Waters Of Lagrange Skilled Nursing Facility, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Lagrange, Indiana.
- Location
- 787 N Detroit St, Lagrange, Indiana 46761
- CMS Provider Number
- 155118
- Inspections on file
- 33
- Latest survey
- March 30, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Waters Of Lagrange Skilled Nursing Facility, The during CMS and state inspections, most recent first.
The facility failed to adequately assess and manage smoking safety for two residents and did not correct a known tripping hazard in a resident hallway. One resident with dementia, impaired vision, and a history of nicotine dependence routinely left the property to smoke and sustained facial fractures and a knee hematoma after falling while smoking outside the entrance, yet her assessments and care plan did not reflect her actual smoking behavior or address safety measures for off‑property smoking. Another resident with lower‑extremity paralysis was later identified as using cigarettes and a vape pen and frequently signed out to smoke off site, while staff reported that smokers went across the parking lot to a neighboring church and sometimes retained smoking materials instead of returning them to nursing staff. The facility’s smoking policy only addressed on‑site designated smoking areas and did not cover safety assessment or locations for off‑property smoking, and a section of bunched, uneven carpet in a rehabilitation hallway—known to administration and associated by interviewees with a prior resident fall, difficulty moving mechanical lifts, and multiple near‑falls—remained unrepaired, creating an ongoing trip hazard.
An LPN in a facility misappropriated controlled medications by administering them without proper assessment and documentation, affecting four residents. Discrepancies were found in the controlled drug records and Medication Administration Records (MAR), with residents confirming they did not receive the medications as recorded. The facility's policy on abuse prevention was not followed, leading to the misappropriation of resident property.
A resident with Alzheimer's disease experienced verbal abuse from a CNA, who was overheard using derogatory language. The resident required maximal to dependent care and had a care plan addressing cognitive impairments. Despite these measures, the incident occurred, violating the facility's abuse prevention policy.
The facility failed to maintain adequate staffing levels, resulting in insufficient care for 82 residents. Multiple complaints and interviews revealed that staff were overworked and unable to provide necessary care, with some shifts having no CNAs available. The facility's corporate office prohibited the use of staffing agencies, worsening the situation. Incidents included a resident falling in the shower and another eloping from the facility, highlighting the compromised safety and well-being of residents.
The facility failed to identify and correct deficiencies affecting all residents, including unreported incidents, inadequate care plans, and staffing issues. A resident's elopement was not reported, and another was left unsupervised despite fall precautions. Staffing shortages contributed to incidents, and a resident's behavior was not properly investigated. The QAPI committee focused mainly on staffing, neglecting other areas.
The facility failed to provide adequate supervision and safety measures, leading to incidents involving four residents. One resident was left unsupervised in a shower, resulting in an injury, while another resident, at high risk for elopement, was found outside after falling from a wheelchair. A third resident smoked without proper supervision, and a fourth resident experienced multiple falls due to insufficient staffing and lack of updated care plan interventions.
A facility failed to maintain consistent documentation of a resident's advance directive. The resident, with a BIMS score indicating no cognitive deficit, had conflicting records regarding their code status. While the care plan noted a DNR status, a physician order showed it was discontinued, and a CPR Status Form indicated CPR should be initiated. The DON was unaware of the resident's current code status, despite facility policy requiring consistent documentation and annual reviews.
A facility failed to notify the family of a resident with severe cognitive impairment about an incident where the resident kissed another resident in the dining room. Despite documentation of the event, neither the family nor the physician was informed. Interviews revealed that the incident was not considered reportable due to both residents having dementia and the kiss being perceived as non-sexual. The facility's policy requires timely reporting of such incidents, which was not followed.
A facility failed to ensure the privacy of a resident's urinary catheter bag, which was visible from the hallway on multiple occasions. The resident, who had an indwelling catheter due to medical conditions, was observed with the catheter bag attached to the bedframe and facing the door. The facility's policy did not address the need for privacy covers, and staff confirmed that the bag should have been covered to protect the resident's dignity.
A resident with severe cognitive impairment and a history of trauma experienced verbal abuse from their POA during a visit. The facility failed to update the resident's care plan to include monitored visitation or restrict the POA's access, despite being aware of the POA's past abusive behavior.
The facility failed to report incidents involving two residents to the appropriate agencies. One resident with severe cognitive impairment kissed another resident, and the incident was not reported. Another resident, at high risk for elopement, was found outside after falling, but the incident was not reported as an elopement. The facility did not adhere to its policy on reporting incidents.
A resident with bipolar disorder and moderate cognitive impairment eloped from the facility with the assistance of a visitor, resulting in a fall and injuries. Despite the resident's care plan indicating high risk for wandering, the incident was not investigated as an elopement, contrary to the facility's policy on incident reporting and investigation.
A resident requiring moderate assistance with bathing did not consistently receive showers as per their care plan due to staffing shortages. Despite being cognitively intact and expressing concerns, the resident's shower schedule was not adhered to, with documentation showing gaps in shower offerings. Staff interviews confirmed the inconsistency, and the facility's policy on bathing was not followed, risking the resident's skin health.
Two residents in a LTC facility were inadequately supervised, leading to significant incidents. One resident with a seizure disorder was left unsupervised in a shower room, resulting in an injury, while another resident with cognitive impairment fell and sustained a pelvic fracture. The facility failed to update care plans and conduct necessary assessments, contributing to these deficiencies.
A facility failed to provide trauma-informed care for a resident with PTSD and other mental health issues. The care plan lacked specific triggers and symptoms, and staff were not fully aware of the resident's needs. The resident experienced verbal abuse from their boyfriend, who was their POA, and the facility did not have a clear plan to address the resident's trauma-related needs.
A resident with dementia displayed various behaviors such as hitting and making sexual comments, but the facility failed to identify specific stressors or triggers and did not tailor interventions to the resident's dementia diagnosis. Incidents involving inappropriate touching and aggression were not adequately investigated, and staff lacked education on observing triggers. The facility's policy required investigation of behaviors, but this was not effectively implemented.
The facility did not post required nursing staffing information in an accessible area for residents and visitors. An empty document holder was found in the lobby where the information should have been displayed. The Administrator was initially unaware of the posting location, and the Director of Nursing confirmed discrepancies in the posted census and date. The facility's policy mandates that staffing information be prominently displayed, which was not followed.
A facility failed to identify and manage a pressure injury on a resident's left calf, initially caused by friction from an air cast. The injury was not correctly identified, and there was no physician's order for the air cast. The resident, with a history of pressure injuries, did not receive effective treatment, leading to a stage three pressure injury with infection. The facility lacked proper documentation, follow-up, and pain management, contributing to the wound's deterioration.
A resident with an unstageable pressure ulcer, diabetes, intellectual disabilities, and neuropathy experienced inadequate pain management. Despite repeated complaints of pain in her right foot, the facility failed to administer prescribed Tylenol on certain days and did not effectively address her pain. Observations and progress notes indicated persistent pain and swelling, yet the facility did not follow its pain management policy to assess and manage the resident's pain adequately.
A resident with a history of alcohol abuse and mental health disorders exhibited escalating aggressive behaviors, causing fear among other residents. The facility failed to implement an effective behavior management plan, and staff reported inadequate training and resources to manage the resident's behaviors. Despite recommendations for medication and stress management, the facility did not provide necessary interventions.
A resident with dementia did not receive appropriate care and services in a memory care unit. Despite a care plan that included participation in structured activities, the resident was often found without engagement, and activities were sporadic. The unit was understaffed, particularly during evening and night shifts, with no dedicated activity personnel, leading to a deficiency in care.
A facility failed to protect a resident from mental abuse when a CNA recorded the resident without permission and shared the video with staff. The resident, who had dementia and other behavioral issues, was recorded during care. The facility's policy on abuse prevention was violated, leading to the CNA's termination.
The facility failed to timely report suspected abuse when a CNA videotaped a resident without permission and shared the video with staff. The incident was not reported to the IDOH until it was brought to corporate's attention, and the CNA who recorded the video continued to provide care for a week before being suspended and terminated.
A CNA recorded a resident without permission and continued to provide care for six days before being suspended. The incident was not reported immediately, and the DON did not suspend the CNA until corporate staff were notified. Staff were re-educated on the abuse policy and cell phone use.
Failure to Ensure Smoking Safety and Correct Tripping Hazards in Resident Hallway
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and evaluate smoking safety for two residents and to maintain an environment free from accident hazards. One resident with Alzheimer’s disease, moderately impaired cognition, impaired vision, and a history of nicotine dependence experienced a fall while smoking outside the facility entrance, resulting in facial fractures and a traumatic hematoma to the right knee. Her MDS and quarterly smoking evaluations documented that she did not use smoking or tobacco products, and her care plan stated she did not smoke at the facility, only occasionally with family on outings. Despite this, she reported routinely going across the parking lot to a nearby church to smoke and, on the day of the fall, chose to smoke near the facility entrance due to windy conditions, sitting on her rolling walker and falling when her coat pocket caught on the walker handle. A pack of cigarettes was observed at her bedside, and her revised care plan did not address that she was an everyday smoker, her safety in ambulating off the property to smoke, staff interventions to ensure her safety off site, or ongoing observations for safe smoking given her cognitive and physical status. A second resident with paralysis of the lower extremities was also not fully assessed and managed for smoking safety. His admission MDS and initial smoking evaluation indicated he did not use tobacco, but a subsequent significant change smoking evaluation documented that he used cigarettes and a vape pen. His care plan identified potential safety hazards and injury related to smoking and noted that the facility had a non‑smoking policy, with interventions to provide a copy of the policy and store smoking materials per facility policy. However, LOA sign in/out forms showed that beginning shortly after admission, he signed himself out multiple times per day for about 20 minutes each time to go smoke, and staff reported that residents who smoked would go across the parking lot to a neighboring church lot to smoke. Staff also stated that residents were to obtain smoking materials from the nurse and return them afterward, but sometimes did not return them. The facility’s smoking policy addressed only smoking in designated outdoor areas when permitted and staff monitoring of those areas, and did not address assessment of resident safety when leaving the property to smoke or where residents were permitted to smoke off site. The facility also failed to ensure the environment was free of accident hazards by not correcting bunched‑up and uneven carpeting in a resident hallway. During observation, the carpeting in the middle of the northwest rehabilitation hallway was rippled and bunched from one resident room to another, creating a tripping hazard in an area where five short‑term stay rooms were occupied. Confidential interviews indicated the carpet had been in this condition for some time and that administration was aware of the problem. Interviewees reported that a resident had fallen in that hallway the previous year, causing severe injuries, that mechanical lifts were difficult to move down the hallway because of the uneven carpet, and that several people had tripped with near falls. Staff and visitors were observed walking in the hallway during the survey, confirming the ongoing presence of the hazard.
Misappropriation of Controlled Medications by LPN
Penalty
Summary
The facility failed to protect residents from the misappropriation of their property, specifically controlled medications, by a Licensed Practical Nurse (LPN). The Director of Nursing (DON) discovered discrepancies during routine compliance audits of controlled medication records. It was found that the LPN administered opioid pain medications to residents without proper assessment and documentation, and the administration records did not match the controlled medication records. This issue affected four residents, identified as Resident K, Resident L, Resident M, and Resident N. Resident K, who had a history of a pelvis fracture and dementia, was prescribed Oxycodone for pain management. The controlled drug record showed that the LPN administered the medication multiple times, but the Medication Administration Records (MAR) lacked documentation for these administrations. Similarly, Resident L, with a heel wound, was prescribed Hydrocodone-Acetaminophen, and the controlled drug record indicated administration by the LPN without corresponding documentation in the MAR. Resident L also reported not requesting or receiving the medication on certain dates. Resident M, diagnosed with arthritis and chronic pain, was prescribed Hydrocodone, and the controlled drug record showed administration by the LPN without documentation in the MAR. Resident M confirmed not receiving the medication on the date in question. Resident N, with a pressure wound, was prescribed Norco, and discrepancies were found in the controlled drug record, including a missing tablet and lack of proper documentation for a wasted dose. The LPN failed to follow protocol by not obtaining a second nurse's signature for the wasted medication. The facility's policy on abuse prevention was not adhered to, leading to the misappropriation of resident property.
Verbal Abuse Incident Involving Resident with Alzheimer's
Penalty
Summary
The facility failed to ensure that residents were free from verbal abuse, as evidenced by an incident involving a Certified Nurse Aid (CNA) and a resident with Alzheimer's disease. The incident was reported to the Indiana Department of Health, indicating that the CNA was overheard being rude and calling the resident a derogatory term. The resident, who had severely impaired cognition and required maximal to dependent care for activities of daily living, was found to have no behaviors or rejection of care prior to the incident. The resident's care plan highlighted cognitive impairments related to dementia and short-term memory loss, with interventions aimed at meeting her needs and monitoring changes in cognitive status. Despite these measures, the verbal abuse incident occurred, which was witnessed by staff. The facility's policy on abuse prevention clearly prohibits verbal abuse, defined as the use of disparaging and derogatory terms within the hearing distance of residents. The incident was part of a complaint investigation, and the facility's failure to prevent this verbal abuse constituted a deficiency.
Inadequate Staffing Leads to Resident Safety Concerns
Penalty
Summary
The facility failed to ensure sufficient nursing staff to meet the needs of all 82 residents, as evidenced by multiple complaints and verified payroll records. On several occasions, the facility was understaffed, with only one CNA or QMA available to care for a large number of residents, including those in the dementia unit. This lack of staffing led to situations where residents were left unattended, and necessary care tasks, such as assisting residents to bed or getting them up for breakfast, were not completed in a timely manner. Interviews with staff members revealed that the facility's management was aware of the staffing issues but had not taken effective measures to address them. Staff reported being overworked and unable to provide adequate care, with some shifts having no CNAs available at all. The facility's corporate office had prohibited the use of staffing agencies, further exacerbating the staffing shortages. Additionally, the facility's scheduling practices were problematic, with terminated employees still appearing on schedules and staff being added to shifts without their knowledge. The inadequate staffing levels resulted in several incidents, including a resident falling in the shower due to being unsupervised and another resident eloping from the facility. Staff members expressed concerns about their ability to monitor residents effectively, particularly those at high risk for falls or requiring assistance with mechanical lifts. The facility's failure to maintain adequate staffing levels compromised the safety and well-being of its residents, as evidenced by the numerous complaints and incidents reported.
Facility Fails to Address Deficiencies Affecting All Residents
Penalty
Summary
The facility failed to establish a process to identify and correct deficiencies, affecting all 82 residents. During the annual survey, several areas of noncompliance were identified, including failure to report and investigate incidents, failure to follow care-planned interventions to prevent accidents, failure to maintain minimum staffing levels, and failure to investigate and identify underlying causes of resident-specific behaviors. These deficiencies were observed through various interviews and record reviews. One incident involved a resident's elopement that was not reported to the proper agencies. The Director of Nursing (DON) indicated that a former employee observed the resident exiting the building and attempted to intervene, but the resident fell from their wheelchair outside the facility. The incident was not investigated as an elopement. Another case involved a resident who was left unsupervised in the shower room, despite their care plan indicating the need for fall precautions, which were not included in the resident's Kardex. Staffing issues were also highlighted, with the DON expressing concerns about short staffing contributing to incidents such as a resident falling from a recliner twice in one day. The facility had been using agency staff to fill gaps, but this practice was halted by the corporate office. Additionally, the Social Services Director noted an incident involving a resident with dementia, where a kiss between two residents was not reported as it was deemed non-sexual. The facility's QAPI committee was in place, but the focus was primarily on staffing issues, with other areas not being adequately addressed.
Inadequate Supervision and Safety Measures in LTC Facility
Penalty
Summary
The facility failed to ensure adequate supervision to prevent accidents, including resident elopement, falls, and unsafe smoking practices. Resident 32 was left unsupervised in a shower room, resulting in an incident where the resident's arm became lodged in a handrail. This occurred due to staffing shortages, which led to a CNA in training providing unsupervised care. The resident had a history of falls and required assistance, as indicated in their care plan, but these precautions were not followed. Resident 19, who was at high risk for elopement due to cognitive impairments, was found outside the facility after being let out by a non-employee. The resident fell from their wheelchair, sustaining injuries. Despite the incident, the facility did not investigate it as an elopement, and the resident's elopement risk assessments were incomplete. The facility's policy required regular supervision and compliance rounds, which were not adequately implemented. Resident 76 was observed smoking outside without proper supervision or a care plan addressing smoking safety. The resident occasionally kept smoking materials in their room, contrary to facility policy. Additionally, Resident 64, who was at high risk for falls, experienced multiple falls due to inadequate supervision and staffing shortages. The care plan did not include new interventions after these incidents, failing to address the resident's fall risk effectively.
Inconsistent Advance Directive Documentation for a Resident
Penalty
Summary
The facility failed to ensure the accuracy of an advance directive for a resident, identified as Resident 4. The resident's medical record indicated a diagnosis of chronic obstructive pulmonary disease, unspecified dementia, schizoaffective disorder, and bipolar disorder. The resident's Quarterly Minimum Data Set (MDS) showed a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive deficit, and required substantial to maximum assistance for activities of daily living. The resident's care plan documented a Do Not Resuscitate (DNR) status, while a physician order indicated that the DNR status had been discontinued. Additionally, a CPR Status Form signed by the resident's representative and physician indicated that CPR should be initiated. During an interview, the Director of Nursing (DON) was unaware of the resident's CPR code status and acknowledged that the code status should be consistent across all documents in the resident's record. The facility's policy stated that each resident's advance directive choices should be honored and incorporated into their care plan, with reviews conducted annually and as needed.
Failure to Notify Family of Resident-to-Resident Contact
Penalty
Summary
The facility failed to notify the family of Resident 63 about an incident involving resident-to-resident contact. Resident 63, who has severe cognitive impairment due to dementia, Parkinson's Disease, major depressive disorder, anxiety disorder, and visual hallucinations, was involved in an incident where they kissed another resident, Resident 49, in the dining room. Despite the incident being documented in a Behavior Charting note, there was no indication in the progress notes that the family or the resident's physician had been informed of the event. Interviews with the Social Service Director (SSD) and the Administrator revealed that the incident was not considered reportable due to both residents having dementia and the kiss being perceived as non-sexual. The SSD noted that Resident 49, who had a history of sexual behaviors, was easily redirected and that the kiss was friendly. The Administrator was unaware of the incident and had no further information regarding family or physician notification. The facility's policy on incidents requires that any incident meeting reporting criteria be reported accurately and timely, which was not adhered to in this case.
Failure to Maintain Privacy of Resident's Catheter Bag
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of a resident's medical condition by allowing the contents of a urinary catheter bag to be visible from the hallway. During multiple observations, Resident 44 was seen lying in bed with a catheter bag attached to the bedframe and facing the door, making it visible to anyone passing by. The observations occurred over several days, and each time the catheter bag contained a visible amount of yellow liquid. The Licensed Practical Nurse (LPN) indicated that catheter bags should be anchored on the opposite side of the bed to prevent visibility from the hallway and should have a privacy cover to protect the resident's dignity. Resident 44's medical records revealed diagnoses of benign prostatic hyperplasia with lower urinary tract symptoms, retention of urine, and neuromuscular dysfunction of the bladder. The resident's care plan included the use of an indwelling urinary catheter and specified that a dignity bag should be in place. However, the facility's current policy on catheters did not address the need for privacy covers to prevent the contents from being visible to casual observers. The Regional Nurse Consultant confirmed that the catheter bag should have been covered to maintain the resident's privacy.
Failure to Prevent Abuse for a Resident with a History of Trauma
Penalty
Summary
The facility failed to prevent abuse for a resident, identified as Resident 41, who experienced a verbal altercation with their Power of Attorney (POA) during a visit. The incident occurred when the POA, who appeared intoxicated, became loud and verbally abusive towards the resident, telling them to stop crying and to get up and walk. The resident expressed fear of the POA, who was subsequently asked to leave the facility. Despite this, the resident's care plan did not reflect the need for monitored visitation or the restriction of the POA from visiting, even though the facility was aware of the POA's past abusive behavior. Resident 41 had a history of trauma and multiple mental health diagnoses, including severe cognitive impairment, anxiety disorder, bipolar disorder, and PTSD. The facility's policy required identifying residents with increased vulnerability to abuse and incorporating these risk factors into their care plans. However, the care plan for Resident 41 did not include necessary interventions to protect them from further abuse, such as monitoring visitation or restricting the POA's access, despite the facility's awareness of the situation.
Failure to Report Incidents Involving Residents
Penalty
Summary
The facility failed to report unusual incidents involving two residents to the appropriate agencies. Resident 63, who has severe cognitive impairment and multiple diagnoses including dementia and Parkinson's Disease, was involved in an incident where they kissed another resident in the dining room. Despite the Social Service Director's assessment that the kiss was not sexual and both residents had dementia, the incident was not reported to the resident's family representative or the appropriate agencies. The Administrator was unaware of the incident, indicating a lapse in communication and reporting procedures. Resident 19, who has moderate cognitive impairment and several other medical conditions, was found outside the facility after reportedly being let out by a visitor. The resident fell from the sidewalk curb, sustaining abrasions and swelling. Despite the incident being observed by a former employee and the resident's care plan indicating a high risk for elopement, the Director of Nursing decided it was not an elopement and did not report it to the proper agencies. The Administrator confirmed that the incident had not been reported, highlighting a failure to adhere to the facility's policy on reporting incidents. The facility's policy, titled 'Guidelines for Incidents/Accidents/Falls,' mandates that any incident meeting reporting criteria should be reported accurately and timely to the appropriate agencies. However, in both cases involving Resident 63 and Resident 19, the facility did not comply with this policy, resulting in a deficiency in reporting unusual incidents. This lack of reporting could potentially impact the safety and well-being of the residents involved.
Failure to Investigate Resident Elopement
Penalty
Summary
The facility failed to investigate the elopement of a resident, identified as Resident 19, who was at high risk for wandering due to her bipolar disorder. The resident's care plan, initiated earlier in the year, included interventions such as the use of a wanderguard and close supervision to prevent elopement. Despite these measures, Resident 19 was found outside the facility by activity personnel after a visitor reportedly assisted her in leaving the building. The resident fell from her wheelchair, sustaining abrasions and swelling on her forehead, and reported pain in her head and hip. The Director of Nursing (DON) indicated that a former employee observed Resident 19 exiting the building and attempted to reach her before she fell. However, the incident was not classified or investigated as an elopement by the facility. The facility's policy on incidents and accidents requires that all such events be identified, reported, and investigated, but this protocol was not followed in this case. The failure to investigate the incident as an elopement represents a deficiency in the facility's adherence to its own policies and procedures.
Inconsistent Shower Provision Due to Staffing Shortages
Penalty
Summary
The facility failed to consistently offer showers to a resident, identified as Resident 48, who required moderate assistance with bathing due to a cerebral infarction and other medical conditions. Despite being cognitively intact and having a care plan that specified showers twice weekly, the resident reported not receiving regular showers and expressed concerns about this issue. The resident's care plan emphasized the importance of personal care preferences, yet documentation showed gaps in shower offerings, with only a few recorded instances of showers being provided or refused over a specified period. Interviews with staff, including a Licensed Practical Nurse and the Director of Nursing, revealed that evening shift showers were inconsistently provided due to staffing shortages. The Director of Nursing acknowledged the lack of documentation for showers between certain dates and was unaware of any habitual refusals by the resident. The facility's policy on bathing highlighted the importance of cleansing the skin and promoting circulation, yet the resident's needs were not consistently met, as evidenced by the resident's dry skin and high risk for skin breakdown noted in progress notes.
Failure to Supervise and Maintain Precautions for Residents
Penalty
Summary
The facility failed to ensure proper supervision and maintain seizure precautions for two residents, leading to significant incidents. Resident 32, who had a history of dementia, osteoarthritis, osteoporosis, and a seizure disorder, was left unsupervised in a shower room due to staffing shortages. Despite being in training and not yet permitted to provide direct care, CNA 30 was directed by CNA 35 to leave Resident 32 unattended. This resulted in Resident 32 being found on the floor with their arm stuck in a handrail, requiring paramedic assistance. The resident's care plan did not address their seizure disorder, and the Kardex lacked necessary precautions for falls and seizures. Another incident involved Resident 5, who was found on the floor near a piano, complaining of pain. Despite being cognitively impaired and requiring assistance for mobility, the resident was not adequately supervised. After the fall, Resident 5 was assisted back into a chair without a thorough pain assessment, and later complained of hip pain. Subsequent hospital evaluation revealed a fracture in the pelvis. The facility's policy required pain assessments and documentation following a fall, which were not completed in this case. Both incidents highlight the facility's failure to adhere to its policies regarding supervision and post-fall assessments. The lack of adequate staffing and failure to update care plans and Kardexes with necessary precautions contributed to these deficiencies. The Director of Nursing acknowledged that Resident 32 should not have been left unsupervised and that their care plan should have included seizure and fall precautions.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for a resident with a history of trauma and multiple mental health diagnoses, including PTSD. The resident's care plan did not identify specific triggers or symptoms related to PTSD, despite the resident having a history of trauma and a trauma score indicating risk for trauma-related symptoms. The care plan interventions were general and did not address the resident's specific needs for trauma-informed care. Additionally, the resident's Kardex did not mention PTSD, and staff were not fully aware of the resident's visitation monitoring needs or specific triggers. The resident experienced several distressing events, including verbal abuse from their boyfriend, who was also their Power of Attorney. The boyfriend's behavior was reported to Adult Protective Services, but the facility did not have a clear plan to address the resident's trauma-related needs or to prevent re-traumatization. The Social Service Director acknowledged the resident's extensive trauma history but was unaware of specific triggers or stressors. The facility's policy required culturally competent, trauma-informed care, but this was not effectively implemented for the resident.
Failure to Address and Manage Dementia-Related Behaviors
Penalty
Summary
The facility failed to ensure that specific behaviors of a resident with dementia were identified, investigated, and communicated with individualized interventions. Resident 49, who has a history of alcohol-induced dementia, anxiety disorder, major depressive disorder, and psychotic disorder with hallucinations, displayed various behaviors such as hitting, kicking, pinching, and making sexual comments. Despite these behaviors being documented in the resident's care plan, the plan lacked specific stressors or triggers for these behaviors, and interventions were not tailored to address the resident's dementia diagnosis. Several incidents involving Resident 49 were noted, including an alleged inappropriate touching of another resident, punching a staff member, and being found in bed with another resident. These incidents were not adequately investigated to determine the root causes, and the care plan did not reflect necessary interventions to prevent recurrence. The facility's policy required investigation of resident behaviors to determine root causes, but this was not effectively implemented for Resident 49. Interviews with facility staff revealed a lack of education on observing specific events or stressors that could trigger resident behaviors. The Qualified Medication Aide indicated that only new behaviors were communicated during shift reports, and the Social Service Director downplayed certain incidents, such as a kiss between residents, as non-sexual due to both having dementia. The facility's memory care unit policy stated it could not accept residents who displayed behaviors that may result in harm, yet Resident 49's behaviors were not adequately managed or documented.
Failure to Post Nursing Staffing Information
Penalty
Summary
The facility failed to ensure that nursing staffing numbers, including the facility name, date, facility census, and total number and actual hours worked per shift by licensed and unlicensed direct care staff, were posted in an area accessible to residents and visitors. During an observation, a plastic document holder was found empty in the front lobby area, where the nursing hours should have been posted. The Administrator was initially unsure of the location of the posting and later indicated that the nursing hours should be posted in the empty document holder. A review of the daily staffing document dated 9/26/24 revealed that it indicated a census of 80, but no nursing hours were listed. The Director of Nursing confirmed that the posted form was dated for the next day and should have reflected a census of 82. Additionally, a staffing notice dated 9/27/24 was observed in the lobby. The facility's policy required that the staffing information be posted in a conspicuous, prominent location accessible to residents and visitors, which was not adhered to in this instance.
Failure to Identify and Manage Pressure Injury
Penalty
Summary
The facility failed to properly identify and manage a pressure injury on a resident's left inner calf, which was initially caused by friction and shear from an air cast on the right leg. The injury was not correctly identified as a pressure injury, and there was no physician's order for the use of the air cast. The resident, who had a history of pressure injuries, did not receive effective treatment to prevent the wound from deteriorating, leading to the development of a stage three pressure injury with infection that required sharp debridement. The resident, identified as having mild cognitive impairment, was frequently incontinent and required substantial assistance with mobility and toileting. Despite being at risk for pressure injuries, the facility did not have adequate assessments or care plans in place. The resident experienced significant pain, which was not effectively managed, and there was a lack of documentation and follow-up on the wound's condition. The facility also failed to notify the physician or family about the wound's progression and did not implement necessary interventions to prevent further skin breakdown. Throughout the period from early August to early September, there were multiple instances where the facility did not document wound assessments, characteristics, or treatments. The resident's pain was not consistently assessed or managed, and there was no documentation of interventions to address the use of the air cast or to provide pressure relief. The facility's lack of effective monitoring and evaluation of the resident's condition contributed to the deterioration of the wound and the resident's ongoing pain and distress.
Inadequate Pain Management for Resident with Pressure Ulcer
Penalty
Summary
The facility failed to provide effective pain management for a resident, identified as Resident L, who was experiencing pain. Resident L had multiple diagnoses, including an unstageable pressure ulcer on the right heel, diabetes, intellectual disabilities, and neuropathy. She had been hospitalized for a hip fracture due to a fall. The resident's care plan, effective from 8/13/24, included interventions for pain management such as assessing pain using a 0-10 scale, administering pain medication, and offering non-pharmacological interventions. Despite these interventions, the resident repeatedly verbalized pain in her right foot, which was not adequately addressed by the facility. Observations on 9/3/24 and 9/4/24 noted that the resident was in pain, yet Tylenol, prescribed for pain relief, was not administered on these days. The resident's Medication Administration Record (MAR) indicated that Tylenol was administered on 9/1/24 and 9/2/24, but it was ineffective in relieving her pain. A nurse's progress note on 9/2/24 confirmed the resident's complaint of pain and swelling in her right foot, with Tylenol being ineffective. A Wound Nurse Practitioner noted on 9/3/24 that the resident refused debridement of her pressure ulcer due to pain, and there was pitting edema and tenderness in the right foot. Despite these documented complaints and observations, the facility did not adequately assess or address the resident's pain, as required by their pain management policy, which emphasizes prompt recognition and assessment of pain, and the use of both pharmacological and non-pharmacological interventions.
Failure to Implement Behavior Management Plan for Resident with Alcohol Abuse History
Penalty
Summary
The facility failed to develop and implement an effective behavior management plan for a resident with a history of alcohol abuse, resulting in altercations and fear among other residents. The resident, identified as Resident G, exhibited behaviors such as verbal and physical aggression, exit-seeking, and delusions. Despite having a history of alcohol dependence, generalized anxiety disorder, and major depressive disorder, the facility did not provide adequate behavioral health care and services to address these issues. Resident G's medical history included alcohol dependence with withdrawal, generalized anxiety disorder, major depressive disorder, mild cognitive impairment, and muscle weakness. Upon admission, the resident had no cognitive impairment but displayed inattention and disorganized thinking. The care plans initiated for Resident G included goals to reduce alcohol consumption and address wandering due to cognitive impairments. However, as the resident's behaviors escalated, including making homophobic slurs, attempting to elope, and becoming verbally and physically aggressive, the facility did not develop a comprehensive behavior management plan. The facility's staff reported a lack of training and resources to manage Resident G's behaviors effectively. There were no specific interventions communicated to the staff, and the facility's behavior management program was not adequately implemented. The resident's behaviors caused distress among other residents, who expressed fear for their safety. Despite recommendations from a psychiatric nurse practitioner for medication management and stress management techniques, the facility did not follow through with these interventions, leading to ongoing safety concerns for both staff and residents.
Inadequate Dementia Care and Activities for Resident
Penalty
Summary
The facility failed to provide appropriate dementia care and services to a resident diagnosed with dementia, identified as Resident E. The resident, who had a history of dementia with behavioral disturbances, delusional disorder, insomnia, major depressive disorder, and diabetes, was observed to have severely impaired cognition and required assistance with daily activities. Despite being on a memory care unit, the resident did not receive consistent or structured activities, which were part of his care plan. Observations revealed that there were no activities or programming on the unit, and the resident was often found sleeping or lying in bed without engagement. The care plan for Resident E included participation in specialized programming and activities such as movies, bingo, and trivia, with a goal of attending at least three activities per week. However, documentation and observations indicated that activities were sporadic and not routinely offered. The resident's spouse confirmed the lack of consistent activities, and staff interviews revealed that the unit was understaffed, particularly during evening and night shifts, with no dedicated activity personnel. The memory care coordinator was only allotted limited hours to update care plans and documentation, further contributing to the lack of structured programming. Progress notes highlighted several incidents where the resident exhibited behaviors such as agitation, confusion, and aggression, often calmed only by the presence of his spouse. Despite these behaviors, there were no new interventions implemented to address the decline in the resident's functional abilities and increase in behaviors. The facility's policy emphasized the importance of meaningful and enjoyable structured activities for residents with dementia, yet this was not reflected in the care provided to Resident E, leading to the deficiency identified in the report.
Failure to Protect Resident from Mental Abuse
Penalty
Summary
The facility failed to ensure a resident's right to be free from abuse, specifically mental abuse, for Resident Q. On 3/19/24, a CNA used their cell phone to create a video of Resident Q without her permission and shared it with several staff members. Resident Q, who had diagnoses including dementia with behavioral disturbance, delusional disorder, and generalized anxiety disorder, was recorded while receiving care. The video was reviewed by the Director of Nursing (DON) and other nurse managers, who determined that the care provided by CNA 7 was appropriate. However, the use of a cell phone to record the resident without permission was a violation of the facility's policy on abuse prevention. CNA 5, who recorded the video, was initially instructed to delete the video and was later suspended and terminated for her actions. The incident was reported to the Indiana Department of Health (IDOH), and the facility's policy on abuse prevention was reviewed. The policy stated that each resident has the right to be free from all types of abuse, including mental abuse, which includes the use of photographs or recordings in a manner that would demean or humiliate residents. Despite the initial review of the video showing no signs of mistreatment by CNA 7, the act of recording the resident without permission constituted mental abuse. The facility's failure to address the use of the cell phone immediately and the delay in taking action against CNA 5 contributed to the deficiency.
Failure to Timely Report Suspected Abuse
Penalty
Summary
The facility failed to ensure a timely report of suspected abuse for Resident Q. On 3/19/24, CNA 7 used their cell phone to videotape Resident Q without her permission while providing pericare. This video was shared with several staff members. CNA 5 reported the mistreatment to the Director of Nursing (DON) and provided the recording. CNA 7 was suspended pending investigation but was allowed to return to work the following day after the allegation was unsubstantiated. The unauthorized recording was not reported to the Indiana Department of Health (IDOH) until someone reported it to corporate on 3/25/24. CNA 5, who still had the recording on her phone, was not suspended pending investigation and continued to provide resident care for approximately one week after the event. Staff anonymously notified corporate staff, leading to CNA 5's suspension and termination. The facility's current policy, titled Abuse Prevention Program, mandates that any alleged violations involving mistreatment, abuse, or neglect must be reported to the Administrator and DON immediately and to the State Licensing and Certification Agency (IDOH) within 24 hours. The DON indicated that the event and CNA 5 should have been reported to IDOH within the required timeframe. The failure to report the incident in a timely manner and the continued employment of CNA 5 without suspension pending investigation were identified as deficiencies in the facility's handling of the situation.
Failure to Protect Resident During Abuse Investigation
Penalty
Summary
The facility failed to ensure protection from abuse for residents while an investigation of abuse was conducted. A CNA used their cell phone to record a resident without permission and shared the recording with several staff members. The incident was not reported immediately, and the involved CNA continued to provide care to residents for six days after the event. The Director of Nursing (DON) was informed of the incident but did not suspend the CNA immediately. Instead, the CNA was told to delete the video. Staff meetings were held, and staff were re-educated on the abuse policy and the use of cell phones. During interviews, it was revealed that the CNA recorded the resident receiving pericare without the resident's or the staff member's knowledge. The CNA did not intervene during the recording but took over care afterward. The recording was shown to the first shift nurse, who reported it to the DON. Despite the facility's policy to immediately suspend staff suspected of abuse, the CNA continued to work until corporate staff were anonymously notified, leading to the CNA's suspension and termination. The facility's current policy on abuse prevention was provided, which mandates immediate suspension of staff suspected of abuse pending investigation.
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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