Waters Of Huntingburg, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Huntingburg, Indiana.
- Location
- 1712 Leland Dr, Huntingburg, Indiana 47542
- CMS Provider Number
- 155217
- Inspections on file
- 41
- Latest survey
- March 20, 2026
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Waters Of Huntingburg, The during CMS and state inspections, most recent first.
A resident’s admission MDS assessment was not completed within the required 14-day timeframe. Surveyors found that the admission MDS, dated with the resident’s admission date, remained incomplete upon record review. In an interview, the DON acknowledged that the admission assessment should have been completed. Facility policy titled “Guidelines for Assessments,” provided by an RN, requires that comprehensive admission MDS assessments be completed no later than the 14th calendar day after admission, but this standard was not met, resulting in a cited deficiency.
Surveyors found that a newly admitted resident with paraplegia, chronic pain, and anxiety did not have a required baseline care plan completed and implemented within 48 hours of admission. Record review showed no baseline care plan in the chart, and the DON acknowledged it should have been completed. Facility policy, provided by an RN, requires a baseline care plan for every new admission within 48 hours to guide initial care and communication, but this was not done for this resident.
Two residents did not receive multiple doses of prescribed routine medications after admission because the medications were not available, despite existing physician orders for methadone, Lyrica, and buspirone to treat chronic pain, anxiety, and related conditions. One resident with anxiety and bipolar disorder missed several days of methadone and Lyrica, and another resident with paraplegia and chronic pain went nearly a full day without routine medications, as documented on the MARs. A nurse documented contacting the pharmacy and being told prescriptions were needed, and the DON acknowledged that late admission orders not sent to pharmacy until the evening could delay medication availability until the following evening, even though the facility’s policy requires routine and emergency pharmacy services to be available seven days a week and 24/7, respectively.
Two residents did not have their comprehensive admission MDS assessments completed within the required 14-day timeframe. Surveyors found that both residents’ admission MDS assessments were incomplete on review, despite facility policy requiring completion no later than the 14th calendar day after admission. In an interview, the MDS nurse reported being occupied with a care plan project and acknowledged not completing all due MDS assessments, and the DON provided the written policy confirming the required assessment timelines.
The facility failed to provide necessary treatment and services for two residents with dementia by not adequately monitoring, documenting, or care-planning for their behaviors, and by not maintaining a safe environment. One resident with severe cognitive impairment and psychotic symptoms had multiple aggressive episodes toward staff and other residents, including entering others’ rooms and grabbing them, yet at least one incident was not documented and the behavior care plan was not updated with new interventions. The same resident was found eating an unsecured denture cleaning tablet left in the room on a dementia unit, contrary to staff expectations that such items be stored away from resident access. Another resident with Alzheimer’s disease, anxiety, psychosis, impaired cognition, and decreased visual acuity was observed sitting on the floor in a common area while nearby CNAs did not assist her until an administrator intervened; this behavior was neither care-planned nor documented or assessed in the nurse’s notes, despite existing care plan directives to supervise, assess the environment, and intervene when inappropriate behaviors occur.
Surveyors found that physician-ordered diets were not followed for two residents. One resident with orders for fortified foods and ice cream at lunch and dinner did not receive ice cream, and staff reported that ice cream was not kept in stock and residents with such orders did not receive it. Another resident with Alzheimer’s disease and anorexia, ordered a fortified, finger food-focused diet, was served the same plated meal as others instead of finger foods, and an LPN confirmed that residents with finger food orders typically received the standard meal. The DON acknowledged there was no specific policy on following diet orders, only a general expectation to follow all physician orders.
A resident with polyneuropathy and moderate cognitive impairment did not receive prescribed doses of Lyrica due to an incorrectly entered physician order by staff, resulting in missed and reduced doses without physician authorization. The resident experienced increased pain, and staff confirmed the medication change was not ordered by a physician.
The facility failed to provide adequate staffing on a locked dementia unit, with no licensed nurse stationed and insufficient documentation of resident behaviors. A resident with severe cognitive impairment exhibited aggressive and inappropriate behaviors that were not consistently documented, while another resident was found in another's bed without proper monitoring. The facility's staffing did not meet its own specifications, and there was no policy related to staffing.
The facility failed to monitor and document behaviors for two residents with dementia, leading to deficiencies in care. One resident exhibited inappropriate sexual behaviors without proper documentation, while another was found in another resident's bed, indicating inadequate monitoring of wandering. Despite care plans and physician orders, staff did not consistently document or address these behaviors, contrary to facility policy.
The facility failed to ensure accurate documentation of resident records for three residents, leading to discrepancies in medical records. Neuro checks were recorded by staff members who were not scheduled to work at the time, and there was no documentation to verify their presence. The facility lacked a current policy for accurate documentation.
The facility failed to notify physicians of critical changes in residents' conditions, including elevated blood sugar levels and missed medication doses. Two residents experienced high blood sugar readings without physician notification, and another resident missed doses of Cefepime for a UTI without the physician being informed. The DON acknowledged the lack of documentation and notification, which was against facility policy.
The facility failed to maintain a sanitary environment, as evidenced by missing documentation of UTIs for three residents and improper hand hygiene and glove use during incontinence care for a resident. Staff did not follow the facility's policies on infection control, leading to deficiencies in infection tracking and prevention.
The facility failed to develop and implement comprehensive care plans for two residents, resulting in unaddressed medical needs. One resident lacked care plans for multiple medications despite having physician's orders, while another resident did not have a care plan for smoking/vaping and a recommended NAS diet restriction was not implemented. The DON acknowledged the oversight and the absence of a policy to ensure prompt execution of dietary recommendations.
A facility failed to provide adequate respiratory care for a resident with COPD. The resident received oxygen without proper monitoring of oxygen saturation levels or the amount of oxygen used. The clinical record lacked a care plan for oxygen use, and staff did not correct the resident's incorrect use of the nasal cannula. The facility's policy required regular monitoring, which was not followed, leading to the deficiency.
The facility did not adhere to professional standards for food service safety, as food temperature logs lacked documentation for 12 out of 19 days. The Dietary Manager noted that newer staff might need re-education on recording food temperatures before serving, as per the facility's policy.
The facility failed to administer or document pneumococcal vaccines for three residents. One resident, severely cognitively impaired, did not receive a second dose of the vaccine. Another resident, with moderate cognitive impairment, had a signed consent but no documentation of the vaccine being offered or administered. A third resident, cognitively intact, also had a signed consent but lacked documentation of the vaccine being ordered or administered. The facility's policy required documentation of vaccine administration or refusal, which was not followed.
A resident with cellulitis and bowel incontinence did not receive care according to physician orders and care plans. The facility failed to notify the physician of changes in the resident's condition, administer treatments with proper orders, and update care plans. Stool samples were not consistently obtained, and wound assessments were incomplete, leading to inadequate care management.
A resident with chronic pressure ulcers did not receive adequate care, as the facility failed to follow care plan interventions, place necessary orders, and correctly stage pressure ulcers. Wound treatments were missed, and documentation was lacking. Skin assessments were not conducted as scheduled, and new treatment orders were not initiated. The facility also lacked a current policy for pressure ulcer prevention and treatment.
A resident with severe cognitive impairment experienced two unwitnessed falls, and the facility failed to conduct necessary neuro checks or update the care plan. Despite policies requiring these actions, staff interviews confirmed that the procedures were not followed, leading to a deficiency in supervision and fall prevention.
A resident with a UTI missed four doses of an IV antibiotic due to a failure in medication administration. The MAR showed missed doses of Cefepime, with no nurse notes or physician notification documented. The DON confirmed the lack of documentation and investigation into the missed doses, contrary to the facility's policy.
The facility failed to securely store medications as required, with a narcotic lock box found unlocked on a medication cart in the 100/200 hall. The ADON confirmed it should have been locked, and the DON provided a policy indicating Schedule II drugs must be stored under double locks.
The facility did not ensure daily updates of nurse staffing sheets, as observed on one occasion when the posted information was outdated by several days. The DON stated that the ADON was responsible for daily checks, and the night shift was to update the sheets nightly. However, the staffing information was not current, violating the BIPA Staffing Posting Requirements policy.
A resident with dementia and behavioral disturbances was given psychotropic medications beyond the 14-day limit without proper documentation or assessment. The facility failed to consistently monitor behaviors and follow physician orders, including conducting an EKG for Geodon use. Staff interviews revealed gaps in documentation and adherence to policies, leading to the deficiency.
A resident with dementia exhibited inappropriate sexual behaviors towards others in a locked dementia unit. Despite physician orders for a Climara patch to manage these behaviors, the facility staff did not administer it, and the care plan was not updated. The facility's behavior management policy was not effectively followed, leading to continued inappropriate actions by the resident.
The facility failed to provide proper foot care for five residents, resulting in long, thick, and curling toenails, as well as ingrown toenails. Residents had not seen a podiatrist due to insurance issues or lack of coordination, and clinical records lacked care plans or notes related to foot care.
The facility failed to ensure a comfortable environment for residents, staff, and the public, as evidenced by sticky floors in 11 of 29 observed rooms. The issue was attributed to the reaction of cleaning chemicals with floor wax, and there was no written plan to address it. Progress on replacing the flooring with vinyl was slow due to the workload and daily maintenance needs of the facility staff.
The facility failed to ensure proper perineal care for two residents, resulting in pain and discomfort. One resident experienced aggressive wiping with a dry washcloth, while another resident's labia was wiped inappropriately despite complaints of pain. Both incidents indicate a failure to follow care plans and facility policies.
The facility failed to follow proper infection control practices during perineal care and bed baths for three residents. Staff did not wash hands for the required duration and did not change gloves between dirty and clean tasks, contrary to the facility's hand hygiene and gloves policies.
Failure to Complete Admission MDS Assessment Within Required 14-Day Timeframe
Penalty
Summary
The deficiency involves the facility’s failure to complete a required admission Minimum Data Set (MDS) assessment within the mandated timeframe for one resident. Record review on 3/19/26 at 11:20 A.M. showed that Resident C’s admission MDS assessment, dated with the resident’s admission date, was incomplete, despite the resident having been admitted on that same date. During an interview on 3/20/26 at 1:35 P.M., the DON stated that Resident C’s admission assessment should have been completed. The facility’s policy, “Guidelines for Assessments,” dated 5/29/24 and provided by RN 4 on 3/20/26 at 10:37 A.M., specifies that comprehensive admission MDS assessments must be completed no later than the 14th calendar day of the resident’s admission. The surveyors determined that this requirement was not met for Resident C, resulting in noncompliance with 410 IAC 16.2-3.1-31(d)(1). This citation relates to intakes 2803022 and 2799537.
Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
Surveyors determined that the facility failed to ensure a baseline care plan was developed and implemented within 48 hours of admission for one of three newly admitted residents with pressure ulcers. Record review on 3/19/26 at 11:20 A.M. showed that Resident C, whose diagnoses included paraplegia, chronic pain, and anxiety, was admitted on an identified date but had no baseline care plan in place. During an interview on 3/20/26 at 1:35 P.M., the DON stated that Resident C’s initial baseline care plan should have been completed. On 3/20/26 at 1:08 P.M., RN 4 provided the facility’s policy, dated 3/23/21, which requires that every resident have a baseline care plan completed and implemented within 48 hours of admission to promote continuity of care and communication among staff, increase resident safety, safeguard against adverse events most likely to occur after admission, and ensure the resident and representative receive a written summary of the initial plan of care. This requirement was not met for Resident C. This citation relates to intakes 2803022 and 2799537 and 410 IAC 16.2-3.1-30(a).
Failure to Provide Timely Access to Prescribed Medications After Admission
Penalty
Summary
The deficiency involves the facility’s failure to ensure that pharmaceutical services provided timely access to prescribed routine medications for two residents after admission, resulting in multiple missed doses due to medications being unavailable. One resident with diagnoses including anxiety, bipolar disorder, and panic disorder reported not receiving all prescribed medications since admission. Record review showed this resident had physician orders for methadone hydrochloride for chronic pain and Lyrica for anxiety, but the March 2026 MAR documented that methadone 10 mg (one tablet in the morning) was not administered on two dates, methadone 10 mg (three tablets in the morning) was not administered on two subsequent dates, and Lyrica 150 mg three times daily was not administered for all three doses on two consecutive days, all due to the medications being unavailable. Nursing notes indicated that on one of those days the nurse called the pharmacy about the Lyrica and methadone, and the pharmacy reported they needed prescriptions. Another resident with paraplegia, chronic pain, and anxiety reported going nearly a full day without any routine medications following admission. Record review showed this resident had physician orders for buspirone 5 mg twice daily and Lyrica 150 mg three times daily, but the February 2026 MAR documented that buspirone was not administered for one evening and the following morning dose, and Lyrica was not administered for one night dose and all three doses the following day, again due to the medications being unavailable. In an interview, the DON stated that if residents are admitted later in the day and physician orders are not sent to the pharmacy before the evening of admission, residents may not receive their medications until the following evening, and that if medications are not available, staff should obtain them from the emergency drug kit if available. The facility’s pharmacy services policy indicated that the pharmacy is to provide routine and timely pharmacy service seven days per week and emergency pharmacy service 24 hours per day, seven days per week.
Failure to Complete Admission MDS Assessments Within Required Timeframe
Penalty
Summary
The deficiency involves the facility’s failure to complete required admission Minimum Data Set (MDS) assessments within the mandated 14-day timeframe for two residents. Record review on 1/23/26 at 10:00 A.M. showed that Resident C’s admission MDS assessment, dated with an admission date documented in the record, was incomplete beyond the required completion window. Similarly, record review on 1/23/26 at 10:40 A.M. showed that Resident D’s admission MDS assessment, also dated with an admission date documented in the record, was incomplete and not finished within 14 calendar days of admission. During an interview on 1/23/26 at 11:55 A.M., the MDS nurse stated she had been busy working on a care plan project and had not completed all due MDS assessments. The DON provided a policy titled “Guidelines for Assessments,” dated 5/29/24, which states that comprehensive admission MDS assessments must be completed no later than the 14th calendar day of the resident’s admission, confirming that the incomplete assessments for these two residents were not done timely as required. No additional clinical history or specific medical conditions for the residents were documented in the report beyond their admission status and the timing and completeness of their MDS assessments.
Failure to Monitor, Document, and Address Dementia-Related Behaviors and Environmental Safety
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary treatment and services for residents with dementia, specifically related to behavior monitoring, care planning, documentation, environmental safety, and staff response. One resident with dementia, mood disturbance, and major depressive disorder with psychotic symptoms had a history of severe cognitive impairment and behavioral symptoms, including aggression toward staff and other residents. Documented incidents included lunging and swinging at staff, verbal aggression, and attempts to grab another resident. Additional facility-reported incidents described the resident making contact with another resident’s neck in a common area and entering another resident’s room and grabbing her forearm, as well as an episode where the resident was found in another resident’s room with both hands firmly gripping her wrist while yelling delusional statements. Despite these events, there was no nursing documentation in the record for at least one of the reported incidents, and the care plan, which addressed behavioral symptoms related to dementia, was not revised with new or updated interventions following the new or escalating behaviors. The same resident was also found eating a denture cleaning tablet (Polydent) after it had been left in his room on the dementia unit. Staff interviews confirmed that denture tablets and other personal hygiene items should not be left in resident rooms on a dementia unit and should instead be stored away from resident access. The incident required consultation with poison control and monitoring for adverse symptoms, but the underlying issue was that the denture tablet had been left unsecured in the room of a cognitively impaired resident. The facility’s own behavior management policy required investigation of behaviors to determine root cause and daily monitoring and documentation of target behaviors, but the record lacked documentation of at least one behavior incident and did not show that the care plan had been updated in response to the resident’s new or increased behaviors. A second resident with Alzheimer’s disease, anxiety, unspecified psychosis, impaired cognition, and decreased visual acuity was observed sitting on the floor in a common area in front of the nurse’s station while two CNAs were nearby and did not assist her until the facility administrator intervened and helped her to a couch. Staff later reported that this resident sometimes sits herself on the floor. The resident’s care plan addressed altered communication, risk for injury and/or social isolation due to decreased visual acuity, impaired cognition, and behavioral symptoms, with interventions such as assessing and modifying the environment for safety, cueing, reorienting, supervising as needed, and intervening when inappropriate behavior is observed. However, there was no specific care plan addressing the resident’s behavior of sitting on the floor, and there was no nursing documentation, observation, or assessment in the progress notes regarding this floor-sitting episode, despite staff acknowledging that a resident found on the floor should be assessed and documented and that staff should consider the reasons for such behavior.
Failure to Follow Physician-Ordered Therapeutic Diets
Penalty
Summary
The deficiency involves the facility’s failure to follow physician-prescribed diets for two residents reviewed for dietary services. For one resident with physician orders for fortified foods with each meal and ice cream with lunch and dinner, nursing staff reported that the facility did not keep ice cream in stock and that residents with orders for ice cream did not receive it. During a mealtime observation, this resident’s lunch tray did not include ice cream, despite the active order. Staff interviews confirmed that ice cream was only available if staff purchased it themselves and that residents with ice cream orders were not provided ice cream as ordered. Another resident, diagnosed with Alzheimer’s disease and anorexia, had physician orders for fortified foods with each meal and a finger food-focused diet. During a mealtime observation, this resident received the same meal as other residents, consisting of fish, noodles, cooked vegetables, and a roll, rather than finger foods. The resident used a fork to poke at the food and took a bite, but the ordered finger food-focused diet was not provided. An LPN stated that residents with orders for finger foods usually did not receive them and instead were given the same meal as everyone else. The DON reported there was no policy specific to following diet orders, but stated it was the policy to follow all physician orders.
Failure to Accurately Transcribe and Administer Routine Medication Orders
Penalty
Summary
A deficiency occurred when the facility failed to ensure the accurate receiving and administration of routine medications for a resident with a diagnosis including unspecified polyneuropathy and moderate cognitive impairment. The resident had physician's orders for Lyrica at specific dosages and times, but due to an incorrectly entered order by facility staff, the resident experienced an interruption in their routine medication and an unprescribed dosage reduction. The medication administration record showed missed doses of Lyrica at various times, and progress notes documented that the resident did not receive the medication as ordered, with pharmacy communication issues and delays in medication delivery. The resident reported increased pain in their legs and feet during the period of reduced medication, and staff confirmed that the change in Lyrica dosage was made without physician authorization. Interviews with nursing staff revealed that the original physician order was entered incorrectly into the electronic record, resulting in the resident receiving less medication than prescribed. Facility policy required that all physician orders be implemented and followed as received, but this was not adhered to in this instance.
Inadequate Staffing and Documentation on Dementia Unit
Penalty
Summary
The facility failed to ensure adequate staffing on the Memory Springs locked dementia unit, as observed during a survey. Over two days, a licensed nurse was not stationed on the unit, and the monitoring and documentation of resident behaviors were not completed over a 30-day review period. The staffing patterns did not align with the facility's Alzheimer's/Dementia Special Care Unit staffing specifications. Observations revealed that the unit was staffed with only one CNA and one activity assistant, with the nurse floating from another part of the building. The daily schedule confirmed the absence of nursing staff and QMAs on the unit during various shifts. Resident C, who has severe cognitive impairment and a history of wandering, exhibited behaviors such as physical aggression and public sexual acts, which were not consistently documented in the nurse's notes. Despite physician orders for behavioral monitoring every shift, there were gaps in documentation, and a facility investigation revealed that inappropriate behaviors were not recorded on several occasions. The lack of adequate staffing and documentation compromised the monitoring of Resident C's behaviors. Resident D, diagnosed with severe cognitive impairment and behavioral disturbances, was found in another resident's bed after being unaccounted for. Despite physician orders for behavioral monitoring, there was no documentation of Resident D's behavior on the night of the incident or of their sadness on a subsequent date. Interviews with staff indicated that behaviors should be documented in the clinical record, but this was not consistently done. The facility lacked a policy related to staffing, contributing to the deficiencies observed.
Failure to Monitor and Document Dementia-Related Behaviors
Penalty
Summary
The facility failed to provide necessary treatment and services for two residents diagnosed with dementia, leading to deficiencies in monitoring and documentation of resident behaviors. Resident C, diagnosed with Alzheimer's disease and vascular dementia, exhibited severe cognitive impairment and daily wandering. Despite physician orders for behavioral monitoring and a care plan addressing inappropriate sexual comments, there was a lack of documentation in the nurse's notes regarding Resident C's sexually inappropriate behaviors on multiple occasions. Additionally, the facility's investigation revealed that staff were aware of these behaviors, yet they were not consistently documented or addressed in the resident's clinical record. Resident D, also diagnosed with dementia and severe cognitive impairment, was found in another resident's bed, indicating a failure to monitor wandering behaviors effectively. Although Resident D's care plan included monitoring for behavioral symptoms and mood decline, there was no documentation of the resident's behavior on the night of the incident or of the resident's sadness and tearfulness on a subsequent date. The facility's policy on handling behavioral emergencies emphasized the need for documentation and monitoring of interventions, which was not adhered to in these cases.
Inaccurate Documentation of Resident Records
Penalty
Summary
The facility failed to ensure accurate documentation of resident records for three residents, leading to discrepancies in the medical records. For Resident B, the neurological evaluation flow sheet lacked staff initials for neuro checks conducted after an unwitnessed fall, and all entries appeared to be in the same handwriting. Resident C's records showed that the Assistant Director of Nursing (ADON) and the MDS Coordinator had initialed neuro checks at times when they were not scheduled to work, according to the facility's work schedules. Similarly, Resident D's records indicated that the ADON and MDS Coordinator had initialed neuro checks outside of their scheduled shifts, with no documentation to support their presence in the facility at those times. During interviews, the MDS Coordinator mentioned that they sometimes visited the facility outside of scheduled hours, which might explain the discrepancies. The ADON admitted that Qualified Medication Aides (QMAs) sometimes collected vital signs, which were later recorded by the ADON. However, there was no documentation to verify these claims. The facility lacked a current policy for accurate documentation, although a Nurse Job Description was provided, which outlined the requirement for signing and dating all entries in residents' medical records.
Failure to Notify Physician of Critical Changes
Penalty
Summary
The facility failed to notify the physician regarding the need to alter treatment for two residents who were reviewed for unnecessary medications. For Resident 30, the facility did not notify the physician of elevated blood sugar readings and significant weight changes. The resident's clinical record showed multiple instances of elevated blood sugar levels, some exceeding 500 mg/dL, and significant weight fluctuations, yet there was no documentation of physician notification. The Director of Nursing (DON) acknowledged that the staff should have notified the physician when blood sugar levels exceeded 450 mg/dL and when there were significant weight changes. Resident L also experienced elevated blood sugar levels, with readings frequently exceeding 400 mg/dL, yet the facility failed to notify the physician. The resident's clinical record lacked documentation of blood sugar parameters for physician notification, and the Medication Administration Record (MAR) did not indicate that the physician was informed of the high blood sugar levels. The Assistant Director of Nursing (ADON) confirmed that staff should notify the physician if blood sugar levels exceed 400 mg/dL and document the notification in progress notes. Additionally, the facility failed to notify the physician of missed doses of Cefepime for Resident F, who was being treated for a urinary tract infection. The Medication Administration Record indicated that several doses were not administered as ordered, and there was no documentation of physician notification or investigation into the missed doses. The DON confirmed that the physician had not been notified of the missed doses, which was against the facility's policy for medication administration errors.
Inadequate Infection Control and Documentation
Penalty
Summary
The facility failed to maintain a safe, sanitary, and comfortable environment to prevent the development and transmission of infections. During a review of the facility's infection tracking binder for July, August, and September 2024, it was found that urinary tract infections (UTIs) for three residents were not documented. Resident K had a UTI in July 2024, Resident J in August 2024, and Resident G in both August and September 2024. The Infection Preventionist admitted that these infections were not tracked due to an inability to complete the documentation, which should have included the resident's name, date, and type of infection. In a separate observation, the facility staff failed to adhere to proper hand hygiene and glove use protocols during incontinence care for Resident M. CNA 7 and RN 5 were observed performing care with inadequate handwashing times and improper glove use. CNA 7 touched various items with gloved hands before and after performing care, failed to change gloves or perform hand hygiene between tasks, and used soiled gloves to touch clean items. RN 5 also did not follow proper hand hygiene protocols, washing hands for only 6 seconds. The facility's policies on perineal care, glove use, and hand hygiene were not followed during this care episode. The facility's Infection Prevention and Control policy, which includes a surveillance system to identify and record infections, was not effectively implemented. The policy requires identifying possible communicable diseases before they spread and maintaining a recording system for infection incidents. However, the facility failed to track and document infections accurately, as evidenced by the missing UTI records. This deficiency was identified in relation to a specific complaint, indicating a lapse in the facility's infection control practices.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for two residents, leading to deficiencies in addressing their medical needs. Resident 18, who has diagnoses including diabetes mellitus type II, generalized anxiety disorder, borderline personality disorder, and bipolar disorder, was found to lack care plans for antianxiety, antipsychotic, antiplatelet, and diabetes medications. Despite having physician's orders for medications such as Latuda, Buspar, Aspirin, Jardiance, and Metformin, the clinical record did not include corresponding care plans to manage these conditions effectively. Similarly, Resident 30, with diagnoses of chronic obstructive pulmonary disease, atherosclerotic heart disease, hypertension, and nicotine dependence, lacked a care plan for smoking/vaping and a no added salt (NAS) diet restriction. Although a dietary progress note recommended adding an NAS restriction due to significant weight gain, this order was not implemented. The Director of Nursing acknowledged the oversight and indicated that the process for implementing dietary recommendations was not followed, as there was no policy in place to ensure such orders were executed promptly.
Failure to Provide Adequate Respiratory Care
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for a resident with chronic obstructive pulmonary disease (COPD). The resident was observed receiving oxygen via nasal cannula at 3 liters per minute (LPM) without proper monitoring of oxygen saturation (O2 sat) levels or the frequency and amount of oxygen used. The clinical record lacked a comprehensive care plan for oxygen use, and there were no parameters set for staff to determine the accurate LPM needed. Observations showed the resident wearing the nasal cannula incorrectly, and staff did not address or correct this issue. The Director of Nursing (DON) indicated that there should have been a care plan and orders for staff to check the resident's O2 sats on room air every shift and as needed for shortness of breath. However, the resident's vitals, including O2 sat, were not consistently checked every shift, and the reason for discontinuation was unknown. The facility's policy required oxygen saturation levels to be measured per physician order and documented every shift, but this was not adhered to, leading to the deficiency.
Failure to Document Food Temperatures
Penalty
Summary
The facility failed to serve food in accordance with professional standards for food service safety, as observed during a survey. The food temperature logs for the period from 9/5/24 to 9/23/24 were reviewed, revealing that food temperatures were not documented for 12 out of 19 days. Specifically, there were no recorded temperatures for dinner on several dates, and on two occasions, no temperatures were recorded for breakfast, lunch, or dinner. The Dietary Manager acknowledged that if temperatures were not documented, it likely meant they were not taken, attributing this lapse to newer staff who may require re-education on the importance of recording food temperatures before serving. The facility's Monitoring Food Temperatures Policy, provided by the DON, mandates that food temperatures be monitored daily to prevent foodborne illness. It specifies that temperatures for all hot and cold foods should be recorded on the Food Temperature Log before serving. Hot foods must be at least 135 degrees Fahrenheit, and cold foods should be 41 degrees Fahrenheit or below. The failure to adhere to this policy was identified as a deficiency during the survey.
Failure to Document and Administer Pneumococcal Vaccines
Penalty
Summary
The facility failed to administer or properly document the pneumococcal immunization for three residents. Resident 20, who was severely cognitively impaired, had received the Prevnar-13 vaccine but lacked documentation for a second dose. The Director of Nursing acknowledged that Resident 20 should have received a second pneumococcal vaccine. Resident 5, with moderate cognitive impairment, had a signed consent form for the pneumococcal vaccine, but there was no documentation of the vaccine being offered, ordered, administered, or refused since the consent was signed. Similarly, Resident 4, who was cognitively intact, had a signed consent form, but the clinical record lacked documentation of the vaccine being ordered, administered, or refused. The facility's policy on pneumococcal vaccination was undated and stated the intent to minimize the risk of residents acquiring or transmitting pneumococcal pneumonia. It required documentation of information provided to residents or their representatives regarding the risks and benefits of the vaccine, as well as documentation of administration, refusal, or medical contraindication. However, the facility failed to adhere to this policy, as evidenced by the lack of documentation in the clinical records of the three residents reviewed.
Failure to Follow Physician Orders and Update Care Plans
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards and a comprehensive person-centered care plan for a resident with bowel and bladder incontinence. The resident, diagnosed with cellulitis of the right lower limb, was not given care as per physician orders, and the physician was not notified of changes in the resident's condition. Treatments were administered without proper orders, care plans were not updated, and wound assessments were not completed. The resident's clinical record indicated a lack of cognitive impairment, frequent bowel incontinence, and a need for extensive assistance with toileting. Physician orders for the resident included stool occult tests every 12 hours for infection control, which were not consistently obtained or documented. The resident experienced an adverse reaction to an antibiotic, resulting in loose stools and skin maceration. Despite this, the facility failed to notify the physician about the inability to obtain stool samples and did not update the care plan to reflect the resident's new skin issues. The Medication Administration Record (MAR) showed multiple instances where stool samples were not obtained, and the clinical record lacked documentation of stool occult test results or lab submissions. Interviews with facility staff revealed a lack of communication and coordination in managing the resident's care. Certified Nurse Aide (CNA) 9 was unaware of the need for stool tests, while Registered Nurse (RN) 3 acknowledged the issue but noted that the resident was no longer experiencing diarrhea. The Director of Nursing (DON) admitted that the physician should have been notified about the missed stool samples and that there was no current facility policy related to wound management. The DON also noted that the resident's skin integrity care plans should have been updated upon returning from the hospital with new skin issues.
Deficient Pressure Ulcer Care in LTC Facility
Penalty
Summary
The facility failed to provide adequate care for a resident with chronic pressure ulcers, leading to deficiencies in wound management and prevention of new ulcers. The resident, who had diagnoses including paraplegia and diabetes mellitus, required extensive assistance with mobility and had two stage 4 pressure ulcers. The care plan interventions were not followed, as orders for wound care were not placed, pressure ulcers were not staged correctly, and dressings were not completed as ordered. The resident's Medication Administration Record (MAR) indicated multiple instances where wound treatments were not performed, and there was a lack of documentation explaining these omissions. Skin assessments were not conducted as scheduled, and the clinical record lacked documentation of wound assessments for significant periods. Additionally, new treatment orders for pressure ulcers were not placed or initiated, and the facility did not have a current policy for the prevention and treatment of pressure ulcers. The Director of Nursing (DON) acknowledged that wound assessments were not part of the clinical records and had not been documented appropriately. The DON also noted that the right buttock pressure ulcer was mis-staged, and wound evaluations were not conducted weekly as required. Furthermore, the facility lacked Interdisciplinary Team (IDT) meetings or notes related to the resident's pressure ulcers, and there was only one care plan in place for multiple pressure ulcer areas, which should have been separated.
Failure to Prevent Falls and Update Care Plans
Penalty
Summary
The facility failed to provide adequate supervision and prevent falls for a resident identified as being at risk for accidents. The resident, who had severe cognitive impairment and required supervision for mobility and toileting, experienced two unwitnessed falls. After these falls, the facility did not complete necessary neurological assessments or update the resident's care plan. Additionally, the fall risk assessments were either not completed or were done incorrectly, failing to account for the resident's use of psychotropic medication. Interviews with facility staff, including a Registered Nurse and the Director of Nursing, confirmed that the required procedures following a fall, such as neuro checks and care plan updates, were not followed. The facility's policies clearly stated that neuro checks should be conducted after any unwitnessed fall and that each fall should prompt a new care plan intervention. However, these protocols were not adhered to, leading to the identified deficiency.
Failure to Administer IV Antibiotic for UTI
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically in the administration of an intravenous antibiotic for a urinary tract infection (UTI). The resident, who had a diagnosis of obstructive uropathy and an indwelling catheter, was prescribed Cefepime to be administered intravenously every six hours for seven days. However, the Medication Administration Record (MAR) indicated that four doses of Cefepime were missed on specific dates and times, with no accompanying nurse notes to explain the omissions. Furthermore, the clinical record lacked documentation of physician notification regarding the missed doses, and there was no investigation conducted to determine the cause of the medication errors. The Director of Nursing (DON) confirmed the absence of nurse notes and physician notification, as well as the lack of an investigation into the missed doses. The facility's Medication Administration Errors policy requires that upon identification of a medication error, a report form should be completed, the physician and family notified, and an investigation conducted, none of which were done in this case.
Medication Storage Deficiency
Penalty
Summary
The facility failed to maintain safe and secure storage of medications, specifically for one of the two medication carts observed. During an observation, it was noted that the narcotic lock box on the medication cart located in the 100/200 hall was unlocked. The Assistant Director of Nursing (ADON) acknowledged that the lock box should have been secured. The Director of Nursing (DON) later provided a current Medication Storage in the Facility policy, dated February 2017, which stated that all drugs classified as Schedule II of the Controlled Substances Act must be stored under double locks.
Failure to Update Nurse Staffing Sheets Daily
Penalty
Summary
The facility failed to ensure that the posted nurse staffing sheets were updated and contained the correct information daily. On September 24, the posted nurse staffing information was observed to be outdated, displaying the date of September 19. During an interview, the Director of Nursing (DON) indicated that the Assistant Director of Nursing (ADON) was responsible for filling out and checking the posted nurse staffing form daily, with the night shift tasked with updating it each night. However, the form was not current as required. The facility's policy, as per the Benefits Improvement and Protection Act of 2000 (BIPA) Staffing Posting Requirements, mandates that skilled nursing facilities (SNFs) and nursing facilities (NFs) must post the facility-specific shift schedule daily at the beginning of each shift, including the current date.
Failure to Monitor and Document Psychotropic Medication Use
Penalty
Summary
The facility failed to adequately monitor and manage a resident's drug regimen, leading to the administration of psychotropic medications beyond the recommended 14-day period without documented rationale. The resident, who had a history of unspecified dementia with behavioral disturbances, depression, and other conditions, was given as-needed psychotropic medications without proper documentation or assessment to justify their continued use. The facility's records showed that behavior monitoring was inconsistent, with several instances where behavior monitoring was marked as 'n' or 'NA' or left blank, indicating a lack of proper documentation and follow-up on the resident's condition. The resident's care plans included the use of psychotropic medications to manage symptoms such as psychosis, depression, and anxiety. However, the facility did not consistently follow through with behavior management techniques or document the effectiveness of interventions before administering medications. The EMAR for several months showed gaps in behavior monitoring, and the facility's policy required that PRN orders for psychotropic drugs be limited to 14 days unless a physician documented a rationale for extending the medication. This policy was not adhered to, as evidenced by the lack of documentation supporting the continued use of these medications. Additionally, the facility failed to conduct an EKG as ordered for the resident due to the use of Geodon, an antipsychotic medication. The EKG was not performed until the resident was sent out for behaviors, which was not in compliance with the physician's orders. Interviews with staff, including the ADON and RN, revealed that there was no assessment or documentation to justify the continuation of psychotropic drugs beyond 14 days, and behavior monitoring was not consistently recorded in the EMAR. This lack of adherence to policies and procedures contributed to the deficiency identified in the report.
Failure to Implement Dementia Care Plan and Physician Orders
Penalty
Summary
The facility failed to provide necessary treatment and services for a resident diagnosed with dementia, leading to inappropriate sexual behaviors. Resident B, who had severe cognitive impairment and required supervision, exhibited inappropriate sexual behaviors towards other residents in a locked dementia unit. Despite having a care plan that included interventions for sexual behaviors, the facility did not update the plan or implement physician orders following incidents involving Resident B and other residents. On two separate occasions, Resident B was involved in incidents of inappropriate touching with other residents. The first incident involved Resident B kissing and making contact with another resident's breast, while the second incident involved inappropriate touching of another resident. Although a Climara patch was ordered to manage Resident B's behaviors, it was not administered as directed. The facility's staff chose not to apply the patch, and there was no documentation of an alternate plan or lasting interventions to prevent further incidents. The facility's investigation revealed that the nursing staff did not implement the ordered Climara patch and instead moved one of the involved residents to another unit. The facility's policy on behavior management was not effectively followed, as there was no evidence of clinical and psychosocial interventions being determined to address Resident B's needs. The lack of action and failure to follow physician orders contributed to the continuation of inappropriate behaviors by Resident B.
Failure to Provide Proper Foot Care
Penalty
Summary
The facility failed to provide proper foot care for five residents, resulting in long, thick, and curling toenails, as well as ingrown toenails. Resident B had been trying to see a podiatrist for three months due to sore and ingrown toenails but was told there was an issue with her insurance. Her clinical records lacked any care plans or notes related to foot care, and she had not seen a podiatrist. The Administrator later indicated that the facility did not deny services based on insurance issues and would investigate further. Resident C had never seen a podiatrist since being in the facility and had long, thick toenails that were starting to curl. He was told that insurance would not cover the service. His clinical records also lacked any care plans or notes related to foot care. The Administrator was unsure if Resident C was diabetic and mentioned that the podiatrist visited every 61 days, which might coincide with Resident C's dialysis schedule. Resident D had toenails curled over every toe, and his family member was cut by one of his nails. His clinical records lacked any care plans or notes related to foot care. Resident F had long toenails, and the CNA was unaware of their condition. His clinical records indicated that his toenails were trimmed once but lacked any further notes on foot care. Resident E had thick, long, yellow, and crusty toenails. Although he was on hospice, there was confusion about whether ancillary services like podiatry were still provided. The podiatrist had been requested not to see Resident E due to her being on hospice, despite her being on the list for the visit.
Facility Fails to Ensure Comfortable Environment Due to Sticky Floors
Penalty
Summary
The facility failed to ensure a comfortable environment for residents, staff, and the public, as evidenced by sticky floors in 11 of 29 observed rooms. The issue was first noted in resident council meeting minutes on 8/2/23, and subsequent observations on 2/1/24 confirmed the persistence of sticky floors in multiple rooms. Interviews with the Housekeeping Supervisor, an LPN, and the Activities Assistant revealed that the stickiness was attributed to the reaction of cleaning chemicals with the floor wax, exacerbated by heat and humidity. The Housekeeping Supervisor acknowledged the difficulty in removing old wax from the original tile floors, which contributed to the problem. Despite these ongoing issues, there was no written plan to address the floor stickiness, and progress on replacing the flooring with vinyl was slow due to the workload and daily maintenance needs of the facility staff responsible for the task. Residents and staff consistently reported the discomfort caused by the sticky floors. The Activities Director had communicated the resident council's complaints to housekeeping and the Administrator, who downplayed the issue by attributing it to cleaning chemicals. However, the Administrator and Maintenance Supervisor admitted that there was no formal plan or estimated completion date for resolving the floor stickiness. The facility staff, including the Administrator, Maintenance Supervisor, and Housekeeping Supervisor, were working on laying new vinyl flooring in some rooms, but the progress was hindered by other maintenance responsibilities. This deficiency was related to Complaint IN00422428.
Failure to Provide Proper Perineal Care
Penalty
Summary
The facility failed to ensure dependent residents received the necessary services to maintain good grooming and personal hygiene for two residents. In the first instance, a CNA continued to wipe a resident during perineal care after the resident complained of pain. The resident, who had a history of morbid obesity, asthma, depression, spinal stenosis, and hypertension, indicated that the CNA had previously used a dry washcloth aggressively, causing pain. Despite the resident's complaints, the CNA continued the care, leading to further discomfort. The resident's clinical records and care plan indicated the need for pericare after every incontinent episode and assistance with toileting, but these were not adequately followed, resulting in the resident experiencing pain and discomfort during care. In the second instance, another CNA did not wipe appropriately for a resident with severe cognitive impairment and frequent incontinence of the bladder. During incontinence care, the CNA wiped the resident's labia in a manner that caused pain, and despite the resident's complaints, the CNA continued to wipe the area, which was observed to be red. The resident's care plan included providing proper hygiene and infection control, but this was not adhered to, leading to the resident experiencing pain and discomfort. The facility's policy indicated that staff should stop immediately and notify the nurse if a resident complained of pain during care, but this protocol was not followed in both cases.
Inadequate Infection Control Practices During Resident Care
Penalty
Summary
The facility failed to ensure proper infection control practices during the provision of perineal care and bed baths for three residents. Specifically, staff members did not wash their hands for the recommended 20-30 seconds, and they failed to change gloves between dirty and clean tasks. For instance, during incontinence care for Resident E, CNA 2 and CNA 4 did not wash their hands adequately and used the same gloves to touch various surfaces and perform different tasks. Similarly, during incontinence care for Resident D, CNA 2 did not wash hands or sanitize before putting on new gloves after removing dirty ones. Additionally, during a bed bath for Resident B, both CNAs did not change gloves after touching potentially contaminated surfaces and did not wash their hands for the required duration. The facility's current hand hygiene policy requires a 20-second lather with soap, and the gloves policy mandates hand hygiene between the removal of used gloves and the application of new ones. However, these protocols were not followed, as evidenced by the observations of the CNAs' practices. The failure to adhere to these infection control practices was confirmed through interviews with staff members, who acknowledged the correct procedures but did not follow them during care. This non-compliance with established infection control policies poses a risk of infection to the residents.
Latest citations in Indiana
Surveyors observed that dietary staff repeatedly worked in kitchen and meal service areas with uncovered facial hair, despite facility policy and state sanitation requirements mandating effective hair restraints. Two dietary aides with short beards or mustaches were seen walking through food preparation areas, taking food temperatures, handling food, and plating meals at steamtables in dining rooms without any facial hair coverings, while the current policy required all hair, including facial hair, to be restrained to prevent contamination.
The facility failed to consistently provide and document required bed-hold policy notices when several residents were transferred to the hospital. In multiple cases, residents with dementia, psychotic disorders, COPD, chronic respiratory failure, altered mental status, and cerebral infarction were sent out for acute changes in condition, and while transfer notes reflected physician and family notifications, they lacked documentation that the bed-hold policy was discussed with the resident or responsible party. Notices of Transfer or Discharge often indicated a copy of the bed-hold policy was sent with the resident, but the records did not show signed and dated acknowledgment by the resident or appropriate representative, including in situations where a resident had moderate cognitive impairment, short-term memory issues, or a documented need for a proxy and a financial POA authorizing an agent for health care decisions.
Surveyors found that the facility failed to provide trauma‑informed and culturally competent care by not incorporating two residents’ extensive trauma histories and specific behavioral triggers into their care plans. One resident with documented homelessness, polysubstance abuse, severe accidents with multiple fractures, viral encephalitis with coma, physical and sexual abuse, loss of family contact, and a past suicide attempt had multiple behavior‑focused care plans that referenced identifying triggers but listed none and did not mention their physical, sexual, medical, or psychosocial trauma. Another resident with TBI from being struck by a truck, an 11‑month coma, long‑term state hospital residence, alleged shooting of a parent, and diagnoses including intermittent explosive disorder and borderline personality disorder had a PASRR identifying a specific trigger and notes of inappropriate sexual behavior, yet their care plans omitted these traumatic events, the identified trigger, and the sexual behavior. Staff interviews confirmed that residents were screened for trauma, but the trauma histories and triggers were not reflected in the individualized plans of care.
A resident with schizophrenia, post‑stroke hemiparesis, and mild cognitive impairment expressed feeling down and wanting to kill himself, but staff did not document asking about a specific plan, did not notify the physician or psychiatric NP as expected, and did not develop or update a care plan addressing depression or suicidal ideation. The SSD documented offering support and initiating 15‑minute checks once, but there was no further follow‑up or documentation of interventions after subsequent suicidal statements made in a care plan meeting with the resident’s father. The DON and Administrator reported that facility policy requires immediate notification of key staff, assessment for a plan and means of self‑harm, and thorough documentation, which were not carried out or reflected in the medical record for this resident.
A resident with schizophrenia, post-stroke hemiparesis, and mild cognitive impairment verbalized suicidal ideation, but the care plan did not address depression or suicidal thoughts, and required assessments and services were not accurately or timely documented. An SSD note recorded the resident saying he wanted to kill himself and referenced 15‑minute checks and a care plan update, yet the active care plan lacked depression/suicidal ideation interventions. Multiple late-entry Social Services notes were later added, describing follow-up visits and the resident denying suicidal ideation, but the SSD later reported she did not typically ask about a suicide plan and did not personally provide individual follow-up visits as described. These practices conflicted with the facility’s policy requiring factual, first-hand, and timely documentation of assessments and services.
A resident was observed with an Albuterol inhaler on an overbed table and later reported keeping the inhaler in a nightstand drawer, with no staff present during these observations. Record review showed the resident had no cognitive impairment on the admission MDS but lacked any documented self-medication administration assessment. The DON acknowledged that the required assessment had not been completed, despite facility policy requiring staff and the practitioner to evaluate each resident’s mental and physical abilities before allowing self-administration of medications.
Surveyors found that the facility submitted inaccurate direct care staffing data to CMS through the PBJ system over multiple days in a quarter. CASPER reports showed apparent gaps in 24-hour licensed nurse coverage, low weekend staffing, and a 1-star staffing rating, while internal staffing sheets documented that licensed nurses were present and the facility was fully staffed on those days. The Administrator reported that the discrepancies were due to PBJ data entry errors, despite a facility policy requiring all PBJ entries to be accurate, auditable, and verifiable against payroll, invoices, or contracts.
Surveyors found that the facility did not provide or document required written transfer/discharge notices and bed-hold policy information for four residents who were sent to the hospital, including individuals with conditions such as dementia, CHF, chronic respiratory failure, and CKD. In each case, progress notes showed that the resident was transferred for acute issues, but the clinical records lacked evidence that written notices were given to the residents or their representatives, and in one case lacked documentation that required information was sent to the receiving provider. Facility leadership, including the ADON, DON, and Administrator, acknowledged that the records did not contain the required documentation, despite a written policy requiring such notices and information exchange.
A resident with Alzheimer’s disease and depression, previously on an antidepressant, exhibited intermittent refusals of medications and care, occasional yelling at staff, and reports of unusual perceptions, such as believing men were in or near her room. Nursing notes over several months documented these refusals and complaints but did not show that the behaviors were evaluated or recorded as dangerous, non-redirectable, or causing significant distress, nor did they document specific non-pharmacological interventions attempted or their outcomes. Despite this, a psychiatric NP later added new diagnoses of schizoaffective disorder, borderline personality disorder, and delusional disorder and ordered an antipsychotic (Seroquel) without a comprehensive evaluation in the record to support these diagnoses. The facility’s psychotropic medication policy, which requires identification and documentation of target behaviors, use of nonpharmacological interventions, and ongoing behavior monitoring, was not followed for this resident.
The facility failed to keep PASARR Level I screenings accurate and current for three residents when new mental health diagnoses and psychoactive medications were initiated. One resident’s PASARR omitted a PTSD diagnosis and an added antidepressant, despite documentation of PTSD on the MDS and care plan and a physician order for Pristiq. Another resident’s PASARR listed only depression and dementia, even after additional diagnoses such as borderline personality disorder, delusional disorder, and schizoaffective disorder were added and an antipsychotic (quetiapine) was ordered, with the MDS later reflecting psychotic disorder, schizophrenia, and depression with antipsychotic and antidepressant use. A third resident’s PASARR did not include a depression diagnosis or newly ordered escitalopram and lorazepam, although the admission MDS documented depression with antianxiety and antidepressant use. These omissions occurred despite facility policy requiring a new Level I review after significant mental status changes, including new mental health diagnoses or new psychotropic medications.
Uncovered Facial Hair During Food Preparation and Meal Service
Penalty
Summary
The deficiency involves the facility’s failure to ensure that food was served in a sanitary and safe manner in accordance with professional standards and facility policy during multiple kitchen and meal service observations. During an initial kitchen observation, two dietary aides were seen walking through the kitchen food preparation area with uncovered facial hair. One aide had facial hair above and below the lip and along the jaw line, approximately one-fourth inch in length, and the other had a mustache of similar length; neither used any facial hair covering. These observations occurred while staff were present in the kitchen area where food was stored and prepared. During subsequent observations on the same day, the same two dietary aides were again observed with uncovered facial hair while directly involved in meal preparation and service. One aide walked through the kitchen while the noon meal was being prepared and placed into a transport cart for service in the south dining room, and later was observed plating the noon meal at the steamtable in that dining room, still without a facial hair covering. The other aide walked through the kitchen while the noon meal was being prepared and placed into the steamtable for the north dining room, took food temperatures, assisted with plating meals at the steamtable, and retrieved food items and supplies from the kitchen, all while having an uncovered mustache approximately one-fourth inch in length. The Dietary Manager stated that staff hair was to be covered when in the kitchen and during meal service, and the facility’s written policy and the cited Indiana Food Establishment Sanitation Requirements both required effective hair restraints, including for facial hair, to prevent contamination of food, equipment, and utensils.
Failure to Provide and Document Bed-Hold Policy at Time of Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure that required bed-hold policy information was provided and documented for four residents transferred to the hospital. For a resident with dementia, psychotic disorder, and autistic disorder who had a BIMS score of 0 indicating severe cognitive impairment, progress notes documented physician notification and guardian notification when the resident was sent to the hospital, but there was no documentation that the bed-hold policy was provided to the responsible party. A Notice of Transfer or Discharge later indicated a copy of the bed-hold policy was sent with the resident. Another resident with COPD and chronic respiratory failure, cognitively intact with a BIMS score of 13, experienced a decline in condition and was transferred to the hospital by ambulance; progress notes documented family notification but did not document any discussion of the bed-hold policy, although a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident. A third resident with altered mental status and cerebral infarction, with a BIMS score of 10 indicating moderate cognitive impairment and documented short-term memory impairment, experienced changes in condition and was transferred to the hospital. Progress notes stated the resident was their own responsible party and that no other notification was completed, and transfer documentation did not include the bed-hold policy, although an untimed Notice of Transfer or Discharge indicated a copy of the bed-hold policy was signed by the resident. A financial power of attorney document in the record showed the resident had designated an agent to act in consent or refusal of health care. For a fourth resident with dementia and osteomyelitis, transfer documentation and a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident, and the transfer form noted the resident required a proxy for decision making. The facility’s policy required that at the time of transfer to a hospital, written notice specifying the duration of the bed-hold policy and information on return to the next available bed be provided, and that a signed and dated copy of the bed-hold notice given to the resident or representative be kept in the resident file, which was not consistently documented for these residents.
Failure to Integrate Trauma Histories and Behavioral Triggers Into Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to identify and incorporate residents’ trauma histories and specific behavioral triggers into their care plans, despite documented histories of significant trauma and behavioral health issues. For one resident, extensive social service and progress notes documented homelessness, polysubstance abuse, major depressive and anxiety disorders, chronic pain, a history of severe car accidents with multiple fractures, viral encephalitis resulting in a three‑month coma, loss of child custody, multiple divorces, physical abuse by a spouse, the death of a fiancé who was struck by a car while in a wheelchair, lack of family contact, and a past suicide attempt by Valium overdose. Additional documentation noted a history of rape by a brother at age eight and prior placement under direct supervision and 15‑minute checks related to suicidal ideation. Despite these documented traumatic events and behavioral health concerns, the resident’s care plans did not identify a history of physical trauma, sexual trauma, homelessness, substance abuse, medical trauma, or attempted suicide. For this same resident, the MDS showed no cognitive deficit and identified behaviors such as verbal aggression and rejection of care, along with diagnoses including seizure disorder, depression, chronic pain syndrome, homelessness, and anxiety disorder. Multiple care plans addressed behaviors such as drug‑seeking, pretending to have seizures for attention or medication, making false allegations, verbal aggression when unable to smoke, and a desire for intimate relationships with consenting male residents. These care plans referenced goals such as effective coping skills, seeking staff support, and compliance with the smoking policy, and they called for identification and reduction of behavioral triggers. However, none of these care plans actually listed any specific triggers. The care plan addressing the resident’s right to consensual intimate relationships focused on assessment and education regarding consent but did not integrate the resident’s extensive trauma history. Staff interviews indicated the resident had displayed sexual behaviors since admission, including an incident where the resident expressed anger at another resident for not buying a soda after engaging in sexual acts. A second resident with a documented history of traumatic brain injury (TBI), dementia, seizure disorder, borderline personality disorder, anxiety, intermittent explosive disorder, tobacco use, and other behavioral/emotional disorders was also affected by the same deficiency. Social history and progress notes documented that this resident sustained a TBI after being hit by a semi‑truck while riding a bicycle at age 18, resulting in an 11‑month coma, followed by 13 years in a state hospital and subsequent residence in a group home. Additional documentation indicated the resident allegedly shot their father at age 26 after being sworn at and had a PASRR identifying TBI, intermittent explosive disorder, and borderline personality disorder, with a specific trigger of hearing the name of the current U.S. President. Progress notes also described inappropriate sexual behavior toward staff, including touching themselves intimately during personal care and refusing to stop when redirected. Despite this, the resident’s care plans, which addressed explosive disorder and history of altercations, risk for decreased psychosocial well‑being, and refusal to bathe or shower, did not list any specific behavioral triggers, did not reference the traumatic events such as being hit by a truck or shooting their father, and did not document the inappropriate sexual behavior. The Administrator and Social Service Director acknowledged that residents were to be screened for trauma and that trauma responses and PTSD should be added to care plans, but the specific trauma histories and triggers for these two residents were not incorporated into their plans of care.
Failure to Assess and Care Plan for Resident Suicidal Ideation
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess, investigate, and care plan for a resident’s suicidal ideation in accordance with its own policy and staff expectations. The resident had diagnoses including schizophrenia, cerebral edema, and hemiparesis/hemiplegia following a cerebral infarction, and a current MDS showed mild cognitive impairment (BIMS score 12). A progress note documented that the resident told the Social Services Director (SSD) he was feeling down and wanted to kill himself; the SSD offered assistance, activities, and initiated 15‑minute checks, and the note stated the care plan was updated. However, the note did not indicate that the SSD asked whether the resident had a plan to kill himself, and there were no additional notes regarding suicidal ideation or follow‑up. Review of the current care plan showed no problem, goal, or interventions addressing depression or suicidal ideation, and progress notes over the following month contained no documentation of physician notification related to the suicidal statement. Further record and interview evidence showed that the care plan conference summary did not document interventions for suicidal ideation, and the SSD acknowledged she did not normally ask residents expressing suicidal ideation if they had a plan. The SSD reported that the resident had admission paperwork mentioning suicidal ideation related to depression after a stroke and that the resident again vocalized suicidal ideation during a care plan meeting with his father, after which emotional support was offered and the father took the resident out on a leave of absence; no further visits or follow‑up were done. The DON stated that, upon notification of suicidal verbalization, staff should assess the resident, ask if there is a plan, remove potential means of self‑harm, immediately notify the psychiatric NP, and document the occurrence, and that a detailed progress note and updated care plan were expected but not present for this resident. The Administrator similarly stated that staff should ask about a plan, document interventions, notify the physician and family, and update the care plan, and indicated the resident should have had a care plan addressing depression with suicidal ideation. The facility’s written policy required immediate notification of the DON, SSD, and physician, an interview including asking about a plan and assessing mood and means for self‑harm, and thorough documentation of mood, behavior, and all actions taken, which were not reflected in the resident’s record.
Incomplete and Inaccurate Documentation of Suicidal Ideation and Follow-Up
Penalty
Summary
The facility failed to ensure accurate, complete, and timely documentation of assessments and services for a resident who verbalized suicidal ideation. Resident 6, who had schizophrenia, cerebral edema, and right-sided hemiparesis/hemiplegia following a cerebral infarction, had a BIMS score of 12 indicating mild cognitive impairment. The resident’s admission paperwork mentioned suicidal ideation related to depression after a stroke, and a Social Services note on 3/11/2026 documented that the resident was feeling down and said he wanted to kill himself. The Social Services Director (SSD) documented that she talked with the resident, coordinated with Activities, advised the resident to contact SSD or nursing if he wanted to talk, and that the resident was scheduled for 15-minute checks and the care plan was updated. However, the current care plan initiated on 2/26/2026 did not address depression or suicidal ideation. Multiple Social Services progress notes were later entered as late entries in April, with effective dates in March, stating that the resident had no plan and no longer had suicidal ideation, that he felt much better after 1:1 time, and that he continued his daily routine and therapy. These late entries described follow-up visits and reassessments of suicidal ideation on several consecutive days, but in interviews the SSD stated she did not normally ask residents about having a plan when they verbalized suicidal ideation and did not recall any other occurrences beyond the initial event. She further indicated she did not personally provide individual follow-up visits with this resident regarding suicidal ideation, despite the late-entry notes describing such visits. The DON acknowledged that late entries had been added to address concern about suicidal verbalization, and the Administrator stated that upon suicidal statements staff should ask about a plan, notify the physician and family, and update the care plan, and that this resident should have had a care plan addressing depression with suicidal ideation. The facility’s documentation policy required factual, first-hand, timely documentation, which was not followed in this case.
Failure to Complete Required Self-Administration Assessment for Inhaler Kept at Bedside
Penalty
Summary
Surveyors identified that a resident was allowed to keep and access an Albuterol inhaler without the facility completing the required self-administration medication assessment. During an initial tour, the resident was observed sitting in a wheelchair with a handheld Albuterol inhaler on the overbed table and no staff present in the room or hallway. On a subsequent observation, the resident again was in a wheelchair and reported that the Albuterol inhaler was stored in the top drawer of the nightstand, where it was found. Review of the clinical record showed an admission MDS indicating no cognitive impairment, but there was no documentation of a self-medication administration assessment. In an interview, the DON confirmed that the resident did not have the required self-medication assessment, despite the facility’s policy stating that staff and the practitioner must assess each resident’s mental and physical abilities to determine whether self-administering medications is clinically appropriate. This failure to complete and document a self-administration medication assessment for a resident who had an Albuterol inhaler kept at bedside constituted noncompliance with the facility’s own policy and with 410 IAC 16.2-3.1-11(a).
Inaccurate PBJ Staffing Data Submission to CMS
Penalty
Summary
The deficiency involves the facility’s failure to electronically submit complete and accurate direct care staffing information to CMS through the Payroll-Based Journal (PBJ) system for 22 days in a fiscal quarter. A CASPER report review on 4/6/26 showed that, according to PBJ data, the facility did not have licensed nursing coverage 24 hours per day on multiple specific dates across three months, had low weekend staffing, and held a 1-star staffing rating. However, review of the facility’s internal staffing sheets for that quarter indicated the facility was fully staffed and had licensed nurse coverage on all of the dates in question. During an interview, the Administrator stated that the PBJ information must have contained data entry errors, as she had verified licensed staff coverage on the timesheets. The facility’s PBJ policy in effect stated that all staffing data entered into the PBJ system would be auditable and verifiable through payroll, invoices, or contracts, but the submitted PBJ data did not accurately reflect the facility’s actual licensed nurse staffing as documented on internal records. No specific residents or clinical conditions were mentioned in the report, and the deficiency centers solely on inaccurate staffing data submission rather than direct resident care events.
Failure to Provide and Document Required Transfer/Discharge and Bed-Hold Notices
Penalty
Summary
The deficiency involves the facility’s failure to provide and document required written notices of transfer/discharge and bed-hold policies, as well as required information to receiving providers, for four residents who were transferred or discharged to the hospital. For a resident with generalized anxiety disorder, major depressive disorder, and dementia, progress notes showed that the resident was sent to the hospital via 911 for chest pain, lower back pain, and shortness of breath and later returned to the facility, but the clinical record lacked documentation that a written Notice of Transfer/Discharge and the bed-hold policy were provided to the resident or representative, and lacked documentation that required information was conveyed to the receiving facility. The ADON and the Administrator both confirmed there was no documentation that these written notices were provided. For a resident with congestive heart failure and muscle weakness who was sent to the emergency room for painful urination and bloody urine, the clinical record lacked documentation that a Notice of Transfer/Discharge or bed-hold policy was given to the resident or representative, which the DON confirmed. Another resident with chronic respiratory failure and diabetes was discharged to the hospital for respiratory failure, and a resident with chronic kidney disease and dementia was discharged to the hospital, but in both cases there was no documentation that a written notice of transfer/discharge or bed-hold policy was provided to the residents or their representatives. Review of the facility’s Transfer and Discharge policy, dated 1/15/26, showed that the policy required the facility to provide written transfer/discharge notices and bed-hold information to residents and representatives and to provide specified information to receiving providers, but the records for these four residents did not contain the required documentation.
Failure to Document Target Behaviors and Non-Pharmacological Interventions Before Initiating Antipsychotic
Penalty
Summary
The deficiency involves the facility’s failure to document how a resident’s behaviors presented danger or distress to self or others, and failure to document non-pharmacological interventions attempted prior to initiating an antipsychotic medication. Resident 6 had documented diagnoses of Alzheimer’s disease, depression, and severe cognitive impairment, and was receiving sertraline for depression. A PASSAR identified only depression and dementia, and the admission MDS listed Alzheimer’s disease and depression as active diagnoses. Over several months, nursing progress notes documented that the resident intermittently reported unusual perceptions, such as believing there were men causing trouble, a man in her room, or a man wanting to marry her and yelling through the walls, but there was no documentation that these episodes caused danger to the resident or others or that they resulted in unmanageable distress. From late April through mid-July, nursing notes primarily described the resident’s frequent refusals of evening and morning medications, blood sugar checks, blood pressure checks, insulin administration, hygiene care, and showers. Staff documented that the resident sometimes yelled at staff, said “Get out!”, was visibly upset by a room move, was leery of staff and asked to see name badges, and became upset about a pillow under her head until it was removed, after which she calmed down. The notes also recorded instances where the resident believed housekeeping had not cleaned her room or that she had not received medications when she had. However, there were no progress notes or assessments indicating that these behaviors were evaluated as dangerous, non-redirectable, or causing significant distress or functional impairment, and no detailed behavior monitoring logs were present as required by facility policy. On a psychiatric NP visit for initial psychotropic medication management, new mental health diagnoses of schizoaffective disorder, borderline personality disorder, and delusional disorder were added, and Seroquel 25 mg, an antipsychotic, was ordered. The clinical record did not contain a comprehensive evaluation to support these new diagnoses, and there was no documentation of target behaviors meeting the facility’s policy criteria for psychotropic use, such as behaviors representing danger to self or others, causing distress and impairment in functional abilities, or clearly attributable to psychosis or mania. The resident’s representative reported that the resident had no prior history of mental health disorders or psychiatric hospitalization and was unaware of the new diagnoses. The facility’s own psychotropic medication policy required identification and documentation of specific target behaviors, use and documentation of nonpharmacological interventions, and ongoing monitoring of behaviors and interventions, which were not reflected in the record for this resident.
Failure to Update PASARR Screens for New Mental Health Diagnoses and Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that Preadmission Screening and Resident Review (PASARR) Level I screenings were accurate and updated when new mental health diagnoses and psychoactive medications were initiated for multiple residents. For one resident with dementia, anxiety, depression, and post-traumatic stress disorder (PTSD), the PASARR completed on admission listed anxiety, depression, and dementia with sertraline and quetiapine, but did not include the PTSD diagnosis or the antidepressant Pristiq, despite the admission MDS and care plan documenting PTSD and a subsequent physician’s order for Pristiq. For another resident with Alzheimer’s disease, borderline personality disorder, delusional disorder, schizoaffective disorder, and depression, the PASARR only reflected depression and dementia with sertraline, even though additional mental health diagnoses were added later and an antipsychotic (quetiapine) was ordered for borderline personality disorder, and the quarterly MDS documented psychotic disorder, schizophrenia, and depression with antipsychotic and antidepressant use. A third resident had diagnoses including Alzheimer’s disease, depression, anxiety disorder, irritability and anger, and nonrheumatic aortic valve stenosis. The PASARR for this resident listed dementia and anxiety with Risperdal but omitted the diagnosis of depression and the medications escitalopram and lorazepam, although physician’s orders were in place for escitalopram for depression and lorazepam for anxiety, and the admission MDS documented depression with antianxiety and antidepressant use. Interviews with the Assistant Director of Nursing confirmed that new Level I PASARR screens should have been completed when new mental health diagnoses and psychoactive medications were added, and that the PASARR for one resident, completed prior to arrival, should have included all mental health diagnoses and medications. The facility’s own policy required notification of the state mental health authority within 14 days after a significant change in mental condition and specified that a new Level I screen is required for new mental health diagnoses or newly prescribed psychotropic medications, which was not followed in these cases.
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