Waters Of Castleton Skilled Nursing Facility, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Indianapolis, Indiana.
- Location
- 8400 Clearvista Pl, Indianapolis, Indiana 46256
- CMS Provider Number
- 155271
- Inspections on file
- 37
- Latest survey
- March 11, 2026
- Citations (last 12 mo.)
- 20
Citation history
Health deficiencies cited at Waters Of Castleton Skilled Nursing Facility, The during CMS and state inspections, most recent first.
Two residents who were cognitively intact and managing their own medications were observed with medication cups at their bedside, containing multiple pills left without staff present, including additional medications placed by an LPN and then left for self-administration. Record review showed multiple scheduled and PRN medications ordered for these residents, but no documented IDT self-administration assessments or physician orders authorizing self-administration, despite a facility policy requiring IDT approval, physician orders, and care plan updates for residents who self-administer medications.
A resident with dementia and depression, who had severely impaired cognition but could make himself understood, reported that another resident had been mean to him, was bothering him, and had hit him on the head in the dining room, causing him to try to avoid that resident. An incident report documented that one resident struck another on the head with an open hand, with no injuries noted, and an LPN separated the residents after being informed of the event by another resident witness; the aggressor did not deny the action, stating the other resident would not be quiet. Observation later showed the aggressor seated behind the abused resident in the dining room, despite an abuse prevention policy that defines physical abuse as willful infliction of injury, including hitting and slapping.
The facility failed to complete and maintain required written statements during an abuse investigation after a resident with Down Syndrome witnessed a verbal argument between a QMA and a CNA. The investigation file contained an incident report and a written statement from the QMA, but no written statement from the CNA, despite the CNA reporting that she had submitted one. The ED stated the CNA’s input was obtained verbally and over the phone and was not documented as a written, signed, and dated statement as required by the facility’s Abuse Prevention Program policy and state regulation.
A resident with paraplegia and neurogenic bladder, who was cognitively intact and on an intermittent self-catheterization regimen, did not consistently receive an adequate supply of single-use 16F straight catheters to follow the ordered every 4–6 hour catheterization schedule. The resident reported repeated delays in obtaining catheters, having only four for an entire day, not emptying his bladder since the prior night, and sometimes reusing catheters when staff either could not locate or reported no supplies. A provider note documented the resident’s concern about running out of catheters and the importance of sterile, single-use technique, while a QMA admitted she was unaware of the increased catheterization frequency and believed it was every 8 hours. Observation showed additional catheters available in the supply room, but only a few at the bedside, and leadership confirmed there was no policy addressing supply availability for self-catheterization.
The facility failed to document and monitor behavioral symptoms as ordered and care planned for two residents with identified behavioral health needs. One resident with dementia and bipolar disorder had a physician’s order and care plan requiring shift‑by‑shift monitoring of specific behaviors, yet no behaviors were recorded on the MAR during the month in which the resident struck another resident, and no behavior note was entered in the clinical record for that incident. Another cognitively intact resident with a personality disorder had an order to monitor and track multiple behaviors and implement specific interventions, but when the resident became curt and then screamed and yelled at an LPN about medication, no behavior was documented on the MAR/TAR and no interventions were recorded in the clinical record. These failures occurred despite facility policy requiring nursing to monitor and document target behaviors daily and to use MAR documentation to trigger progress notes.
A resident with multiple behavioral health diagnoses did not receive a scheduled antipsychotic injection despite the medication being available, and the provider was not notified of the missed dose. Nursing staff inconsistently documented and implemented interventions for frequent medication refusals, and the resident's care plan did not include all effective strategies known to staff, resulting in a deficiency related to behavioral health services.
A resident with cognitive impairment and a history of falls was found transferring from a wheelchair to bed without anti-roll backs in place and while wearing non-nonskid socks. The resident was confused about a wheelchair switch and refused staff assistance. Required fall interventions were not timely implemented or maintained after a fall event.
Two residents did not receive multiple scheduled doses of prescribed medications, including IV antibiotics and controlled substances, due to unavailability and lapses in medication administration records. Documentation showed repeated instances where medications were not on hand or not signed off as administered, despite facility policy requiring prompt action when medications are unavailable.
Two residents experienced significant delays in staff response to call lights, with one resident typically waiting at least 30 minutes and another waiting up to 30 minutes despite requiring substantial toileting assistance. Additionally, a resident and her family reported repeated, unwanted offers of incontinence briefs, which they found humiliating. These actions did not align with facility policies on prompt assistance and resident dignity.
The facility did not ensure timely notification to the physician and family for two residents who experienced significant changes in condition: one with a substantial weight loss while on enteral feedings, and another who developed a new open neck wound related to a trach collar. Documentation did not show that notifications were made promptly as required by policy.
A resident with multiple medical conditions and moderate cognitive impairment did not have a comprehensive care plan addressing their bathing and hygiene needs. Staff interviews confirmed that a care plan for ADLs was overlooked, and a family member reported the resident received very few showers.
A resident with significant medical and cognitive needs did not receive scheduled bathing and hygiene care, as records showed infrequent showers and incomplete documentation of care provided. The resident's care plan for ADLs was not developed as required, and a grievance about the shower schedule was not properly resolved in the documentation.
A resident dependent on continuous enteral feeding experienced an interruption in nutrition when the feeding solution became inaccessible to staff overnight. This resident also suffered a significant weight loss of over 10% in less than a month, which was not promptly identified or addressed by the interdisciplinary team, nor was the physician or family notified as required by facility policy. Documentation failed to reflect the feeding interruption or timely interventions related to the weight loss.
A resident with a tracheostomy developed a new laceration on the neck, but staff failed to document when the wound was first identified, what initial care was provided, and notifications to the physician, family, or administration. The family only became aware of the wound during a radiology appointment, and the nurse who first found the wound did not document the event, resulting in incomplete records.
The facility failed to maintain safe food temperatures during meal service, affecting nearly all residents. Observations revealed that mixed vegetables, fish filets, and French fries were held at temperatures below the required minimum of 135 degrees Fahrenheit, contrary to the facility's food safety guidelines.
The facility did not ensure RN coverage for at least eight consecutive hours a day, seven days a week, affecting all residents. The absence of RN coverage on specific dates was confirmed by the Staffing Coordinator and DON, with no agency staff used since early April. The facility also lacked a policy on RN coverage.
The facility failed to administer medications and collect urine samples as ordered, affecting multiple residents. A resident with a leg fracture did not have a timely orthopedic follow-up, while another relying on a gastric tube had inadequate weight monitoring. Additionally, a resident's urine sample was not collected, and another did not receive prescribed medications for diabetes and hypertension. These issues indicate non-compliance with physician orders and care plans.
The facility failed to document COVID-19 vaccination education and status for five residents, lacking records of whether they were informed about the 2023-2024 vaccine's benefits and risks, received the vaccine, or refused it. An interview with the Nurse Consultant confirmed the absence of verification for offering or administering the vaccine, despite the facility's policy emphasizing the importance of staying up to date with vaccinations.
A facility failed to maintain a resident's dignity during meal assistance. A resident with dementia and cognitive impairment required help with eating, as per her care plan. During an observation, a CNA was seen standing while assisting the resident with her meal, contrary to the facility's policy that emphasizes treating residents with respect and dignity. The Nurse Consultant confirmed that the CNA should have been sitting to align with the policy.
A resident, who was cognitively intact and had a history of stroke, was dissatisfied with a new rule requiring him to transport his teapot and tea bags from his room to the dining room for each meal. This change forced him to use a wheelchair instead of crutches, and he was not given a reason for the restriction. The Activities Director confirmed the resident's dissatisfaction, but a grievance form was not completed, and the facility's grievance policy was not followed.
The facility failed to submit accurate RN staffing data to CMS, as the PBJ report showed no RN coverage on several dates despite evidence of RN 9 working those days. The system may not have been updated to reflect RN 9's title change after obtaining her license. The facility lacked a policy for PBJ data submission.
The facility inaccurately coded MDS assessments for four residents, indicating bed rails were used as restraints when they were actually used for bed mobility. Interviews with the MDS Coordinator confirmed the coding errors, which were contrary to the facility's policy using the RAI Manual.
A facility failed to accurately complete an MDS assessment for a resident, missing two falls that occurred during the look-back period. The regular MDS staff was on medical leave, and the facility did not have a specific policy for MDS assessments, relying instead on the RAI manual.
Failure to Assess and Authorize Resident Self-Administration of Medications
Penalty
Summary
The deficiency involves the facility’s failure to have the interdisciplinary team (IDT) timely determine and document that self-administration of medications was clinically appropriate for two cognitively intact residents who were self-administering medications. For one resident with a diagnosis including personality disorder, record review showed multiple current physician orders for daily and scheduled medications such as aspirin, docusate sodium, acetaminophen, vitamin B-12, gabapentin, Prempro, hydroxyzine, and lisinopril. During observation, this resident was in bed with a bedside table holding a cup containing multiple morning medications, with no staff present. The resident stated she was able to take her own medications and would take them later due to heartburn. An LPN then entered to administer lisinopril, placed a second medication cup with the pill on the bedside table next to the first cup, and left the room, leaving the resident in possession of both cups. The clinical record for this resident lacked a current self-administration assessment and a physician’s order authorizing self-administration. For the second resident, who had a diagnosis including schizophrenia and was assessed as cognitively intact on admission, physician orders included Tums every six hours as needed and Buspar three times a day. Observation found this resident sitting on her bed with a bedside table holding a medication cup containing one greenish pill and one pinkish pill, which the resident identified as Tums. The clinical record for this resident also lacked a documented self-administration assessment and a physician’s order to self-administer medications. In an interview, the Nurse Consultant confirmed she was unable to locate current self-administration assessments for either resident. The facility’s self-medication assessment policy required that self-administration be ordered by the attending physician and approved by the IDT, with assessments offered during routine IDT assessments and care plans updated at least quarterly or with changes, but these steps were not documented for the two residents involved.
Failure to Protect Resident From Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident when one resident struck another on the head with an open hand. The abused resident, identified as having dementia, depression, and severely impaired cognition per a recent MDS, was otherwise able to make himself understood, understood others, and had no behaviors noted during the assessment period. His care plan addressed impaired cognitive function with goals for maintaining orientation. A follow-up progress note documented that he had a resident-to-resident encounter over a weekend and that, although he reported not being bothered, staff observed he appeared anxious afterward. In an interview, he stated that another resident had been mean to him, was “messing with him,” had hit him, and sat behind him in the dining room, leading him to try to stay away from that resident. The facility’s investigation file documented an incident report stating that one resident made contact with the other resident’s head using an open hand, with no injuries noted. An LPN reported she separated the two residents after being informed of the incident by another resident witness, and that the alleged aggressor did not deny hitting the other resident, stating the other resident would not be quiet. Observation of the dining room showed the alleged aggressor sitting at a table behind the abused resident. The facility’s Abuse Prevention Program policy defined abuse as the willful infliction of injury, intimidation, or punishment resulting in physical harm, pain, or mental anguish, and specifically included hitting and slapping as physical abuse. Despite this policy, the resident experienced physical contact to the head from another resident.
Incomplete Documentation of Abuse Investigation After Staff Verbal Altercation Witnessed by Resident
Penalty
Summary
The deficiency involves the facility’s failure to conduct and document a thorough abuse investigation after a resident with Down Syndrome witnessed a verbal altercation between two staff members. The incident report, dated 12/27/25, indicated that the resident observed a verbal disagreement between a QMA and a CNA at the nurses’ station. The facility’s Abuse Prevention Program policy required the charge nurse to complete an incident report and obtain written, signed, and dated statements from the person reporting the incident and from any witnesses, with completed copies provided to the Administrator or person in charge within 24 hours of the incident. Record review and interviews showed that the investigation file contained an incident report and a written statement from the QMA, but did not contain a written statement from the CNA involved in the argument. The ED stated there was no written statement from the CNA and that the CNA had been interviewed verbally with the weekend supervisor, but the interview was not documented. In contrast, the CNA reported that she had written a statement on the date of the incident and given it to the ED, and described the argument as starting over her refusal to serve regular-consistency food to residents on mechanically altered diets. The ED later indicated the CNA’s statement had been taken over the phone and maintained that no written statement had been provided, resulting in incomplete documentation of the abuse investigation in violation of facility policy and state regulation 410 IAC 16.3.1-28(d).
Failure to Ensure Adequate Intermittent Catheter Supply for Self-Catheterizing Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure an adequate supply of urinary catheters was available for a resident who performed intermittent self-catheterization. The resident had diagnoses including paraplegia and neuromuscular dysfunction of the bladder, with a care plan noting risk for infection related to neurogenic bladder and the need for intermittent self-catheterization. A physician visit note documented that the resident reported running low on straight catheters, expressed concern about being forced to reuse catheters, and referenced a history of recurrent UTIs with sepsis. The physician emphasized the importance of sterile, single-use technique and ordered 16F straight catheters for intermittent catheterization. Despite this order and plan, the resident reported ongoing problems obtaining sufficient catheter supplies and interruptions in his catheterization schedule. He stated he was supposed to catheterize every 4–6 hours, understood the plan, and was motivated to adhere to it, but indicated that on the survey day he had been asking since the morning for catheters and had not emptied his bladder since the previous night. He reported that staff were only giving him four catheters for the day instead of at least five as he had been told by the medical provider, and that he sometimes had to reuse catheters at night when staff either did not know where supplies were or reported that supplies were gone. During an interview, he showed his bedside drawer, which contained only three new packaged catheters, which he indicated was all he would receive for the day. Staff interviews and observations further demonstrated gaps in ensuring adequate catheter availability. The nurse practitioner confirmed the resident should receive enough catheters to empty his bladder at least every 4–6 hours and as needed, depending on fluid intake. The QMA responsible for ordering catheters stated she had previously given the resident nearly a full box of 20 catheters over a weekend and believed he was to catheterize every 8 hours; she was unaware that the frequency had changed to every 4–6 hours because nursing staff had not updated her. At the time of observation, there was a box with nineteen 16F catheters for the resident in the supply room, and evening and night staff had access to that room, yet the resident still had only a limited number of catheters at bedside. The nurse consultant acknowledged that the facility did not have a policy for self-catheterization that addressed the availability of supplies.
Failure to Document and Monitor Behavioral Symptoms for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to document and monitor behavioral health symptoms as ordered and care planned for two residents with identified behavioral health needs. Resident D had diagnoses including dementia and bipolar disorder, with a physician’s order dated 4/24/25 directing staff to monitor each shift for specific behaviors such as delusions, hallucinations, tearfulness, crying, verbal expressions of sadness, anger, yelling, cursing, insomnia, anxiety, skin picking, and physical aggression. A quarterly MDS dated 1/9/26 showed moderately impaired cognition and no behaviors during the assessment period, while a care plan revised on 1/21/26 identified multiple behavioral symptoms and directed staff to evaluate behavioral symptoms and intervene when inappropriate behavior was observed. Despite this, the February 2026 MAR indicated no behaviors for the month, and the clinical record lacked a behavior note addressing a resident‑to‑resident bodily contact incident in which Resident D struck another resident. On 2/24/26, an incident report in the facility’s investigation file documented that Resident D made contact with another resident’s head using an open hand, with no injuries reported. The Social Services Director stated that Resident D was not normally aggressive and that when a resident exhibits new behaviors, the nurse should document the behavior in the clinical record using a behavior progress note so it can be reviewed in the morning meeting. The Interdisciplinary Team discussed the incident but did not identify a root cause, and there were no new care plans or interventions added to Resident D’s behavior care plan following the event. LPN 12, who separated the residents, reported that another resident had witnessed the incident, that Resident D did not deny hitting the other resident, and that Resident D stated the other resident would not be quiet, which LPN 12 assumed was the reason for the behavior. The facility also failed to document and track behaviors for Resident B, who had a diagnosis including a personality disorder and was cognitively intact per a quarterly MDS dated 12/16/25. A physician’s order dated 8/12/25 required staff to monitor and track a range of behaviors, including calling emergency services, false accusations/beliefs, anxiety, tearfulness, insomnia, refusal of care, verbal aggression, throwing objects, OCD behaviors, crying, verbal expressions of sadness, racial slurs, self‑isolation, anger, yelling, and cursing, and to implement interventions such as redirection, snacks, fluids, diversionary activities, toileting, change of environment, pain assessment, rest, and comfort. The March 2026 MAR/TAR indicated no behaviors as of 3/11/26; however, during an observation and subsequent interview, Resident B was curt, then later screamed and yelled at an LPN about medication, and the LPN was unsure why the resident was upset. Resident B’s clinical record lacked documentation of this behavior and lacked any documented interventions implemented at that time, despite facility policy stating that nursing monitors for target behaviors daily and documents them, and that nurses should document behaviors on the MAR to trigger a progress note.
Failure to Administer Antipsychotic Medication and Notify Provider for Resident with Behavioral Health Needs
Penalty
Summary
A resident with diagnoses including anxiety, paranoid schizophrenia, dementia, and depression was readmitted to the facility following a psychiatric hospitalization, with orders to receive Uzedy, an atypical antipsychotic, via subcutaneous injection every 30 days. The medication was not administered as ordered on the scheduled date, and the medication administration record (MAR) indicated it was not given, with a note stating it was unavailable. However, pharmacy records and direct observation confirmed that the medication was present in the facility at the time it was due. The Director of Nursing (DON) confirmed there was no documentation that the physician or nurse practitioner was notified of the missed dose, as required by facility policy. Interviews with nursing staff revealed inconsistent practices regarding medication administration and documentation. One LPN reported not seeing the medication in the cart and did not prepare it in advance, assuming the resident would refuse, and could not confirm if the nurse practitioner was notified of the missed dose. The nurse practitioner stated she was not informed about the missed injection and emphasized the importance of the medication for the resident's stabilization, especially given his refusal of oral medications. The MAR also showed frequent refusals of oral Depakote, with varying documentation of interventions used to encourage acceptance, such as education, encouragement, and attempts to offer medication with food, though not all interventions were consistently documented or reflected in the care plan. The resident's care plans addressing refusal of care and medication did not include all effective interventions known to staff, such as offering snacks or crushing medications with food, despite these being recognized strategies by staff and discussed in interviews. The facility's policies required individualized care planning and prompt notification of the physician when medications were refused or missed, but these procedures were not fully implemented. The lack of administration of the antipsychotic medication, failure to notify the provider, and incomplete care planning and documentation for medication refusals led to the identified deficiency.
Failure to Timely Implement and Maintain Fall Interventions
Penalty
Summary
A deficiency was identified when a resident with multiple psychiatric diagnoses, including borderline personality disorder, bipolar disorder, schizoaffective disorder, generalized anxiety disorder, and major depressive disorder, experienced a fall while attempting to transfer from a wheelchair to bed. The resident was assessed as moderately cognitively impaired and had a history of two or more falls since the last MDS assessment. The care plan included interventions such as anti-roll backs for the wheelchair and the use of nonskid footwear, but these interventions were not consistently implemented. On the day of observation, the resident was found sitting in a wheelchair without anti-roll backs, and was wearing fluffy socks instead of nonskid socks while transferring herself from the wheelchair to the bed. The resident expressed confusion and frustration about her wheelchair being switched out by staff for maintenance to apply anti-roll backs, and refused assistance from the ADON during the transfer. The lack of timely implementation of fall interventions and failure to ensure interventions were in place contributed to the deficiency.
Failure to Provide and Administer Ordered Medications
Penalty
Summary
The facility failed to ensure that prescribed medications, including narcotic and IV antibiotics, were administered as ordered and were readily available for use for two residents. One resident with diagnoses including osteomyelitis, pressure ulcer, paraplegia, and muscle spasm did not receive multiple scheduled doses of IV ceftolozane-tazobactam due to the medication being unavailable or on hold, as documented in progress notes and the electronic medication administration record (EMAR). Additionally, this resident did not receive several scheduled doses of pregabalin for neuropathy pain because the medication was not available, with progress notes indicating repeated notifications to the pharmacy and delayed receipt of the medication. Another resident with multiple psychiatric diagnoses, including borderline personality disorder, bipolar disorder, schizoaffective disorder, generalized anxiety disorder, and major depressive disorder, experienced lapses in the administration of clonazepam, as evidenced by missing controlled drug record forms for several periods and instances where administration was not signed off. The facility's policy required contacting the pharmacy or supervisor if a medication was ordered but not present, but this was not consistently followed, resulting in missed doses for both residents.
Delayed Call Light Response and Inappropriate Incontinence Care Offerings
Penalty
Summary
The facility failed to honor residents' rights to dignity and timely assistance, as evidenced by delayed responses to call lights and inappropriate offers of incontinence briefs. One resident, who was cognitively intact and had resided in the facility for over five years, reported that it typically took a minimum of 30 minutes for staff to respond to her call light, with delays occurring on all shifts, especially at night. Another resident's family member reported that the resident, who was non-ambulatory, cognitively intact, and required substantial assistance for toileting, experienced similar delays, with call lights going unanswered for 20 to 30 minutes. On one occasion, the family member had to seek staff assistance directly, and even after intervention, the resident continued to wait for help. Additionally, the same resident and her family reported that staff repeatedly offered her an incontinence brief despite their explicit refusals, which they found humiliating, particularly given the resident's young age. The facility's policies required prompt response to call lights and emphasized respect for resident dignity and preferences, including changing residents upon discovery of incontinence and allowing them to wear what they choose. However, these policies were not consistently followed, resulting in residents experiencing undignified care and delayed assistance.
Failure to Timely Notify Physician and Family of Significant Change in Condition
Penalty
Summary
The facility failed to ensure timely notification of significant changes in condition to the attending physician and family for two residents. In the first case, a resident with a history of multiple strokes, severe cognitive impairment, and requiring enteral feedings experienced a significant weight loss of over 10% in less than one month. Despite weekly interdisciplinary team reviews and documentation of weights, there was no evidence that the physician or family were notified of this significant weight loss at the time it occurred. Documentation inconsistencies were noted, and the significant weight loss was not clearly identified or communicated until much later, with no record of timely notification to the responsible parties. In the second case, a resident with severe cognitive impairment, tracheostomy, and feeding tube developed a new open area (laceration) on the neck, likely related to trach collar elastic. The open area was identified during a skin check, and while documentation indicated the physician and responsible party were updated, there was no clear record of when the wound was first identified, what immediate treatment was provided, or when notifications occurred. The family member only became aware of the wound during a radiology appointment, and there was a lack of documentation regarding the initial discovery and notification process. The facility's policy requires prompt notification of changes in resident condition to the physician and responsible party to ensure appropriate care and resident rights. In both cases, the documentation failed to demonstrate that timely notifications were made as required by facility policy and regulatory standards.
Failure to Develop Comprehensive Care Plan for Bathing and Hygiene Needs
Penalty
Summary
A deficiency was identified when the facility failed to develop a comprehensive care plan addressing the bathing and hygiene care needs for one resident. The resident, who had diagnoses including pneumonia, cirrhosis of the liver, gait and mobility abnormalities, cognitive communication deficit, and general muscle weakness, was assessed as moderately cognitively impaired and required moderate staff assistance for bathing and supervision for hygiene care. Despite these needs, a comprehensive care plan for activities of daily living (ADLs), specifically bathing and hygiene, was not found in the resident's clinical record. Interviews with facility staff confirmed the absence of a care plan for the resident's ADLs. The MDS Coordinator acknowledged overlooking the development of a care plan based on the admission MDS and baseline care plan. The facility's policy requires a baseline care plan within 48 hours of admission and a comprehensive care plan to follow, but this process was not completed for the resident in question. A family member also reported that the resident received very few showers during their stay.
Failure to Provide Adequate Bathing and Hygiene Care
Penalty
Summary
A deficiency occurred when a resident with multiple medical conditions, including pneumonia, cirrhosis, mobility issues, cognitive impairment, and muscle weakness, did not receive adequate bathing and hygiene care as required. The resident's Minimum Data Set (MDS) assessment indicated a need for moderate staff assistance with bathing or showering and supervision for hygiene care, with a strong preference for choosing the manner of bathing. Despite a scheduled bathing routine, records showed that over a 25-day period, the resident received only three bed baths, one partial bath, and no showers. In the following month, the resident received three partial baths and one shower over 30 days. The lack of consistent bathing was confirmed by a family member, who reported that the resident received very few showers during their stay. Further review revealed that the MDS Coordinator failed to develop a care plan for activities of daily living (ADLs) based on the admission MDS and baseline care plan. Additionally, a grievance form submitted by the resident regarding the shower schedule was documented, and although the facility indicated that the concern was addressed and a shower was provided, the bathing documentation did not reflect that any bathing occurred on the date in question. These findings demonstrate a failure to provide necessary care and assistance for bathing and hygiene to a resident unable to perform these activities independently.
Failure to Provide Continuous Enteral Feeding and Timely Response to Significant Weight Loss
Penalty
Summary
A resident with a history of multiple strokes resulting in significant paralysis and an inability to swallow safely required continuous enteral (gastric) feedings via a feeding tube. On one occasion, the resident's feeding ran out during the night and was not resumed for several hours because the feeding solution was locked in an office and inaccessible to nursing staff. The feeding was not restarted until the morning, resulting in an interruption of the prescribed continuous nutrition. The resident's clinical record showed a significant weight loss of more than 10% in less than one month, dropping from 236.0 pounds to 205.3 pounds. Despite this substantial weight loss, interdisciplinary team notations failed to identify or address the weight loss in a timely manner. Documentation did not reflect that the attending physician or the resident's family had been notified of the significant weight loss on the relevant dates. Facility policies required prompt notification of changes in a resident's condition, including significant weight loss, to the physician and responsible party. However, the records and interviews confirmed that such notifications and timely interventions were not conducted as required. Additionally, the medication administration and nursing progress notes did not document the interruption in enteral feeding, further indicating a lack of appropriate monitoring and response to the resident's nutritional needs.
Failure to Document Identification and Notification of New Wound
Penalty
Summary
The facility failed to thoroughly document the identification and management of a newly discovered open area on a resident with a tracheostomy. The resident, who was severely cognitively impaired, nonverbal, nonambulatory, and dependent on staff for all care, was found to have a new laceration on the left side of the neck. The clinical record included a Weekly Skin Check and a Weekly Wound Event form, both dated the same morning, which noted the wound's size, drainage, and treatment with steri strips. However, there was no documentation indicating when the open area was first identified, what initial treatment was provided before the skin check, or any notifications to the attending physician, family, or facility administration regarding the new wound and the resident's departure for a radiology appointment. Interviews revealed that the family was not informed of any skin concerns prior to discovering the wound at a radiology appointment, and the nurse who initially identified the wound did not document the event. The DON confirmed being notified by the night shift nurse about the wound but found no documentation from that nurse, only from the wound nurse who assessed the area later. The facility also lacked a specific policy on documentation, as confirmed by the Corporate Nurse. These documentation gaps resulted in incomplete records regarding the resident's change in condition and communication with responsible parties.
Failure to Maintain Safe Food Temperatures
Penalty
Summary
The facility failed to maintain safe food temperatures during meal service, potentially affecting 48 of 49 residents. During an observation of the lunch service in the main kitchen, it was noted that the steam table contained mixed vegetables and fish filets at temperatures of 121.8 degrees Fahrenheit and 107 degrees Fahrenheit, respectively. These temperatures were below the required minimum of 135 degrees Fahrenheit, as indicated by Facility staff. Additionally, in the upstairs kitchenette, French fries were observed on the steam table at a temperature of 120 degrees Fahrenheit, also below the safe holding temperature. The facility's Food Safety Handout, dated 9/28/2020, specifies that hot foods should be held at temperatures between 135 degrees Fahrenheit and 170 degrees Fahrenheit.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to maintain the required Registered Nurse (RN) coverage for at least eight consecutive hours a day, seven days a week, which had the potential to affect all 49 residents in the facility. The Payroll Based Journal (PBJ) Staffing Data Report for the third quarter of the 2024 Federal Fiscal Year revealed that there was no RN coverage on specific dates, including 4/20/24 and 4/21/24. Interviews with the Staffing Coordinator and the Director of Nursing (DON) confirmed the absence of RN coverage on these dates, as the facility's RN weekend option nurse did not work, and no agency nursing staff had been used since 4/1/24. Additionally, the facility lacked a policy regarding RN coverage, as indicated by the Nurse Consultant during an interview.
Medication and Care Plan Deficiencies
Penalty
Summary
The facility failed to administer medications and collect urine samples as ordered, impacting several residents. Resident 42, who was admitted with a healing leg fracture, did not have a timely follow-up orthopedic appointment scheduled. Despite a physician's note indicating the need for an orthopedic follow-up, the appointment was only made after a delay, as observed during an interview with LPN 4. The Director of Nursing acknowledged that the appointment should have been scheduled sooner. Resident 30, who relies on a gastric tube for nutrition, did not have his weight monitored as recommended by the registered dietician. Despite a significant weight gain noted in August, there was no recorded weight for September, and weekly weights were not completed as requested. This oversight was confirmed during an interview with a Nurse Consultant, who noted that the facility's SWAT Program Meeting Guidance was not followed. Additionally, Resident 11's urine sample was not collected as ordered, and Resident 29 did not receive prescribed medications for diabetes and hypertension on multiple occasions. The Medication Administration Record showed several instances where insulin and clonidine were not administered as ordered, and there was no documentation to justify withholding these medications. Resident 95 also did not have a urine sample collected as ordered for a lab test. These deficiencies highlight a pattern of non-compliance with physician orders and care plans, as confirmed by interviews with the Nurse Consultant.
Lack of COVID-19 Vaccination Documentation for Residents
Penalty
Summary
The facility failed to ensure that the medical records of five residents included documentation indicating that the residents or their representatives were provided education regarding the benefits and potential risks associated with the 2023-2024 COVID-19 vaccine. Additionally, there was no documentation on whether the COVID-19 vaccine was administered to these residents or if they did not receive the vaccine due to medical contraindications or refusal. The residents involved were identified as Residents 11, 18, 20, 24, and 30, and their clinical records were reviewed on October 3, 2024. During an interview with the Nurse Consultant on October 4, 2024, it was confirmed that there was no verification that the 2023-2024 COVID-19 vaccination was offered, refused, medically contraindicated, or that education regarding the vaccination was provided to the residents in question. The facility's policy, provided by the Nurse Consultant, emphasized the importance of remaining up to date with COVID-19 vaccinations and offering resources and counseling, but it did not reference the need for documentation in the residents' clinical records regarding education or vaccination status.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to maintain a resident's dignity during meal assistance. Resident 2, who has a diagnosis of dementia and cognitive impairment as indicated in a Quarterly Minimum Data Set assessment, required assistance with eating according to her Activities of Daily Living care plan. During an observation in the dining room, a Certified Nursing Assistant (CNA) was seen standing while assisting Resident 2 with her meal, rather than sitting, which is contrary to the facility's resident rights policy. This policy emphasizes treating residents with respect and dignity, including providing care in a manner that enhances their quality of life. The Nurse Consultant confirmed that the CNA should have been sitting while assisting the resident, aligning with the policy to ensure a dignified existence for residents.
Failure to Address Resident Grievance Timely
Penalty
Summary
The facility failed to address a resident's grievance in a timely manner, as evidenced by the case of a resident who was cognitively intact and had a history of stroke. The resident had been storing a Tupperware container with a teapot and tea bags in the dining room for years. However, he was recently informed that he could no longer store it there and had to transport it back and forth from his room to the dining room for each meal. This change made it difficult for him, as he had to revert to using a wheelchair instead of crutches to carry the container, and he was not provided with a reason for this new restriction. The Activities Director confirmed the resident's dissatisfaction with the new storage rule and acknowledged that a grievance form was not filled out regarding the resident's concern. The facility's grievance policy outlines a process for addressing resident concerns, including completing a form, discussing it in a CQI meeting, and ensuring the resident is satisfied with the resolution. However, in this case, the process was not followed, as the resident's grievance was not documented or addressed according to the facility's policy.
Inaccurate RN Staffing Data Submission to CMS
Penalty
Summary
The facility failed to submit accurate direct care staffing information to the Centers for Medicare and Medicaid Services (CMS) regarding the correct category of work for a Registered Nurse (RN) for all 49 residents. The Payroll Based Journal (PBJ) Staffing Data Report for the third quarter of the 2024 Federal Fiscal Year showed no RN coverage on several dates, despite evidence from the Daily Nursing Schedule and time sheets indicating RN coverage on those dates. The Staffing Coordinator, who has been in the role for almost three years, indicated that RN 9, the weekend option nurse, worked on the dates in question but the system may not have been updated to reflect RN 9's title change to RN after obtaining her license in March 2024. The facility lacked a policy regarding PBJ data submission, as confirmed by the Nurse Consultant.
Inaccurate MDS Coding for Bed Rail Use
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for four residents, leading to a deficiency in the accuracy of resident assessments. Resident 1, diagnosed with paraplegia, had an Admission MDS assessment indicating daily use of bed rails as a restraint. Resident 12, with dementia, had a Quarterly MDS assessment also indicating daily use of bed rails as a restraint. Resident 22, diagnosed with hypertension, had a Quarterly MDS assessment showing daily use of bed rails as a resident. Resident 42, with depression, had an Admission MDS assessment indicating daily use of bed rails as a restraint. Interviews with the MDS Coordinator and the Regional MDS Coordinator revealed that the MDS assessments were inaccurately coded, as the bed rails were used for bed mobility, not as restraints. The facility used the Resident Assessment Instrument (RAI) Manual as their policy.
Failure to Accurately Complete MDS Assessment for Falls
Penalty
Summary
The facility failed to ensure a Minimum Data Set (MDS) assessment was correctly completed for a resident, specifically regarding falls. Resident B, who was admitted with multiple diagnoses including encephalopathy, diabetes, rheumatoid arthritis, and cognitive function issues, had an MDS assessment dated 10-9-23. This assessment incorrectly indicated that the resident had no falls from the time of admission through the assessment reference date. However, the clinical record showed that Resident B had sustained two falls on 10-8-23, one at 2:00 a.m. and another at 5:30 p.m. Interviews revealed that during the time of the MDS assessment, the regular MDS staff was on medical leave, and a corporate MDS person was filling in. Despite this, it appeared that the regular MDS staff conducted the assessment. The Executive Director confirmed that the facility does not have a specific policy for MDS assessments but follows the most current Resident Assessment Instrument (RAI) manual. The manual requires a thorough review of all available sources for any falls during the look-back period, which was not adhered to in this case.
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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