University Park Rehabilitation And Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Fort Wayne, Indiana.
- Location
- 1400 Medical Park Dr, Fort Wayne, Indiana 46825
- CMS Provider Number
- 155567
- Inspections on file
- 45
- Latest survey
- February 19, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at University Park Rehabilitation And Healthcare during CMS and state inspections, most recent first.
The facility did not ensure that an RN was on duty for 8 consecutive hours each day, as required. Review of the nursing schedule and time clock records showed that on several days, the only RN present worked less than 8 hours, and there was no documentation to confirm that the DON or ADON provided the remaining required coverage.
Surveyors found that food items in the kitchen and unit refrigerators were not consistently labeled, dated, or properly stored, with some leftovers left uncovered and undated. Staff were observed not following hygiene protocols, including a CNA entering the kitchen without a hairnet. Facility policies requiring labeling, dating, and separation of resident and staff food were not followed, affecting all residents served by the kitchen.
The facility did not maintain ongoing QAPI oversight for previously identified deficiencies involving labeling and dating food items in the kitchen and proper maintenance of facility waste in the dumpster. After a period of review, these issues were closed without continued monitoring or inclusion in the QAPI program, despite being cited in a prior survey.
Surveyors observed that air vents and return air ducts in multiple units were covered with numerous grey dust clumps, with dust falling onto surfaces when covers were opened. The Maintenance Director and Administrator confirmed that filters and vent covers were cleaned monthly, but high-traffic areas near the residents' smoking area accumulated significant dust. Facility policy required monthly cleaning and dust removal from vents.
The facility did not ensure accurate and consistent weight monitoring for two residents, resulting in significant discrepancies in recorded weights. One resident with failure to thrive and diabetes had fluctuating weights without documentation of refusals, and reweights requested by the dietician were not always obtained. Another resident with chronic conditions also had large variations in weight records, despite facility policy requiring accuracy. Staff interviews and documentation revealed inconsistent weighing practices.
A resident with cognitive impairment and a history of substance abuse repeatedly exhibited behaviors such as yelling, refusal of medications, and emotional distress. The care plan did not address these specific behaviors or triggers, and staff were not consistently aware of or addressing the resident's needs as required by facility policy.
Medications and biologicals were found to be improperly stored and labeled in two medication storage areas. Expired Pulmicort was present in the medication room, open vials of insulin lacked opened dates, and an expired bottle of Konvomep was not refrigerated as required. Interviews with an LPN and the DON confirmed these practices were not in line with facility policy.
A resident with diabetes and other health conditions had two blood glucose readings above 500 mg/dL, but the physician was not notified as required by facility policy. An LPN confirmed that such notification was expected, and the facility's policy supported this requirement.
The facility did not ensure snacks were consistently available to all residents during nighttime hours. A resident reported that snacks were often gone in the evening and not suitable for those with diabetes or dental issues, while others noted that snacks were sometimes taken by a few individuals, leaving none for others. Staff confirmed that snacks were only available when delivered by dietary staff, and when they ran out, there was no way to provide more, as staff could not access the kitchen.
Garbage and refuse were observed improperly contained, with dumpster lids and doors left open and trash bags hanging out, leading to scattered refuse in the lawn, parking lot, and sidewalks. Staff interviews confirmed that dumpsters should be kept closed and trash should not be present in outdoor areas, but facility policy was not consistently followed.
An LPN failed to follow infection control protocols by not disinfecting equipment after use on a resident, not performing hand hygiene after glove removal and before handling medication carts, and by handling a water pitcher and ice scoop without hand hygiene. These actions were not consistent with facility policies as confirmed by nursing leadership.
A resident with multiple chronic conditions experienced a fall and later showed an acute change in mental status, including confusion and unclear speech. The facility failed to notify the physician of these changes in a timely manner, as required. The Administrator acknowledged the need for physician notification, but no policy was provided by the facility regarding this process.
A facility failed to accurately code a quarterly MDS assessment for a resident with a history of chronic conditions and pressure ulcers. Upon readmission after hospitalization, the resident had pressure wounds, but the initial MDS assessment inaccurately reported no unhealed pressure ulcers. A subsequent assessment corrected this error, indicating an unhealed pressure ulcer. The facility's staff acknowledged the need to follow RAI guidance for accurate assessments.
A facility failed to monitor and assess a resident with a history of substance use disorder and multiple falls. The resident was hospitalized after several falls and tested positive for illegal drugs, despite not using drugs or alcohol in the past year. The facility lacked a care plan for relapse or positive drug tests, and staff were unaware of the positive test results. The facility did not have a policy for monitoring residents with substance use diagnoses who tested positive for drugs.
A facility failed to ensure an effective behavior care plan and proper documentation for a resident with mental disorders, including schizophrenia and bipolar disorder. The resident, with a history of UTIs, reported inappropriate touching by staff, leading to hospitalization. Despite ongoing delusions and hallucinations attributed to a UTI, these behaviors were not documented as required. Staff interviews revealed a lack of documentation and monitoring, contributing to the deficiency.
The facility's kitchen was found to be unsanitary, with issues such as open and undated food items, an open back door near dumpsters, and inadequate handwashing by staff. The kitchen floor was dirty, and there was a lack of housekeeping staff to clean it. These deficiencies indicate a failure to maintain food safety and hygiene standards.
The facility failed to ensure proper labeling and dating of food products, as identified during an annual survey. Despite having a policy requiring foods needing temperature control to be labeled and dated, these procedures were not followed. The QAPI committee, responsible for reviewing dietary services, did not include a Performance Improvement Plan for dietary in their reviewed plan, indicating a lack of effective communication and documentation.
The facility failed to maintain a clean environment in four resident rooms, with issues such as urine odors, dirty floors, and uncleaned mattresses. Observations showed inadequate cleaning practices, and interviews revealed challenges in maintaining cleanliness due to resident behavior. The facility's cleaning schedules and policies were not effectively implemented in the affected areas.
A resident with right-sided weakness and a history of falls was observed leaning to the right in their wheelchair, indicating a failure by the facility to maintain correct posture. The care plan lacked specific interventions and assistive devices to address the resident's postural issues, despite therapy evaluations and staff awareness of the problem.
A resident with a history of traumatic brain injury and vascular dementia was observed leaning dangerously in their wheelchair, increasing their fall risk. Despite multiple falls and a high fall risk score, the care plan did not address the resident's tendency to lean to the right. Facility staff were unaware of the need for specific interventions to mitigate this risk, leading to inadequate supervision and fall prevention measures.
A facility failed to maintain respiratory equipment properly for a resident, leading to potential contamination. A face mask was found unbagged and undated on a nebulizer machine, and a suction machine with a full container and open tube was observed without dates. The resident required tracheostomy care and had a history of cerebral infarction and acute respiratory failure. Facility policies required weekly replacement and labeling of equipment, but these were not followed.
The facility failed to identify and address trauma triggers and mental health needs for two residents with PTSD, anxiety, and depression. Care plans lacked specific focuses on these conditions and did not include resident-specific behaviors or stressors. Staff interviews revealed a lack of awareness regarding the residents' triggers and mental health diagnoses, contributing to deficiencies in care.
The facility failed to secure medications for two residents, leading to deficiencies in medication management. One resident had unsecured Tylenol pills left on the bedside table, with no assessment for self-administration. Another resident had a bottle of povidone iodine left unsecured on the dresser, with no orders for self-administration. Facility policy required medications to be secured and ingested under supervision.
The facility failed to properly contain and dispose of garbage and refuse, as observed during a survey. The kitchen door was propped open, and the dumpster lids were open with trash bags inside. Trash and food debris were scattered around the dumpster and parking lot, with numerous cigarette butts on the pavement. Staff interviews confirmed that the dumpster lids should be closed and the area kept clean, as per facility policy.
Failure to Maintain 8-Hour Consecutive RN Coverage
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for 8 consecutive hours each day, as required. Review of the nursing schedule for the period of 4/3/25 through 4/10/25 showed that on multiple days, the only RN scheduled worked less than 8 consecutive hours. Specifically, on 4/4/25, 4/5/25, and 4/7/25, the RN's time clock entries indicated shifts significantly shorter than 8 hours. The Director of Nursing (DON) stated that on some days, the DON or Assistant Director of Nursing (ADON) covered the remaining hours, but there was no time clock or other documentation available to confirm that the 8-hour RN coverage requirement was met on those days. At the time of the survey exit, the facility could not provide evidence that the consecutive 8-hour RN coverage was maintained.
Failure to Properly Store, Label, and Date Food Items and Ensure Employee Hygiene
Penalty
Summary
The facility failed to ensure proper food storage, labeling, dating, and employee hygiene practices in the kitchen and unit refrigerators. Observations revealed multiple open food items in the walk-in cooler and freezer, such as a container of bananas foster, a bag of parsley, strawberries, and corn, that were not labeled or dated. Additionally, leftover salads and fruit cocktail were left uncovered and undated on a cart adjacent to the tray line, and these items were not properly stored or discarded. The Dietary Manager confirmed that these practices did not align with facility policy, which requires all leftovers and opened produce to be labeled, dated, and covered. Furthermore, a Certified Nurse Aide was observed in the kitchen without a hairnet, contrary to the facility's hygiene policy. Additional observations in unit refrigerators showed containers of grapes, cheese and crackers, and other food items without labels or dates, some of which belonged to residents and others to staff. Items such as ice cream and a candy bar were also found without proper labeling or dating. Staff interviews confirmed that all items should be labeled with the resident's name and date, and that staff should not store personal food in resident-designated refrigerators. The facility's policies on food preparation, handling, and storage were not followed, resulting in the deficiency affecting all residents served by the kitchen.
Failure to Sustain QAPI Oversight for Kitchen and Waste Deficiencies
Penalty
Summary
The facility failed to maintain an ongoing process within its Quality Assurance and Performance Improvement (QAPI) program to address and prevent the recurrence of previously identified deficiencies. Specifically, during an annual survey, surveyors found non-compliance related to labeling and dating food items in the kitchen and the maintenance of facility waste in the dumpster. Although these issues were identified and the facility committed to correcting them, a review of the current QAPI program revealed that performance improvement plans did not include ongoing monitoring or actions related to these specific deficiencies. The Administrator confirmed that after six months of review, the concerns were considered closed and the QAPI team shifted focus to other areas, without ensuring sustained improvement in the previously cited areas.
Failure to Maintain Clean and Sanitary Air Vents Throughout Facility
Penalty
Summary
The facility failed to maintain a clean and sanitary environment on all three units observed, affecting 65 residents. During a facility tour, multiple air vents were found to be covered with numerous grey clumps of dust, including those above the 200 hall nurses' station, near the 300-hall entrance, and near a resident room. Further observation revealed pencil eraser-sized grey clumps on the vented cover of a return air duct above the hallway near the east nurses' station, and when the Maintenance Director opened the cover, clumps of dust fell onto the nurses' station counter and floor. The filter inside the return air duct, dated 3/26/25, was visibly covered in dust. Interviews with the Maintenance Director and Administrator confirmed that filters and vent covers were scheduled for monthly cleaning, and that the area in question typically accumulated significant dust due to its proximity to the residents' smoking area and high traffic. Facility policy required monthly cleaning of exhaust fans and removal of dust from vents.
Failure to Ensure Accurate Weight Monitoring for Two Residents
Penalty
Summary
The facility failed to ensure accurate weights were obtained for two residents, resulting in inconsistent and unreliable weight records. For one resident with diagnoses including adult failure to thrive, major depressive disorder, and type 2 diabetes, the medical record showed significant fluctuations in recorded weights over several months, with no documentation of weight refusals. The care plan identified the resident as severely underweight and required regular weight monitoring and reporting of significant changes. However, progress notes indicated that reweights requested by the dietician were not always obtained, and staff did not consistently use the same scale or subtract wheelchair weight as needed. The Director of Nursing acknowledged noticing weight inconsistencies and attributed them to improper weighing practices. Another resident with multiple chronic conditions, including heart failure and chronic kidney disease, also had significant discrepancies in recorded weights, with large variations between measurements. The facility's policy required accurate and consistent weight measurement, including zeroing the scale and immediate recording, but the documented weights for this resident showed substantial differences within short timeframes. Staff interviews confirmed that unusual weight readings were to be reported, but the records did not reflect consistent adherence to these procedures.
Failure to Provide Resident-Specific Behavioral Health Interventions
Penalty
Summary
The facility failed to provide resident-specific behavioral health interventions for a resident with multiple diagnoses, including congestive heart failure, emphysema, cognitive communication deficit, and a history of substance abuse. The resident exhibited ongoing behaviors such as frequent yelling, refusal of medications and care, and expressions of emotional distress, including being tearful and missing family. Despite repeated documentation of these behaviors and their ineffectiveness to redirection, the care plan did not address these specific behaviors or identify resident-specific stressors. The care plan only included general interventions such as encouraging socialization, providing non-judgmental support, and offering psychiatric services as needed. Staff interviews revealed that the Social Service Director was not aware of the resident's specific behaviors, such as yelling and refusal of medications, until they were noted in behavior logs and report sheets. Regular interdisciplinary team meetings, where new behaviors would typically be reviewed, had not occurred during the week due to the annual state survey. Although the resident had signed up for substance abuse counseling, they refused to participate in the sessions. Facility policy required precise documentation of behaviors and inclusion of identified behaviors in the resident's plan of care, which was not followed in this case.
Improper Storage and Labeling of Medications
Penalty
Summary
Surveyors observed that medications and biologicals were not properly stored and labeled in two of four storage areas. In the 200 hall medication room, six out of seven boxes of Pulmicort were found to be expired. In the 200 hall medication cart, two open vials of insulin lacked an opened date, and a bottle of liquid Konvomep was expired and not refrigerated as required by its label. Interviews with an LPN and the Director of Nursing confirmed that expired medications should be removed and that opened medications should be labeled, in accordance with facility policy. The facility's policy also states that medications requiring refrigeration should not be stored in the medication cart and that outdated medications should be removed immediately from stock.
Failure to Notify Physician of Critically High Blood Glucose Results
Penalty
Summary
The facility failed to notify the physician of significant abnormal laboratory results for a resident with diagnoses including type 2 diabetes, obesity, depression, and hypertension. Record review revealed that the resident had two critically high blood glucose readings, one at 527 mg/dL and another at 560 mg/dL, both of which exceeded the facility's policy threshold for physician notification (>500 mg/dL). Progress notes did not indicate that the physician was notified of either result. During an interview, an LPN confirmed that it was facility policy to notify a physician when a glucose measurement was over 500 mg/dL. The current policy, as provided by the DON, also required physician notification for glucose levels above 500 mg/dL.
Failure to Provide Consistent Nighttime Snack Availability
Penalty
Summary
The facility failed to ensure that snacks were consistently available to residents during nighttime hours, as required by policy and resident needs. Observations revealed that the west hall refrigerator only contained a few resident-labeled snack packages, with no general snacks accessible to all residents, and no dry snack storage was present on the unit. Interviews with staff confirmed that general snacks were not stored on the unit and were only available when delivered by kitchen staff. When snacks were delivered, they were distributed to residents, but leftovers were kept at the nurses' station and often ran out, leaving nothing available for residents during the night. Multiple residents reported that snacks were frequently unavailable in the evening and nighttime, with some noting that available snacks were not suitable for diabetic residents or those with dental issues. Residents also described situations where snacks were taken by a few individuals, leaving others without access. Staff interviews corroborated these accounts, indicating that when snacks ran out, there was no way to provide more, and staff were not permitted to access the kitchen to obtain additional food. The facility's policy required snacks to be offered at bedtime, but this was not consistently achieved.
Improper Containment and Disposal of Garbage and Refuse
Penalty
Summary
Garbage and refuse were not properly contained within the facility's dumpster during multiple observations. On two separate occasions, the dumpster was found with its lid or side door open, and trash bags were observed partially hanging out. There were multiple tears in the trash bags, with items such as fast-food cups, lids, straws, and other refuse visible and accessible. Additionally, various types of trash, including cups, snack wrappers, gloves, and cigarette packs, were found scattered throughout the lawn, parking lot, sidewalks, and grassy enclosures near the dumpster area. Interviews with facility staff confirmed that all dumpster doors and lids should be closed to prevent rodent access and that trash should not be present in the surrounding outdoor areas. The facility's policy required the maintenance supervisor or designee to verify that dumpster lids were closed three times daily after each meal service, and that waste should be stored to protect it from animals. Despite these policies, the observations indicated that proper procedures were not consistently followed, resulting in the deficiency.
Failure to Follow Infection Control Procedures During Resident Care
Penalty
Summary
The facility failed to maintain proper infection prevention and control procedures during multiple observed instances involving a licensed practical nurse (LPN). In one case, the LPN placed a laptop on a resident's mattress during a blood glucose measurement, allowing the resident's covered foot to come into contact with the device. After use, the LPN did not disinfect the laptop or the glucometer before placing them on the medication cart and storing the glucometer in a drawer. The LPN stated that the glucometer was only used for that resident. Additionally, the LPN was observed administering an intramuscular injection while wearing gloves, but did not perform hand hygiene after removing the gloves and before touching the medication cart. In another instance, the LPN handled a water pitcher and ice scoop without performing hand hygiene after returning from the medication room. Interviews with the Assistant Director of Nursing (ADON) and Director of Nursing (DON) confirmed that these actions were not in accordance with facility policies, which require cleaning and disinfecting equipment between uses and performing hand hygiene at specified times.
Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to notify the physician of a change in condition for a resident following a fall. The resident, who had diagnoses including non-alcohol related cirrhosis of the liver with liver cancer, dementia, and other chronic conditions, was admitted for rehabilitation services after a fall that resulted in a fractured neck vertebrae. On a specific date, the resident was found on the floor next to his bed, having slid out of it, but was initially reported to have no apparent injuries and was alert and oriented. However, later that day, the resident exhibited an acute change in mental status, including confusion and unclear speech, which was not communicated to the physician or Nurse Practitioner until later that night. The facility's documentation did not indicate that the physician was notified of the resident's acute change in mental status and unclear speech until several hours after the incident. The Administrator confirmed that the physician should be notified of such changes and that this notification should be documented in the resident's record. However, there was no policy provided by the facility regarding the notification of changes in resident condition to the physician.
Inaccurate MDS Assessment for Resident with Pressure Ulcers
Penalty
Summary
The facility failed to ensure an accurate quarterly Minimum Data Set (MDS) assessment for a resident, identified as Resident F, who was reviewed for assessments. Resident F had a medical history that included chronic obstructive pulmonary disease, chronic kidney disease, and lymph edema. Following a hospitalization for encephalopathy, the resident was readmitted to the facility with a pressure area on her left heel and a pressure wound on her right ankle. However, the quarterly MDS assessment dated 10/3/24 inaccurately indicated that Resident F had no unhealed pressure ulcers, despite the presence of these wounds. A subsequent MDS assessment dated 10/4/24 corrected this error, indicating that Resident F had one unhealed pressure ulcer, which was unstageable with suspected deep tissue injury. The facility's Administrator and Regional Nurse Consultant acknowledged that MDS assessments should be completed according to the Resident Assessment Instrument (RAI) guidance, which requires reviewing medical records, interviewing direct care staff, and examining the resident to accurately code skin conditions. This deficiency was related to a complaint identified as IN00447233.
Failure to Monitor Resident with Substance Use Disorder
Penalty
Summary
The facility failed to ensure proper monitoring and assessments for a resident with a history of substance use disorder and multiple falls. Resident C, who had a history of substance use disorder, was hospitalized following multiple falls and an acute illness. During hospitalization, a urine drug test was positive for illegal drugs, although the resident had not used drugs or alcohol in the past year. The facility was aware of the resident's substance use disorder prior to admission but did not have a care plan addressing potential relapse or positive drug tests. Resident C had several falls within a short period, and staff noted increased drowsiness, which led to adjustments in her medication regimen. Despite these adjustments, the resident continued to experience falls and was found to have a positive urine drug screen for substances she was not prescribed. The facility's guidelines for residents with a history of substance abuse included random drug screens and potential medication adjustments, but there was no specific care plan for addressing a relapse or positive drug test results. Interviews with staff revealed a lack of awareness regarding the resident's positive drug test and the necessary monitoring or assessments following such results. The facility did not have a policy or procedure for monitoring or assessing residents with a substance use diagnosis who tested positive for drugs. This lack of protocol and communication contributed to the facility's failure to adequately address the resident's condition and ensure her safety.
Failure to Document and Monitor Behavioral Health in Resident with Mental Disorders
Penalty
Summary
The facility failed to ensure an effective behavior care plan, behavioral assessments, behavior monitoring, and documentation for a resident diagnosed with multiple mental disorders, including major depressive disorder, bipolar disorder, and schizophrenia. The resident, who also had a history of urinary tract infections (UTIs), was not adequately monitored for changes in behavior associated with these infections. Despite having a care plan that included interventions for managing her mental health conditions, the plan did not account for her history of UTIs and the associated behavioral changes. On one occasion, the resident reported inappropriate touching by a staff member, which led to her being transported to the hospital. Upon her return, she continued to exhibit delusions and hallucinations, which were attributed to a UTI. However, these behaviors were not documented in the progress notes as required by the facility's policy. The resident's care plan was not updated to reflect her recent experiences and the potential impact of UTIs on her mental state. Interviews with facility staff, including the Director of Nursing and a Licensed Practical Nurse, revealed that there was a lack of documentation regarding the resident's behaviors and the history of UTIs. The facility's policy on behavioral assessment and monitoring was not followed, as there was no thorough evaluation of the resident's changing behavioral symptoms, nor was there documentation of any improvements or worsening in her condition. This oversight contributed to the deficiency in providing appropriate care for the resident's mental health needs.
Sanitation and Food Safety Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to maintain the kitchen in a sanitary manner, affecting the food safety for all 59 residents who consumed meals prepared there. During an observation, red spots of dried liquid were found on the wall near the kitchen entry door, and a partially eaten piece of toast with jelly and a Styrofoam cup filled with oatmeal were left unattended in the meal service area. The back door leading to the outside was left open, allowing potential contamination from the nearby dumpsters. In the dry storage area, an open bag of thickener was exposed to air, and in the walk-in cooler, various food items were uncovered, undated, and open to air, including mixed fruit, chocolate pudding, parmesan cheese, shredded cheese, chopped lettuce, shredded carrots, hot dogs, and sliced black olives. Additionally, the kitchen floor was observed to be dirty with numerous spots and crumbs, and there was a lack of housekeeping or maintenance staff to clean it. The facility's staff also failed to adhere to proper handwashing protocols. The Dietary Manager washed her hands for only 11 seconds, and another staff member rinsed her hands for just 5 seconds after dropping a serving spoon on the floor. The facility's policies on employee hygiene, food safety, and sanitation were not followed, as evidenced by the lack of labeling, covering, and dating of food items, and the absence of an internal thermometer in the walk-in cooler and freezer. These deficiencies indicate a significant lapse in maintaining food safety and hygiene standards in the facility's kitchen.
Deficiency in Food Labeling and Dating Practices
Penalty
Summary
The facility failed to implement a process to identify and correct deficiencies, specifically regarding the labeling and dating of food products. During the annual survey, noncompliance was identified in the kitchen sanitation practices, particularly in the labeling and dating of food items. The facility had a policy in place that required all foods needing temperature control to be labeled, covered, and dated, and for opened food packages to be marked with the open date to determine when to discard them. However, the survey findings indicated that these procedures were not being followed, leading to the deficiency. The QAPI committee, which included various department heads such as the Executive Director, DON, and Director of Food Services, was responsible for reviewing segments of care, including dietary services, in their monthly meetings. Despite dietary being an ongoing topic in these meetings, the Performance Improvement Plan (PIP) for dietary was not included in the reviewed QAPI Plan. This oversight suggests a lack of effective communication and documentation within the committee, contributing to the recurrence of the deficiency in food labeling and dating practices.
Facility Fails to Maintain Clean Environment in Resident Rooms
Penalty
Summary
The facility failed to maintain a clean and safe environment in four out of five rooms reviewed, affecting four residents. Observations revealed multiple cleanliness issues, including yellow/orange spots on the floor near a resident's bed with a foley catheter, wadded up incontinence pads, and a strong urine odor in Resident 35's room. Resident 14's room had gray spots and sticky marks consistent with wheelchair wheels. Resident 5's room had dirty clothes on the floor, and Resident 32's room had a pervasive urine odor emanating into the hall, which was attributed to the mattress by the Assistant Director of Nursing. The facility's housekeeping schedules indicated that rooms in the 300 Hall were cleaned on specific dates, but the cleaning was insufficient to address the observed issues. Interviews with the Chief Nursing Officer and the Executive Director revealed challenges in maintaining cleanliness due to residents refusing to bathe or leave their rooms. The facility's Quality Assurance and Performance Improvement plan focused on other halls, with no indication that the 300 Hall was included. The facility's policy required daily cleaning, including sweeping, mopping, and washing mattresses if needed, but these procedures were not adequately followed in the affected rooms.
Failure to Maintain Resident's Posture in Wheelchair
Penalty
Summary
The facility failed to provide adequate care to maintain correct posture for a resident, identified as Resident 4, who was observed multiple times leaning to the right side while seated in a wheelchair. Despite staff interventions to assist the resident into an upright position, the resident continued to lean, indicating a lack of effective measures to address the issue. The resident's medical history included generalized muscle weakness, wheelchair dependence, and right-sided weakness due to a traumatic brain injury, which contributed to their difficulty in maintaining an upright posture. The resident's care plan did not adequately address the risk of leaning to the right while in the wheelchair, nor did it include necessary assistive devices to prevent this posture. Although the resident had been evaluated by therapy services, the care plan lacked specific interventions to address the resident's postural issues. The resident had a history of falls and injuries related to their right-sided weakness, yet the care plan did not reflect these risks or provide appropriate strategies to mitigate them. Interviews with facility staff revealed a lack of awareness and action regarding the resident's postural needs. The Chief Nursing Officer and Physical Therapy Assistant acknowledged the resident's refusal of assistive devices and therapy recommendations but did not ensure these were incorporated into the care plan. The facility's policy required care to prevent functional decline, yet the resident's posture and associated risks were not adequately managed, leading to the deficiency identified by surveyors.
Inadequate Supervision and Fall Risk Management for Resident
Penalty
Summary
The facility failed to provide adequate supervision and address the risk of falls for a resident, identified as Resident 4, who was observed multiple times leaning dangerously to the right side while seated in a wheelchair. Despite being assisted occasionally by staff to an upright position, the resident was often left in a precarious position without further assistance. The resident's care plan did not address the specific issue of leaning to the right, which was a significant factor in their fall risk. Resident 4 had a complex medical history, including traumatic brain injury, generalized muscle weakness, and vascular dementia, contributing to their impaired mobility and increased fall risk. The resident's care plan acknowledged various risk factors for falls but failed to include interventions specifically targeting the resident's tendency to lean to the right in their wheelchair. Despite multiple falls and a high fall risk score, the care plan lacked specific actions or interventions to mitigate the risk associated with the resident's leaning posture. Interviews with facility staff, including the Chief Nursing Officer and a Physical Therapy Assistant, revealed a lack of awareness and action regarding the resident's leaning posture and its contribution to falls. The facility's policy required a resident-centered plan of care for fall risks, but this was not adequately implemented for Resident 4. The resident's fall risk assessments consistently indicated high scores, yet no new interventions were added to address the ongoing issue of falls, particularly those related to the resident's posture in the wheelchair.
Failure to Maintain Respiratory Equipment Properly
Penalty
Summary
The facility failed to maintain respiratory equipment properly for a resident, leading to potential contamination. During an observation, a respiratory face mask was found lying on top of a nebulizer machine without a bag or date, and cloudiness was noted on the edges of the mask. Additionally, a suction machine with a container full of cloudy liquid and an open tube was observed, with no dates on the container or tubing. The resident involved had a history of cerebral infarction, type 2 diabetes, and acute respiratory failure, and required tracheostomy care and suctioning. The facility's policies required that respiratory equipment, including nebulizer masks and tubing, be replaced weekly, labeled, and dated. However, these guidelines were not followed, as indicated by the Corporate Nursing Officer, who confirmed that the equipment should have been bagged, dated, and covered. The facility's policy on tracheostomy care did not address storage guidelines for respiratory equipment not in use, and no additional policies were available for review.
Failure to Address Trauma Triggers and Mental Health Needs
Penalty
Summary
The facility failed to ensure that triggers were identified, communicated, and interventions were in place to avoid or alleviate re-traumatization for two residents, Resident 2 and Resident 22. Resident 2 was observed with a flat facial expression and avoided eye contact during an interview. The resident's medical history included anxiety, major depressive disorder, nicotine use, and PTSD. Despite having a care plan that addressed psychosocial impairment, the plan did not include specific focuses for anxiety, depression, delusions, paranoia, or PTSD. Additionally, the care plan lacked details on resident-specific behaviors, signs of distress, and stressors such as loud noises, touch, affection, or certain smells. Resident 22, who was observed sitting in a wheelchair and smiling, reported experiencing bad feelings related to being a trauma survivor. The resident's medical history included generalized anxiety disorder, major depressive disorder, traumatic brain injury, impulsiveness, nicotine use, and PTSD. Although the resident's care plan addressed altered activity patterns and risk of impaired safety, it did not include a focus on depression, anxiety, or PTSD. The care plan also failed to identify resident-specific behaviors, signs of distress, and stressors such as changes in routine or living arrangements. Interviews with facility staff revealed a lack of awareness regarding the residents' triggers and mental health diagnoses. A Qualified Medication Aide was unaware of Resident 22's triggers and plans for relocation, while the Chief Nursing Officer was not informed about the facility's process for monitoring behaviors or the absence of care plans for mental health diagnoses. The facility's policy required identifying trauma survivors and their triggers, but this was not effectively implemented, leading to deficiencies in the care provided to the residents.
Medication Security Deficiencies
Penalty
Summary
The facility failed to ensure medications were secured for two residents, leading to deficiencies in medication management. For one resident, two Tylenol pills were left unsecured on the bedside table, with the resident indicating that the nurse had left them for him to take at his convenience. The resident, who was cognitively intact, was not informed that medications needed to be secured if not taken immediately. The Chief Nursing Officer confirmed that there was no assessment for the resident to self-administer medications, and the facility's policy required staff to ensure medications were ingested before leaving the room. In another instance, a bottle of povidone iodine was left unsecured on a resident's dresser, visible from the hallway. The resident explained that staff left the dressing supplies in the room for convenience. The resident had mild cognitive impairment and a stage 3 pressure ulcer, with physician orders for wound care involving the iodine solution. There were no physician orders or assessments for self-administration of medications for this resident. The facility's policy required all medications to be secured in a locked storage area, accessible only to authorized personnel.
Improper Garbage Disposal and Containment
Penalty
Summary
The facility failed to ensure proper containment and disposal of garbage and refuse, as observed during a survey. The kitchen door leading to the outside loading dock was found propped open, with all kitchen staff occupied at the opposite end of the kitchen. The dumpster, located approximately 34 feet from the kitchen door, had its lids open with bags of trash inside. Additionally, a bag of trash was observed torn open on the ground in front of the dumpster. Various food debris, including partial pieces of pizza, open Chinese food containers, fast food cups, straws, bags, soda bottles, cans, used gloves, lip balm, plastic bags, and other debris, were scattered around the dumpster, in the grassy area nearby, and throughout the parking lot. Numerous cigarette butts were also noted on the pavement in the loading area. Interviews with staff revealed that all departments were responsible for ensuring the dumpster lids were closed and that no trash was left on the ground. The Regional Director of Operations confirmed that the dumpster lids should be closed, and the area around the dumpster should be free of debris. Additionally, the kitchen door should not be propped open when unattended. The facility's policy, titled "Store, Distribute, and Serve Food Safely and Disposal of Garbage and Refuse," dated November 2022, was reviewed and indicated that dumpsters should always remain covered, with no garbage on the ground, and waste properly contained. The policy also stated that loading docks used for garbage and clean food transport should be kept clean and free of debris, and the garbage storage area should be maintained in a sanitary condition to prevent pest harborage and feeding.
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Surveyors observed that dietary staff repeatedly worked in kitchen and meal service areas with uncovered facial hair, despite facility policy and state sanitation requirements mandating effective hair restraints. Two dietary aides with short beards or mustaches were seen walking through food preparation areas, taking food temperatures, handling food, and plating meals at steamtables in dining rooms without any facial hair coverings, while the current policy required all hair, including facial hair, to be restrained to prevent contamination.
The facility failed to consistently provide and document required bed-hold policy notices when several residents were transferred to the hospital. In multiple cases, residents with dementia, psychotic disorders, COPD, chronic respiratory failure, altered mental status, and cerebral infarction were sent out for acute changes in condition, and while transfer notes reflected physician and family notifications, they lacked documentation that the bed-hold policy was discussed with the resident or responsible party. Notices of Transfer or Discharge often indicated a copy of the bed-hold policy was sent with the resident, but the records did not show signed and dated acknowledgment by the resident or appropriate representative, including in situations where a resident had moderate cognitive impairment, short-term memory issues, or a documented need for a proxy and a financial POA authorizing an agent for health care decisions.
Surveyors found that the facility failed to provide trauma‑informed and culturally competent care by not incorporating two residents’ extensive trauma histories and specific behavioral triggers into their care plans. One resident with documented homelessness, polysubstance abuse, severe accidents with multiple fractures, viral encephalitis with coma, physical and sexual abuse, loss of family contact, and a past suicide attempt had multiple behavior‑focused care plans that referenced identifying triggers but listed none and did not mention their physical, sexual, medical, or psychosocial trauma. Another resident with TBI from being struck by a truck, an 11‑month coma, long‑term state hospital residence, alleged shooting of a parent, and diagnoses including intermittent explosive disorder and borderline personality disorder had a PASRR identifying a specific trigger and notes of inappropriate sexual behavior, yet their care plans omitted these traumatic events, the identified trigger, and the sexual behavior. Staff interviews confirmed that residents were screened for trauma, but the trauma histories and triggers were not reflected in the individualized plans of care.
A resident with schizophrenia, post‑stroke hemiparesis, and mild cognitive impairment expressed feeling down and wanting to kill himself, but staff did not document asking about a specific plan, did not notify the physician or psychiatric NP as expected, and did not develop or update a care plan addressing depression or suicidal ideation. The SSD documented offering support and initiating 15‑minute checks once, but there was no further follow‑up or documentation of interventions after subsequent suicidal statements made in a care plan meeting with the resident’s father. The DON and Administrator reported that facility policy requires immediate notification of key staff, assessment for a plan and means of self‑harm, and thorough documentation, which were not carried out or reflected in the medical record for this resident.
A resident with schizophrenia, post-stroke hemiparesis, and mild cognitive impairment verbalized suicidal ideation, but the care plan did not address depression or suicidal thoughts, and required assessments and services were not accurately or timely documented. An SSD note recorded the resident saying he wanted to kill himself and referenced 15‑minute checks and a care plan update, yet the active care plan lacked depression/suicidal ideation interventions. Multiple late-entry Social Services notes were later added, describing follow-up visits and the resident denying suicidal ideation, but the SSD later reported she did not typically ask about a suicide plan and did not personally provide individual follow-up visits as described. These practices conflicted with the facility’s policy requiring factual, first-hand, and timely documentation of assessments and services.
A resident was observed with an Albuterol inhaler on an overbed table and later reported keeping the inhaler in a nightstand drawer, with no staff present during these observations. Record review showed the resident had no cognitive impairment on the admission MDS but lacked any documented self-medication administration assessment. The DON acknowledged that the required assessment had not been completed, despite facility policy requiring staff and the practitioner to evaluate each resident’s mental and physical abilities before allowing self-administration of medications.
Surveyors found that the facility submitted inaccurate direct care staffing data to CMS through the PBJ system over multiple days in a quarter. CASPER reports showed apparent gaps in 24-hour licensed nurse coverage, low weekend staffing, and a 1-star staffing rating, while internal staffing sheets documented that licensed nurses were present and the facility was fully staffed on those days. The Administrator reported that the discrepancies were due to PBJ data entry errors, despite a facility policy requiring all PBJ entries to be accurate, auditable, and verifiable against payroll, invoices, or contracts.
Surveyors found that the facility did not provide or document required written transfer/discharge notices and bed-hold policy information for four residents who were sent to the hospital, including individuals with conditions such as dementia, CHF, chronic respiratory failure, and CKD. In each case, progress notes showed that the resident was transferred for acute issues, but the clinical records lacked evidence that written notices were given to the residents or their representatives, and in one case lacked documentation that required information was sent to the receiving provider. Facility leadership, including the ADON, DON, and Administrator, acknowledged that the records did not contain the required documentation, despite a written policy requiring such notices and information exchange.
A resident with Alzheimer’s disease and depression, previously on an antidepressant, exhibited intermittent refusals of medications and care, occasional yelling at staff, and reports of unusual perceptions, such as believing men were in or near her room. Nursing notes over several months documented these refusals and complaints but did not show that the behaviors were evaluated or recorded as dangerous, non-redirectable, or causing significant distress, nor did they document specific non-pharmacological interventions attempted or their outcomes. Despite this, a psychiatric NP later added new diagnoses of schizoaffective disorder, borderline personality disorder, and delusional disorder and ordered an antipsychotic (Seroquel) without a comprehensive evaluation in the record to support these diagnoses. The facility’s psychotropic medication policy, which requires identification and documentation of target behaviors, use of nonpharmacological interventions, and ongoing behavior monitoring, was not followed for this resident.
The facility failed to keep PASARR Level I screenings accurate and current for three residents when new mental health diagnoses and psychoactive medications were initiated. One resident’s PASARR omitted a PTSD diagnosis and an added antidepressant, despite documentation of PTSD on the MDS and care plan and a physician order for Pristiq. Another resident’s PASARR listed only depression and dementia, even after additional diagnoses such as borderline personality disorder, delusional disorder, and schizoaffective disorder were added and an antipsychotic (quetiapine) was ordered, with the MDS later reflecting psychotic disorder, schizophrenia, and depression with antipsychotic and antidepressant use. A third resident’s PASARR did not include a depression diagnosis or newly ordered escitalopram and lorazepam, although the admission MDS documented depression with antianxiety and antidepressant use. These omissions occurred despite facility policy requiring a new Level I review after significant mental status changes, including new mental health diagnoses or new psychotropic medications.
Uncovered Facial Hair During Food Preparation and Meal Service
Penalty
Summary
The deficiency involves the facility’s failure to ensure that food was served in a sanitary and safe manner in accordance with professional standards and facility policy during multiple kitchen and meal service observations. During an initial kitchen observation, two dietary aides were seen walking through the kitchen food preparation area with uncovered facial hair. One aide had facial hair above and below the lip and along the jaw line, approximately one-fourth inch in length, and the other had a mustache of similar length; neither used any facial hair covering. These observations occurred while staff were present in the kitchen area where food was stored and prepared. During subsequent observations on the same day, the same two dietary aides were again observed with uncovered facial hair while directly involved in meal preparation and service. One aide walked through the kitchen while the noon meal was being prepared and placed into a transport cart for service in the south dining room, and later was observed plating the noon meal at the steamtable in that dining room, still without a facial hair covering. The other aide walked through the kitchen while the noon meal was being prepared and placed into the steamtable for the north dining room, took food temperatures, assisted with plating meals at the steamtable, and retrieved food items and supplies from the kitchen, all while having an uncovered mustache approximately one-fourth inch in length. The Dietary Manager stated that staff hair was to be covered when in the kitchen and during meal service, and the facility’s written policy and the cited Indiana Food Establishment Sanitation Requirements both required effective hair restraints, including for facial hair, to prevent contamination of food, equipment, and utensils.
Failure to Provide and Document Bed-Hold Policy at Time of Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure that required bed-hold policy information was provided and documented for four residents transferred to the hospital. For a resident with dementia, psychotic disorder, and autistic disorder who had a BIMS score of 0 indicating severe cognitive impairment, progress notes documented physician notification and guardian notification when the resident was sent to the hospital, but there was no documentation that the bed-hold policy was provided to the responsible party. A Notice of Transfer or Discharge later indicated a copy of the bed-hold policy was sent with the resident. Another resident with COPD and chronic respiratory failure, cognitively intact with a BIMS score of 13, experienced a decline in condition and was transferred to the hospital by ambulance; progress notes documented family notification but did not document any discussion of the bed-hold policy, although a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident. A third resident with altered mental status and cerebral infarction, with a BIMS score of 10 indicating moderate cognitive impairment and documented short-term memory impairment, experienced changes in condition and was transferred to the hospital. Progress notes stated the resident was their own responsible party and that no other notification was completed, and transfer documentation did not include the bed-hold policy, although an untimed Notice of Transfer or Discharge indicated a copy of the bed-hold policy was signed by the resident. A financial power of attorney document in the record showed the resident had designated an agent to act in consent or refusal of health care. For a fourth resident with dementia and osteomyelitis, transfer documentation and a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident, and the transfer form noted the resident required a proxy for decision making. The facility’s policy required that at the time of transfer to a hospital, written notice specifying the duration of the bed-hold policy and information on return to the next available bed be provided, and that a signed and dated copy of the bed-hold notice given to the resident or representative be kept in the resident file, which was not consistently documented for these residents.
Failure to Integrate Trauma Histories and Behavioral Triggers Into Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to identify and incorporate residents’ trauma histories and specific behavioral triggers into their care plans, despite documented histories of significant trauma and behavioral health issues. For one resident, extensive social service and progress notes documented homelessness, polysubstance abuse, major depressive and anxiety disorders, chronic pain, a history of severe car accidents with multiple fractures, viral encephalitis resulting in a three‑month coma, loss of child custody, multiple divorces, physical abuse by a spouse, the death of a fiancé who was struck by a car while in a wheelchair, lack of family contact, and a past suicide attempt by Valium overdose. Additional documentation noted a history of rape by a brother at age eight and prior placement under direct supervision and 15‑minute checks related to suicidal ideation. Despite these documented traumatic events and behavioral health concerns, the resident’s care plans did not identify a history of physical trauma, sexual trauma, homelessness, substance abuse, medical trauma, or attempted suicide. For this same resident, the MDS showed no cognitive deficit and identified behaviors such as verbal aggression and rejection of care, along with diagnoses including seizure disorder, depression, chronic pain syndrome, homelessness, and anxiety disorder. Multiple care plans addressed behaviors such as drug‑seeking, pretending to have seizures for attention or medication, making false allegations, verbal aggression when unable to smoke, and a desire for intimate relationships with consenting male residents. These care plans referenced goals such as effective coping skills, seeking staff support, and compliance with the smoking policy, and they called for identification and reduction of behavioral triggers. However, none of these care plans actually listed any specific triggers. The care plan addressing the resident’s right to consensual intimate relationships focused on assessment and education regarding consent but did not integrate the resident’s extensive trauma history. Staff interviews indicated the resident had displayed sexual behaviors since admission, including an incident where the resident expressed anger at another resident for not buying a soda after engaging in sexual acts. A second resident with a documented history of traumatic brain injury (TBI), dementia, seizure disorder, borderline personality disorder, anxiety, intermittent explosive disorder, tobacco use, and other behavioral/emotional disorders was also affected by the same deficiency. Social history and progress notes documented that this resident sustained a TBI after being hit by a semi‑truck while riding a bicycle at age 18, resulting in an 11‑month coma, followed by 13 years in a state hospital and subsequent residence in a group home. Additional documentation indicated the resident allegedly shot their father at age 26 after being sworn at and had a PASRR identifying TBI, intermittent explosive disorder, and borderline personality disorder, with a specific trigger of hearing the name of the current U.S. President. Progress notes also described inappropriate sexual behavior toward staff, including touching themselves intimately during personal care and refusing to stop when redirected. Despite this, the resident’s care plans, which addressed explosive disorder and history of altercations, risk for decreased psychosocial well‑being, and refusal to bathe or shower, did not list any specific behavioral triggers, did not reference the traumatic events such as being hit by a truck or shooting their father, and did not document the inappropriate sexual behavior. The Administrator and Social Service Director acknowledged that residents were to be screened for trauma and that trauma responses and PTSD should be added to care plans, but the specific trauma histories and triggers for these two residents were not incorporated into their plans of care.
Failure to Assess and Care Plan for Resident Suicidal Ideation
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess, investigate, and care plan for a resident’s suicidal ideation in accordance with its own policy and staff expectations. The resident had diagnoses including schizophrenia, cerebral edema, and hemiparesis/hemiplegia following a cerebral infarction, and a current MDS showed mild cognitive impairment (BIMS score 12). A progress note documented that the resident told the Social Services Director (SSD) he was feeling down and wanted to kill himself; the SSD offered assistance, activities, and initiated 15‑minute checks, and the note stated the care plan was updated. However, the note did not indicate that the SSD asked whether the resident had a plan to kill himself, and there were no additional notes regarding suicidal ideation or follow‑up. Review of the current care plan showed no problem, goal, or interventions addressing depression or suicidal ideation, and progress notes over the following month contained no documentation of physician notification related to the suicidal statement. Further record and interview evidence showed that the care plan conference summary did not document interventions for suicidal ideation, and the SSD acknowledged she did not normally ask residents expressing suicidal ideation if they had a plan. The SSD reported that the resident had admission paperwork mentioning suicidal ideation related to depression after a stroke and that the resident again vocalized suicidal ideation during a care plan meeting with his father, after which emotional support was offered and the father took the resident out on a leave of absence; no further visits or follow‑up were done. The DON stated that, upon notification of suicidal verbalization, staff should assess the resident, ask if there is a plan, remove potential means of self‑harm, immediately notify the psychiatric NP, and document the occurrence, and that a detailed progress note and updated care plan were expected but not present for this resident. The Administrator similarly stated that staff should ask about a plan, document interventions, notify the physician and family, and update the care plan, and indicated the resident should have had a care plan addressing depression with suicidal ideation. The facility’s written policy required immediate notification of the DON, SSD, and physician, an interview including asking about a plan and assessing mood and means for self‑harm, and thorough documentation of mood, behavior, and all actions taken, which were not reflected in the resident’s record.
Incomplete and Inaccurate Documentation of Suicidal Ideation and Follow-Up
Penalty
Summary
The facility failed to ensure accurate, complete, and timely documentation of assessments and services for a resident who verbalized suicidal ideation. Resident 6, who had schizophrenia, cerebral edema, and right-sided hemiparesis/hemiplegia following a cerebral infarction, had a BIMS score of 12 indicating mild cognitive impairment. The resident’s admission paperwork mentioned suicidal ideation related to depression after a stroke, and a Social Services note on 3/11/2026 documented that the resident was feeling down and said he wanted to kill himself. The Social Services Director (SSD) documented that she talked with the resident, coordinated with Activities, advised the resident to contact SSD or nursing if he wanted to talk, and that the resident was scheduled for 15-minute checks and the care plan was updated. However, the current care plan initiated on 2/26/2026 did not address depression or suicidal ideation. Multiple Social Services progress notes were later entered as late entries in April, with effective dates in March, stating that the resident had no plan and no longer had suicidal ideation, that he felt much better after 1:1 time, and that he continued his daily routine and therapy. These late entries described follow-up visits and reassessments of suicidal ideation on several consecutive days, but in interviews the SSD stated she did not normally ask residents about having a plan when they verbalized suicidal ideation and did not recall any other occurrences beyond the initial event. She further indicated she did not personally provide individual follow-up visits with this resident regarding suicidal ideation, despite the late-entry notes describing such visits. The DON acknowledged that late entries had been added to address concern about suicidal verbalization, and the Administrator stated that upon suicidal statements staff should ask about a plan, notify the physician and family, and update the care plan, and that this resident should have had a care plan addressing depression with suicidal ideation. The facility’s documentation policy required factual, first-hand, timely documentation, which was not followed in this case.
Failure to Complete Required Self-Administration Assessment for Inhaler Kept at Bedside
Penalty
Summary
Surveyors identified that a resident was allowed to keep and access an Albuterol inhaler without the facility completing the required self-administration medication assessment. During an initial tour, the resident was observed sitting in a wheelchair with a handheld Albuterol inhaler on the overbed table and no staff present in the room or hallway. On a subsequent observation, the resident again was in a wheelchair and reported that the Albuterol inhaler was stored in the top drawer of the nightstand, where it was found. Review of the clinical record showed an admission MDS indicating no cognitive impairment, but there was no documentation of a self-medication administration assessment. In an interview, the DON confirmed that the resident did not have the required self-medication assessment, despite the facility’s policy stating that staff and the practitioner must assess each resident’s mental and physical abilities to determine whether self-administering medications is clinically appropriate. This failure to complete and document a self-administration medication assessment for a resident who had an Albuterol inhaler kept at bedside constituted noncompliance with the facility’s own policy and with 410 IAC 16.2-3.1-11(a).
Inaccurate PBJ Staffing Data Submission to CMS
Penalty
Summary
The deficiency involves the facility’s failure to electronically submit complete and accurate direct care staffing information to CMS through the Payroll-Based Journal (PBJ) system for 22 days in a fiscal quarter. A CASPER report review on 4/6/26 showed that, according to PBJ data, the facility did not have licensed nursing coverage 24 hours per day on multiple specific dates across three months, had low weekend staffing, and held a 1-star staffing rating. However, review of the facility’s internal staffing sheets for that quarter indicated the facility was fully staffed and had licensed nurse coverage on all of the dates in question. During an interview, the Administrator stated that the PBJ information must have contained data entry errors, as she had verified licensed staff coverage on the timesheets. The facility’s PBJ policy in effect stated that all staffing data entered into the PBJ system would be auditable and verifiable through payroll, invoices, or contracts, but the submitted PBJ data did not accurately reflect the facility’s actual licensed nurse staffing as documented on internal records. No specific residents or clinical conditions were mentioned in the report, and the deficiency centers solely on inaccurate staffing data submission rather than direct resident care events.
Failure to Provide and Document Required Transfer/Discharge and Bed-Hold Notices
Penalty
Summary
The deficiency involves the facility’s failure to provide and document required written notices of transfer/discharge and bed-hold policies, as well as required information to receiving providers, for four residents who were transferred or discharged to the hospital. For a resident with generalized anxiety disorder, major depressive disorder, and dementia, progress notes showed that the resident was sent to the hospital via 911 for chest pain, lower back pain, and shortness of breath and later returned to the facility, but the clinical record lacked documentation that a written Notice of Transfer/Discharge and the bed-hold policy were provided to the resident or representative, and lacked documentation that required information was conveyed to the receiving facility. The ADON and the Administrator both confirmed there was no documentation that these written notices were provided. For a resident with congestive heart failure and muscle weakness who was sent to the emergency room for painful urination and bloody urine, the clinical record lacked documentation that a Notice of Transfer/Discharge or bed-hold policy was given to the resident or representative, which the DON confirmed. Another resident with chronic respiratory failure and diabetes was discharged to the hospital for respiratory failure, and a resident with chronic kidney disease and dementia was discharged to the hospital, but in both cases there was no documentation that a written notice of transfer/discharge or bed-hold policy was provided to the residents or their representatives. Review of the facility’s Transfer and Discharge policy, dated 1/15/26, showed that the policy required the facility to provide written transfer/discharge notices and bed-hold information to residents and representatives and to provide specified information to receiving providers, but the records for these four residents did not contain the required documentation.
Failure to Document Target Behaviors and Non-Pharmacological Interventions Before Initiating Antipsychotic
Penalty
Summary
The deficiency involves the facility’s failure to document how a resident’s behaviors presented danger or distress to self or others, and failure to document non-pharmacological interventions attempted prior to initiating an antipsychotic medication. Resident 6 had documented diagnoses of Alzheimer’s disease, depression, and severe cognitive impairment, and was receiving sertraline for depression. A PASSAR identified only depression and dementia, and the admission MDS listed Alzheimer’s disease and depression as active diagnoses. Over several months, nursing progress notes documented that the resident intermittently reported unusual perceptions, such as believing there were men causing trouble, a man in her room, or a man wanting to marry her and yelling through the walls, but there was no documentation that these episodes caused danger to the resident or others or that they resulted in unmanageable distress. From late April through mid-July, nursing notes primarily described the resident’s frequent refusals of evening and morning medications, blood sugar checks, blood pressure checks, insulin administration, hygiene care, and showers. Staff documented that the resident sometimes yelled at staff, said “Get out!”, was visibly upset by a room move, was leery of staff and asked to see name badges, and became upset about a pillow under her head until it was removed, after which she calmed down. The notes also recorded instances where the resident believed housekeeping had not cleaned her room or that she had not received medications when she had. However, there were no progress notes or assessments indicating that these behaviors were evaluated as dangerous, non-redirectable, or causing significant distress or functional impairment, and no detailed behavior monitoring logs were present as required by facility policy. On a psychiatric NP visit for initial psychotropic medication management, new mental health diagnoses of schizoaffective disorder, borderline personality disorder, and delusional disorder were added, and Seroquel 25 mg, an antipsychotic, was ordered. The clinical record did not contain a comprehensive evaluation to support these new diagnoses, and there was no documentation of target behaviors meeting the facility’s policy criteria for psychotropic use, such as behaviors representing danger to self or others, causing distress and impairment in functional abilities, or clearly attributable to psychosis or mania. The resident’s representative reported that the resident had no prior history of mental health disorders or psychiatric hospitalization and was unaware of the new diagnoses. The facility’s own psychotropic medication policy required identification and documentation of specific target behaviors, use and documentation of nonpharmacological interventions, and ongoing monitoring of behaviors and interventions, which were not reflected in the record for this resident.
Failure to Update PASARR Screens for New Mental Health Diagnoses and Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that Preadmission Screening and Resident Review (PASARR) Level I screenings were accurate and updated when new mental health diagnoses and psychoactive medications were initiated for multiple residents. For one resident with dementia, anxiety, depression, and post-traumatic stress disorder (PTSD), the PASARR completed on admission listed anxiety, depression, and dementia with sertraline and quetiapine, but did not include the PTSD diagnosis or the antidepressant Pristiq, despite the admission MDS and care plan documenting PTSD and a subsequent physician’s order for Pristiq. For another resident with Alzheimer’s disease, borderline personality disorder, delusional disorder, schizoaffective disorder, and depression, the PASARR only reflected depression and dementia with sertraline, even though additional mental health diagnoses were added later and an antipsychotic (quetiapine) was ordered for borderline personality disorder, and the quarterly MDS documented psychotic disorder, schizophrenia, and depression with antipsychotic and antidepressant use. A third resident had diagnoses including Alzheimer’s disease, depression, anxiety disorder, irritability and anger, and nonrheumatic aortic valve stenosis. The PASARR for this resident listed dementia and anxiety with Risperdal but omitted the diagnosis of depression and the medications escitalopram and lorazepam, although physician’s orders were in place for escitalopram for depression and lorazepam for anxiety, and the admission MDS documented depression with antianxiety and antidepressant use. Interviews with the Assistant Director of Nursing confirmed that new Level I PASARR screens should have been completed when new mental health diagnoses and psychoactive medications were added, and that the PASARR for one resident, completed prior to arrival, should have included all mental health diagnoses and medications. The facility’s own policy required notification of the state mental health authority within 14 days after a significant change in mental condition and specified that a new Level I screen is required for new mental health diagnoses or newly prescribed psychotropic medications, which was not followed in these cases.
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