Waters Of Georgetown, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Georgetown, Indiana.
- Location
- 1002 Sister Barbara Way, Georgetown, Indiana 47122
- CMS Provider Number
- 155770
- Inspections on file
- 32
- Latest survey
- March 30, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Waters Of Georgetown, The during CMS and state inspections, most recent first.
The facility failed to provide adequate nursing staff coverage, resulting in one nurse and sometimes no aide in a Villa, or one nurse and one aide shared between two separate Villas. Staff reported being unable to complete required care, including meal preparation, transfers requiring two staff, cleaning, and timely medication passes, when working short. Multiple residents with diabetes, pain, mobility limitations, and mechanical lift needs described long waits for call lights, toileting, transfers, and bedtimes, and consistently late medications, especially insulin and pain medications, when staff were covering more than one Villa or when no staff were present in a Villa for extended periods. MAR reviews confirmed repeated late administration of ordered insulin doses for several residents, correlating with the documented staffing shortages and split assignments between Villas.
Surveyors found that three cognitively intact residents with diabetes did not receive their ordered insulin within the required one-hour window before or after scheduled administration times. Long-acting and short-acting insulins were repeatedly given late, including doses administered after midnight and several hours past ordered morning, midday, afternoon, and bedtime times. Residents reported not getting medications on time, and one resident stated the nurse was busy covering two Villas. A staff member explained that medication passes were delayed due to assisting with full-body mechanical lifts, two-person transfers, and covering multiple Villas, despite a facility policy requiring medications to be administered as prescribed and in accordance with good nursing practice.
The deficiency involved two separate failures in care processes. In one case, a resident with a DNR order, diagnosed with chronic subdural hemorrhage, heart failure, and dementia, was found deceased by a CNA, and the nurse documented the death, but there was no documentation that a second nurse verified the death as required by facility practice. In another case, a resident with macular degeneration and glaucoma was seen by an optometrist who ordered new eye medications, discontinuation of an existing eye drop, and initiation of combination glaucoma drops, but these orders were not transcribed into the clinical record on the day they were written, contrary to staff statements and facility policy that orders should be implemented as received.
Two residents with dementia and other conditions affecting coordination and mobility did not have properly functioning motion sensor alarms as ordered or as required by facility policy. In both cases, surveyors observed motion sensor units inside the rooms that detected movement, but the corresponding hallway alarm boxes did not chime because their switches were not turned on. For one resident, there was no MD order or family notification documented for the alarm despite staff statements that such devices require a physician’s order. For the other resident, there were existing MD orders and a care plan directing use of a motion sensor alarm every shift and checks for proper functioning, but the alarm was not active at the time of observation.
Surveyors determined that the facility failed to document PRN narcotic pain medication administration on the MARs for three residents with conditions such as osteoarthritis, diabetes, depression, lymphedema, and fibromyalgia. Although controlled drug records showed multiple administrations of Hydrocodone-Acetaminophen and Tramadol in accordance with physician orders, the corresponding MARs lacked entries for these doses, contrary to facility policy requiring nurses to initial the MAR when administering medications.
Chronic understaffing resulted in nurses and aides being unable to provide timely medication administration and adequate assistance with daily living tasks. Residents with diabetes experienced repeated delays in receiving scheduled insulin, and staff were unable to complete essential care duties due to being assigned to multiple units and responsibilities. Both staff and residents reported frequent delays and incomplete care, with documentation confirming numerous late medication administrations and missed care tasks.
The facility did not ensure proper monitoring and documentation for two residents with midline catheters, including missing flush orders and site assessments, and failed to follow physician orders for holding blood pressure medications when vital signs were out of range for two other residents. Medication administration records and staff interviews confirmed these deficiencies.
A resident with an indwelling catheter and neuromuscular bladder dysfunction did not have urine output documented every shift as ordered by the physician. Review of records showed several missed documentation instances across multiple shifts, despite facility policy and staff acknowledgment that physician orders must be followed.
A repeated deficiency for insufficient staffing was not adequately addressed by the facility's QAPI process, as documentation focused on staffing numbers without evidence of effective interventions or systemic changes. Staffing records showed inconsistent coverage, including instances where a single nurse was responsible for multiple areas and also performed aide duties, potentially affecting all residents.
Residents were frequently left without engagement in scheduled or meaningful activities, with staff overwhelmed by other duties and the Activity Director spending minimal time facilitating programs. Activities listed on the calendar were not conducted, and residents, including those with dementia, were not adequately supported or informed about available activities. The lack of an effective activity program affected all residents' physical, mental, and psychosocial well-being.
The facility did not consistently provide the required 8-hour consecutive RN coverage on multiple days, with some days having no RN coverage and others having less than the mandated hours. This deficiency had the potential to impact all residents in the facility, as confirmed by facility leadership.
Multiple staff and resident interviews, along with direct observations, revealed that only one CNA and one nurse were typically present per villa, leading to delays in care, incomplete tasks, and residents sometimes being left unsupervised. A resident with dementia and a history of elopement was able to leave the courtyard unsupervised due to staff being occupied elsewhere, and staff reported difficulty providing required showers and assistance for residents needing two-person transfers.
Several residents with significant medical and cognitive impairments did not receive timely or adequate assistance with ADLs, including bathing, hygiene, and transfers, due to insufficient staffing. Staff interviews and documentation revealed that only one CNA was typically assigned per building, leading to delays and missed care tasks, especially for residents needing two-person assistance or mechanical lifts. Observations confirmed that residents remained unkempt, in soiled clothing or bedding, and missed scheduled showers and hygiene care.
The facility did not ensure that respiratory care supplies, such as humidifier bottles and oxygen tubing, were changed according to physician orders for four residents with chronic respiratory conditions. Observations found undated or outdated equipment and, in one case, an empty humidification bottle, despite clear orders for weekly maintenance. The facility also could not provide its Respiratory Therapy policy when requested.
The facility did not maintain complete and up-to-date infection surveillance documentation, with missing details such as onset dates, symptoms, culture results, and isolation status for multiple infections. The infection control binder was not kept current, and monitoring for infection patterns was not documented, affecting all residents. Interviews confirmed the binder was missing and had to be reconstructed retroactively, in violation of the facility's infection control policy.
A resident with Alzheimer's disease and dementia, identified as an elopement risk, was able to leave a secured area unsupervised through an unlocked courtyard gate. Despite care plan interventions and a facility policy requiring supervision, the resident exited while staff were occupied elsewhere, and the gate was found unlatched with the padlock unsecured. Staff could not determine how the gate was unlocked, and the resident was found outside after ringing the doorbell to re-enter.
A resident with diabetes and other medical conditions experienced multiple critically high blood glucose readings, but there was no documentation that the physician or responsible party were notified as required by physician orders and facility policy. Nursing staff interviews confirmed that such notifications should have occurred, but the clinical record did not reflect this.
A resident with diabetes and a right ankle wound received care from both facility staff and an external wound clinic, but the facility failed to document wound assessments and did not include wound center reports in the clinical record. Staff were unaware of current wound status and treatments, relying on family updates due to missing documentation and lack of communication with the external clinic.
Two residents with diabetes did not receive their prescribed insulin doses as ordered, with multiple instances of late administration or missed doses of both Humalog and Lantus. Facility staff failed to follow physician orders and internal medication administration guidelines, resulting in deviations from scheduled insulin administration.
Qualified Medication Aides (QMAs) signed off on wound care treatments for several residents with stage 3, stage 4, and unstageable pressure ulcers, which is outside their authorized scope of practice. Facility policy and state guidelines require that only licensed nurses perform and document such treatments, but QMAs reported signing off when nurses forgot. Staff interviews and record reviews confirmed these actions, and facility policy outlining QMA limitations was provided.
The facility did not maintain adequate nursing staff coverage, resulting in periods when Villas were left unattended and essential care tasks were delayed or incomplete. Staff reported being required to cover multiple areas, and on one occasion, a resident in a wheelchair exited the facility unsupervised while both the nurse and aide were occupied elsewhere. Staffing records confirmed multiple shifts with missing nurses or aides, directly impacting resident care and supervision.
The facility did not consistently monitor or document side effects for residents on anticoagulants, insulin, and diuretics, nor did it ensure completion of ordered wound care treatments for a resident with an abdominal wall abscess. These deficiencies were identified through review of clinical records and staff interviews, which showed missing documentation and incomplete treatments as required by care plans and physician orders.
Multiple residents did not have their medication administration accurately documented, with some medications recorded as given when they were not available, and narcotic pain medications administered without corresponding entries in the MAR. Staff interviews confirmed that required documentation procedures were not consistently followed, resulting in discrepancies between physician orders, pharmacy records, and facility logs.
A resident with intact cognition reported that a nurse engaged in sexually inappropriate behavior during care, including physical contact and comments that caused discomfort. The incident was reported to a CNA and then to an LPN, but the investigation was incomplete, as other staff and residents were not interviewed and the nurse was not suspended as required by facility policy.
The facility did not consistently provide or document required catheter care and urine output monitoring for two residents with indwelling catheters, despite physician orders and care plans specifying these actions. Multiple shifts lacked documentation of urine output, and catheter care was not recorded as required.
A resident with an ostomy did not have their ostomy care and output consistently documented or completed as ordered by the physician. Review of records showed multiple shifts where output was not recorded and at least one instance where care was not provided, despite care plan and physician orders requiring these actions.
A resident with depression, anxiety, and osteoporosis did not receive scheduled doses of Hydrocodone-Acetaminophen and Xanax as ordered by the physician. Review of records showed that neither medication was administered or signed out at the scheduled time, despite facility policy requiring adherence to physician orders.
The facility failed to provide a resident-centered activities program, affecting all residents. Observations showed no activities in multiple villas, with staff unable to facilitate due to being understaffed. Residents B, C, D, and E, with various cognitive impairments, had care plans for activities that were not implemented. The facility lacked an activities director, and the activities calendar was not followed. The Executive Director acknowledged these issues, and a consulting company's oversight was insufficient.
The facility experienced significant staffing shortages, leading to inadequate care for residents across multiple Villas. Staff members were often required to work alone or cover multiple units, resulting in delays in care such as assistance with transfers and bathing. The absence of an activities director further impacted residents' quality of life, as there were no regular planned activities. The facility's staffing plan was not followed, with frequent vacancies and staff floating between units, affecting the care and services provided to residents.
A resident with severe cognitive impairment and behavioral issues, including exit-seeking, was left unsupervised in a common area. Despite documented behaviors such as yelling and wandering, the care plan was not updated to include necessary interventions. Observations and interviews indicated inadequate staffing and supervision, contributing to the deficiency.
The facility failed to provide adequate incontinence care and bathing for two residents. One resident, with impaired mobility, was left in a wheelchair for hours and found with reddened skin due to inadequate care. Another resident, with severe cognitive impairment, had an overfilled urine drainage bag and received only one of eight scheduled showers in December. The facility's policies on regular checks and bathing were not followed, leading to these deficiencies.
The facility failed to ensure resident safety from falls due to improper use and maintenance of motion sensor alarms for two residents. One resident, with a history of falls and cognitive impairment, experienced multiple falls due to non-functioning alarms and inadequate supervision. Another resident, also cognitively impaired, fell due to malfunctioning alarms and lack of assistance. Staff interviews revealed inconsistencies in alarm maintenance and supervision, contributing to the incidents.
The facility failed to update a resident's care plan to address her refusal to remove blankets, which contributed to a heat rash. Despite staff efforts to manage the room temperature and encourage the resident to remove the blankets, the care plan was not revised to reflect these issues.
Insufficient Nursing Staff Leading to Delayed Medications and Care
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff on multiple shifts, resulting in inadequate medication administration and assistance with activities of daily living for all residents. Staffing records and timecards for March 2026 showed repeated instances where individual Villas had only one nurse and no aide, or one nurse and one aide shared between two Villas, during both day and night shifts. On several nights, a single nurse and a single aide were responsible for residents in two separate free‑standing buildings, requiring them to leave one Villa without staff while they moved to the other. In at least one instance, a nurse scheduled for night shift did not clock in until early the following morning, further reducing coverage. Staff interviews confirmed that staffing was described as "awful" and that promised staffing levels of two aides per Villa or one nurse for two Villas with two aides were not consistently met. Because of this understaffing, nurses and aides were unable to complete required care tasks in a timely manner. Staff reported that when only one aide and one nurse were available for two Villas, the nurse had to pass medications in both buildings and also assist with transfers requiring two staff, causing delays in medication administration and resident care. One staff member reported working alone in a Villa with nine residents, having to prepare meals, wash dishes, administer medications, complete treatments, provide resident care, and perform charting without an aide. Another staff member stated that she could not complete cleaning and laundry tasks on most days and tried to do them only on Sundays when there were no showers. Staff also reported that residents who required full body mechanical lifts often had to wait to get up or be put to bed because two staff were needed for transfers and the second staff member was frequently in another Villa. Multiple residents with intact cognition reported not receiving medications and assistance in a timely manner due to lack of staff. One resident stated that insulin was received, but other medications were late, and another described medication timing as "hit and miss" when one nurse had to cover two Villas. Several residents reported consistently late medications and long waits for call lights to be answered, especially at night, with one resident stating they waited over an hour for a call light response and were frequently told by staff that there was not enough time. Residents who required mechanical lifts, including those with osteoarthritis, morbid obesity, diabetes, and lower extremity amputations, reported long waits to get out of bed, to use the bathroom, or to be put back to bed. One resident described waiting over 90 minutes for assistance to the bathroom, ultimately incontinent while waiting, and not receiving medications until late at night. Medication administration records (MARs) documented repeated late administration of insulin for several residents with diabetes. One resident ordered to receive long‑acting insulin between 8:00 p.m. and 11:00 p.m. had doses given after midnight on multiple dates, including one dose administered at 4:46 a.m. Another resident ordered fast‑acting insulin before meals at 7:00 a.m., 11:00 a.m., and 4:00 p.m. had numerous doses given significantly late, including morning doses after 8:40 a.m. and midday doses after 12:40 p.m. A third resident with orders for morning long‑acting insulin and pre‑meal and bedtime short‑acting insulin had many doses documented as late, with morning doses given after 10:00 a.m., midday doses after 12:40 p.m. or later, afternoon doses after 5:45 p.m. or later, and bedtime doses given close to or after midnight. Residents also reported periods when no staff were present in their Villa for extended times in the evening, during which they could not obtain pain medication or diabetic medication on time. These findings collectively show that the facility did not ensure adequate nursing staff each day to meet residents’ needs for timely medication administration and assistance with daily living. The facility’s own guideline document on Standard Supervision and Monitoring stated that staff assignments were to be based on resident needs and acuity, and that resident needs, including physical needs, would be met by providing as much hands‑on care as necessary. However, the documented staffing patterns, staff accounts, resident interviews, and MAR reviews demonstrate that the actual staffing levels did not meet these expectations. Residents experienced delays in transfers, toileting, and bedtimes, and insulin and other medications were repeatedly administered outside the ordered times, directly linked by staff and residents to the lack of sufficient nursing and aide coverage in the Villas.
Repeated Late Administration of Insulin Medications
Penalty
Summary
The deficiency involves the facility’s failure to administer insulin medications within one hour before or after the prescribed times for three residents with diabetes. Resident E, who had intact cognition and a care plan for diabetes management, had a physician’s order for Insulin Glargine 20 units subcutaneously between 8:00 p.m. and 11:00 p.m. Review of the March 2026 MAR showed multiple instances where this insulin was given more than an hour past the ordered time window, including administrations after midnight and as late as 4:46 a.m. Resident E reported that he did not always receive his medications on time. Resident H, who also had intact cognition and diagnoses including diabetes and bilateral lower extremity amputations, had orders for Insulin Lispro 12 units subcutaneously before meals at 7:00 a.m., 11:00 a.m., and 4:00 p.m. The March 2026 MAR documented numerous occasions when these insulin doses were administered more than an hour after the scheduled times, with morning, midday, and afternoon doses all being delayed. During an interview, Resident H stated she had to wait for her medications because the nurse was busy in another Villa and had two medication passes to complete. Resident L, cognitively intact and admitted for pain and diabetes management, had orders for Lantus 10 units subcutaneously at 9:00 a.m. and Humalog per sliding scale before meals and at bedtime at 7:30 a.m., 11:30 a.m., 4:30 p.m., and 10:00 p.m. The March 2026 MAR showed repeated late administrations of both long-acting and short-acting insulin, with doses given well beyond one hour after the scheduled times, including late morning, afternoon, evening, and after-midnight administrations. Resident L reported that she could not get her pain or diabetic medications on time. During the survey, a staff member stated that medications were administered late because nurses had to stop medication passes to assist with full-body mechanical lifts, two-person transfers, or cover two separate Villas, and the facility’s Medication Administration Policy required medications to be administered as prescribed in accordance with good nursing principles and practices.
Failure to Verify Death per Policy and Delay in Transcribing Physician Orders
Penalty
Summary
The deficiency involved the facility’s failure to follow its own process for verification of death for a resident with DNR status. Resident C, who had diagnoses including nontraumatic chronic subdural hemorrhage, heart failure, and dementia, was found by a CNA to have expired. The nurse documented that upon entering the room, the resident was unresponsive, pale, cold, and not breathing, and that the resident had a DNR order. The time of death was recorded as 10:22 p.m., and the physician and family were notified. However, the clinical record did not contain documentation that a second nurse assessed and verified the resident’s death, despite staff indicating that two nurses were required to verify the death of a resident with DNR status. A second deficiency involved the failure to timely transcribe and implement physician orders for another resident. Resident D, who had diagnoses including macular degeneration and glaucoma, was seen by an optometrist, who prescribed artificial tears three times daily, Preservision AREDS 2 capsules twice daily, discontinuation of Latanoprost eye drops, and initiation of Brimonidine 0.1%–dorzolamide 2% eye drops twice daily. The clinical record lacked documentation of these prescribed orders on the date they were written and showed they were not documented until several days later. Staff reported that orders should be transcribed on the same day they are written, and the facility’s policy stated that all physician orders received pertaining to the resident will be implemented and followed as the orders are received.
Failure to Ensure Proper Use and Functioning of Motion Sensor Alarms for Residents at Risk for Falls
Penalty
Summary
The facility failed to ensure that motion sensor alarms were properly functioning and appropriately ordered for residents at risk for falls. For one resident with dementia, moderate anxiety, and Parkinsonism, surveyors observed a motion sensor system consisting of a small box on the floor inside the room and an alarm box on the hallway handrail outside the door. Although a yellow light illuminated on the floor unit when motion was detected, the hallway alarm did not sound because the chime switch was not fully in the "on" position. The resident’s clinical record did not contain a physician’s order for the motion sensor alarm, nor documentation that the family had been notified or had agreed to the alarm placement, despite staff statements that motion sensors should only be used with a physician’s order and that they should be active when residents at risk for falls are alone in their rooms. The facility also failed to ensure proper functioning of a motion sensor alarm for another resident with dementia, chronic pain, anxiety, and lack of coordination, who had an existing physician’s order for a motion sensor alarm every shift and an order for staff to check the alarm’s proper functioning every shift. The resident’s care plan documented that the resident was at risk for falls and was to have a motion sensor alarm as ordered for safety. During observation, surveyors noted the same alarm configuration, with a floor unit inside the room and an alarm box on the hallway handrail. The yellow light on the floor unit illuminated with motion, but the hallway alarm did not chime because the chime switch was not turned on, contrary to the physician’s order and care plan requirements for continuous use and regular function checks.
Failure to Document PRN Narcotic Administration on MARs
Penalty
Summary
Surveyors found that the facility failed to ensure that medication administration records (MARs) accurately reflected the administration of PRN narcotic pain medications for three residents. For Resident E, who had diagnoses including osteoarthritis, lymphedema, diabetes, and depression, a physician’s order dated 1/21/26 directed Hydrocodone-Acetaminophen 5-325 mg every 6 hours as needed for pain. The March 2026 controlled drug record showed multiple administrations of this narcotic throughout the month, but the March 2026 MAR contained no corresponding documentation of these doses. During the survey, a staff member stated that when a PRN pain medication is administered, the MAR should be signed by the nurse, and the facility’s Medication Administration Policy Guideline dated 1/25/19 required that the MAR be initialed by the person administering the medication. Similar discrepancies were identified for Residents H and L. Resident H, with diagnoses including diabetes and depression, had a physician’s order dated 3/21/26 for Tramadol 50 mg every 6 hours as needed for pain. The March 2026 controlled drug record documented several administrations of Tramadol, but the March 2026 MAR lacked documentation of these doses. Resident L, diagnosed with diabetes, depression, and fibromyalgia, had an order dated 5/21/25 for Hydrocodone 5-325 mg every 4 hours as needed for pain. The March 2026 controlled drug record listed frequent administrations of this narcotic throughout the month, yet the March 2026 MAR did not contain documentation of these administrations. These findings showed that the facility did not maintain MARs in accordance with its own policy and accepted professional standards for these three residents.
Chronic Understaffing Leads to Delayed Medication and Inadequate Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, resulting in delayed medication administration and inadequate assistance with activities of daily living. Observations during the survey period revealed that staff members, including nurses and aides, were consistently unable to complete their assigned duties in a timely manner due to chronic understaffing. Nurses were responsible for passing medications in multiple units, often resulting in medication passes being out of compliance with required administration windows. Aides were tasked with multiple responsibilities, including meal preparation, serving, cleaning, and laundry, in addition to direct resident care, which further contributed to delays and incomplete care. Multiple residents with complex medical needs, such as diabetes requiring scheduled insulin administration, experienced repeated delays in receiving their medications. Medication Administration Records (MARs) for several residents documented numerous instances where insulin and other medications were administered significantly later than ordered, sometimes by several hours. Residents and staff interviews corroborated these findings, with reports of medications being given late at night or well past the scheduled times, and residents having to wait extended periods for assistance with transfers or toileting, especially those requiring two-person assistance or mechanical lifts. Staff interviews indicated that float aides, intended to provide additional support, were frequently unavailable due to call-ins, leaving only one aide per unit and one nurse covering multiple units. This staffing pattern made it difficult to ensure timely care, particularly for residents at high risk for falls or those requiring extensive assistance. The facility's staffing sheets confirmed frequent changes in staffing patterns and instances where only one nurse was available for several units, further exacerbating the delays in care and medication administration. Residents expressed frustration and concern over the delays, and staff reported an inability to complete essential care tasks, resulting in missed showers, incomplete cleaning, and delayed or missed medication doses.
Failure to Monitor Midlines and Adhere to Medication Administration Parameters
Penalty
Summary
The facility failed to ensure proper monitoring and documentation for residents with midline catheters and did not consistently follow physician orders for medication administration. Specifically, two residents with midlines did not have orders in place for flushing the lines before and after medication administration, nor was there documentation of monitoring the midline sites for infiltration or signs of infection. Additionally, for one resident, there was no documentation regarding the removal of the midline or confirmation that the catheter tip was intact upon removal. These lapses were observed through record review and staff interviews, which confirmed that such monitoring and documentation should have been performed every shift. The facility also failed to follow medication administration parameters for residents prescribed blood pressure medications. One resident received Midodrine HCl despite having systolic blood pressures outside the ordered parameters on multiple occasions, and another resident was administered a hypertensive medication without documentation of a pulse being obtained as required by the physician's order. These deficiencies were identified through review of medication administration records and vital sign reports, as well as staff interviews confirming that medications should be held if vital signs are out of the specified range.
Failure to Document Catheter Output as Ordered
Penalty
Summary
The facility failed to ensure that a resident with an indwelling catheter had their urine output documented every shift as ordered by the physician. The resident, who had a diagnosis including neuromuscular dysfunction of the bladder, had a physician's order requiring staff to monitor and record catheter output each shift. Review of the medication administration records for August and September revealed multiple instances where urine output was not documented on specified day and night shifts. Staff confirmed that physician orders are required to be followed, and facility policy also mandates adherence to physician orders to provide essential care.
Repeated Failure to Address Sufficient Staffing Deficiency
Penalty
Summary
The facility failed to identify and address an ongoing quality deficiency related to insufficient staffing, which had been cited in multiple previous surveys. Despite the existence of a Quality Assurance and Performance Improvement (QAPI) plan, the facility's QAPI meetings and documentation primarily focused on tracking terminations, new hires, and open positions, without evidence of implemented interventions or systemic changes to resolve the staffing issue. The QAPI workbook lacked documentation of corrective actions or monitoring of interventions for the continued deficiency. Staffing records revealed inconsistent staffing patterns, with periods where only one nurse and one aide were scheduled per villa, and instances during night shifts where a single nurse was responsible for multiple villas, sometimes also covering aide duties due to call-ins. These staffing shortages were not adequately addressed through the QAA process, and the repeated deficiency had the potential to affect all 64 residents in the facility. The report does not mention specific residents' medical histories or conditions at the time of the deficiency.
Failure to Provide Ongoing and Individualized Activity Program
Penalty
Summary
The facility failed to provide an ongoing activity program designed to meet the interests and support the physical, mental, and psychosocial well-being of each resident. Multiple observations across several villas revealed that residents were often left sitting in common areas, dining rooms, or in their rooms without engagement in any scheduled or meaningful activities. Despite the presence of an activity calendar, activities such as reading the news, trivia games, music class, balloon toss, and karaoke were not conducted as scheduled. Residents were frequently observed asleep, sitting idly, or simply looking around, with no staff or activity personnel facilitating engagement. Interviews with staff, including CNAs and the Activity Director, indicated that CNAs were overwhelmed with other duties such as meal preparation, cleaning, laundry, and resident care, leaving them unable to conduct activities. The Activity Director was reported to spend minimal time in each villa, often just dropping off coloring pages and newsletters, which were not well received by residents. Activities that did occur were brief and infrequent, and there was a lack of communication to residents about when and where activities would take place. Residents expressed a desire for more activities, outings, and clearer information about scheduled events, but these needs were not being met. Residents with dementia and other conditions requiring encouragement and assistance to participate in activities were not adequately supported, as indicated by care plans and staff interviews. The activity program was not individualized or adapted to the cognitive and physical abilities of all residents, particularly those in the dementia unit. Family members and staff confirmed the lack of appropriate and consistent activities, and the activity calendar was not followed. The deficiency affected all residents in the facility, as the program did not meet regulatory requirements for supporting residents' well-being through meaningful activities.
Failure to Provide Required 8-Hour RN Coverage
Penalty
Summary
The facility failed to provide the required 8-hour consecutive registered nurse (RN) coverage per day for one of the two months reviewed, specifically in June 2025. Review of the nursing schedules for May and June 2025 revealed that on several days, the facility either had no RN coverage or had RN coverage for less than the required 8 consecutive hours. Specifically, on 6/5/25, only 6.5 hours of RN coverage was provided; on 6/6/25 and 6/7/25, only 5 hours each day; and on 6/8/25 and 6/13/25, there was no RN coverage at all. The Regional Director of Clinical Operations confirmed awareness of these gaps, and it was noted that the DON was a working DON who also covered other areas as needed. This deficiency had the potential to affect all 66 residents residing in the facility at the time.
Insufficient Staffing Leads to Delays and Incomplete Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, as evidenced by multiple staff interviews and direct observations. Staff consistently reported that only one CNA was assigned per villa, with occasional floaters available on certain days, but not consistently throughout the week. CNAs were responsible for a wide range of duties, including resident care, transfers requiring two staff, toileting, showers, cleaning, laundry, meal preparation, and activities. Staff described frequent situations where they had to wait for assistance from a nurse or another staff member to perform tasks requiring two people, such as mechanical lifts or transfers, resulting in delays in care and incomplete tasks. Some staff admitted to skipping or abbreviating showers and cleaning due to time constraints, and residents sometimes had to wait for care or assistance. Direct observations confirmed that at times, only one CNA and one nurse were present in a villa, and there were periods when no staff were visible because they were assisting residents in their rooms. Residents requiring two-person assistance for transfers or mechanical lifts were present, and staff expressed concerns about resident safety, particularly for those at risk of falls. One resident reported being left alone in a villa with no staff present and would have to seek help if needed. Staff also indicated that the workload was overwhelming, especially when floaters were not available, and that management did not assist with direct care tasks. A specific incident involved a resident with Alzheimer's disease and dementia, identified as an elopement risk, who was able to leave the courtyard unsupervised because the only nurse on duty was in another villa and the CNA was assisting another resident. The resident was found outside the villa by staff after ringing the doorbell, and the courtyard gate was found unlocked. Staff noted that wander guards had been discontinued, and the lack of sufficient supervision contributed to the resident's unsupervised exit. Additionally, staff reported difficulty in providing required showers and daily care for residents needing two-person assistance, sometimes resulting in only partial care being provided.
Failure to Provide Timely and Adequate ADL Assistance Due to Insufficient Staffing
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for three residents who required significant staff support. Multiple staff interviews revealed that only one CNA was typically assigned per building or villa, with additional help from nurses or floating aides only when available. Staff reported frequent delays in providing care, especially for residents needing two-person assistance or mechanical lifts, as the CNA often had to wait for another staff member to become available. CNAs were also responsible for a wide range of non-care duties, including meal preparation, serving, cleaning, and laundry, which further limited their ability to provide timely and complete resident care. Resident 3, who had multiple medical conditions including diabetes, chronic respiratory failure, and cognitive impairment, required maximal staff assistance for transfers, bed mobility, personal hygiene, and bathing. Observations showed that this resident repeatedly requested help getting out of bed and with personal care, but was told by the CNA that she was too busy with other tasks. Documentation indicated that the resident missed several scheduled showers and hair washes, and there was no record of refusal. The resident was observed remaining in bed, unkempt, and in the same gown over multiple days. Resident 41, diagnosed with Alzheimer's disease, Parkinson's disease, and other chronic conditions, also required substantial or maximum assistance for ADLs. Family members reported not seeing staff for extended periods, and records showed the resident did not have her hair washed for two months. The resident was observed in bed with a strong urine and body odor, and the CNA had to change urine-soaked bedding and clothing. Resident 10, with dementia and other significant health issues, was also found to have missed scheduled showers and received only a partial bath on one occasion, with no other bathing documented for two months. These findings demonstrate a pattern of insufficient staffing and unmet care needs for residents requiring assistance with ADLs.
Failure to Provide Timely and Appropriate Respiratory Care and Equipment Maintenance
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care and maintenance for four residents who required respiratory therapy. For each resident, physician orders specified the use of oxygen therapy, including the prescribed flow rate, and required weekly changes of humidifier bottles and oxygen cannula/tubing, typically on Sunday night shifts or as needed. However, record reviews and direct observations revealed that these supplies were not changed as ordered. For example, humidifier bottles and oxygen tubing were found to be undated or dated well before the most recent scheduled change, and in one case, a humidification bottle was found empty. Additionally, the facility did not provide a copy of its Respiratory Therapy policy when requested. The residents involved had significant respiratory diagnoses, including chronic respiratory failure, chronic obstructive pulmonary disease (COPD), and respiratory failure with hypoxia. Despite clear care plans and physician orders outlining the need for regular maintenance and monitoring of respiratory equipment, staff did not consistently follow these protocols. The lack of timely equipment changes and proper documentation was observed for all four residents reviewed, indicating a systemic failure to adhere to prescribed respiratory care procedures.
Failure to Maintain Complete Infection Surveillance Documentation
Penalty
Summary
The facility failed to maintain appropriate infection prevention and control practices, specifically in the area of surveillance documentation. Over a period from January to mid-June 2025, infection control records were incomplete, lacking critical information such as date of onset, symptoms, culture dates and results, re-culture dates, isolation status, resolution dates, and whether the infections met established criteria. This incomplete documentation was noted for multiple types of infections, including respiratory, urinary tract, skin, and blood infections, affecting all residents in the facility. Additionally, the facility's infection control book, which should have contained up-to-date surveillance and tracking information, was missing for a significant period. The absence of this documentation hindered the facility's ability to monitor infection patterns and trends, as evidenced by the lack of monitoring records on villa floorplans. Interviews with the DON, IP, and RDCO confirmed that the infection prevention binder was not maintained as required and had to be reconstructed retroactively for the first half of 2025. The facility's own infection prevention and control policy required a surveillance system capable of identifying and tracking communicable diseases, ensuring timely reporting, and implementing appropriate isolation measures. However, the lack of complete and current documentation meant that these policy requirements were not met, potentially impacting the facility's ability to prevent and control the spread of infections among residents and staff.
Failure to Supervise Elopement Risk Resident Resulting in Unsupervised Exit
Penalty
Summary
The facility failed to provide adequate supervision for a resident identified as an elopement risk, resulting in the resident leaving the secured area unsupervised. The resident, who had diagnoses of Alzheimer's disease and dementia, was care planned for elopement risk with interventions such as reorientation, locked courtyard gate, diversional activities, and visual checks. Despite these interventions, the resident was able to exit through a courtyard gate that was found to be unlatched and unlocked, with the padlock hanging on the latch. Staff were unaware of how the gate became unlocked, and the resident was found outside the facility after ringing the doorbell to be let back in. At the time, staffing was limited, with only one LPN and one CNA present, both occupied with other duties. The resident had a documented history of wandering, exit-seeking behaviors, and previous attempts to leave with visitors. Multiple nurse notes indicated ongoing wandering and exit-seeking, including attempts to follow visitors out and requests to go outside. Staff interviews confirmed that the resident was not under direct supervision at the time of the incident, and the facility's elopement prevention policy required adequate supervision for residents at risk. The maintenance director, who had access to the gate key, was unavailable for interview, and management could not determine how the gate was unlocked.
Failure to Notify Physician and Responsible Party of Critically High Blood Glucose Levels
Penalty
Summary
The facility failed to notify the physician and the resident's responsible party regarding multiple instances of elevated blood glucose levels for one resident. The resident had a history of atrial fibrillation, hypertension, edema, diabetes, a right ankle wound, and unspecified dementia. Physician orders required staff to notify the physician if the resident's blood sugar exceeded 400 mg/dL. Despite this, record review showed several occasions where the resident's blood sugar was above this threshold, including readings of 421, 445, 520, 400, and 418 mg/dL. There was no documentation indicating that the physician or responsible party had been notified of these critical values. Interviews with nursing staff confirmed that the protocol was to notify the provider and family immediately if blood glucose values were outside the critical range, and to document the change and notifications. The facility's own guidelines also required notification of any critical lab value. However, the clinical record lacked evidence that these notifications occurred for the resident's elevated blood glucose levels, constituting a failure to follow established procedures for change of condition notification.
Failure to Document and Communicate Wound Care Assessments
Penalty
Summary
The facility failed to ensure proper communication and documentation regarding wound care for a resident with type II diabetes and a right ankle abrasion. Physician orders for wound care changed multiple times over several months, specifying different treatments and dressing protocols. However, after a wound assessment on 4/17/25, there was no further documentation of wound assessments, measurements, or wound appearance in the clinical record, despite ongoing care and weekly visits to a hospital wound care center. The facility's records did not include wound care notes or reports from the hospital wound care center, and these documents were not scanned into the resident's clinical record for staff access. Interviews revealed that staff were unaware of the current status and treatment details of the resident's wound, relying instead on information from the resident's family. The LPN indicated that nurses could not access wound center reports and were not informed of wound measurements or treatments provided by the wound care center. The Regional Director of Clinical Operations confirmed that no staff member was responsible for scanning external wound care documents into the record after the medical records staff left the facility. As a result, there was a lack of communication and documentation between the facility and the external wound clinic, leading to incomplete records and potential gaps in care.
Failure to Administer Insulin as Prescribed for Two Residents
Penalty
Summary
The facility failed to ensure that insulin was administered as prescribed for two residents with diabetes and other significant medical conditions. For one resident, there were multiple instances where insulin doses were either administered late or omitted entirely. Specifically, Humalog and Lantus insulins were not given at the times ordered by the physician, with some doses being delayed by several hours and one morning dose not administered at all. Documentation showed that staff did not provide a reason for these deviations from the prescribed schedule. For the second resident, Lantus insulin ordered for bedtime was repeatedly administered several hours late, often during the early morning hours of the following day. Additionally, scheduled doses of Humalog were not administered on several occasions despite the resident's blood sugar levels being above the threshold specified in the physician's order. Facility guidelines required medications to be administered according to physician orders and documented at the time of administration, but these protocols were not followed in the cases reviewed.
QMAs Documented Wound Care Outside Scope of Practice
Penalty
Summary
Qualified Medication Aides (QMAs) at the facility signed off on wound care treatments for multiple residents with pressure ulcers that were outside their scope of practice. Specifically, QMAs documented completion of treatments for residents with stage 3, stage 4, and unstageable pressure ulcers, which, according to facility policy and state guidelines, should only be performed and documented by licensed nursing staff. The clinical records for four residents showed that QMAs signed for wound care treatments on several occasions, despite these wounds being more severe than a stage one, which is the limit of their authorized practice. Interviews with staff confirmed that QMAs are not permitted to perform or document treatments for wounds above stage one, and that nurses are responsible for these tasks. However, QMAs reported that they sometimes signed off on treatments if a nurse forgot to do so. The facility's policy and state regulations were provided, clearly stating the limitations of the QMA role, including restrictions on documenting treatments performed by others and on treating wounds more severe than stage one.
Failure to Provide Adequate Nursing Staff and Supervision
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the needs and ensure the safety of all residents, as evidenced by multiple staff interviews, staffing records, and direct observations. Staff members reported frequent understaffing, with aides and nurses often required to cover multiple Villas simultaneously, leaving some Villas unattended for periods ranging from two to ten minutes. Staff described situations where they were unable to complete essential care tasks, such as showers and timely assistance with toileting, due to insufficient staffing. Staffing sheets confirmed several instances where there was no nurse or aide present in specific Villas during various shifts. On one occasion, a resident in a wheelchair exited the facility unsupervised while the nurse assigned to that Villa was attending to duties in another Villa, and the aide was occupied providing care in a resident's room. The resident was returned to the Villa by the Director of Rehabilitation. These events demonstrate that the facility did not consistently have a licensed nurse in charge on each shift or enough staff present to meet residents' needs and ensure their safety.
Failure to Monitor and Document Medication Side Effects and Complete Ordered Treatments
Penalty
Summary
The facility failed to provide appropriate monitoring and documentation for residents receiving high-risk medications and treatments. For one resident with diabetes, peripheral vascular disease, and systemic lupus, there was no documentation of monitoring for side effects related to anticoagulant and insulin therapy upon readmission, despite care plans requiring observation for bleeding and glycemic events. Another resident receiving warfarin for a history of stroke did not have documented monitoring for potential complications such as hemorrhage, rash, or thrombocytopenia, as outlined in the care plan. A third resident on diuretic therapy for congestive heart failure lacked documentation of monitoring for dehydration, which was required by the care plan. Additionally, a resident with an abdominal wall abscess and a physician's order for wound packing four times daily had multiple missed treatments, as indicated by gaps in the treatment administration record. These missed treatments occurred on several dates and times throughout the month, with no documentation to explain the omissions. The deficiencies were identified through record review and staff interviews, which confirmed the expectation for regular monitoring and documentation for these conditions and treatments.
Failure to Accurately Document and Administer Medications
Penalty
Summary
The facility failed to ensure accurate documentation and administration of medications for multiple residents, as evidenced by missing or incorrect entries in the medication administration records (MAR) and controlled drug records. For several residents with diagnoses such as hypothyroidism, diabetes, cellulitis, and chronic obstructive pulmonary disease, the MARs lacked documentation of medication administration on specific dates and times, despite physician orders requiring these medications. In some cases, medications were not available in the facility at the time they were documented as administered, and there was no evidence that emergency drug kits were used to provide the medications. Additionally, for residents prescribed narcotic pain medications, the controlled drug records indicated that the medications were administered, but the corresponding MARs did not reflect these administrations. Interviews with nursing staff confirmed that medications should not be signed as given if they were not available or not administered, and that both the controlled drug record and MAR should be completed when narcotic medications are given. However, these procedures were not consistently followed. The deficiencies were identified through clinical record reviews and staff interviews, which revealed discrepancies between medication orders, pharmacy delivery records, controlled drug logs, and MAR documentation. The facility's own medication administration guidelines require that medications be administered as prescribed and that the MAR be initialed by the person administering the medication, but these standards were not met for several residents during the review period.
Failure to Thoroughly Investigate Alleged Abuse and Follow Facility Policy
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident with intact cognition and multiple diagnoses, including diabetes, anxiety, insomnia, and GERD. The resident reported that a registered nurse was sexually inappropriate during care, including rubbing her arm and leg, nuzzling her neck, and making comments that made her uncomfortable. The resident immediately reported the incident to a CNA, who then informed an LPN. The LPN attempted to gather more information but noted the resident was confused at the time and did not want the nurse to continue providing care. The nurse in question denied the incident and was not suspended during the investigation, contrary to facility policy. The investigation was incomplete as the LPN did not interview other staff or residents in the relevant areas. Additionally, there were prior concerns reported by staff regarding the nurse, including reports of an odor of alcohol, but these were not substantiated at the time. The facility's abuse prevention policy required immediate reporting, documentation, and suspension of staff suspected of abuse, but these steps were not fully followed. The incident and the facility's response were documented as part of a complaint investigation.
Failure to Document and Provide Indwelling Catheter Care as Ordered
Penalty
Summary
The facility failed to provide appropriate care and documentation for residents with indwelling catheters. For one resident with urinary retention, the care plan and physician's orders required catheter care and urine output documentation every shift. However, multiple instances were identified where urine output was not documented on both day and night shifts, and catheter care was not recorded on at least one occasion. Staff interviews confirmed that all physician orders and care plans should be followed, and facility policy requires adherence to these orders. A second resident with neuromuscular dysfunction of the bladder also had a care plan and physician's orders for urine output documentation every shift. Review of the treatment administration record revealed several shifts where urine output was not documented. These findings demonstrate that the facility did not consistently follow physician orders and care plans for catheter care and monitoring for two residents reviewed.
Failure to Document and Complete Ostomy Care as Ordered
Penalty
Summary
The facility failed to ensure proper documentation and completion of ostomy care for a resident with an ostomy status diagnosis. The resident's care plan required staff to administer treatments as ordered, and a physician's order specified that ostomy care should be provided and liquid output recorded every shift. However, review of the treatment administration record for March 2025 revealed multiple instances where documentation of ostomy output was missing on both day and night shifts, and there was at least one instance where ostomy care was not completed as ordered. These omissions were identified during a review of the resident's clinical record and treatment administration records.
Failure to Administer Scheduled Narcotic and Anti-Anxiety Medications as Ordered
Penalty
Summary
A deficiency occurred when a resident with diagnoses including depression, anxiety, and age-related osteoporosis did not receive scheduled doses of Hydrocodone-Acetaminophen for pain and Xanax for anxiety as ordered by the physician. The resident's care plan required administration of these medications as prescribed, with specific orders for both medications to be given every six hours. Review of the medication administration record and controlled drug record for the relevant date showed that neither medication was administered or signed out at the scheduled time. Staff confirmed that all physician orders are expected to be followed, and facility policy requires adherence to physician orders.
Failure to Provide Resident-Centered Activities Program
Penalty
Summary
The facility failed to provide a resident-centered activities program, affecting all 63 residents. Observations and interviews revealed that multiple villas had no activities present, and staff were unable to facilitate activities due to being understaffed and overburdened with other duties. For instance, LPNs and CNAs were often covering multiple units, leaving no time for activities. Additionally, the facility lacked an activities director, and the activities calendar provided by a consulting company was not followed or posted. Residents B, C, D, and E were specifically reviewed for activities. Resident E, with severe cognitive impairment, had a care plan that included reviewing the monthly calendar and inviting family to activities, but this was not implemented. Resident C, interested in reading and watching TV, was supposed to receive leisure materials and a calendar, but these were not provided. Resident B, with severe cognitive impairment, had a care plan to participate in chosen activities, but no activities were offered. Resident D, with impaired cognitive function, was supposed to have a program of activities accommodating his abilities, but this was not provided. The Executive Director acknowledged the absence of an activities director and the failure to implement the activities calendar. The facility had hired a consulting company to provide activities oversight, but the consultant's visits were infrequent and poorly documented. The lack of a structured activities program and insufficient staffing led to the deficiency, as residents were left without meaningful engagement or stimulation.
Staffing Shortages Lead to Deficient Resident Care
Penalty
Summary
The facility failed to ensure adequate staffing levels across its various units, leading to deficiencies in resident care and services. Observations and interviews revealed that the facility's layout, consisting of multiple independent buildings or 'Villas', required staff to move between units, which was not always feasible due to staffing shortages. Each Villa housed up to ten residents, many of whom required assistance with bathing, mobility, and other activities of daily living. However, the facility often had only one staff member per Villa, who was responsible for a wide range of tasks, including personal care, meal preparation, and general cleaning. This staffing inadequacy resulted in delays in care, such as residents having to wait for assistance with transfers or not receiving regular baths. Interviews with staff members, including QMAs, LPNs, and CNAs, highlighted the challenges faced due to insufficient staffing. Staff reported working alone for extended shifts, sometimes covering multiple Villas, which compromised their ability to provide timely and adequate care. For instance, residents requiring two staff members for transfers often had to wait for assistance, and those needing mechanical lifts were sometimes left in bed due to the lack of available staff. Additionally, the absence of an activities director meant that there were no regular planned activities for residents, further impacting their quality of life. The facility's staffing schedule and as-worked schedules from September to December 2024 showed numerous instances of staff shortages, with nurses and aides frequently floating between Villas or working alone. This pattern of understaffing was consistent and widespread, affecting the facility's ability to meet the needs of all residents. The facility's assessment tool indicated a staffing plan that was not adhered to, as evidenced by the frequent vacancies and the need for staff to cover multiple units. This deficiency was linked to complaints and was cross-referenced with failures in providing resident-centered activities and necessary care for activities of daily living.
Failure to Update Care Plan for Resident with Behavioral Issues
Penalty
Summary
The facility failed to update the care plan for a resident with severe cognitive impairment and multiple behavioral issues, including exit-seeking and restlessness. The resident, who had a history of cerebral infarction, dementia, and mobility issues, exhibited behaviors such as yelling, disrobing, and wandering towards exits. Despite these behaviors being documented in progress notes, the resident's care plan was not revised to include interventions for increased confusion, one-on-one supervision, or exit-seeking behaviors. Observations revealed that the resident was left unsupervised in the common area, despite being identified as unsafe to be left alone. Interviews with the resident's family member and facility staff indicated a lack of adequate staffing and supervision. The Director of Nursing had recently returned to work after an absence, and the Executive Director confirmed that only one secured unit was available, which was not where the resident was located. This deficiency was related to a specific complaint, highlighting the facility's failure to ensure the resident's care plan was appropriately updated and implemented.
Deficiencies in Incontinence Care and Bathing for Residents
Penalty
Summary
The facility failed to provide adequate care and assistance for activities of daily living for two residents, specifically in the areas of incontinence care and bathing. Resident D, who has a history of flaccid hemiplegia, muscle weakness, and impaired mobility, was not assisted in a timely manner for toileting and repositioning. On one occasion, Resident D was left in a wheelchair for an extended period without being transferred to bed as scheduled, due to staff shortages. When finally attended to, the resident was found with edema in the lower extremities and dark reddened skin on the buttocks and scrotum, indicating inadequate incontinence care. Additionally, Resident D did not receive the scheduled number of showers, receiving only partial baths on several occasions. Resident E, who has severe cognitive impairment and requires assistance with all personal hygiene activities, was also neglected in terms of bathing and catheter care. The resident was observed with an overfilled urine drainage bag attached to the ankle, which was not addressed by staff despite being visible. The resident's bathing schedule was not adhered to, with only one of eight scheduled showers being provided in December, and the resident had not refused any bathing. Furthermore, Resident E was found on the floor after attempting to dress independently, highlighting the lack of adequate supervision and assistance. The facility's policies on bathing and incontinence care were not followed, as evidenced by the lack of regular checks and changes for incontinence and the failure to provide scheduled showers. The Assistant Director of Nursing confirmed the discrepancies in the bathing records, and the facility's guidelines emphasize the need for regular assistance and documentation, which were not met in these cases. These deficiencies were identified during a complaint investigation, indicating systemic issues in the facility's care practices.
Failure to Ensure Resident Safety from Falls
Penalty
Summary
The facility failed to ensure the safety of residents from falls by not properly utilizing and maintaining motion sensor alarms for two residents. Resident 20, who had a history of falls and was at risk due to conditions such as dementia and osteoporosis, experienced multiple falls. The motion sensor alarm intended to alert staff was often not functioning or not turned on, leading to several incidents where the resident attempted to transfer herself without assistance, resulting in falls. Despite having a care plan that included the use of motion sensor alarms and other safety measures, the alarms were not consistently checked for functionality, and staff did not always respond promptly when alarms were triggered. Resident 5, who was severely cognitively impaired and had a history of falls, also experienced falls due to inadequate supervision and malfunctioning alarms. The resident's care plan included the use of a motion sensor alarm at night to alert staff of any attempts to transfer without assistance. However, there were instances where the alarm did not function properly, and the resident was found on the floor after attempting to use the bathroom unassisted. The facility's failure to ensure the alarms were functioning and to provide adequate supervision contributed to the resident's falls. Interviews with staff revealed inconsistencies in the procedures for checking and maintaining the motion sensor alarms. Staff were responsible for replacing batteries and ensuring alarms were operational, but there were lapses in these duties. The Maintenance Director had recently taken over the responsibility of checking alarms, but this was not consistently done. The facility's policy required daily checks of alarm functionality, but this was not adhered to, leading to repeated incidents of residents falling without timely intervention.
Failure to Update Care Plan for Resident's Refusal to Remove Blankets
Penalty
Summary
The facility failed to ensure that Resident B's care plan was updated in response to her refusal to remove blankets, which contributed to a heat rash. Resident B, diagnosed with dementia, depression, and anxiety, was observed resting in bed with multiple blankets. The care plan, initially dated 6/17/22 and revised on 1/29/24, included interventions for a skin rash but did not address the resident's refusal to remove blankets, which was identified as a contributing factor to her condition. Progress notes indicated that the resident had a rash on her lower back, which was assessed by a nurse practitioner as a possible heat rash due to excessive blankets and a warm room. Despite staff efforts to manage the room temperature and encourage the resident to remove the blankets, the care plan was not revised to reflect these issues. The facility's policy on comprehensive, person-centered care plans was not followed, leading to the deficiency noted in the report.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
