for wound care. The resident, who had a history of a right femur fracture, acute posthemorrhagic anemia, and dementia, was admitted to the facility following surgical repair of the right femur. Despite the presence of a dressing on the surgical site and a right leg immobilizer, the facility did not complete an assessment of the skin under the immobilizer upon admission. The resident's care plan indicated a risk for skin breakdown and required weekly skin assessments, which were not documented in the clinical record. Additionally, there were no physician orders for the care of the surgical site or the immobilizer at the time of admission. The facility's staff, including an LPN and the DON, failed to obtain clarification for the missing orders, and the dressing on the surgical wound was not removed or changed as per the surgeon's instructions. Interviews with facility staff and the orthopedic surgeon's nurse revealed that the dressing should have been changed five days post-surgery, but this was not done. The facility's policies required a thorough head-to-toe assessment at admission and verification of physician orders, which were not followed in this case. The lack of weekly skin assessments and failure to address the missing orders contributed to the deficiency in the resident's wound care management.
Failure to Report Alleged Abuse Incident
Penalty
Summary
The facility staff failed to report an allegation of abuse involving Resident C and Resident D to the Administrator as per the facility's policy. Resident C reported that Resident D entered her room multiple times, argued, yelled, and kicked her in the left shin. Although Resident C experienced soreness, there was no open wound. The incident was not documented in Resident C's clinical record, and the Director of Nursing (DON) and Administrator were not informed of the incident in November 2024. Interviews with staff revealed that RN 6 was informed by Resident C about the incident but did not document it in the clinical record. LPN 4 and CNA 3 were aware of the incident but did not report it to the Administrator. Resident C's clinical record, reviewed on January 29, 2025, showed no entry of the incident or any assessment following it. Resident C was cognitively intact with diagnoses including lymphedema, venous insufficiency, peripheral vascular disease, major depressive disorder, and cellulitis. Resident D, who had moderate cognitive impairment and diagnoses of vascular dementia with mood disturbance and major depressive disorder, also had no record of the incident in her clinical notes. The facility's policy, revised in June 2023, required all abuse allegations to be reported immediately to the Executive Director, which was not adhered to in this case.
Failure to Reconcile Controlled Medications
Penalty
Summary
The facility failed to ensure proper reconciliation of controlled medications for two of the three medication carts reviewed, specifically the 200 Unit and 300 Unit medication carts. The 200 Unit Shift Change Verification of Controlled Substances log from October 1 to October 4 lacked necessary information, including signatures and count completion for several shifts. On October 1, the night shift nurse did not sign the log, and an LPN later placed the night shift nurse's initials on the sheet for both blank spots. The Director of Nursing (DON) indicated that the log was not signed for the night shift on October 1 because they believed the signatures were placed on the wrong log. The log lacked documentation of count completion for each shift during shift changes in October 2024. Similarly, the 300 Unit Shift Change Verification of Controlled Substances log from October 1 to October 7 was missing on-coming and off-going shift signatures and reconciliation of controlled medication counts for multiple shifts. The facility's policy, dated February 1, 2018, required that incoming and outgoing nurses count all controlled substances at the change of each shift and document this on the Shift Change Verification of Controlled Substances form. However, this policy was not adhered to, leading to incomplete documentation and reconciliation of controlled medications.
Medication and Weight Monitoring Deficiencies
Penalty
Summary
The facility failed to administer medications according to physician orders for two residents. Resident 19, who has multiple diagnoses including flaccid hemiplegia and dysphagia, did not receive her prescribed dose of hydrocodone-acetaminophen on two occasions. The narcotic count sheet indicated the medication was not removed for her dose on one of these occasions. Similarly, Resident 51, diagnosed with Parkinson's disease and dementia, missed doses of hydrocodone-acetaminophen and warfarin. The narcotic count sheet showed discrepancies, suggesting possible drug diversion, as the medication was signed out but not documented as administered in the electronic medical record (eMAR). The facility also failed to obtain daily weights for Resident 65, who has acute respiratory failure and congestive heart failure, as per physician orders. The clinical record lacked documentation of daily weights on several specified dates, and there was no indication of resident non-compliance. Interviews with nursing staff revealed that daily weights were supposed to be obtained by CNAs and reported to nurses, but this process was not consistently followed. The Director of Nursing (DON) acknowledged the failure to monitor daily weights effectively, noting that the position responsible for this task was vacant until recently. The facility's policies for medication administration and resident weight monitoring were not effectively implemented. The medication administration policy was not provided, and the weight monitoring policy required weights to be taken no less than monthly or as per physician orders. The DON and nursing staff interviews highlighted gaps in the documentation and monitoring processes, contributing to the deficiencies in medication administration and weight monitoring.
Failure to Prevent Falls for Cognitively Impaired Resident
Penalty
Summary
The facility failed to provide adequate supervision and implement immediate, resident-centered interventions to prevent falls for a cognitively impaired resident. The resident, who had severe cognitive impairment due to vascular dementia and Alzheimer's disease, was observed with injuries consistent with a recent fall. Despite having a physician's order to use a walker for mobility, the resident was frequently seen ambulating without it, leading to multiple falls. The resident's care plan included interventions such as keeping personal items within reach and encouraging the use of a walker, but these were not effectively implemented. The resident experienced several falls, both witnessed and unwitnessed, with varying degrees of injury. On multiple occasions, the resident was observed wandering without her walker, and staff failed to redirect her or ensure she used her walker. Video surveillance footage showed the resident wandering without assistance, and staff did not intervene to prevent her from entering other residents' rooms, which was a known risk factor for her falls. The facility's policy on fall management was not adequately followed, as evidenced by the lack of immediate new interventions after falls and the absence of a stop sign across doorways, which was a known effective method of redirection for the resident. Interviews with staff revealed that the resident was known to wander frequently and required constant reminders to use her walker. However, on the day of the fall resulting in significant injuries, staff did not provide the necessary supervision or redirection. The resident's fall management plan was not effectively implemented, as evidenced by the continued falls and lack of immediate interventions. The facility's failure to provide adequate supervision and implement resident-centered interventions contributed to the resident's repeated falls and injuries.
Verbal Abuse by Staff Member
Penalty
Summary
The facility failed to prevent verbal abuse by a staff member towards a resident. The incident involved Nurse Aide (NA) 6 and Resident C. NA 6 was overheard by CNA 8 using inappropriate language towards Resident C, specifically whispering 'Shut the f--k up' while providing care. This incident was reported immediately by CNA 8 to the Assistant Director of Nursing (ADON), and NA 6 was subsequently suspended and later terminated after admitting to the inappropriate language during an interview with the Administrator and the Director of Nursing (DON). Resident C, who was on hospice and not alert and oriented, did not hear the inappropriate language and showed no signs of distress according to Social Services follow-up. However, the use of such language was considered verbal abuse as per the facility's policy on abuse prohibition, reporting, and investigation. The incident occurred when NA 6 was called in on his day off and arrived at the facility frustrated and not in uniform. He was supposed to assist CNA 8 in the Memory Care Unit. During the shift, NA 6 displayed a poor attitude and was not actively assisting with resident care. When asked to help change Resident C, who was in pain and moaning, NA 6 stood by the bedside looking at his phone and then whispered the inappropriate language. CNA 8 immediately reported the incident to the ADON, who then escorted NA 6 out of the building. The facility's investigation included interviews with the involved staff members and a review of the incident. NA 6 admitted to using inappropriate language out of frustration. The facility's policy defines verbal abuse as the use of oral, written, or gestured language that includes disparaging and derogatory terms to residents or their families, regardless of their ability to comprehend. The incident was documented, and NA 6 was disciplined according to the facility's policy on abuse prohibition.
Failure to Account for Controlled Medications at Time of Administration
Penalty
Summary
The facility failed to ensure controlled medications were accounted for at the time of administration in the Memory Care Unit. During a narcotic count observation, an LPN indicated she needed to sign off the controlled drugs given that morning before completing the narcotic count. She had been sidetracked by a resident who was screaming. The medications for multiple residents, including lorazepam, tramadol, and hydrocodone-acetaminophen, were signed out during the observation for various times earlier that morning. During an interview with the DON, it was revealed that the facility did not have a specific policy for signing off controlled medications, although the expectation was that nurses would sign off medications as they administered them. The DON provided a skills check-off titled Medication Administration Observation, which indicated that controlled medications should be signed out at the time of removal. This deficiency was related to Complaint IN00433743.
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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