Valley View Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Elkhart, Indiana.
- Location
- 333 W Mishawaka Rd, Elkhart, Indiana 46517
- CMS Provider Number
- 155496
- Inspections on file
- 40
- Latest survey
- February 9, 2026
- Citations (last 12 mo.)
- 2 (1 serious)
Citation history
Health deficiencies cited at Valley View Healthcare Center during CMS and state inspections, most recent first.
A newly admitted resident with type 2 DM, gastrostomy, dysphagia, and post-stroke hemiplegia arrived from a rehab hospital with orders for multiple critical medications and continuous enteral nutrition with water flushes, but the facility did not transcribe or implement these orders for several days. No admission orders were present in the record for this period, the MAR showed delayed initiation of insulin, antiepileptic, antihypertensive, and other medications, and there was no documentation of tube feeding, water flushes, or other nutrition/hydration. Care plans for nutrition and tube feeding were also delayed. The resident was later found diaphoretic, hypoxic, and with a blood glucose reading beyond the glucometer’s range, and was sent to the hospital, where labs confirmed severe hyperglycemia, hypernatremia, and extreme volume depletion consistent with hyperosmolar hyperglycemic state.
A resident with COPD, DM2, AFib, CHF, and an indwelling catheter had decreased oral intake and concern for dehydration, leading to orders for CBC, CMP, BNP, and later a STAT UA with reflex and culture after increased confusion and decreased urine output. Nursing staff collected a urine specimen and refrigerated it for lab pickup, but the DON later confirmed the lab orders were never entered into the lab portal and the specimen was never picked up, so the ordered tests were not completed. Over subsequent days the resident became lethargic, confused, hypotensive, hypoxic, and had swallowing difficulties, ultimately requiring EMS transfer to the hospital, where labs showed severe leukocytosis, hyperkalemia, markedly elevated BUN/creatinine, and a UA positive for UTI, with diagnoses including uremic encephalopathy, AKI, hyperkalemia, acute hypoxic respiratory failure, and pneumonia.
A resident with multiple serious health conditions required CPR after being found unresponsive. An LPN and an RN performed CPR and used an AED, but both staff members did not have current CPR certification at the time. The facility's policy required current CPR certification, but this was not followed during the event.
Surveyors found that food was not stored or served in a sanitary manner, with unsealed and undated items in kitchen storage, improper storage of employee beverages, open containers, and unsanitary serving practices by CNAs. Food containers in the pantry were also found unlabeled and undated, all contrary to facility policy and professional standards.
Surveyors found that the facility did not change PICC line dressings as ordered for three residents, with dressings left in place beyond the required weekly interval, some becoming rolled up or peeling and exposing the insertion site. Staff interviews confirmed the dressings should have been changed weekly, and documentation errors were identified where tasks were marked as completed without being performed.
Surveyors found that several residents did not receive their prescribed medications, and staff failed to document administration or notify physicians of missed doses. Medication storage was also improper, with opened and unlabeled eye drops mixed with other drugs and expired insulin pens in use. These deficiencies were identified through record reviews, MAR audits, staff interviews, and direct observation.
The facility did not ensure accurate documentation or timely completion of PICC dressing changes for three residents. Dressings were observed to be overdue or improperly applied, while the medical records and TARs indicated changes had been completed. Nursing staff admitted to signing off on tasks that had not been performed, and there was no documentation of resident refusal. The facility's policy required accurate and truthful documentation, which was not followed.
Multiple infection control deficiencies were observed, including a resident with a soiled and undated tracheostomy stoma dressing improperly disposed of, two residents with PICC line dressings that were overdue for changes or improperly maintained, and lapses in hand hygiene and glove use by LPNs during medication administration and glucometer cleaning. These actions did not follow facility policies or physician orders.
A resident's code status was not documented consistently in the medical record. Although staff interviews and several documents indicated the resident was a full code and capable of making his own decisions, a POST form listed a Do Not Attempt Resuscitation status, resulting in unclear documentation regarding the resident's wishes.
Two residents who were dependent on staff for activities of daily living did not receive adequate personal hygiene and nail care. One resident experienced missed showers and developed a large, matted mass of hair due to insufficient hair care, while another had excessively long toenails because nursing staff failed to provide or arrange for appropriate nail trimming. Staff interviews and documentation confirmed lapses in following care plans and facility policy.
The facility failed to protect two residents from verbal abuse by an LPN, who used foul language during a medication pass. Despite grievances filed, the Administrator did not report the incident as abuse or conduct a thorough investigation, contrary to the facility's policy that considers foul language as verbal abuse.
A facility failed to report a verbal abuse incident involving a resident with chronic respiratory conditions. An LPN allegedly used foul language during a medication pass, which was reported by another resident. Despite the grievance being presented to the Administrator, the incident was not reported to the Department of Health, and no investigation was conducted, contrary to the facility's policy.
A facility failed to investigate an allegation of verbal abuse involving two residents. An LPN was reported to have used foul language towards a resident during a medication pass, which was witnessed by another resident. Despite the facility's policy requiring investigation of such incidents, the Administrator did not conduct a thorough investigation or report the incident to the Department of Health, relying instead on the LPN's denial of the allegations.
The facility failed to properly assess, educate, and document smoking supervision for a resident, leading to indoor smoking incidents. Despite a care plan indicating independence, a new assessment required supervision without documented justification. Staff were allegedly instructed not to document these incidents, violating facility policy.
The facility failed to store food and maintain equipment in a sanitary manner, affecting all 84 residents receiving meals. Issues included mold on a resident's water container, mold in a refrigerator, improperly sealed food items, and cookware with missing Teflon. The Dietary Manager and Corporate Nurse acknowledged these deficiencies.
The facility failed to develop comprehensive and person-centered care plans for six residents with behaviors and dementia care. The care plans included general interventions but lacked specific, individualized strategies to manage the residents' unique behaviors and needs. The Corporate Nurse and Corporate Infection Prevention Nurse confirmed the care plans were not person-centered.
The facility failed to ensure a medication cart was kept locked when unattended on the memory care unit. An LPN confirmed the cart should have been locked, as per the facility's policy. This deficiency had the potential to affect 22 residents.
The facility failed to maintain a safe, clean, and comfortable environment, with issues such as broken window blinds, missing dresser handles, a bathroom door without a handle, mold in a storage closet, and dirty kitchen appliances and cabinets observed on the 200 and 400 halls. The Administrator acknowledged these issues, and the Corporate Nurse confirmed the lack of a specific policy regarding the environment.
The facility failed to ensure a resident's Level One PASARR assessment was completed accurately and did not update the Level 1 review despite the resident receiving antipsychotic medication for psychosis. The discrepancy was identified during a record review and confirmed by the Corporate Nurse.
The facility failed to provide adequate assistance with ADLs for two residents, resulting in one resident having oily hair and dirty fingernails and another resident needing to be shaved. Documentation and adherence to care plans were inconsistent, leading to inadequate personal hygiene care.
The facility failed to maintain oxygen equipment in a sanitary manner for a resident, who was observed on multiple occasions with a nasal cannula connected to an oxygen concentrator that had a thick layer of dust on its filter. Despite physician's orders and facility policy requiring weekly cleaning, the filter remained dirty over several days.
The facility failed to assess a resident upon return from dialysis procedures, despite physician orders and care plan interventions specifying the need for post-dialysis evaluations. Interviews with staff and the Corporate Nurse confirmed that these assessments were not conducted on multiple occasions.
The facility failed to provide appropriate serving sizes for residents receiving pureed meals, as observed when a resident received only one tablespoon of pureed green beans instead of the required 1/2 cup. Staff confirmed the portion did not meet dietary requirements.
Failure to Implement Admission Orders for Medications, Tube Feeding, and Hydration
Penalty
Summary
The deficiency involves the facility’s failure to transcribe and implement physician-ordered medications, nutrition, and hydration for a newly admitted resident. The resident was admitted from a rehabilitation hospital with diagnoses including hemiplegia following a stroke, type 2 diabetes mellitus, gastrostomy, and dysphagia, and was comatose with feeding via a tube. An interdisciplinary team conference note from the sending rehabilitation hospital, provided at the time of admission, listed multiple critical medications and continuous tube feeding with Vital 1.2 at 65 mL/hr and a 25 mL/hr water flush. Despite this, there were no admission orders in the resident’s record from the date of admission until two days later. Physician orders for the resident’s medications and tube feeding flushes were not written until two days after admission, and the Medication Administration Record (MAR) showed that some medications (glargine insulin, levetiracetam, metformin) were first administered only on that date, with others (aspirin, hydrochlorothiazide, Jardiance, lisinopril) not started until the following day. The MAR documented initiation of Jevity 1.2 tube feeding and water flushes even later, and there was no documentation of any tube feeding, water flushes, or other fluids or nutritional feedings from admission until that time. Care plans addressing altered nutritional status and tube feeding needs were also not initiated until two days after admission, with no care plans in place prior to that date. A nursing progress note later documented that when a nurse entered the resident’s room to administer medications, the resident was found sweaty, with an oxygen saturation of 85% on room air, no obtainable blood pressure, and a blood glucose monitor reading “HI,” indicating a level beyond the device’s measurable range. Emergency services were called, and hospital records showed the resident had a blood glucose of 954 mg/dL, hypernatremia, extreme volume depletion, and acute kidney injury, and was admitted to a higher-acuity unit for hyperosmolar hyperglycemic state. An RN interview confirmed that, upon auditing the admission orders the Monday after the weekend admission, she discovered that medication, tube feeding, and hydration orders had not been initiated and that there was no documentation of these being provided during the initial days after admission, despite facility policy requiring timely admission evaluation, medication reconciliation, hydration, and 72-hour admission progress notes with vital signs and assessments.
Removal Plan
- Facility staff was in-serviced regarding enteral general nutrition guidelines, laboratory and radiological services, notification of change of conditions, admission evaluations, blood glucose point of care testing, physician orders, clinical morning meeting and admission audits.
- A house-wide clinical assessment of all residents was completed.
- All new resident admissions were reviewed.
- Audits were implemented regarding newly admitted residents.
Failure to Complete Ordered Laboratory Tests and STAT Urinalysis
Penalty
Summary
The deficiency involves the facility’s failure to obtain and process physician‑ordered laboratory tests, including a STAT urinalysis, for a resident with multiple chronic conditions. The resident had diagnoses including COPD, type 2 diabetes, atrial fibrillation, and congestive heart failure, and had an indwelling urinary catheter. On 12/16/2025, the resident’s potassium chloride dose was decreased for hypokalemia. On 12/23/2025, nursing documentation noted the resident was refusing to eat or drink with concern for dehydration, and new orders were obtained for a CBC with differential, a comprehensive metabolic panel, and a BNP to follow up heart failure, leukocytosis, and to rule out significant dehydration. On 12/26/2025, during a telehealth NP encounter prompted by increased confusion and reports from staff that the resident was hard to awaken and had decreased urinary output, an order was placed for a STAT urinalysis with reflex and culture and for staff to push oral fluids. Nursing documentation on 12/27/2025 at 5:17 A.M. indicated that a urine specimen was collected at 4:30 A.M. and placed in a refrigerator on the 100 hall to await laboratory pickup. Subsequent documentation showed that on 1/1/2026 the resident was lethargic but responsive to verbal stimuli and had swallowing difficulties, with food being held in the mouth or residual food after meals, whereas prior assessments had documented the resident as alert and oriented times three. On 1/2/2026, an NP monthly follow‑up encounter documented the resident as lethargic, barely responsive, hypotensive, hypoxic, with dry mucous membranes, tachypnea, diminished breath sounds, and applesauce with medication remaining in the mouth, and the resident was thought to be in acute respiratory failure with hypoxia and referred to the ED. A nursing note later that morning described the resident as initially interactive, then declining with hypotension, fluctuating oxygen saturations, non‑verbal status, moaning with movement, edema, generalized weakness, and difficulty swallowing, leading to a 911 call. Hospital evaluation that day revealed markedly elevated WBC, critically high potassium, severely elevated BUN and creatinine, and a urinalysis positive for UTI, with diagnoses including uremic encephalopathy, acute hypoxic respiratory failure, acute kidney injury, hyperkalemia, and pneumonia. In an interview, the DON stated that the ordered laboratory work had not been entered into the lab portal to be drawn and that the urinalysis specimen, although collected, was never picked up by the lab, and acknowledged that the ordered tests should have been completed.
Staff Performed CPR Without Current Certification
Penalty
Summary
Nursing staff failed to maintain current CPR certification while providing care to a resident who required cardiopulmonary resuscitation. The resident, who had diagnoses including pericardial effusion, breast cancer, heart valve insufficiency, and hypertension, was found unresponsive and without a pulse or respirations. Upon discovery, a CNA notified a nurse, and an LPN began CPR while emergency services were called. The facility's documentation indicated the sequence of events, including the initiation of CPR and the use of an AED, until EMS arrived and transferred the resident to the emergency room. Interviews with the involved staff revealed that both the LPN and an RN who participated in the CPR event did not have current CPR certification at the time of the incident. Both staff members obtained their CPR certification online only after the event. The facility's policy required staff to be properly trained and certified in CPR according to American Heart Association guidelines, but this was not followed during the incident.
Failure to Store and Serve Food in a Sanitary Manner
Penalty
Summary
Surveyors observed multiple failures in food storage and service practices throughout the facility, including the kitchen, pantries, and dining rooms. During a kitchen tour, unsealed and undated food items were found in both the freezer and refrigerator, such as fish, chicken patties, cheeses, hot dogs, and vegetables. Employee beverages were also improperly stored in the freezer. In the dry goods room, undated and open packages of noodles, buns, and powdered milk were present. Staff interviews confirmed that all food should be properly sealed, dated, and that personal items should not be stored with food. Additional observations included a soup bowl left inside bins of brown and powdered sugar, open spice containers, and dish soap stored next to spices, all of which were acknowledged as improper by dietary staff. During meal service in the main dining room, beverage pitchers were left uncovered and CNAs served drinks and meal plates without maintaining sanitary technique, such as placing thumbs on the eating surface of plates. In the Memory Care pantry, several food containers were found unlabeled and undated. Facility policies reviewed by surveyors required all foods to be sealed, labeled, and dated, and for storage areas to be organized to prevent cross-contamination. These observed practices were not in compliance with facility policy and professional standards, affecting all residents who consumed food from these areas.
Failure to Timely Change PICC Line Dressings for Multiple Residents
Penalty
Summary
Surveyors identified that the facility failed to appropriately change the dressings of residents with peripherally inserted central catheter (PICC) lines for three residents. In one instance, a resident's PICC line dressing was observed to be rolled up and exposing the insertion site, with the dressing dated ten days prior and the resident reporting it had not been changed in over a week. The resident's care plan required weekly dressing changes and visual inspection each shift, but there was no documentation of refusal or completed dressing changes. Another resident's PICC line dressing was observed to be peeling up along all edges and was dated three weeks prior, despite a physician order for weekly changes. The unit manager confirmed the dressing should have been changed weekly. A third resident was observed with a PICC line dressing that was peeling at the base and dated ten days prior, with subsequent observation showing the PICC had been removed and a bruise present at the site. The resident's care plan and physician order also required weekly dressing changes. Interviews revealed that a QMA had marked the dressing change as completed in the electronic medical record without actually performing the task, and an LPN later charted the task in error. The facility's policy required PICC dressing changes on admission or 24 hours post-insertion, then weekly and as needed, but this was not followed for the residents reviewed.
Failure to Administer and Store Medications as Ordered
Penalty
Summary
The facility failed to provide medications to residents as ordered by their physicians for four out of six residents whose medication records were reviewed. Specifically, multiple residents did not receive prescribed medications, including nitroglycerin patches, omeprazole, trazodone, mirtazapine, melatonin, insulin glargine, terazosin, Novolog, atorvastatin, ertapenem, vancomycin, and Santyl ointment, on various dates. The medication administration records (MARs) lacked documentation of medication refusals or physician notifications regarding missed doses. The Director of Nursing (DON) indicated that she believed the medications had been administered but acknowledged that staff failed to sign off on the MARs as required by facility policy. Additionally, medication storage practices were found to be deficient. During observations of medication carts, surveyors found opened bottles of eye drops not stored in pharmacy-labeled containers, mixed with other medications, and an open insulin pen that had expired but was still in use. The facility's policy required medications to be stored in pharmacy-labeled containers, separated by type, and for staff to check expiration dates before administration. These requirements were not followed, as confirmed by staff interviews and direct observation. The residents involved had complex medical histories, including diagnoses such as Parkinson's disease, anxiety disorder, insomnia, myocardial infarction, major depressive disorder, dementia, diabetes mellitus, hypertension, cerebral palsy, chronic kidney disease, congestive heart failure, and more. The deficiencies were identified through record reviews, medication administration record audits, staff interviews, and direct observation of medication storage practices.
Failure to Accurately Document and Complete PICC Dressing Changes
Penalty
Summary
The facility failed to ensure accurate documentation and timely completion of PICC (peripherally-inserted central catheter) dressing changes for three residents. For one resident, the PICC line dressing was observed to be dated a week prior to the documented change, and the Treatment Administration Record (TAR) indicated the dressing change was completed on a date that did not match the actual dressing observed. Interviews with nursing staff revealed that documentation was sometimes completed in error, with staff acknowledging that they had signed off on tasks that had not been performed. The Director of Nursing confirmed that treatments should only be signed off after completion. Another resident's PICC dressing was observed to be overdue for a change, with the dressing dated significantly earlier than the documented change dates in the TAR. Staff interviews indicated uncertainty about how their initials appeared on the TAR, with admissions that documentation may have been completed accidentally or inappropriately passed to the next shift. A third resident's PICC dressing was found to be rolled up and exposing the insertion site, with the resident reporting the dressing had not been changed in over a week. The medical record lacked documentation of any refusal of dressing changes, and the responsible nurse admitted to signing off on the task without completing it. The facility's policy required timely and accurate documentation, which was not followed in these instances.
Infection Control Lapses in Tracheostomy, PICC Line, and Medication Administration
Penalty
Summary
The facility failed to adhere to infection prevention and control standards in several instances involving tracheostomy care, PICC line care, and medication administration. For one resident with a tracheostomy stoma, the dressing was observed to be dirty, stained, and undated. During a dressing change, the LPN disposed of the soiled dressing in the resident's room trash instead of the designated biohazard container. Physician orders and care plans specified proper care and disposal procedures, but these were not followed. Two residents with PICC lines were found to have dressings that were either not changed according to the prescribed schedule or were improperly maintained. One resident's PICC dressing was peeling and overdue for a change, while another's dressing was rolled up, exposing the insertion site, and had not been changed as ordered. Documentation did not indicate any refusal of care by the residents, and staff interviews confirmed that the dressings should have been changed per protocol and physician orders. Infection control lapses were also observed during medication administration. An LPN failed to change gloves or perform hand hygiene between administering oral medications and eye drops, and placed medication containers directly on bedside tables without barriers. Additionally, glucometers were handled and cleaned without proper hand hygiene or use of barriers, and staff did not always perform hand hygiene after glove removal. Facility policies required hand hygiene and use of barriers, but these were not consistently followed during observed care.
Inconsistent Documentation of Resident Code Status
Penalty
Summary
The facility failed to ensure that a resident's code status was documented consistently throughout the medical record. Interviews with both an LPN and the Social Service Designee confirmed that the resident was considered a full code and was capable of making his own legal decisions. The resident had communicated his wish to be a full code to staff. The clinical record review showed that the resident had multiple diagnoses, including hemiplegia, chronic obstructive pulmonary disease, cerebrovascular disease, hypertension, and other conditions, and was assessed as cognitively intact. Despite this, documentation in the medical record was inconsistent. A physician order and the care plan both indicated the resident was a full code, while a POST (Physician Orders for Scope of Treatment) form indicated a Do Not Attempt Resuscitation (DNAR) status. This inconsistency resulted in the resident's code status being unclear in the medical record, contrary to facility policy, which requires staff to verify and document the resident's wishes regarding CPR.
Failure to Provide Adequate Personal Hygiene and Nail Care
Penalty
Summary
The facility failed to provide adequate care and assistance with activities of daily living for two residents who were dependent on staff for personal hygiene. One resident, who was cognitively intact but required substantial assistance due to multiple diagnoses including multiple sclerosis and adult failure to thrive, reported not recalling the last time she was offered a shower and had only received bed baths, with the last one occurring about a week prior. Observations over several days revealed the resident had a large, matted mass of hair at the back of her head, and she could not remember when her hair was last brushed. Shower documentation showed missed scheduled showers, and it was unclear why hair care was not provided to prevent matting, despite care plan interventions indicating the need for staff assistance with bathing and personal hygiene. Another resident, who was severely cognitively impaired and fully dependent on staff for bathing, was observed on multiple occasions to have toenails that were very long and extended past the ends of her toes. Staff interviews indicated that nail care was supposed to be included in the showering process, and that nurses were responsible for trimming toenails or referring residents to a podiatrist if needed. However, the nursing staff had not reported this resident's need for podiatry care, resulting in a lack of appropriate nail care. The facility's policy stated that foot care, including nail trimming, should be performed by a professional for some residents, but this process was not followed for the resident in question.
Failure to Protect Residents from Verbal Abuse
Penalty
Summary
The facility failed to ensure freedom from verbal abuse for two residents, Resident F and Resident G. The incident involved a Licensed Practical Nurse (LPN) who was reported to have used foul language towards Resident F during a medication pass. Resident F, who has chronic obstructive pulmonary disease and chronic respiratory failure, requested fresh water and a breathing treatment from LPN 5. The nurse denied the breathing treatment due to a high heart rate and did not provide fresh water, leading to a verbal exchange where Resident F called the nurse a derogatory term. LPN 5 reportedly responded by calling Resident F the same derogatory term. Resident F reported feeling intimidated and afraid of not receiving her medication when LPN 5 was on duty. The incident was witnessed by Resident G, who confirmed the exchange of derogatory terms between Resident F and LPN 5. Despite the grievance filed by Resident F, the facility's Administrator did not report the incident as abuse to the Department of Health, nor did they conduct a thorough investigation or interview other staff or residents about the allegations. The facility's policy on abuse and neglect indicates that the use of foul language directed at a resident constitutes verbal abuse. However, the Administrator did not view the interaction as possible abuse and did not follow up with a comprehensive investigation. The grievance form indicated that the nurse was counseled on her attitude, but there was no evidence of further action or interviews conducted to address the allegations of verbal abuse.
Failure to Report Verbal Abuse Incident
Penalty
Summary
The facility failed to report an occurrence of verbal abuse to the Department of Health involving a resident, identified as Resident F. The incident was initially reported through a grievance filed by another resident, Resident G, who alleged that an LPN used foul language towards Resident F during a medication pass. Resident F, who has chronic obstructive pulmonary disease and chronic respiratory failure with hypoxia, was involved in an interaction where she requested water and a breathing treatment from the LPN. The LPN denied the breathing treatment due to a high heart rate and was reportedly rude, leading to a verbal exchange where both parties used inappropriate language. The grievance indicated that the LPN called Resident F a derogatory term after closing and reopening the door. Despite the grievance being presented to the Administrator, the incident was not reported to the Department of Health, and no investigation was conducted. Employees interviewed during the survey confirmed awareness of the incident and identified it as verbal abuse, yet no further interviews or investigations were initiated by the facility. The Administrator acknowledged interviewing Resident F and the LPN but did not view the interaction as abuse, thus failing to report it. The facility's policy on abuse, neglect, and misappropriation of property clearly states that foul language directed at a resident constitutes verbal abuse and requires timely notification to relevant agencies. The Administrator's actions did not align with this policy, as the incident was not reported, and no comprehensive investigation was conducted.
Failure to Investigate Allegation of Verbal Abuse
Penalty
Summary
The facility failed to investigate an allegation of verbal abuse involving two residents, Resident F and Resident G. Resident F reported that during a medication pass, an LPN was rude and used foul language towards her. The incident began when Resident F requested water to take her medication, and the LPN responded by taking the medication away and indicating she would return when Resident F was ready. Resident F, upset by the LPN's tone and behavior, called the LPN a derogatory term, to which the LPN responded in kind. Resident F later reported feeling intimidated and afraid of not receiving her medication when the LPN was on duty. Resident G, who witnessed the interaction, confirmed the LPN's rude behavior and use of foul language. Despite these allegations, the facility's Administrator did not conduct a thorough investigation. The Administrator interviewed Resident F but did not report the incident to the Department of Health, as she did not perceive it as abuse. The Administrator also failed to interview other staff or residents, relying solely on the LPN's denial of using foul language. The facility's policy on abuse, neglect, and misappropriation of property clearly states that foul language directed at a resident constitutes verbal abuse and requires timely investigation. However, the Administrator did not adhere to this policy, as no comprehensive investigation was conducted, and the incident was not reported as required. This lack of action and failure to follow protocol led to the deficiency cited in the report.
Failure to Properly Document and Supervise Resident Smoking
Penalty
Summary
The facility failed to ensure proper assessment, education, and care planning regarding smoking for one resident, identified as Resident D. The deficiency was identified through observation, interviews, and record reviews. A complaint was filed indicating that some residents had been smoking in their rooms, and it was alleged that the Administrator instructed staff not to document these incidents. Resident D was observed smoking in the designated smoking area under supervision, although his care plan indicated he was an independent smoker. However, a smoking assessment later indicated that Resident D required supervision, but there were no documented changes in his condition to justify this change. Interviews revealed that Resident D and another resident smoked indoors due to being unable to go outside on a cold day. The Director of Nursing confirmed this incident, while the Administrator claimed awareness of only one resident smoking indoors. A staff member, Employee 6, confirmed that a new smoking assessment was conducted for Resident D, indicating the need for supervision. The facility's policy required documentation of smoking supervision changes and notification of residents and families, which was not adhered to in this case.
Sanitation and Food Storage Deficiencies
Penalty
Summary
The facility failed to store food and maintain equipment in a sanitary manner, which had the potential to affect all 84 residents receiving meals from the kitchen. During an interview, a resident indicated that his plastic water container had turned black due to mold, and staff had never washed it. Observations confirmed the presence of mold on the resident's water container. The Corporate Nurse acknowledged that the container was dirty and should have been sanitized. A kitchen tour revealed several sanitary issues, including a buildup of ice on the freezer floor, mold on a refrigerator shelf, a dented can of pumpkin, and improperly sealed bags of whipped topping and parmesan cheese. Additionally, two skillets had a buildup of grease, and four skillets had missing Teflon. The Dietary Manager confirmed that these conditions were unacceptable and acknowledged that chipped Teflon could contaminate food. The facility's policies on maintaining a clean kitchen and proper food storage were not followed, as indicated by the Corporate Infection Prevention Nurse.
Failure to Develop Person-Centered Care Plans for Residents with Dementia and Behavioral Issues
Penalty
Summary
The facility failed to develop comprehensive and person-centered care plans for six residents with behaviors and dementia care. Resident 66's care plan did not adequately address her psychosocial well-being and behavioral disturbances, despite her diagnoses of dementia, depression, anxiety, mood disorder, and psychosis. The care plan included general interventions such as administering medications and encouraging participation in activities but lacked specific, individualized strategies to manage her unique behaviors and needs. The Corporate Nurse confirmed that the care plan was not person-centered. Resident 17's care plan also lacked person-centered interventions. Despite her diagnoses of cerebral palsy, type 2 diabetes, depression, anxiety, hallucinations, and dementia, the care plan only included generic interventions like administering medications and encouraging participation in activities. The Corporate Infection Prevention Nurse acknowledged that the care plans were not tailored to the resident's specific needs. Similarly, Resident 77's care plan did not provide individualized interventions for her Alzheimer's, dementia, major depressive disorder, psychosis, hallucinations, and psychotic disorder with delusions. The care plan included general strategies such as 1:1 staff supervision and offering tasks to divert attention but failed to address her unique behavioral issues. The Corporate Infection Prevention Nurse confirmed the lack of person-centered care. Additionally, Residents 5, E, and F had care plans that did not adequately address their specific needs, such as frustration due to confusion, refusal of care, and personal hygiene issues. The Corporate Nurse confirmed that these care plans were not person-centered either.
Unlocked Medication Cart on Memory Care Unit
Penalty
Summary
The facility failed to ensure a medication cart was kept locked when unattended during a random observation on the memory care unit. Specifically, on 4/18/2024 at 11:10 A.M., the 400 hall medication cart was found unlocked with no staff in the vicinity. During an interview at 11:12 A.M., an LPN confirmed that the cart should have been locked. The facility's policy, provided by the Corporate Nurse and dated 8/2020, mandates that medication carts must be locked when not attended by authorized personnel. This deficiency had the potential to affect the 22 residents residing on the memory care unit.
Environmental Deficiencies in Facility
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for residents, staff, and the public. During an environmental tour, several deficiencies were observed on the 400 hall, including broken window blinds, missing dresser drawer handles, a bathroom door without a handle, and a window blind on the floor. Additionally, the 400 unit dining room had broken blinds, an unplugged oven with dried food particles and grease stains, and dirty kitchenette drawers and cabinets. A storage closet was found to be unlocked, with a hole in the ceiling, insulation and water leakage, and mold growth on the wall. On the 200 hall, the Activity room had a dirty microwave with dried food substance and rust. The Administrator acknowledged the issues, indicating that blinds and doors were being replaced and that kitchenette items should be clean. The Corporate Nurse confirmed that there was no specific policy regarding the environment, and it would fall under resident rights. These findings were related to Complaint IN00430346.
Failure to Accurately Complete PASARR Assessment
Penalty
Summary
The facility failed to ensure that Resident 66's Level One PASARR (Preadmission Screening and Resident Review) assessment was completed accurately and did not complete an updated Level 1 review. Resident 66, who was admitted with diagnoses of major depressive disorder and dementia, had medication orders for Quetiapine, an antipsychotic, which was administered daily in March and April 2023. However, the PASARR form dated 4/7/2023 did not list any mental health medications, and the Level 1 screen indicated no need for a Level II review, stating there was no evidence of a PASARR condition of an intellectual/developmental disability or a serious behavioral health condition. This discrepancy was identified during a record review on 4/18/2024 and confirmed in an interview with the Corporate Nurse on 4/24/2024, who acknowledged that the Level 1 was not completed accurately and should have been updated. The facility's policy on PASRR, dated 8/14/2020, requires resident reviews when there is a significant change in a resident's physical or mental condition. Despite this policy, the facility did not complete an updated Level 1 review for Resident 66, who was receiving antipsychotic medication for psychosis. This oversight was highlighted during the survey, indicating a failure to adhere to the established PASRR procedures and ensure accurate and up-to-date assessments for residents with significant mental health conditions.
Failure to Provide Adequate ADL Assistance
Penalty
Summary
The facility failed to ensure residents requiring assistance with Activities of Daily Living (ADL) received adequate assistance with hair and nail care and bathing. Resident E was observed on multiple occasions with oily hair and long, dirty fingernails. Resident E's records indicated dependency on staff for bathing and personal hygiene, yet there was no documentation of refusal of care. The care plan for Resident E included daily hand washing and weekly nail care, but these interventions were not adequately provided. Interviews with staff revealed that hair and nail care were supposed to be performed during showers or bed baths, and refusals were to be documented, but there were no shower sheets available for Resident E in the shower book. Resident M was observed with a large growth of whiskers, indicating a need for shaving. The resident's records showed a requirement for staff assistance with all ADLs and a preference for choosing between a tub bath, shower, or bed bath. Despite this, Resident M's shower documentation indicated infrequent showers and bed baths, with some dates marked as not applicable. Interviews with staff confirmed that care refusals should be documented, but there was inconsistency in the documentation. The Corporate Nurse confirmed that the resident should have received two showers per week, as per the facility's policy on routine nursing care and nail and hair service.
Failure to Maintain Oxygen Equipment in a Sanitary Manner
Penalty
Summary
The facility failed to maintain oxygen equipment in a sanitary manner for Resident 21, who was observed on multiple occasions with a nasal cannula connected to an oxygen concentrator that had a thick layer of dust on its filter. Observations were made on 4/17/2024, 4/19/2024, and 4/22/2024, each time noting the dirty filter. Resident 21's medical history included chronic respiratory failure with hypoxia, congestive heart failure, and chronic obstructive pulmonary disease. Physician's orders indicated that the oxygen concentrator filter should be cleaned weekly with soap and water, specifically at bedtime every Sunday, but this was not adhered to as evidenced by the dirty filter observed over several days. Interviews with LPN 5 and the Corporate Nurse confirmed that the oxygen concentrator's filter was dirty and should have been cleaned weekly. The facility's policy, titled 'Oxygen Therapy Using Concentrators,' also stipulated that filters and machines should be cleaned once a week. Despite these guidelines, the facility did not ensure the proper maintenance of the oxygen concentrator, leading to the deficiency noted in the report.
Failure to Conduct Post-Dialysis Assessments
Penalty
Summary
The facility failed to assess a resident upon return from dialysis procedures for Resident 34, who had diagnoses including end stage renal dialysis and dependence on dialysis. The resident's care plan indicated the need for monitoring vital signs and completing post-dialysis evaluations. However, post-dialysis evaluations were not completed on multiple dates from January to February 2024. Interviews with LPNs and the Corporate Nurse confirmed that post-dialysis assessments were not conducted as required by the facility's policy. Resident 34's Quarterly Minimum Data Set (MDS) assessment indicated that the resident's cognition was intact and that she received dialysis services. Despite physician orders and care plan interventions specifying the need for pre- and post-dialysis weight measurements and monitoring, the facility did not perform the necessary post-dialysis evaluations on numerous occasions. This lapse in care was acknowledged by the Corporate Nurse during the survey, confirming the deficiency in following the established protocol for post-dialysis care.
Inadequate Serving Sizes for Pureed Meals
Penalty
Summary
The facility failed to provide appropriate serving sizes for residents receiving pureed meals. During an observation in the dining room, it was noted that one resident received only approximately one tablespoon of pureed green beans instead of the required 1/2 cup. Interviews with the Qualified Medication Aide (QMA) and the Dietary Manager (DM) confirmed that the portion served did not meet the dietary requirements. The Corporate Infection Prevention Nurse provided the pureed menu, which specified a 1/2 cup serving size using a #10 scoop, but acknowledged that there was no specific policy for portion sizes, and they relied on the menu for guidance.
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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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