Waters Of Clifty Falls, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Madison, Indiana.
- Location
- 950 Cross Ave, Madison, Indiana 47250
- CMS Provider Number
- 155209
- Inspections on file
- 44
- Latest survey
- January 22, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Waters Of Clifty Falls, The during CMS and state inspections, most recent first.
A resident with diabetes, DVT, and an arterial heel ulcer did not receive wound care in accordance with wound NP orders when treatments documented on the ETAR were entered at a lower frequency than ordered and with delays in initiating updated regimens. Initial twice-daily wound care was carried out only once daily, and later changes to Santyl and then Dakins-based dressings ordered by the wound NP were not promptly transcribed or adjusted to the correct frequency. Interviews showed that the ADON waited for the NP’s written report before changing orders and did not route new wound treatments through the primary physician, despite facility policy requiring that physician orders be implemented as received.
A resident with a Stage 4 sacral pressure ulcer present on admission did not consistently receive ordered wound care. Wound NP orders for cleansing with Dakin’s solution, application of collagen or collagen with silver, calcium alginate, skin prep, and use of a wound vac with specified frequencies were either delayed in initiation, incompletely transcribed, or not documented as performed on multiple days, as shown on the ETAR. An LPN confirmed that blank ETAR entries indicated missed treatments, and the ADON reported that NP orders were entered after receiving reports one to two days post-visit, despite facility policies requiring timely implementation of physician orders and necessary treatment for pressure injuries.
A resident with multiple medical conditions, who was cognitively intact, was subjected to disrespectful and hurtful comments by a CNA, including remarks about being difficult to care for and not being liked by staff. Other staff confirmed witnessing these comments, and the resident felt ridiculed and embarrassed, ultimately not wanting to get out of bed. Facility policy requires residents to be treated with dignity and respect, which was not followed in this case.
A resident with a history of restlessness and agitation received an anti-anxiety medication outside the prescribed time frame, and staff failed to document the behaviors that warranted the second dose. Facility policy required both timely administration and documentation of target behaviors prior to administering psychoactive medications, but these procedures were not followed.
A resident with type 2 diabetes was given an incorrect dose of long-acting insulin after an LPN transcribed a hospital order for 5 units as 70 units at bedtime. The error was not caught during chart review, and another LPN administered the incorrect dose, resulting in the resident becoming unresponsive and requiring emergency hospitalization. The facility's policy for double-checking admission orders was not followed.
Staff left computer screens on medication carts unattended and visible in hallways, displaying residents' names, medication lists, and other personal information. In the dementia unit, staff disposed of meal tickets with resident names in a regular trash can instead of a shred container, exposing confidential information. These actions did not comply with facility policy or HIPAA privacy requirements.
Staff failed to consistently assess and document required vital signs before administering cardiac medications with hold parameters, resulting in several residents receiving antihypertensive or hypotensive medications outside of prescribed limits or without proper assessment. Additionally, an LPN administered insulin using a pen device without performing the required priming step as outlined by the manufacturer.
Surveyors found that flour and sugar were stored in containers with improper lids, and a scoop was left inside the sugar container. Dietary staff acknowledged these practices did not follow facility policy, which requires proper sealing of food items and separate storage of scoops.
Staff did not consistently use required gowns and gloves when providing wound care to residents on Enhanced Barrier Precautions, despite clear signage and available supplies. Additionally, a resident with an indwelling urinary catheter was repeatedly observed with the catheter bag and tubing dragging on the floor, contrary to facility policy. These lapses occurred even though facility policies and orders specified the necessary infection control measures.
A resident was found with multiple medications at bedside and no staff present, despite lacking both an assessment and a physician order to self-administer drugs. The resident was cognitively intact and had several chronic diagnoses, but facility staff confirmed that required procedures for self-administration, including interdisciplinary team approval and documentation on the MAR, were not completed.
A discharge MDS assessment for a resident who was admitted from the hospital and discharged home on the same day was not transmitted to CMS within the required timeframe. The assessment was never added to a batch for transmission, and the Regional MDS Coordinator confirmed the delay. The facility lacked a specific policy for transmitting MDS assessments, relying instead on the RAI manual.
A resident with a below-the-knee amputation and severe cognitive impairment was regularly observed wearing a prosthetic leg and required daily staff assistance to put it on, but the care plan did not reflect the use of the prosthesis or provide guidance for staff. Multiple staff members confirmed the resident's use of the prosthetic, and facility policy required care plans to be updated to reflect such needs.
A resident with severe cognitive impairment and multiple medical conditions did not consistently receive wound care as ordered by the physician. There were delays in initiating new wound care orders, incorrect transcription of treatment frequencies, and several instances where wound care was not documented as completed. The ADON confirmed that these lapses were due to errors in transcription and untimely implementation of orders.
A resident with quadriplegia and impaired mobility did not have hand or elbow splints applied as ordered by the physician, despite documentation by nursing staff and CNAs indicating otherwise. Observations over several days confirmed the splints were not in use, and staff interviews revealed that documentation reflected PROM exercises rather than actual splint application.
A resident with severe cognitive impairment and multiple medical conditions continued to receive a citalopram dose above the recommended maximum for several weeks after a pharmacist and NP agreed to reduce the dose. The facility did not address the pharmacy recommendation within the required timeframe, as confirmed by staff and policy review.
Surveyors found that medications and biologicals were not properly stored or labeled on two medication carts and in a medication room. Issues included an undated insulin pen left unrefrigerated, opened inhalers without open dates, a tuberculin serum vial used beyond its recommended period, and unlabeled acetaminophen suppositories. Staff interviews confirmed these items were not handled according to policy and manufacturer instructions.
The facility did not ensure timely receipt and reporting of critical lab results for two residents, including a missed follow-up on a critical potassium level and failure to obtain a seizure medication level after a fall. These lapses resulted in incomplete monitoring and communication of important clinical information.
A resident with a colostomy did not have documentation in the clinical record of colostomy appliance changes for several months, despite staff confirming that changes were performed regularly. The facility's policy required documentation of such care, but records only noted the presence and amount of stool, not the appliance changes themselves.
A resident who was moderately cognitively impaired and required substantial ADL assistance was found with soiled linens, including disposable underwear with a strong urine odor, left on the floor near the bed. Staff confirmed the resident could not have removed the linens herself and acknowledged that dirty linens should not be left on the floor, resulting in a failure to maintain a sanitary, homelike environment as required by facility policy.
The facility did not accurately post daily nurse staffing information, as required. During two observations, the nurse staffing posting available for visitors was outdated by over a month. An interview with the ADON confirmed that postings should be updated daily, and no facility policy on this process was provided.
Several residents who required staff assistance with toileting and mobility were left without a functioning bathroom call light system for an extended period. Residents reported broken call lights, exposed wiring, and ineffective alternative alert methods, resulting in delayed assistance and reliance on roommates or ineffective bells to summon help. Staff and maintenance interviews confirmed the ongoing system failures and incomplete repairs.
A staff member failed to treat a resident with respect and dignity by using derogatory language and referencing a weight loss spokesperson while providing personal care. The incident involved a resident with severe cognitive impairment and multiple medical conditions, and was witnessed and reported by another staff member.
A facility failed to prevent the misappropriation of a resident's medication, involving a cognitively intact resident with multiple diagnoses. During a shift change, a narcotic medication card and count sheet were missing. The facility had received morphine sulfate cards, which were incorrectly ordered and not used, and a new Percocet card was not added to the count by an LPN. The discrepancy was noticed the next morning. Interviews revealed missing documentation and non-compliance with facility policies on controlled substances and delivery manifest.
A medication security breach occurred when a QMA left a cup of medications unattended on a cart, allowing a resident with a history of mental health issues to take medications not prescribed to them. The incident involved missing Clonazepam and Tamsulosin, which were later found in the resident's room. The facility's policy requires medications to be secured and accessible only to authorized personnel.
The facility failed to report an alleged misappropriation of residents' medications by a QMA to the Indiana Department of Health. A complainant informed the Administrator about the QMA allegedly stealing medications, but the Administrator did not report the incident as required by the facility's policy. The facility's investigation found no discrepancies in narcotic sheets, and the QMA tested negative for substances.
A facility failed to thoroughly investigate an allegation of medication misappropriation by a QMA. Despite conducting an investigation, the facility did not suspend the staff member or notify law enforcement, as required by their policy. The investigation lacked documentation of resident interviews and assessments, and staff interviews were not recorded.
The facility failed to store medications properly, with outdated insulin pens and vials found on multiple medication carts, and a bottle of lorazepam intensol not refrigerated as required. Facility policies for medication storage and disposal were not adhered to, resulting in these deficiencies.
The facility failed to follow infection control guidelines during meal preparation, affecting 93 residents. Observations revealed unsanitary conditions in the kitchen, including crumbs, splatters, and dust on surfaces, and improper food storage. The Dietary Manager was seen with hair hanging out of her hair net, violating personal hygiene standards. Cleaning schedules were outdated, and no recent cleaning logs were available, indicating a lack of adherence to facility policies.
The facility failed to identify and manage pressure ulcers for three residents, leading to the development and worsening of wounds. One resident, severely cognitively impaired, developed new wounds despite recommendations for pressure reduction. Another resident, cognitively intact, had a Stage 3 ulcer due to shoe friction, which was not identified until it reached an advanced stage. A third resident, moderately cognitively impaired, was observed without required heel boots, increasing the risk of ulcer progression.
A facility failed to provide proper urinary catheter care for a resident with a history of UTIs. During care, a CNA did not clean a brown substance from the catheter tubing after changing the resident's brief. The resident, who was severely cognitively impaired, had multiple physician orders for antibiotics and required catheter care every shift. The facility's policy on catheter care was not followed during the observed incident.
A facility failed to follow physician's orders for a resident's feeding tube care. An RN rapidly administered liquid nourishment using a syringe plunger instead of the gravity method, and used an incorrect water flush amount. Interviews with staff revealed inconsistencies in understanding feeding tube procedures. The resident, with cognitive impairment and a swallowing disorder, had specific orders that were not followed during the incident.
A resident with an AV graft for dialysis was not properly monitored by the facility staff. Despite the care plan requiring monitoring for bruit and thrill, the nursing staff did not assess or document the graft site as needed. The facility's policy required evaluation of AV shunts, but this was not adhered to, resulting in a deficiency in care.
A facility failed to limit PRN orders for Alprazolam to 14 days for a resident with anxiety, despite pharmacy recommendations. The resident's physician did not evaluate or renew the order, and the Psychiatric NP did not address it due to the resident's refusal to consent to be seen. The facility's policy requiring a response to pharmacy recommendations within seven days was not followed.
The facility failed to ensure accurate documentation of narcotic medication administration for four residents, with missing entries in the MAR and unaccounted controlled drug record forms. Interviews revealed incomplete documentation practices, leading to a deficiency in maintaining medical records according to professional standards.
The facility failed to prevent medication errors for a resident diagnosed with anxiety, who received an additional dose of Clonazepam without a physician's order and had a scheduled dose not documented on the controlled drug record. These errors were confirmed by the Assistant Director of Nursing and the Director of Nursing.
Failure to Timely Implement and Follow Wound NP Treatment Orders
Penalty
Summary
The deficiency involves the facility’s failure to follow and timely implement wound care orders for a cognitively intact resident with diagnoses including DVT and diabetes, who was admitted with an arterial ulcer on the left heel. On admission, a wound NP ordered the ulcer to be cleansed with wound cleanser or normal saline, betadine applied, covered with an abdominal pad, and lightly wrapped with rolled gauze twice daily; however, the ETAR for September and October showed the order entered and carried out only once daily. A subsequent wound NP note changed the treatment to cleansing with wound cleanser or normal saline, application of Santyl, and coverage with an abdominal pad and rolled gauze daily, but the ETAR showed this new order was not initiated until five days later. Later, the wound NP ordered the same ulcer to be cleansed with wound cleanser or normal saline, skin prep applied to the peri-wound, Dakins-moistened fluffed gauze applied, and covered with a silicone bordered superabsorbent dressing twice daily. The November ETAR reflected a physician order for this treatment only once daily from early to mid-month, and it was not changed to twice daily until several days after the NP’s order. Interviews revealed that wound treatments were documented in the ETAR and blanks indicated missed treatments, and that the ADON waited one to two days after the NP’s visit to receive a report and then transcribe new orders, without going through the resident’s primary physician. Facility policy required that all physician orders received be implemented and followed as they are received, but the wound NP’s treatment orders were not promptly or accurately reflected in the resident’s treatment records.
Failure to Implement and Follow Wound Care Orders for Stage 4 Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to follow and timely implement wound care treatment orders for a cognitively intact resident with a Stage 4 sacral pressure ulcer that was present on admission. The resident had multiple wound NP notes documenting specific treatment orders, including cleansing with Dakin’s solution, application of collagen or collagen with silver, calcium alginate, skin prep to the periwound, and use of a wound vac with specified frequency. On one occasion, a new daily treatment order dated 09/17/2025 was not initiated until 09/23/2025, as shown on the September ETAR. On another occasion, a new order dated 10/22/2025 to cleanse with Dakin’s solution, apply collagen particles, and apply continuous wound vac therapy three times per week was not fully transcribed; the ETAR only reflected changing the wound vac dressing every three days and lacked instructions to cleanse with Dakin’s or apply collagen particles. Further, a subsequent NP order dated 10/29/2025 to cleanse with Dakin’s solution, apply collagen particles, and apply continuous wound vac therapy on Wednesdays and Saturdays was not reflected as a changed order on the October ETAR. A later NP order dated 12/10/2025 for daily cleansing with Dakin’s solution, application of skin prep to the periwound, collagen with silver, calcium alginate, and a silicone bordered superabsorbent dressing was not initiated until 12/19/2025, and the December ETAR lacked documentation that treatments were completed on multiple specific dates. Interviews with an LPN and the ADON confirmed that wound treatments were to be documented in the ETAR and that blanks indicated treatments were not completed, and that the ADON transcribed NP orders after receiving a report one to two days after NP visits. Facility policies required that all physician orders be implemented as received and that residents with pressure ulcers receive necessary treatment and services consistent with professional standards of practice.
Failure to Treat Resident with Dignity and Respect
Penalty
Summary
A resident with diagnoses including heart failure, depression, and hypertension, and who was cognitively intact, reported being treated disrespectfully by a Certified Nursing Assistant (CNA). The resident stated that the CNA made hurtful comments, including saying that nobody at the facility liked her, that she was difficult to care for and roll over, and that she could not do anything on her own. The resident felt ridiculed and embarrassed by these remarks, even after the CNA later apologized. The resident also reported that she no longer wanted to get out of bed following these interactions. Other staff members corroborated the resident's account, stating that they witnessed the CNA making comments about the resident being difficult to care for. One staff member noted that after the CNA made these remarks, she left the resident's room, and the resident subsequently did not want to get out of bed. The facility's policy, as provided by the administrator, states that residents have the right to be treated with dignity and respect, which was not upheld in this instance.
Failure to Document Behaviors and Administer Anti-Anxiety Medication Within Prescribed Time Frame
Penalty
Summary
A deficiency occurred when a resident with diagnoses including restlessness and agitation exhibited physically aggressive behaviors, such as attempting to throw a chair and flipping tables. Following these incidents, a nurse practitioner ordered Lorazepam 0.5 mg IM every 8 hours as needed for anxiety. The resident received the first dose at 8:15 p.m., with the next eligible dose at 3:15 a.m. However, the second dose was administered at 2:30 a.m., which was outside the prescribed time frame. Additionally, there was no documentation in the clinical record of the resident's behaviors to justify the administration of the second dose of Lorazepam. Facility policy required that psychoactive medications, including anti-anxiety drugs, be administered in accordance with physician orders and within 60 minutes of the scheduled time, with nursing staff responsible for monitoring and documenting target behaviors. Interviews confirmed that behaviors should be documented in the nurses' notes and that medications can be administered within an hour before or after the scheduled time. The lack of documentation for the resident's behaviors prior to the second dose, as well as the administration of the medication outside the appropriate time frame, constituted a significant medication error.
Significant Medication Error Due to Incorrect Insulin Order Transcription
Penalty
Summary
A significant medication error occurred when a resident with type 2 diabetes was admitted with a hospital discharge order for insulin glargine 5 units at bedtime. However, the facility admission order was incorrectly transcribed by an LPN as 70 units at bedtime, a substantial deviation from the original order. This error was not identified during the chart check or morning meeting, and the incorrect dose was subsequently administered by another LPN, who questioned the amount but proceeded as per the written order. Following the administration of the incorrect insulin dose, the resident was initially alert and cooperative, but later was found unresponsive with low blood pressure, decreased oxygen saturation, and a blood glucose of 58. Emergency services were called, and the resident was transferred to the hospital, where intubation was required due to non-responsiveness. The facility's policy required two nurses to review admission orders for accuracy, but this double-check process was not completed prior to the incident.
Failure to Protect Resident Health Information and Confidentiality
Penalty
Summary
Staff failed to maintain the privacy and confidentiality of residents' personal and medical records on multiple occasions. During continuous observation, a computer screen on a medication cart was left open and unattended in a hallway, displaying a resident's name and medication list. Several residents and staff passed by the cart while the screen was visible, and the responsible LPN left the area without securing the information. The screen remained exposed until another staff member eventually closed it. In a separate observation, another computer screen on a medication cart was left unattended outside the nurse's station, displaying multiple residents' names, pictures, and room numbers. Residents and staff walked by the cart while the information was visible, and the screen was only closed when a nurse returned to the cart. Additionally, staff in the dementia unit failed to properly dispose of resident meal tickets containing personal information. After serving lunch, staff placed meal cards with residents' names in a regular trash can instead of the designated shred container. The error was acknowledged by staff during interviews, and the meal tickets were retrieved from the trash. These actions were inconsistent with the facility's policy and HIPAA requirements for protecting resident health information.
Failure to Follow Medication Hold Parameters and Insulin Pen Guidelines
Penalty
Summary
The facility failed to follow physician's orders regarding medication administration and did not adhere to manufacturer guidelines for insulin pen usage for five residents. For several residents with hypertension and hypotension, staff did not consistently assess or document required vital signs, such as blood pressure and heart rate, prior to administering cardiac medications with specific hold parameters. In multiple instances, medications were given even when residents' vital signs were outside the prescribed parameters, or without any documentation that the necessary assessments were performed. One resident with hypertension and chronic kidney disease received Metoprolol without documentation of blood pressure and heart rate assessments for the evening dose. Another resident with severe cognitive impairment and orthostatic hypotension was administered Midodrine without evidence that blood pressure was checked prior to each dose, as required. Additional residents received antihypertensive medications despite their blood pressure or heart rate being below the physician-ordered thresholds for holding the medication. In one case, a resident received Coreg and Lisinopril when their diastolic blood pressure or heart rate was below the specified limits. The facility also failed to follow manufacturer instructions for insulin pen administration. During an observation, an LPN administered Lantus insulin using a pen device without priming the pen as directed by the manufacturer. The manufacturer's insert specifies that a safety test (priming) must be performed before each injection to ensure proper dosing and pen function, but this step was omitted during the observed administration.
Improper Storage of Dry Food Items in Kitchen
Penalty
Summary
During a kitchen tour, surveyors observed that a large clear plastic container of flour was stored on a metal shelf with an ill-fitting lid that was not designed for the container. Additionally, a large clear plastic container of sugar was found on a metal shelf with a plastic scoop left inside the container. Dietary staff confirmed that the scoop should not have been left in the sugar and that the lids used were not the correct ones for the containers. At the time of observation, the noon meal had already been prepared and no staff were actively using the flour or sugar. The containers were located within ten feet of an exterior door. Facility policy requires all open products to be sealed properly to prevent contamination and for scoops to be stored outside of bins in a clean, designated space.
Failure to Follow Enhanced Barrier Precautions and Proper Catheter Care
Penalty
Summary
Staff failed to follow infection prevention and control guidelines for multiple residents, specifically regarding the use of Enhanced Barrier Precautions (EBP) and the management of urinary catheter tubing and drainage bags. For several residents with pressure wounds and orders for EBP, staff, including a nurse practitioner and a licensed practical nurse, entered rooms and provided wound care without donning required gowns, despite clear signage and available supplies indicating the need for gowns and gloves during high-contact care activities. This was observed on multiple occasions for residents with cognitive impairments and complex medical histories, including stroke, depression, obesity, quadriplegia, and pressure ulcers. Additionally, a resident with an indwelling urinary catheter was repeatedly observed with her catheter bag and tubing dragging on the floor while propelling herself in her wheelchair. The resident reported that staff consistently placed the catheter bag under her wheelchair, resulting in the bag and tubing coming into contact with the floor. The resident had a recent history of urinary tract infection, and observations confirmed that the catheter bag and tubing were not properly managed, with cloudy urine and sediment noted in the tubing. The facility's own policy emphasized the importance of proper catheter care to prevent catheter-associated urinary tract infections. Facility policies for both EBP and catheter care were available and provided by facility leadership, outlining the need for appropriate use of personal protective equipment and proper catheter management. Despite these policies, staff did not adhere to the required infection control practices during direct care activities, as confirmed by both observation and staff interviews.
Failure to Assess and Authorize Resident Self-Administration of Medications
Penalty
Summary
A resident was observed lying in bed with two medicine cups on the over-bed table, one containing a single pill and the other containing seven pills. The resident stated that the medications had been there for some time and believed they included gabapentin, a muscle relaxer, and cholesterol medications, but was unsure about the identity of the other pills. There were no nursing staff present in the room at the time of observation. The resident's clinical record indicated cognitive intactness and diagnoses including hypertension, diabetes, hyponatremia, and depression. Upon review, the clinical record did not contain an assessment for the resident to self-administer medications, nor was there a physician's order permitting self-administration. Interviews with facility staff confirmed that a physician's order and an assessment are required for residents to self-administer medications, and that the resident in question did not have such authorization. Facility policy also requires an interdisciplinary team approval and a physician order for self-administration, which were not present in this case.
Failure to Timely Transmit MDS Discharge Assessment
Penalty
Summary
The facility failed to ensure that a Minimum Data Set (MDS) assessment was transmitted to the Centers for Medicare and Medicaid Services (CMS) within the required timeframe for one resident. Specifically, a discharge assessment dated 12/28/24 for a resident who was admitted from the hospital and discharged home on the same day was not added to a batch for transmission to CMS. Record review confirmed the assessment was never transmitted, and during an interview, the Regional MDS Coordinator acknowledged the oversight, stating the assessment should have been sent sooner. Additionally, the facility did not have a policy regarding the transmission of MDS assessments and relied on the RAI manual for guidance.
Failure to Update Care Plan for Resident's Prosthetic Leg
Penalty
Summary
A deficiency was identified when the facility failed to revise and update a resident's care plan to reflect the use of a prosthetic leg. The resident, who had a below-the-knee amputation of the left leg and was severely cognitively impaired, was consistently observed wearing a prosthetic leg and required daily assistance from nursing staff to put it on. Despite these observations and staff interviews confirming the resident's regular use of the prosthesis, the care plan only addressed assistance with activities of daily living (ADLs) related to the amputation and did not mention the prosthetic leg or provide guidance for staff regarding its use. The resident's clinical record and Minimum Data Set (MDS) assessment also failed to indicate the presence or use of a limb prosthesis, even though the resident had been using it for several years. Multiple staff members, including the MDS Coordinator, LPN, and CNA, acknowledged the resident's use of the prosthetic leg and their involvement in assisting with it. The Assistant Director of Nursing confirmed that the care plan should have included information about the prosthesis to provide direction for CNAs. Facility policy required comprehensive care plans to be reviewed and updated at least quarterly or more often if the resident's condition changed, but this was not done in this case.
Failure to Timely Implement and Document Pressure Ulcer Treatment Orders
Penalty
Summary
The facility failed to follow physician's orders for wound care treatments for a resident with a history of severe cognitive impairment, cerebral palsy, orthostatic hypotension, depression, and pressure ulcers. Multiple wound nurse practitioner (NP) assessment reports documented changes in wound care orders for a Stage 4 pressure ulcer to the left ischium, including specific instructions for cleansing, application of collagen or Dakins solution, and dressing frequency. However, there were repeated delays in initiating new treatment orders, with some orders not implemented until several days after being written. Additionally, some orders were transcribed incorrectly, such as a daily treatment being entered as twice daily, and negative pressure wound therapy orders not being updated in a timely manner. Review of the electronic treatment administration record (ETAR) revealed several dates where documentation of wound care was missing, indicating that treatments were not completed as ordered. Interviews with the Assistant Director of Nursing (ADON) confirmed that orders were either transcribed incorrectly or not implemented in a timely fashion, and that missing documentation in the ETAR meant the treatment was not performed. The facility's policy required following physician orders, but this was not consistently done for the resident's pressure ulcer care.
Failure to Apply Splint Devices as Ordered for Resident with Limited Mobility
Penalty
Summary
The facility failed to ensure that splint devices were applied as ordered for a resident with significant physical impairments. Multiple observations over several days showed that the resident, who had diagnoses including traumatic brain injury, quadriplegia, and respiratory failure, was not wearing the prescribed hand or elbow splints while in bed. The resident was dependent on staff for all activities of daily living and had impaired mobility in both upper and lower extremities. Despite physician orders specifying that bilateral hand splints should be applied in the morning for three hours, followed by bilateral elbow splints for three hours, the devices were not observed in use during multiple checks. The splints were found stored in the resident's room rather than being applied as ordered. Interviews with staff and review of documentation revealed discrepancies between recorded care and actual practice. Nursing staff and CNAs documented in the electronic records that the splints were applied daily, but both a nurse and a CNA admitted during interviews that the resident had not worn the splints for a long time. The CNA clarified that her documentation referred to performing passive range of motion (PROM) exercises, not the application of splints, and that she had not applied the devices as ordered. The facility's policy required following physician orders, but this was not adhered to in the resident's care.
Delayed Response to Pharmacy Recommendation for Medication Dose Adjustment
Penalty
Summary
The facility failed to ensure timely action on a pharmacy recommendation for a resident with multiple diagnoses, including severe cognitive impairment, heart failure, diabetes, non-Alzheimer's dementia, anxiety, and depression. The resident was prescribed citalopram at a dose of 40 mg twice daily, which exceeded the maximum recommended daily dose. On 02/15/25, the consulting pharmacist recommended reducing the dose to 40 mg per day, and the Nurse Practitioner agreed with this recommendation on 02/26/25. Despite the agreement, the resident continued to receive the higher dose of citalopram from 02/15/25 through 03/11/25, with the medication order only being changed on 03/12/25. The facility's policy required a response to pharmacy recommendations within 7 days, but this was not met. During an interview, the Clinical Corporate Support Nurse confirmed that pharmacy recommendations should be addressed in a timely manner and acknowledged that the medication order should have been changed sooner.
Medication Storage and Labeling Deficiencies Identified
Penalty
Summary
Surveyors observed multiple failures in the proper storage and labeling of medications and biologicals. On one medication cart, an unopened and undated Fiasp insulin pen for a resident was found outside of the refrigerator, and the LPN present was unable to confirm when it had been removed or by whom, despite the requirement for unopened pens to remain refrigerated. On another cart, opened inhalers for two residents were found without open dates, contrary to manufacturer instructions that specify discard timelines based on the date of first use. The LPN confirmed that inhalers should be dated when opened. In the medication room of the Dementia Unit, a bottle of tuberculin serum was found with an open date exceeding the 30-day usage limit, and acetaminophen suppositories were present without labeling or resident identification. The QMA acknowledged that the suppositories should have been labeled with a resident's name. Facility policy and manufacturer instructions provided by clinical staff confirmed the requirements for proper storage, dating, and labeling of these medications and biologicals.
Failure to Ensure Timely Lab Result Reporting and Completion
Penalty
Summary
The facility failed to ensure timely receipt and reporting of critical laboratory test results and completion of ordered lab tests for two residents. For one resident with multiple diagnoses including heart failure, renal insufficiency, and diabetes, a critical potassium level was identified, and repeat labs were ordered. However, the results of a subsequent STAT lab were not followed up on or reported to the nurse practitioner as required, and there was no documentation in the resident's record regarding the results or physician notification until several days later. The facility's policy required charge nurses to monitor and ensure timely receipt and reporting of lab results, but this was not followed in this instance. For another resident with a seizure disorder and other conditions, after an unwitnessed fall believed to be related to seizure activity, the care team decided to obtain a Vimpat (seizure medication) level to check for therapeutic range. However, the resident's record did not show that the Vimpat level was ever obtained, and facility staff confirmed that the test was not completed as intended. These failures demonstrate lapses in following through with critical lab monitoring and reporting processes for residents with significant medical needs.
Failure to Document Colostomy Appliance Changes
Penalty
Summary
The facility failed to document colostomy care for one resident with a history of severe cognitive impairment and multiple diagnoses, including colostomy status. The resident had an open-ended physician's order for colostomy appliance changes as needed, but the clinical record did not contain documentation of any appliance changes for several months. Interviews with nursing staff confirmed that the colostomy appliance was changed frequently, and aides documented the presence and amount of stool in the appliance each shift, but there was no record of the actual appliance changes in the clinical record. Observation of the resident's colostomy showed it was clean and free of infection at the time of survey. The Assistant Director of Nursing stated that colostomy care was performed daily and the appliance should be changed every three days, in accordance with facility policy. However, the required documentation of colostomy care and appliance changes was missing from the resident's clinical record, which did not align with accepted professional standards or the facility's own policy.
Soiled Linens Left on Floor Compromises Sanitary Environment
Penalty
Summary
A deficiency was identified when a resident was observed lying in bed with a stack of soiled linens, including a sheet and a pair of disposable underwear with a strong urine odor, placed on the floor approximately ten inches from the foot of the bed. This condition persisted during two separate observations within a short time frame. The resident was found lying on clean sheets and denied any concerns when asked. Staff interviews revealed that the dirty linens should not have been placed or left on the floor, and that the resident would not have been able to remove the linens herself due to her condition. The resident in question was moderately cognitively impaired and required substantial assistance with activities of daily living, including personal hygiene, and used a wheelchair. The facility's policy requires the environment to be safe, sanitary, functional, and comfortable. The failure to promptly remove soiled linens from the resident's room and prevent their placement on the floor resulted in a failure to maintain a sanitary and homelike environment for the resident.
Failure to Accurately Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to accurately post daily nurse staffing information as required. During two separate observations, the nurse staffing posting was found on the desk at the nurse's station by the front door, visible to visitors, but both postings were dated over a month prior to the observation date. An interview with the Assistant Director of Nursing confirmed that the nurse staff posting should be updated daily. No facility policy regarding nurse staff posting was provided during the survey.
Failure to Maintain Functioning Bathroom Call Light System
Penalty
Summary
The facility failed to provide functioning bathroom call lights for four of six residents reviewed, resulting in residents being unable to summon assistance while in the bathroom or bathing areas. Multiple residents reported that the bathroom call lights had been broken for up to two weeks, with one resident indicating she had to use her bedside call light to get help for her roommate in the bathroom. Observations revealed an open electrical box with exposed wires in one bathroom and no alternative alert system within reach. Residents described having to wait extended periods for help or relying on roommates to seek assistance, as the shared bathroom's call system was not operational. In some cases, a small bell was provided as an alternative, but residents reported it was ineffective in alerting staff. Certified Nurse Aide and Maintenance Director interviews confirmed ongoing issues with the call light system, including failed repairs that led to additional call lights becoming nonfunctional. The Maintenance Director acknowledged that a custom part was needed and that some room call lights were not working, with only a bell available as a substitute. Observations further confirmed that pressing the call light in certain rooms did not produce an audible alert at the nurse's station. The facility's policy required increased monitoring in the event of call light failure, but the report does not indicate that this was consistently implemented during the period of deficiency. The affected residents all required varying levels of staff assistance with toileting and mobility, and all used wheelchairs.
Failure to Ensure Resident Dignity During Personal Care
Penalty
Summary
A staff member failed to treat a resident with respect and dignity when a Certified Nurse Aide (CNA) called the resident a derogatory name and referred to her by the name of a weight loss spokesperson while assisting with personal care. This incident was witnessed by a Qualified Medical Assistant (QMA), who reported that the CNA made these comments while helping the resident pull up her pants and before laying her back down. The resident involved was severely cognitively impaired, with diagnoses including cerebral palsy, contracture, and adult failure to thrive, as documented in her most recent Minimum Data Set (MDS) assessment. The resident did not visibly react to the comments, likely due to her cognitive status. The facility's policy on dignity requires staff to be polite and respectful at all times and prohibits the use of profanity or vulgar language in the presence of residents.
Misappropriation of Resident's Medication
Penalty
Summary
The facility failed to prevent the misappropriation of a resident's medication, specifically involving Resident D, who was cognitively intact and had diagnoses including diabetes mellitus, manic depression, psychotic disorder, and schizophrenia. An incident report revealed that during a shift change, a narcotic medication card and narcotic count sheet were missing. The facility had received three cards of morphine sulfate for Resident D, which were incorrectly ordered and not used, and were placed in the narcotic box. Additionally, a new card of Percocet was delivered but not added to the medication card count by LPN 4, leading to a discrepancy noticed by LPN 5 the following morning. Interviews with the DON and ADON indicated that the pharmacy delivery process involved verification and sign-off by two nurses, but the required documentation was missing for the morphine cards. The facility's policies on controlled substances and delivery manifest required maintaining medication records and reviewing delivery contents, but these procedures were not followed, resulting in the inability to locate the second card of morphine and the associated documentation. This deficiency was related to a complaint investigation.
Medication Security Breach Involving Resident
Penalty
Summary
The facility failed to store medications securely, as evidenced by an incident involving Resident D and a medication cart. During a medication pass, a Qualified Medication Aide (QMA) left a cup of medications on top of the medication cart unattended while taking a resident's vital signs. Resident D, who was cognitively intact and had a history of osteomyelitis, bipolar disorder, psychotic disorder, psychoactive substance abuse, and schizophrenia, took the cup of medications. The medications included Metformin, Lamictal, Clonazepam, and Tamsulosin. After the incident, it was discovered that Clonazepam and Tamsulosin were missing, while the other medications were found in Resident D's room. The Director of Nursing (DON) confirmed that the medications were left unsecured on the cart, and the QMA admitted to leaving the medications unattended. The facility's policy on medication storage requires that medications be accessible only to authorized personnel and that medication carts be visible and inaccessible to residents. The incident was documented, and the facility conducted a risk management assessment. However, the facility did not report the incident to the Indiana Department of Health, as Resident D did not experience any adverse reactions from taking the medications.
Failure to Report Alleged Misappropriation of Medications
Penalty
Summary
The facility failed to report an alleged violation of misappropriation of residents' medications to the Indiana Department of Health in a timely manner. A complainant informed the Facility Administrator that a Qualified Medication Aide (QMA) was allegedly stealing medications from residents and giving them to someone she knew. The Administrator acknowledged receiving this information but did not report the allegation to the Indiana Department of Health as required by the facility's Abuse Prevention Program policy. The investigation conducted by the facility included reviewing narcotic sheets, which showed no discrepancies, and a drug screen for the QMA, which tested negative for all substances. The facility's policy mandates immediate notification to the Indiana State Department of Health (ISDH) and law enforcement officials when an alleged or suspected case of abuse or neglect is reported. However, the Administrator did not follow this protocol, as she did not report the allegation of misappropriation to the ISDH. The QMA in question was not suspended and was not working in the facility on the day the allegation was made. The facility's investigation documentation included a list of days the QMA worked passing medications and the results of the drug screen, but no further action was taken to report the incident to the appropriate authorities.
Failure to Investigate Allegation of Medication Misappropriation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse related to a staff member and misappropriation of medications. The Administrator indicated that there were no allegations of misappropriation of medication since she had been working at the facility. However, a complaint was made that a Qualified Medication Aide (QMA) was stealing medications from residents and giving them to someone she knew. The facility conducted an investigation by reviewing residents' narcotic sheets, checking with the pharmacy, interviewing the staff member in question, and performing a drug screen, which was negative. They also interviewed some staff members who reported no suspicious activity. However, the staff member was not formally suspended pending the results of the investigation. The investigation documentation provided by the facility included a list of days the QMA worked, current Controlled Drug Receipt Record/Disposition Forms, and drug screening results. However, the investigation lacked documentation that cognitively intact residents were interviewed regarding medication administration or pain management, and cognitively impaired residents were not assessed for signs or symptoms of pain. Staff interviews were not documented, and there was no indication that law enforcement was notified of the suspicion of a crime. The facility's Abuse Prevention Program policy required that staff suspected of abuse be suspended and that law enforcement be notified, which was not followed in this case.
Medication Storage Deficiencies
Penalty
Summary
The facility failed to store medications appropriately, as observed in four medication carts. On the In Motion Medication Cart, a vial and a pen of Humalog insulin for a resident were found with open dates exceeding the 28-day usage period, yet they were still in use. Similarly, on the Living Well Short Medication Cart, a Fiasp insulin pen for another resident was observed with an open date that exceeded the 28-day usage period, and a NovoLog insulin pen was found with an open date that exceeded its use-by date. Additionally, another Fiasp insulin pen for a different resident appeared unused but was past the 28-day period. On the Living Well Long Medication Cart, a bottle of lorazepam intensol for a resident was found undated and not refrigerated as required. The facility's policies for medication storage and disposal were not adhered to, as evidenced by the presence of outdated and improperly stored medications. The facility's policies clearly state the storage requirements and disposal timelines for these medications, which were not followed, leading to the deficiencies observed.
Infection Control and Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to infection control guidelines during meal preparation, affecting 93 of 95 residents who received food from the kitchen. During an initial kitchen tour, several deficiencies were observed, including a back door left slightly open, a trash can with a swarm of gnats nearby, and uncovered trays of desserts. The kitchen was found to be unsanitary, with crumbs and splattered liquid stains on the bottom shelves of food prep tables and wheeled carts. Additionally, a silver wire shelf unit was covered in gray dust, and the dry storage room had food items improperly stored on the floor. The Dietary Manager (DM) was observed with hair hanging out of her hair net while working over food, indicating a failure to maintain personal hygiene standards. A second kitchen observation revealed continued non-compliance with infection control standards. The DM again had hair hanging out of her hair net, and the kitchen remained unsanitary with crumbs, food splatters, and dust present on various surfaces, including food prep tables, carts, and racks. The cleaning schedule was outdated, with the latest available from February, and no cleaning logs were found for April, May, or June. The facility's policies required daily cleaning of certain items and good personal hygiene, including wearing hair restraints, which were not followed. These observations highlight the facility's failure to maintain a clean and sanitary kitchen environment, as well as proper personal hygiene during food preparation.
Failure to Identify and Manage Pressure Ulcers
Penalty
Summary
The facility failed to properly identify and follow physician's orders for pressure ulcer care for three residents, leading to the development and worsening of pressure ulcers. Resident 15, who was severely cognitively impaired and at risk for pressure ulcers, was admitted with a Stage 3 pressure ulcer on the right hip. Despite recommendations for ongoing pressure reduction and repositioning, new wounds developed, including a deep tissue injury to the left heel and unstageable pressure ulcers to the left iliac crest and sacrum. The clinical record lacked documentation of interventions such as floating heels or using a low air loss mattress before the new wounds were identified. Resident 37, who was cognitively intact and at risk for pressure ulcers, developed a Stage 3 pressure ulcer on the top of the left foot due to shoes rubbing against the area. The wound was not identified until it reached Stage 3, and the clinical record lacked documentation of the wound's identification prior to this stage. The facility's failure to promptly identify and address the wound contributed to its progression. Resident 38, who was moderately cognitively impaired, had an unstageable pressure ulcer on the right heel present on admission. Despite physician orders to maintain bilateral heel boots, the resident was observed multiple times without the boots, and the boots were reportedly missing for three weeks. The lack of adherence to physician orders and failure to provide necessary pressure-reducing equipment contributed to the resident's ongoing risk for pressure ulcer development.
Inadequate Urinary Catheter Care for a Resident with UTIs
Penalty
Summary
The facility failed to provide appropriate urinary catheter care for a resident with a recent history of urinary tract infections (UTIs). During an observation, a CNA was seen providing peri-care to a resident with a catheter. The CNA noticed a brown granular substance behind the resident's tailbone and on the catheter tubing but did not clean the substance from the catheter. The CNA proceeded to change the resident's brief and handled trash bags with gloved hands without cleaning the catheter tubing. The resident involved was severely cognitively impaired and had a history of cerebral palsy, a pressure ulcer in the sacral region, and recurrent UTIs. The resident's medical records showed multiple physician orders for antibiotics to treat UTIs and an order for urinary catheter care every shift. The facility's policy on indwelling urinary catheter care required cleansing the urethral area first, followed by the proximal third of the catheter, which was not adhered to during the observed care.
Failure to Follow Physician's Orders for Feeding Tube Administration
Penalty
Summary
The facility failed to adhere to the physician's orders regarding the administration of feeding tube care for a resident, identified as Resident 33. During an observation, it was noted that the RN administering the bolus liquid nourishment did not follow the prescribed method. The RN rapidly pushed the liquid nourishment through the feeding tube using a syringe plunger, rather than allowing it to flow gradually by gravity as per the facility's guidelines and the physician's orders. Additionally, the RN did not use the correct amount of water for flushing the feeding tube, administering only 30 cc instead of the prescribed 160 cc. Interviews with facility staff, including an LPN and the DON, revealed inconsistencies in the understanding and execution of the feeding tube procedures. The LPN indicated that she would use the gravity method for bolus feeds and split the prescribed flush amount before and after the feeding. The DON confirmed that the staff should administer bolus feeds by gravity and only use force if there was a problem. However, the observation of the RN's actions contradicted these statements, indicating a lack of adherence to the established procedures. The resident involved, Resident 33, was moderately cognitively impaired with diagnoses including emphysema, hypertension, and dementia. The resident had a swallowing disorder and required a feeding tube. The clinical records showed that the resident had specific physician orders for enteral feeding and flushing, which were not followed during the observed incident. The facility's policy and guidelines for enteral feeding were not adhered to, as evidenced by the RN's actions during the feeding tube administration.
Failure to Monitor Dialysis Access Site
Penalty
Summary
The facility failed to adequately monitor a dialysis access site for a resident who required dialysis services. The resident, who was cognitively intact and had diagnoses including heart failure and renal insufficiency, had an AV graft in his right arm for dialysis, which had been used since early June. Despite the resident's dialysis care plan specifying the need to monitor the shunt for bruit and thrill and observe the site after dialysis, the facility staff did not assess the graft site as required. The resident's clinical record lacked a physician's order to monitor the AV graft site, and the nursing staff did not document any assessment of the graft. During interviews, it was revealed that the nursing staff, including RN 2, did not assess the AV graft for bruit and thrill, nor did they document any assessments in the resident's record. The Assistant Director of Nursing confirmed that there should have been a physician's order for nursing staff to assess the AV graft, and the facility's policy required licensed nurses to evaluate AV shunts, fistulas, and grafts to detect potential complications. However, these procedures were not followed, leading to the deficiency in care for the resident receiving dialysis treatment.
Failure to Limit PRN Psychotropic Medication Orders
Penalty
Summary
The facility failed to ensure that PRN orders for psychotropic medications were limited to 14 days for a resident who was cognitively intact and had diagnoses including heart failure, renal insufficiency, anxiety, and depression. The resident had an open-ended PRN order for Alprazolam, an anti-anxiety medication, which was not reviewed or renewed appropriately as per regulatory guidelines. The order, which started on February 22, 2024, was not evaluated for its continued necessity or extended with documented rationale by the physician, despite pharmacy recommendations on March 15 and April 24, 2024. The resident continued to receive the PRN Alprazolam medication in March, April, May, and June without the required physician's response to the pharmacy's recommendations. The Assistant Director of Nursing indicated that the resident's physician intended for the Psychiatric Nurse Practitioner to address the recommendation, but the resident refused to consent to be seen by the Psych NP. Consequently, the responsibility reverted to the resident's physician, who did not address the recommendation. The facility's policy required a documented response to pharmacy recommendations within seven days, which was not adhered to in this case.
Failure to Accurately Document Narcotic Medication Administration
Penalty
Summary
The facility failed to ensure that residents' medication administration records accurately reflected the administration of narcotic pain medication for four residents (Residents C, D, E, and F). Specifically, the medication administration records (MAR) for these residents lacked documentation of the administration of prescribed narcotic medications at various times. For instance, Resident C's MAR lacked documentation for Hydrocodone-Acetaminophen administration on specific dates in January and February 2024. Similarly, Resident D's MAR lacked documentation for Tramadol administration on multiple dates in January, February, and March 2024. Resident E's MAR also lacked documentation for Percocet administration on numerous dates in January 2024, and Resident F's MAR lacked documentation for Hydrocodone-Acetaminophen administration on several dates in January, February, and March 2024. Additionally, the facility failed to account for controlled drug record forms for three of the four residents reviewed. The clinical records for Residents C, E, and F lacked documentation of the administered narcotic count sheets (controlled drug reports) for various periods. For example, Resident C's clinical record lacked documentation of the narcotic count sheets for several periods between January and March 2024. Resident E's clinical record lacked documentation of the narcotic count sheets from February 3, 2024, through March 31, 2024. Resident F's clinical record lacked documentation of the controlled drug records between February 8, 2024, and March 22, 2024. Interviews with the Assistant Director of Nursing (ADON) and a Licensed Practical Nurse (LPN) revealed that the facility's policy required medications to be signed out on the narcotic count sheet and then signed off on the MAR to show the medication had been administered. However, the ADON indicated that the requested controlled drug reports could not be found, and the LPN confirmed that the documentation was incomplete. The facility's failure to maintain accurate and complete medication administration records and controlled drug reports resulted in a deficiency related to safeguarding resident-identifiable information and maintaining medical records in accordance with accepted professional standards.
Medication Administration Errors for Resident E
Penalty
Summary
The facility failed to ensure medication errors did not occur for Resident E, who was diagnosed with anxiety and prescribed Clonazepam, 0.5 mg, to be administered three times a day. On 1/5/24, the resident received an additional dose of Clonazepam at 9:00 a.m., which was not documented in the physician's order. Additionally, on 1/26/24, the resident's scheduled dose of Clonazepam at 10:00 p.m. was signed off on the Medication Administration Record (MAR) but was not documented on the controlled drug record. These discrepancies indicate medication administration errors, as confirmed by the Assistant Director of Nursing and the Director of Nursing during interviews on 4/4/24. The Assistant Director of Nursing provided a current, undated copy of the facility's document titled 'Medication Administration Errors,' which outlines that a medication error includes administration without an order and missed medication. The findings were related to Complaint IN00429501 and were based on interviews and record reviews conducted on 4/3/24 and 4/4/24. The facility's failure to document and administer medications accurately led to the identified deficiencies in pharmaceutical services for Resident E.
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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