Waters Of Batesville, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Batesville, Indiana.
- Location
- 958 E Hwy 46, Batesville, Indiana 47006
- CMS Provider Number
- 155233
- Inspections on file
- 34
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Waters Of Batesville, The during CMS and state inspections, most recent first.
Two cognitively intact residents with multiple comorbidities, including cerebral palsy, HF, diabetes, and bowel/bladder incontinence, reported that a CNA used profane, demeaning, and hostile language toward them, delayed or begrudged assistance with toileting, and displayed irritable, dramatic behavior during care that made them uncomfortable. Other staff and residents had previously observed and reported the CNA being verbally rude, impatient, and snappy with residents. These behaviors conflicted with facility policies prohibiting condescending or profane speech and any disparaging or derogatory verbal language that constitutes abuse.
A resident with traumatic and anoxic brain injury, anxiety, and depression, who was cognitively intact and exhibiting depressive symptoms, told an LPN they wanted to kill themself after being informed they could not receive additional Adderall. The LPN documented the resident as a danger to self or others for suicide potential and notified the physician, and the resident was placed on frequent checks. However, the comprehensive care plan was not updated to include suicidal ideation or related interventions until weeks after this documented suicidal statement, despite facility policy and the social services director’s acknowledgment that such a statement constitutes suicidal ideation requiring care planning.
Surveyors found that the facility failed to adequately supervise two residents, one with dementia and elopement risk and another on suicide-related 1:1 observation. A resident with a wander guard and a documented history of exit-seeking was able to learn a door code, leave the building unsupervised, and was later found outside minimally clothed, cold, and with minor scratches. At the same time, both this resident and another on 1:1 observation were monitored by a single staff member seated in a hallway between their rooms, often without continuous direct visual contact and with no staff stationed in the main hallway leading to exit doors. Staff and facility policy defined 1:1 as continuous direct visual surveillance, yet interviews confirmed that one staff was assigned to both residents and might have to let one resident walk away if the other could not be left, demonstrating a failure to provide the ordered level of supervision and to keep the environment free of accident hazards.
A facility failed to follow proper medication administration protocols, including incorrect priming of an insulin pen and not adhering to hold parameters for blood pressure medications. Residents received medications without appropriate monitoring of vital signs, contrary to physician orders.
The facility did not maintain the required RN coverage for eight consecutive hours a day on 16 out of 21 days reviewed. The nursing schedule showed a lack of RN presence on several weekends from July 2024 to February 2025. The DON admitted to staffing issues, and the facility's policy requires RN coverage for at least eight hours daily, which was not met.
The facility failed to store medications appropriately, with issues such as unlabeled insulin pens, loose pills in medication carts, and outdated Tuberculin serum in the medication room. An LPN identified an insulin pen without a resident's name and labeled it before administration. The facility's policy requires safe and secure storage, but observations showed non-compliance.
A facility failed to notify a physician when a resident's blood glucose levels exceeded the threshold set in medical orders. The resident, with multiple health conditions including diabetes, had orders for insulin administration and required physician notification if glucose levels were above 351. Despite several instances of elevated glucose levels, the physician was not informed. Interviews with staff confirmed the oversight, which was against the facility's policy.
A resident's health information was improperly displayed in a public area, revealing their contact isolation status and guidelines for Candida auris. Facility staff confirmed that such information should remain private, and the DON was unaware of the posting. The resident was moderately cognitively impaired and had a current order for contact isolation.
A facility failed to follow a physician's order for daily weight monitoring of a resident with multiple health conditions, missing numerous weight records over a period of time. An LPN confirmed that CNAs were responsible for obtaining weights, but the facility's policy on accurate weight measurement was not consistently followed, leading to a deficiency.
The facility failed to maintain vascular access sites for two residents, leading to missed IV medication doses. One resident with osteomyelitis had a Midline catheter that was not flushed regularly, while another with a stump infection experienced missed doses due to PICC line issues and lack of medication. The facility's policies on flushing were not followed, and there was inadequate documentation and follow-up on physician recommendations.
A facility failed to complete necessary assessments for a resident requiring dialysis, leading to a deficiency. The resident, with conditions including heart failure and diabetes, reported attending dialysis three times a week. However, the facility did not consistently complete the required assessments before and after treatments, as confirmed by the DON. Additionally, the resident experienced delays in receiving assistance upon returning from dialysis, highlighting a lack of adherence to the facility's Dialysis Guideline policy.
The facility failed to provide timely IV antibiotics to two residents, resulting in missed doses. One resident with osteomyelitis missed six doses due to a lack of IV tubing, while another with a UTI did not receive Merrem on multiple occasions due to unavailability. Additionally, a resident experienced a delay in receiving an increased dose of Vancomycin due to the medication not being available. The facility's pharmacy policies were not effectively followed, contributing to these deficiencies.
A facility failed to conduct timely A1C tests for a resident with diabetes, as ordered by the physician. The resident's A1C tests were missed in June and September, despite a policy to ensure timely lab work. The DON confirmed the absence of records for the missing tests.
The facility failed to maintain a kitchen exterior door in good working order, as observed during three inspections. The door was cracked open, with a broken draft stopper creating a gap at the bottom. The Maintenance Director was informed weeks prior but had no documentation for repair. The facility's policy required timely maintenance, but the door remained unfixed.
A facility failed to notify a physician when a resident's blood glucose levels exceeded the set threshold. The resident, with multiple diagnoses including diabetes, had orders for Humalog insulin and additional doses based on a sliding scale. Despite elevated glucose levels on several occasions, discrepancies in documentation and lack of physician notification were noted. Interviews confirmed the physician should have been informed, as per facility policy.
A facility failed to update a care plan for a resident who engaged in inappropriate sexual behavior. Despite a reported incident, the care plan interventions had not been revised since August. The resident was placed on 15-minute monitoring, which was discontinued the next day without further interventions. Staff were aware of the behavior, but no new measures were implemented after the incident.
The facility failed to follow a physician's orders for a resident's laboratory tests, resulting in the tests not being conducted. The resident, who was cognitively intact and had multiple diagnoses, was supposed to have a CBC, CMP, and BNP drawn. A QMA attempted to draw blood but was unsuccessful, and no follow-up was conducted. The Administrator found no lab report and believed the order was incorrectly transcribed and dropped. An LPN confirmed that blood work should be collected the same day, but this did not occur.
The facility failed to ensure accurate medication administration records for four residents, leading to discrepancies between the Controlled Drug Receipt/Record/Disposition Form and the EMAR for narcotic pain medications. An RN indicated that documentation should occur in both the EMAR and on paper count sheets, but reviews showed missing documentation on specified dates.
A resident sustained a burn on his back during a TENS therapy session when the pad folded over on his skin. The therapist was following the device's directions and had used it multiple times without issues. The resident's wound was treated by a Wound NP and was improving, but the facility lacked documentation of the device's inspection since 11/14/22.
Failure to Prevent Verbal Abuse and Demeaning Conduct by CNA
Penalty
Summary
The facility failed to protect residents from verbal abuse by CNA 6, resulting in multiple incidents involving two cognitively intact residents. Resident D, who has cerebral palsy, diabetes, renal insufficiency, and is frequently incontinent of bowel and bladder, reported that after he requested bathroom assistance, CNA 6 told him she would come back later because she had other people to worry about. While he waited, he experienced a bowel accident and, after ringing the call light again, reported that CNA 6 told him to keep his mouth shut and not get into other people's business. Resident D also reported overhearing CNA 6 in the hallway saying she was sick and tired of taking care of him while she gathered supplies to clean him after the accident. In a separate incident on an unknown date, Resident D reported that CNA 6 told him that if he did not do what she wanted regarding use of the call light, he would need to find another nurse to help. A QMA later documented that Resident D stated CNA 6 told him to "shut his damn mouth" when he tried to explain what he wanted regarding a personal care item, repeated the directive, and then left the room. Resident F, who has heart failure, diabetes, and is occasionally incontinent of urine and frequently incontinent of bowel, reported that CNA 6 was hostile, overly dramatic, and made negative sound effects while assisting him, which made him feel uncomfortable. In a confidential witness statement, Resident F described CNA 6 as irritable, clumsy, and grumpy over several days, with an attitude suggesting he was upset and taking it out on the resident. The QMA’s statement indicated that Resident F told her CNA 6 seemed to be having a bad day, was not in a pleasant mood, and that this made him feel uncomfortable, a feeling he had not experienced before. Additional staff interviews indicated that, prior to these events, other residents had reported CNA 6 being more stressed, irritated when residents were not fast enough during care, verbally rude, impatient, and snappy, and that such concerns had been reported to the Administrator. These actions and behaviors conflicted with the facility’s DIGNITY and ABUSE PREVENTION PROGRAM policies, which prohibit condescending, critical, or argumentative speech, profanity or vulgar words in the presence of residents, and any disparaging or derogatory verbal language that meets criteria for abuse.
Failure to Timely Care Plan for Resident Suicidal Ideation
Penalty
Summary
The deficiency involves the facility’s failure to timely develop and update a care plan addressing suicidal ideation for a resident with documented suicide risk. The resident, who was cognitively intact, had diagnoses including traumatic brain dysfunction, anoxic brain damage, anxiety, and depression, and was documented as having little interest or pleasure in activities nearly every day, feeling down or hopeless at least half the days, feeling tired nearly every day, and feeling bad about themself. On one afternoon, a progress note documented a change in condition when the resident requested Adderall and was informed it was not due; the resident then began crying, pointed to their neck, and mouthed words that the LPN eventually interpreted as the resident stating they wanted to kill themself. The progress note indicated the resident was considered a danger to self or others for suicide potential, and the physician was notified. Despite this documented suicidal statement and identification of suicide potential, the resident’s care plan did not include any care plan addressing suicidal ideation until several weeks later. The LPN confirmed in interview that the resident had asked for more Adderall, became visibly upset and tearful, and affirmed that they wanted to kill themself when asked directly. The Social Service Director stated that residents are care planned for suicidal ideation when a nurse asks if they want to kill themself and the resident says yes, and acknowledged that this would be considered suicidal ideation. The facility’s policy on Baseline and Comprehensive Care Plans requires that every resident have a care plan that expands on mental and psychosocial needs, but the care plan for this resident lacked an intervention for suicidal ideation during the period following the documented suicidal statement.
Failure to Prevent Elopement and Provide True One-to-One Supervision
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and prevent elopement for a resident with known exit-seeking behavior, and failure to provide true one-to-one (1:1) supervision for two residents ordered to be on 1:1 observation. Resident C had diagnoses including non-Alzheimer’s dementia and arthritis and a physician’s order for a wander guard on his ankle with daily checks for placement and function due to elopement risk. His care plan identified him as at risk for elopement based on a history of wandering and dementia, with interventions such as monitoring doors when staff and visitors come and go and redirecting him from unsafe areas. Social services documented that the day before the elopement incident he attempted to follow a visitor out of the facility, triggering his wander guard alarm, after which 15‑minute monitoring was initiated for 48 hours. On a cold night when outdoor temperatures ranged between 23 and 34 degrees Fahrenheit, Resident C reported that he told staff he did not want to be at the facility and had been told he could not go outside. He stated he then went to a facility door, used a code to exit, and remained outside until he became cold and returned by waving at staff through a side door window. Staff interviews established that around 8:30 p.m. an LPN responded to a wander guard alarm at the front door and saw Resident C in his powered scooter heading down the hallway, and around 9:00 p.m. she saw him sitting in front of the nurse’s station. An RN reported seeing him in the atrium with other residents at about 9:15 p.m. At approximately 9:45 p.m., staff could not locate him and initiated missing resident protocol; he was then found standing outside the doors at the end of a hallway, wearing only a cowboy hat and black underwear, cold, scared, and shivering, with small scratches on his arm and above his left ear. He was sent to the emergency room and later returned with no additional injuries identified. The maintenance director explained that most doors had alarms that would sound even when a code was used, and that two of three non‑alarmed doors had wander guard alarms; however, the back doors of the main dining room could be opened with a punch code without any additional alarm, and the administrator stated that cameras were not working, so the exit door used by Resident C could not be determined. The deficiency also includes the facility’s failure to provide actual 1:1 supervision as defined in its own policy and by staff and the physician for Residents B and C. Resident B, who was cognitively intact with diagnoses including traumatic brain dysfunction, anxiety, and depression, had recently been hospitalized for an attempted suicide and was readmitted on 1:1 observation, where she remained. Observations showed Resident B lying in bed with a staff member sitting in the hallway outside her room, and at one point there was no call light within her reach. Resident C’s room was directly across the hall, and both residents were on 1:1 observation. A staff member was observed sitting between their rooms in the hallway, with no staff present in the main hallway leading to the main entrance; from the residents’ rooms, approximately nine steps led to the main hallway and another nineteen steps to two exit doors with push keypads and alarms, and if either resident walked nine steps down the hall, they would be out of the staff member’s sight. On another observation, the assigned staff member was looking at her phone while sitting outside their rooms, and at one point Resident C was in the bathroom with the door closed while the ADON sat in the hallway. Multiple staff interviews confirmed that both Residents B and C were on 1:1 observation and that documentation was done on paper. The primary care physician stated that 1:1 observation meant one staff to one resident. The ADON and administrator, along with the corporate clinical nurse, described 1:1 as having eyes on the resident at all times, with a staff member posted where they could visibly see the resident at all times, and the facility’s written policy on one‑on‑one supervision required a staff member to remain in direct supervision of the resident, with direct visual surveillance at all times. However, staff also reported that one staff member was assigned to both residents on 1:1, and that if Resident C was not redirectable and no additional staff were available, the assigned nurse would have to let him walk away because she could not leave Resident B. The social services director was unsure whether 1:1 meant one staff to one resident and stated that if Resident C walked up the main hallway, she would leave Resident B to follow him. These observations and statements show that the facility did not maintain continuous direct visual supervision of each resident on 1:1 observation and did not ensure adequate supervision to prevent elopement and other accidents for Residents B and C.
Failure to Follow Medication Administration Protocols
Penalty
Summary
The facility failed to properly prime an insulin pen before administering it to a resident. During a medication administration observation, an LPN was observed using a Fiasp insulin pen for a resident without holding the pen upwards as required to ensure no air was present. The LPN administered the insulin with the door open, which was not in accordance with the proper procedure. The package insert for the insulin pen clearly stated the need to hold the pen with the needle pointing up during priming, which was not followed. The facility also failed to monitor and document vital signs appropriately before administering medications with specific hold parameters. For one resident, Metoprolol was administered without documenting vital signs on multiple occasions, despite physician orders to hold the medication if the heart rate was below 60 or blood pressure was below 110/60. Similarly, another resident received Carvedilol even when their blood pressure or heart rate was below the specified parameters, as documented in the EMAR over several months. Additionally, a resident was administered Midodrine despite having a systolic blood pressure greater than the hold parameter of 120, as per physician orders. This occurred on numerous occasions, as evidenced by the EMAR records. Interviews with nursing staff and the DON confirmed that the facility's policy was to check vital signs and hold medications based on the parameters, which was not adhered to in these cases.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to provide the required registered nurse (RN) coverage for eight consecutive hours a day for 16 out of the 21 days reviewed. The nursing schedule revealed that there was no RN on duty for the required hours on several weekends spanning from July 2024 to February 2025. During an interview, the Director of Nursing (DON) acknowledged staffing issues in the previous months. The facility's policy mandates RN coverage for at least eight consecutive hours per day, seven days a week, which was not adhered to during the specified dates.
Medication Storage Deficiencies
Penalty
Summary
The facility failed to store medications appropriately, as observed during a survey. In one instance, an LPN removed a Fiasp insulin pen from a medication cart that was not stored in a plastic bag and lacked a resident's name or identifying information. The pen was labeled with an opened date but was not associated with a specific resident until the LPN identified it as belonging to a resident who was the only user of that insulin type. The LPN then labeled the pen with the resident's name before administering the insulin. Additionally, the Front Medication Cart contained several loose pills of various types and a drawer covered in a spilled substance, indicating a lack of proper medication storage and organization. Further observations revealed that the Rehab Medication Cart also contained loose pills, and an LPN acknowledged that insulin pens should be labeled with a resident's name. In the 39 Hall Medication Room, two opened vials of Tuberculin serum were found, one of which was outdated and should have been discarded after 30 days. The facility's policy on medication storage, dated February 2017, was provided, indicating that medications and biologicals should be stored safely and securely following manufacturer recommendations. However, the observations during the survey indicated non-compliance with these storage protocols.
Failure to Notify Physician of Elevated Blood Glucose Levels
Penalty
Summary
The facility failed to notify the physician when a resident's blood glucose levels were out of range for one of the residents reviewed. The resident, who was cognitively intact, had multiple diagnoses including diabetes, anemia, coronary artery disease, heart failure, hypertension, anxiety, and depression. The resident had medical orders to receive Humalog insulin three times a day and additional doses based on a sliding scale, with instructions to notify the physician if blood glucose levels exceeded 351. However, the facility did not notify the physician when the resident's blood glucose levels were documented as being above this threshold on multiple occasions. The discrepancy in blood glucose documentation was noted in the Electronic Medication Administration Record (EMAR) and Vitals Reports for several dates across November and December 2024, and January and February 2025. Despite the blood glucose levels being recorded as higher than 351, there was no indication that the physician was informed. Interviews with a Licensed Practical Nurse (LPN) and the Director of Nursing (DON) confirmed that the physician should have been notified according to the facility's policy. The facility's policy mandates notifying the resident's attending physician and representative of changes in the resident's condition or status.
Resident's Health Information Inappropriately Posted Publicly
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of a resident's medical records by posting personal health information in a public setting. Specifically, signage on the door of a resident's room indicated that the resident was in contact isolation and under enhanced barrier precautions. Additionally, a document titled 'Guidelines for addressing Candida auris' was posted on the wall next to the door, directly above the resident's name and room number. This public display of the resident's health information was observed on two separate occasions. Interviews with facility staff, including an LPN and the Director of Nursing (DON), confirmed that resident information, such as diagnoses and medication lists, should remain private and not be publicly displayed. The DON and the Regional Nurse Consultant were unaware of the posted documentation and acknowledged that it should not have been there. A review of the resident's clinical record indicated that the resident was moderately cognitively impaired and had a current order for contact isolation due to a Candida auris infection. The facility's policy on protected health information, provided by the DON, emphasized the confidentiality of health information that identifies an individual.
Failure to Monitor Resident's Daily Weight
Penalty
Summary
The facility failed to adhere to a physician's order for daily weight monitoring of a resident, identified as Resident 29, who was cognitively intact and had multiple diagnoses including diabetes, anemia, coronary artery disease, heart failure, hypertension, anxiety, and depression. The physician's order, initiated on 12/28/24, required daily weights and notification if the resident's weight increased by more than 3 pounds in a day or 5 pounds in a week. However, the clinical record showed missing daily weights on numerous dates between 12/30/24 and 02/04/25. During an interview, an LPN confirmed that CNAs were responsible for obtaining the resident's weight and informing the nurse, who would then document it and notify the physician if necessary. The facility's policy emphasized the importance of accurate weight measurement for assessing nutritional and health status, and the potential impact of inaccurate measurements on care plans. Despite this policy, the facility did not consistently record the resident's weight as required, leading to a deficiency in maintaining the resident's health through proper monitoring.
Deficiencies in IV Site Maintenance and Medication Administration
Penalty
Summary
The facility failed to provide proper maintenance for vascular access sites for two residents, leading to deficiencies in the administration of IV fluids and medications. Resident 4, who was admitted with an infected heel wound and osteomyelitis, had a Midline catheter that was not flushed regularly, resulting in missed IV antibiotic doses due to a lack of supplies and issues with the venous access site. The clinical records lacked documentation of regular flushing of the vascular access sites, and there were no physician's orders to maintain the patency of the sites. Resident 38, admitted with a right stump infection, also experienced deficiencies in IV medication administration. The resident had a PICC line for antibiotic administration, but the clinical record showed missed doses due to unavailability of medication and issues with the PICC line placement. Although there was a physician's order to flush the IV-midline, it lacked scheduling details, resulting in the absence of documentation for flushing from the clinical record. Additionally, there was a failure to follow up on a recommendation for a central line placement, with incomplete documentation related to the scheduling and completion of this procedure. The facility's policies required specific flush orders to be documented and followed to ensure catheter patency and prevent medication incompatibility. However, the lack of proper documentation and adherence to these policies contributed to the deficiencies observed. Interviews with staff revealed that orders for flushing were not properly inputted into the system, and there was a lack of follow-up on physician recommendations, further exacerbating the issues with vascular access site maintenance.
Failure to Complete Dialysis Assessments for Resident
Penalty
Summary
The facility failed to complete necessary assessments for a resident requiring dialysis, leading to a deficiency in care. Resident 24, who is cognitively intact and has diagnoses including heart failure, hypertension, renal insufficiency, and diabetes, reported attending dialysis treatments three times a week. However, the facility did not consistently complete the required assessments before and after these treatments. The Director of Nursing (DON) confirmed that staff were supposed to fill out the DIALYSIS/OBSERVATION COMMUNICATION FORM each time the resident went for dialysis, but the forms were incomplete, with only a few records available for December. Additionally, the resident expressed concerns about having to wait in her wheelchair with her coat on for extended periods after returning from dialysis, indicating a lack of timely assistance from staff. The facility's current Dialysis Guideline policy emphasizes the importance of communication between the dialysis provider and the facility staff, including the review of daily weights and changes in condition. Despite this, the facility failed to adhere to these guidelines, as evidenced by the incomplete documentation and the resident's reported experiences.
Failure to Provide Timely IV Antibiotics
Penalty
Summary
The facility failed to provide timely IV antibiotics to two residents, resulting in missed doses. Resident 4, who was admitted with acute osteomyelitis of the right ankle and foot, missed six doses of IV antibiotics due to a lack of IV tubing. The facility ran out of tubing for two days, and the pharmacy did not send tubing with the medications. Although the facility ordered tubing from a supplier, it was discovered that the supplier no longer carried it, leading to a delay in treatment until the pharmacy delivered the necessary supplies. Resident 29, diagnosed with a UTI, did not receive the prescribed IV antibiotic Merrem on multiple occasions due to the medication being unavailable. The pharmacy was expected to deliver the medication, but it was not received in a timely manner, resulting in missed doses over several days. Progress notes indicated repeated communication with the pharmacy, but the medication was not delivered as expected, leading to further delays in treatment. Additionally, Resident 38 experienced a delay in receiving an increased dose of Vancomycin due to the medication not being available in the emergency drug kit. The resident's trough level indicated a need for an increased dose, but the clinical record lacked an order for the increase, and the medication was on hold for several days. The facility's policies on pharmacy hours and delivery schedules were not effectively followed, contributing to the deficiencies in medication administration.
Failure to Conduct Timely A1C Tests for a Resident
Penalty
Summary
The facility failed to obtain required blood tests for a resident, identified as Resident 27, who was moderately cognitively impaired and had diagnoses including diabetes, anxiety, and hypertension. The resident's physician had ordered an A1C test every three months, starting from June 2023. However, the facility only conducted the A1C tests in March and December of 2024, missing the tests that should have been conducted in June and September of that year. During an interview, the Director of Nursing confirmed that the facility did not have records of the missing A1C tests. The facility's policy on lab scheduling and tracking was intended to ensure timely lab work, but it was not followed in this instance.
Kitchen Door Maintenance Deficiency
Penalty
Summary
The facility failed to maintain a kitchen exterior door in good working order, which was observed during three separate kitchen inspections. The door was found to be cracked open about 1/2 to 1 inch, allowing visibility to the outside. Additionally, the door draft stopper at the bottom was broken on the right side, creating an approximately 2-inch gap. This issue was noted during observations on multiple occasions, and the Dietary Manager was seen closing the door during one of the inspections. The Maintenance Director was informed of the broken door a few weeks prior to the inspection, but there was no documentation indicating that the door needed to be fixed. The kitchen staff had been educated to ensure the door remained closed, despite its inability to shut properly. The facility's policy required maintenance requests to be addressed in a timely manner, with urgent issues being prioritized. However, the broken door had not been repaired, and the Maintenance Director indicated it would be fixed by the end of the day.
Failure to Notify Physician of Elevated Blood Glucose Levels
Penalty
Summary
The facility failed to notify the physician when a resident's blood glucose levels were out of range for one of the residents reviewed. Resident 29, who was cognitively intact, had multiple diagnoses including diabetes, anemia, coronary artery disease, heart failure, hypertension, anxiety, and depression. The resident had medical orders to receive Humalog insulin three times a day and additional doses based on a sliding scale, with instructions to notify the physician if blood glucose levels exceeded 351. However, the facility did not notify the physician when the resident's blood glucose levels were above this threshold on multiple occasions. The clinical records showed discrepancies in the documented blood glucose levels for the scheduled insulin and the sliding scale insulin, even though both doses were administered together. For instance, on several dates, the blood glucose levels documented for the scheduled insulin were significantly higher than those documented for the sliding scale insulin. Interviews with the LPN and the DON confirmed that the physician should have been notified when the blood glucose levels were outside the call parameters, as per the facility's policy. However, there was no indication that the physician was informed of these elevated levels, leading to a deficiency in the facility's notification process.
Failure to Update Care Plan for Resident's Inappropriate Behavior
Penalty
Summary
The facility failed to update a resident's care plan related to behaviors, specifically for a resident who engaged in inappropriate sexual behavior. Resident E, who was cognitively intact and diagnosed with multiple sclerosis and depression, was involved in a reported incident where he engaged in sexual touching with another resident in a common area. Despite having a care plan that addressed inappropriate behavior, the interventions had not been updated since August, even after the incident in October. The care plan included interventions such as monitoring the resident in common areas and educating staff to redirect him from female residents' rooms, but these were not revised following the new incident. Interviews and record reviews revealed that Resident E was placed on 15-minute monitoring after the incident, but this was discontinued the next day without further interventions. Staff were aware of Resident E's behavior, and a stop sign was placed on Resident F's door to prevent inappropriate interactions. However, the Social Service Director was on leave, and the Administrator and DON did not implement new interventions after the incident. The facility's policy required care plans to be reviewed and updated based on changes in the resident's condition, but this was not adhered to in this case.
Failure to Follow Physician's Orders for Laboratory Services
Penalty
Summary
The facility failed to follow a physician's orders for obtaining laboratory services for Resident B, who was cognitively intact and had diagnoses including diabetes, GERD, and ESRD. A physician's order dated 09/11/24 required the staff to obtain a CBC, CMP, and BNP for the resident. However, during an interview, Resident B indicated that a QMA attempted to draw her blood but was unsuccessful, and although she was told another nurse would return, no one did. The Administrator confirmed that there was no laboratory report for Resident B for the specified date and believed the order was incorrectly transcribed and subsequently dropped from the system after 24 hours. An LPN stated that blood work should be collected the same day it is ordered, and there was no reason for the order not to have been collected. The facility's policies on following physician orders and lab scheduling/tracking were reviewed, indicating that the facility should ensure ordered lab work is obtained, but these policies were not followed in this instance.
Medication Administration Record Discrepancies
Penalty
Summary
The facility failed to ensure that the medication administration records accurately reflected the administration of narcotic pain medication for four residents. Resident B, who was cognitively intact and had diagnoses including diabetes and arthritis, had discrepancies between the Controlled Drug Receipt/Record/Disposition Form and the Electronic Medication Administration Record (EMAR) for Hydrocodone-Acetaminophen on multiple dates. Similarly, Resident D, also cognitively intact with diagnoses including heart failure and polyneuropathy, had discrepancies in the administration records for Hydrocodone-Acetaminophen on several dates. Resident G, with diagnoses including diabetes and kidney disease, had discrepancies in the administration records for Tramadol. Lastly, Resident H, who was moderately cognitively impaired with diagnoses including hip fracture and seizure disorder, had discrepancies in the administration records for Oxycodone on multiple dates. During an interview, RN 2 indicated that the facility's procedure required nurses to document the administration of controlled medications both in the computer EMAR and on the paper controlled medication count sheets. However, the review of the clinical records and the EMARs for the four residents showed a lack of documentation for the administration of the narcotic pain medications on the specified dates and times. The facility's policy on medication administration, dated February 2017, was provided by the Director of Nursing and indicated that all medications should be administered safely and appropriately, with documentation in the appropriate spaces on the Medication Administration Record (MAR).
Resident Sustains Burn During TENS Therapy
Penalty
Summary
The facility failed to ensure a resident did not sustain a skin injury during therapy. Resident B, who was in the facility for back issues and participated in physical therapy, sustained a burn on his back while using a TENS (Transcutaneous Electrical Nerve Stimulation) machine. The incident occurred when the pad of the TENS machine folded over on the resident's skin, causing a burn. The therapist was following the directions on the TENS unit and had used the device on the resident multiple times without issues. However, during this session, the pad moved and folded, leading to the injury. The resident did not report feeling any discomfort during the session, and the therapist turned off the machine when it indicated a problem with the pads. The wound was assessed and treated by a Wound NP, and the resident reported pain from the burn. The TENS device had been inspected annually, with the most recent inspection occurring on 11/14/22, which showed no concerns. The facility lacked documentation of any inspection since that date. The resident's clinical record indicated he was cognitively intact and had diagnoses including diabetes, arthritis, spinal stenosis, and intervertebral disc displacement. The wound was a second-degree burn, which was improving but still painful for the resident. The facility's policy on Low Voltage Electrical Stimulation indicated treatments should be administered by designated personnel under the supervision of a licensed therapist, but the therapist did not visually monitor the resident's skin throughout the session. The therapist acknowledged that he would likely monitor residents' skin more closely in the future.
Latest citations in Indiana
Surveyors observed that dietary staff repeatedly worked in kitchen and meal service areas with uncovered facial hair, despite facility policy and state sanitation requirements mandating effective hair restraints. Two dietary aides with short beards or mustaches were seen walking through food preparation areas, taking food temperatures, handling food, and plating meals at steamtables in dining rooms without any facial hair coverings, while the current policy required all hair, including facial hair, to be restrained to prevent contamination.
The facility failed to consistently provide and document required bed-hold policy notices when several residents were transferred to the hospital. In multiple cases, residents with dementia, psychotic disorders, COPD, chronic respiratory failure, altered mental status, and cerebral infarction were sent out for acute changes in condition, and while transfer notes reflected physician and family notifications, they lacked documentation that the bed-hold policy was discussed with the resident or responsible party. Notices of Transfer or Discharge often indicated a copy of the bed-hold policy was sent with the resident, but the records did not show signed and dated acknowledgment by the resident or appropriate representative, including in situations where a resident had moderate cognitive impairment, short-term memory issues, or a documented need for a proxy and a financial POA authorizing an agent for health care decisions.
Surveyors found that the facility failed to provide trauma‑informed and culturally competent care by not incorporating two residents’ extensive trauma histories and specific behavioral triggers into their care plans. One resident with documented homelessness, polysubstance abuse, severe accidents with multiple fractures, viral encephalitis with coma, physical and sexual abuse, loss of family contact, and a past suicide attempt had multiple behavior‑focused care plans that referenced identifying triggers but listed none and did not mention their physical, sexual, medical, or psychosocial trauma. Another resident with TBI from being struck by a truck, an 11‑month coma, long‑term state hospital residence, alleged shooting of a parent, and diagnoses including intermittent explosive disorder and borderline personality disorder had a PASRR identifying a specific trigger and notes of inappropriate sexual behavior, yet their care plans omitted these traumatic events, the identified trigger, and the sexual behavior. Staff interviews confirmed that residents were screened for trauma, but the trauma histories and triggers were not reflected in the individualized plans of care.
A resident with schizophrenia, post‑stroke hemiparesis, and mild cognitive impairment expressed feeling down and wanting to kill himself, but staff did not document asking about a specific plan, did not notify the physician or psychiatric NP as expected, and did not develop or update a care plan addressing depression or suicidal ideation. The SSD documented offering support and initiating 15‑minute checks once, but there was no further follow‑up or documentation of interventions after subsequent suicidal statements made in a care plan meeting with the resident’s father. The DON and Administrator reported that facility policy requires immediate notification of key staff, assessment for a plan and means of self‑harm, and thorough documentation, which were not carried out or reflected in the medical record for this resident.
A resident with schizophrenia, post-stroke hemiparesis, and mild cognitive impairment verbalized suicidal ideation, but the care plan did not address depression or suicidal thoughts, and required assessments and services were not accurately or timely documented. An SSD note recorded the resident saying he wanted to kill himself and referenced 15‑minute checks and a care plan update, yet the active care plan lacked depression/suicidal ideation interventions. Multiple late-entry Social Services notes were later added, describing follow-up visits and the resident denying suicidal ideation, but the SSD later reported she did not typically ask about a suicide plan and did not personally provide individual follow-up visits as described. These practices conflicted with the facility’s policy requiring factual, first-hand, and timely documentation of assessments and services.
A resident was observed with an Albuterol inhaler on an overbed table and later reported keeping the inhaler in a nightstand drawer, with no staff present during these observations. Record review showed the resident had no cognitive impairment on the admission MDS but lacked any documented self-medication administration assessment. The DON acknowledged that the required assessment had not been completed, despite facility policy requiring staff and the practitioner to evaluate each resident’s mental and physical abilities before allowing self-administration of medications.
Surveyors found that the facility submitted inaccurate direct care staffing data to CMS through the PBJ system over multiple days in a quarter. CASPER reports showed apparent gaps in 24-hour licensed nurse coverage, low weekend staffing, and a 1-star staffing rating, while internal staffing sheets documented that licensed nurses were present and the facility was fully staffed on those days. The Administrator reported that the discrepancies were due to PBJ data entry errors, despite a facility policy requiring all PBJ entries to be accurate, auditable, and verifiable against payroll, invoices, or contracts.
Surveyors found that the facility did not provide or document required written transfer/discharge notices and bed-hold policy information for four residents who were sent to the hospital, including individuals with conditions such as dementia, CHF, chronic respiratory failure, and CKD. In each case, progress notes showed that the resident was transferred for acute issues, but the clinical records lacked evidence that written notices were given to the residents or their representatives, and in one case lacked documentation that required information was sent to the receiving provider. Facility leadership, including the ADON, DON, and Administrator, acknowledged that the records did not contain the required documentation, despite a written policy requiring such notices and information exchange.
A resident with Alzheimer’s disease and depression, previously on an antidepressant, exhibited intermittent refusals of medications and care, occasional yelling at staff, and reports of unusual perceptions, such as believing men were in or near her room. Nursing notes over several months documented these refusals and complaints but did not show that the behaviors were evaluated or recorded as dangerous, non-redirectable, or causing significant distress, nor did they document specific non-pharmacological interventions attempted or their outcomes. Despite this, a psychiatric NP later added new diagnoses of schizoaffective disorder, borderline personality disorder, and delusional disorder and ordered an antipsychotic (Seroquel) without a comprehensive evaluation in the record to support these diagnoses. The facility’s psychotropic medication policy, which requires identification and documentation of target behaviors, use of nonpharmacological interventions, and ongoing behavior monitoring, was not followed for this resident.
The facility failed to keep PASARR Level I screenings accurate and current for three residents when new mental health diagnoses and psychoactive medications were initiated. One resident’s PASARR omitted a PTSD diagnosis and an added antidepressant, despite documentation of PTSD on the MDS and care plan and a physician order for Pristiq. Another resident’s PASARR listed only depression and dementia, even after additional diagnoses such as borderline personality disorder, delusional disorder, and schizoaffective disorder were added and an antipsychotic (quetiapine) was ordered, with the MDS later reflecting psychotic disorder, schizophrenia, and depression with antipsychotic and antidepressant use. A third resident’s PASARR did not include a depression diagnosis or newly ordered escitalopram and lorazepam, although the admission MDS documented depression with antianxiety and antidepressant use. These omissions occurred despite facility policy requiring a new Level I review after significant mental status changes, including new mental health diagnoses or new psychotropic medications.
Uncovered Facial Hair During Food Preparation and Meal Service
Penalty
Summary
The deficiency involves the facility’s failure to ensure that food was served in a sanitary and safe manner in accordance with professional standards and facility policy during multiple kitchen and meal service observations. During an initial kitchen observation, two dietary aides were seen walking through the kitchen food preparation area with uncovered facial hair. One aide had facial hair above and below the lip and along the jaw line, approximately one-fourth inch in length, and the other had a mustache of similar length; neither used any facial hair covering. These observations occurred while staff were present in the kitchen area where food was stored and prepared. During subsequent observations on the same day, the same two dietary aides were again observed with uncovered facial hair while directly involved in meal preparation and service. One aide walked through the kitchen while the noon meal was being prepared and placed into a transport cart for service in the south dining room, and later was observed plating the noon meal at the steamtable in that dining room, still without a facial hair covering. The other aide walked through the kitchen while the noon meal was being prepared and placed into the steamtable for the north dining room, took food temperatures, assisted with plating meals at the steamtable, and retrieved food items and supplies from the kitchen, all while having an uncovered mustache approximately one-fourth inch in length. The Dietary Manager stated that staff hair was to be covered when in the kitchen and during meal service, and the facility’s written policy and the cited Indiana Food Establishment Sanitation Requirements both required effective hair restraints, including for facial hair, to prevent contamination of food, equipment, and utensils.
Failure to Provide and Document Bed-Hold Policy at Time of Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure that required bed-hold policy information was provided and documented for four residents transferred to the hospital. For a resident with dementia, psychotic disorder, and autistic disorder who had a BIMS score of 0 indicating severe cognitive impairment, progress notes documented physician notification and guardian notification when the resident was sent to the hospital, but there was no documentation that the bed-hold policy was provided to the responsible party. A Notice of Transfer or Discharge later indicated a copy of the bed-hold policy was sent with the resident. Another resident with COPD and chronic respiratory failure, cognitively intact with a BIMS score of 13, experienced a decline in condition and was transferred to the hospital by ambulance; progress notes documented family notification but did not document any discussion of the bed-hold policy, although a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident. A third resident with altered mental status and cerebral infarction, with a BIMS score of 10 indicating moderate cognitive impairment and documented short-term memory impairment, experienced changes in condition and was transferred to the hospital. Progress notes stated the resident was their own responsible party and that no other notification was completed, and transfer documentation did not include the bed-hold policy, although an untimed Notice of Transfer or Discharge indicated a copy of the bed-hold policy was signed by the resident. A financial power of attorney document in the record showed the resident had designated an agent to act in consent or refusal of health care. For a fourth resident with dementia and osteomyelitis, transfer documentation and a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident, and the transfer form noted the resident required a proxy for decision making. The facility’s policy required that at the time of transfer to a hospital, written notice specifying the duration of the bed-hold policy and information on return to the next available bed be provided, and that a signed and dated copy of the bed-hold notice given to the resident or representative be kept in the resident file, which was not consistently documented for these residents.
Failure to Integrate Trauma Histories and Behavioral Triggers Into Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to identify and incorporate residents’ trauma histories and specific behavioral triggers into their care plans, despite documented histories of significant trauma and behavioral health issues. For one resident, extensive social service and progress notes documented homelessness, polysubstance abuse, major depressive and anxiety disorders, chronic pain, a history of severe car accidents with multiple fractures, viral encephalitis resulting in a three‑month coma, loss of child custody, multiple divorces, physical abuse by a spouse, the death of a fiancé who was struck by a car while in a wheelchair, lack of family contact, and a past suicide attempt by Valium overdose. Additional documentation noted a history of rape by a brother at age eight and prior placement under direct supervision and 15‑minute checks related to suicidal ideation. Despite these documented traumatic events and behavioral health concerns, the resident’s care plans did not identify a history of physical trauma, sexual trauma, homelessness, substance abuse, medical trauma, or attempted suicide. For this same resident, the MDS showed no cognitive deficit and identified behaviors such as verbal aggression and rejection of care, along with diagnoses including seizure disorder, depression, chronic pain syndrome, homelessness, and anxiety disorder. Multiple care plans addressed behaviors such as drug‑seeking, pretending to have seizures for attention or medication, making false allegations, verbal aggression when unable to smoke, and a desire for intimate relationships with consenting male residents. These care plans referenced goals such as effective coping skills, seeking staff support, and compliance with the smoking policy, and they called for identification and reduction of behavioral triggers. However, none of these care plans actually listed any specific triggers. The care plan addressing the resident’s right to consensual intimate relationships focused on assessment and education regarding consent but did not integrate the resident’s extensive trauma history. Staff interviews indicated the resident had displayed sexual behaviors since admission, including an incident where the resident expressed anger at another resident for not buying a soda after engaging in sexual acts. A second resident with a documented history of traumatic brain injury (TBI), dementia, seizure disorder, borderline personality disorder, anxiety, intermittent explosive disorder, tobacco use, and other behavioral/emotional disorders was also affected by the same deficiency. Social history and progress notes documented that this resident sustained a TBI after being hit by a semi‑truck while riding a bicycle at age 18, resulting in an 11‑month coma, followed by 13 years in a state hospital and subsequent residence in a group home. Additional documentation indicated the resident allegedly shot their father at age 26 after being sworn at and had a PASRR identifying TBI, intermittent explosive disorder, and borderline personality disorder, with a specific trigger of hearing the name of the current U.S. President. Progress notes also described inappropriate sexual behavior toward staff, including touching themselves intimately during personal care and refusing to stop when redirected. Despite this, the resident’s care plans, which addressed explosive disorder and history of altercations, risk for decreased psychosocial well‑being, and refusal to bathe or shower, did not list any specific behavioral triggers, did not reference the traumatic events such as being hit by a truck or shooting their father, and did not document the inappropriate sexual behavior. The Administrator and Social Service Director acknowledged that residents were to be screened for trauma and that trauma responses and PTSD should be added to care plans, but the specific trauma histories and triggers for these two residents were not incorporated into their plans of care.
Failure to Assess and Care Plan for Resident Suicidal Ideation
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess, investigate, and care plan for a resident’s suicidal ideation in accordance with its own policy and staff expectations. The resident had diagnoses including schizophrenia, cerebral edema, and hemiparesis/hemiplegia following a cerebral infarction, and a current MDS showed mild cognitive impairment (BIMS score 12). A progress note documented that the resident told the Social Services Director (SSD) he was feeling down and wanted to kill himself; the SSD offered assistance, activities, and initiated 15‑minute checks, and the note stated the care plan was updated. However, the note did not indicate that the SSD asked whether the resident had a plan to kill himself, and there were no additional notes regarding suicidal ideation or follow‑up. Review of the current care plan showed no problem, goal, or interventions addressing depression or suicidal ideation, and progress notes over the following month contained no documentation of physician notification related to the suicidal statement. Further record and interview evidence showed that the care plan conference summary did not document interventions for suicidal ideation, and the SSD acknowledged she did not normally ask residents expressing suicidal ideation if they had a plan. The SSD reported that the resident had admission paperwork mentioning suicidal ideation related to depression after a stroke and that the resident again vocalized suicidal ideation during a care plan meeting with his father, after which emotional support was offered and the father took the resident out on a leave of absence; no further visits or follow‑up were done. The DON stated that, upon notification of suicidal verbalization, staff should assess the resident, ask if there is a plan, remove potential means of self‑harm, immediately notify the psychiatric NP, and document the occurrence, and that a detailed progress note and updated care plan were expected but not present for this resident. The Administrator similarly stated that staff should ask about a plan, document interventions, notify the physician and family, and update the care plan, and indicated the resident should have had a care plan addressing depression with suicidal ideation. The facility’s written policy required immediate notification of the DON, SSD, and physician, an interview including asking about a plan and assessing mood and means for self‑harm, and thorough documentation of mood, behavior, and all actions taken, which were not reflected in the resident’s record.
Incomplete and Inaccurate Documentation of Suicidal Ideation and Follow-Up
Penalty
Summary
The facility failed to ensure accurate, complete, and timely documentation of assessments and services for a resident who verbalized suicidal ideation. Resident 6, who had schizophrenia, cerebral edema, and right-sided hemiparesis/hemiplegia following a cerebral infarction, had a BIMS score of 12 indicating mild cognitive impairment. The resident’s admission paperwork mentioned suicidal ideation related to depression after a stroke, and a Social Services note on 3/11/2026 documented that the resident was feeling down and said he wanted to kill himself. The Social Services Director (SSD) documented that she talked with the resident, coordinated with Activities, advised the resident to contact SSD or nursing if he wanted to talk, and that the resident was scheduled for 15-minute checks and the care plan was updated. However, the current care plan initiated on 2/26/2026 did not address depression or suicidal ideation. Multiple Social Services progress notes were later entered as late entries in April, with effective dates in March, stating that the resident had no plan and no longer had suicidal ideation, that he felt much better after 1:1 time, and that he continued his daily routine and therapy. These late entries described follow-up visits and reassessments of suicidal ideation on several consecutive days, but in interviews the SSD stated she did not normally ask residents about having a plan when they verbalized suicidal ideation and did not recall any other occurrences beyond the initial event. She further indicated she did not personally provide individual follow-up visits with this resident regarding suicidal ideation, despite the late-entry notes describing such visits. The DON acknowledged that late entries had been added to address concern about suicidal verbalization, and the Administrator stated that upon suicidal statements staff should ask about a plan, notify the physician and family, and update the care plan, and that this resident should have had a care plan addressing depression with suicidal ideation. The facility’s documentation policy required factual, first-hand, timely documentation, which was not followed in this case.
Failure to Complete Required Self-Administration Assessment for Inhaler Kept at Bedside
Penalty
Summary
Surveyors identified that a resident was allowed to keep and access an Albuterol inhaler without the facility completing the required self-administration medication assessment. During an initial tour, the resident was observed sitting in a wheelchair with a handheld Albuterol inhaler on the overbed table and no staff present in the room or hallway. On a subsequent observation, the resident again was in a wheelchair and reported that the Albuterol inhaler was stored in the top drawer of the nightstand, where it was found. Review of the clinical record showed an admission MDS indicating no cognitive impairment, but there was no documentation of a self-medication administration assessment. In an interview, the DON confirmed that the resident did not have the required self-medication assessment, despite the facility’s policy stating that staff and the practitioner must assess each resident’s mental and physical abilities to determine whether self-administering medications is clinically appropriate. This failure to complete and document a self-administration medication assessment for a resident who had an Albuterol inhaler kept at bedside constituted noncompliance with the facility’s own policy and with 410 IAC 16.2-3.1-11(a).
Inaccurate PBJ Staffing Data Submission to CMS
Penalty
Summary
The deficiency involves the facility’s failure to electronically submit complete and accurate direct care staffing information to CMS through the Payroll-Based Journal (PBJ) system for 22 days in a fiscal quarter. A CASPER report review on 4/6/26 showed that, according to PBJ data, the facility did not have licensed nursing coverage 24 hours per day on multiple specific dates across three months, had low weekend staffing, and held a 1-star staffing rating. However, review of the facility’s internal staffing sheets for that quarter indicated the facility was fully staffed and had licensed nurse coverage on all of the dates in question. During an interview, the Administrator stated that the PBJ information must have contained data entry errors, as she had verified licensed staff coverage on the timesheets. The facility’s PBJ policy in effect stated that all staffing data entered into the PBJ system would be auditable and verifiable through payroll, invoices, or contracts, but the submitted PBJ data did not accurately reflect the facility’s actual licensed nurse staffing as documented on internal records. No specific residents or clinical conditions were mentioned in the report, and the deficiency centers solely on inaccurate staffing data submission rather than direct resident care events.
Failure to Provide and Document Required Transfer/Discharge and Bed-Hold Notices
Penalty
Summary
The deficiency involves the facility’s failure to provide and document required written notices of transfer/discharge and bed-hold policies, as well as required information to receiving providers, for four residents who were transferred or discharged to the hospital. For a resident with generalized anxiety disorder, major depressive disorder, and dementia, progress notes showed that the resident was sent to the hospital via 911 for chest pain, lower back pain, and shortness of breath and later returned to the facility, but the clinical record lacked documentation that a written Notice of Transfer/Discharge and the bed-hold policy were provided to the resident or representative, and lacked documentation that required information was conveyed to the receiving facility. The ADON and the Administrator both confirmed there was no documentation that these written notices were provided. For a resident with congestive heart failure and muscle weakness who was sent to the emergency room for painful urination and bloody urine, the clinical record lacked documentation that a Notice of Transfer/Discharge or bed-hold policy was given to the resident or representative, which the DON confirmed. Another resident with chronic respiratory failure and diabetes was discharged to the hospital for respiratory failure, and a resident with chronic kidney disease and dementia was discharged to the hospital, but in both cases there was no documentation that a written notice of transfer/discharge or bed-hold policy was provided to the residents or their representatives. Review of the facility’s Transfer and Discharge policy, dated 1/15/26, showed that the policy required the facility to provide written transfer/discharge notices and bed-hold information to residents and representatives and to provide specified information to receiving providers, but the records for these four residents did not contain the required documentation.
Failure to Document Target Behaviors and Non-Pharmacological Interventions Before Initiating Antipsychotic
Penalty
Summary
The deficiency involves the facility’s failure to document how a resident’s behaviors presented danger or distress to self or others, and failure to document non-pharmacological interventions attempted prior to initiating an antipsychotic medication. Resident 6 had documented diagnoses of Alzheimer’s disease, depression, and severe cognitive impairment, and was receiving sertraline for depression. A PASSAR identified only depression and dementia, and the admission MDS listed Alzheimer’s disease and depression as active diagnoses. Over several months, nursing progress notes documented that the resident intermittently reported unusual perceptions, such as believing there were men causing trouble, a man in her room, or a man wanting to marry her and yelling through the walls, but there was no documentation that these episodes caused danger to the resident or others or that they resulted in unmanageable distress. From late April through mid-July, nursing notes primarily described the resident’s frequent refusals of evening and morning medications, blood sugar checks, blood pressure checks, insulin administration, hygiene care, and showers. Staff documented that the resident sometimes yelled at staff, said “Get out!”, was visibly upset by a room move, was leery of staff and asked to see name badges, and became upset about a pillow under her head until it was removed, after which she calmed down. The notes also recorded instances where the resident believed housekeeping had not cleaned her room or that she had not received medications when she had. However, there were no progress notes or assessments indicating that these behaviors were evaluated as dangerous, non-redirectable, or causing significant distress or functional impairment, and no detailed behavior monitoring logs were present as required by facility policy. On a psychiatric NP visit for initial psychotropic medication management, new mental health diagnoses of schizoaffective disorder, borderline personality disorder, and delusional disorder were added, and Seroquel 25 mg, an antipsychotic, was ordered. The clinical record did not contain a comprehensive evaluation to support these new diagnoses, and there was no documentation of target behaviors meeting the facility’s policy criteria for psychotropic use, such as behaviors representing danger to self or others, causing distress and impairment in functional abilities, or clearly attributable to psychosis or mania. The resident’s representative reported that the resident had no prior history of mental health disorders or psychiatric hospitalization and was unaware of the new diagnoses. The facility’s own psychotropic medication policy required identification and documentation of specific target behaviors, use and documentation of nonpharmacological interventions, and ongoing monitoring of behaviors and interventions, which were not reflected in the record for this resident.
Failure to Update PASARR Screens for New Mental Health Diagnoses and Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that Preadmission Screening and Resident Review (PASARR) Level I screenings were accurate and updated when new mental health diagnoses and psychoactive medications were initiated for multiple residents. For one resident with dementia, anxiety, depression, and post-traumatic stress disorder (PTSD), the PASARR completed on admission listed anxiety, depression, and dementia with sertraline and quetiapine, but did not include the PTSD diagnosis or the antidepressant Pristiq, despite the admission MDS and care plan documenting PTSD and a subsequent physician’s order for Pristiq. For another resident with Alzheimer’s disease, borderline personality disorder, delusional disorder, schizoaffective disorder, and depression, the PASARR only reflected depression and dementia with sertraline, even though additional mental health diagnoses were added later and an antipsychotic (quetiapine) was ordered for borderline personality disorder, and the quarterly MDS documented psychotic disorder, schizophrenia, and depression with antipsychotic and antidepressant use. A third resident had diagnoses including Alzheimer’s disease, depression, anxiety disorder, irritability and anger, and nonrheumatic aortic valve stenosis. The PASARR for this resident listed dementia and anxiety with Risperdal but omitted the diagnosis of depression and the medications escitalopram and lorazepam, although physician’s orders were in place for escitalopram for depression and lorazepam for anxiety, and the admission MDS documented depression with antianxiety and antidepressant use. Interviews with the Assistant Director of Nursing confirmed that new Level I PASARR screens should have been completed when new mental health diagnoses and psychoactive medications were added, and that the PASARR for one resident, completed prior to arrival, should have included all mental health diagnoses and medications. The facility’s own policy required notification of the state mental health authority within 14 days after a significant change in mental condition and specified that a new Level I screen is required for new mental health diagnoses or newly prescribed psychotropic medications, which was not followed in these cases.
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