Waters Of Rockport Skilled Nursing Facility, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Rockport, Indiana.
- Location
- 815 W Washington St, Rockport, Indiana 47635
- CMS Provider Number
- 155274
- Inspections on file
- 29
- Latest survey
- March 10, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Waters Of Rockport Skilled Nursing Facility, The during CMS and state inspections, most recent first.
A resident’s funds were misappropriated when a QMA stole multiple checks from the resident’s checkbook and used them without consent. One check was successfully cashed for $700.00, and another for $1,200.00 was attempted but not completed after the QMA fled the bank when asked for identification, leaving a driver’s license behind. Review of the resident’s checkbook showed several missing checks, and the facility’s investigation confirmed that the QMA had taken and used the resident’s checks in violation of the facility’s abuse and misappropriation policy.
A resident with aphasia following intracranial hemorrhage and existing pressure ulcers was admitted with physician orders for specific coccyx and right buttock wound care, but no baseline care plan was in place for several days after admission. Record review showed that the baseline care plan was not completed and implemented until multiple days post-admission, despite facility policy requiring completion within 48 hours and the ADON’s acknowledgement that baseline care plans should be initiated within one to two days. This delay resulted in noncompliance with the facility’s own baseline care plan policy and regulatory requirements.
A resident with multiple comorbidities and dependence for mobility was admitted with intact skin but soon developed a coccyx pressure area that was documented as a Stage 1 ulcer and later as an unstageable pressure injury. Although the care plan identified an alteration in skin integrity and called for evaluation and treatment changes, the MAR/TAR showed no routine wound treatment orders or documented treatments to the coccyx for extended periods after both initial admission and subsequent readmission. Hospital records identified an unstageable pressure injury present on arrival, and later facility wound assessments documented an ongoing unstageable coccyx ulcer with slough and moderate serosanguinous exudate. In interviews, an LPN and an RN confirmed that admission/readmission wound assessments should trigger wound orders and weekly wound evaluations, but coccyx wound assessments were not documented for several weeks, resulting in a failure to provide pressure ulcer care consistent with facility policy and professional standards.
A resident with severe cognitive impairment and a high risk for falls experienced multiple falls, including one with major injury, due to the facility's failure to update the care plan, implement and review interventions, and provide adequate supervision. Most falls occurred while the resident was in a wheelchair in the lobby, and recommended interventions were not consistently put into practice or documented. Inconsistent follow-up, lack of IDT meetings, and incomplete neurological checks further contributed to the deficiency.
The facility did not ensure that kitchen staff, including the kitchen manager, had the necessary food service certification. Only the regional dietary manager was certified, while the rest of the kitchen staff were not yet certified and had only been registered for a future certification class. Facility policy required appropriate orientation and training for the dietary manager, but this had not been completed.
Several residents with complex medical conditions had blank entries on their MARs and TARs, indicating a failure to document the administration of prescribed medications and treatments. Nursing staff and the DON were unable to explain the missing documentation, citing possible computer or shift change issues, despite facility policy requiring all administered medications to be recorded.
Surveyors found that multiple rooms did not meet the required minimum square footage per resident, with several double occupancy rooms providing only 77.32 sq. ft. per resident and single rooms offering 90.52 sq. ft., both below regulatory standards. The Administrator confirmed the room sizes and referenced existing waivers.
A resident with dementia, anxiety, and depression was repeatedly administered Ativan and Zoloft without consistent assessment of effectiveness or implementation of non-pharmacological interventions. Despite documentation that Ativan was often ineffective, additional doses were given, and the resident experienced increased confusion and functional decline. The care plan lacked individualized strategies, and there was no evidence of mental health professional involvement, contrary to facility policy.
Three residents had inaccurate MDS assessments, including failure to document a completed Level 2 PASRR, omission of a recent UTI diagnosis despite antibiotic treatment, and incorrect coding of antibiotic use without supporting physician orders. The MDS Coordinator confirmed these assessment errors.
A resident with severe dementia and a history of falls was repeatedly left inactive in a Broda chair, despite documented interests in activities and a care plan calling for engagement. Staff did not consistently offer or facilitate participation in activities, and the resident experienced increased restlessness, functional decline, and multiple falls. Interviews and records showed a lack of individualized interventions or specialized dementia programming, contrary to facility policy.
The facility did not consistently post nurse staffing sheets for the correct day, with observations showing outdated sheets displayed at main entrances and a lack of postings on weekends. Interviews with the DON and Scheduler Coordinator confirmed that postings were delayed until after the start of the first shift and not completed on weekends, contrary to facility policy requiring daily postings at the beginning of each shift.
A facility failed to prevent pressure ulcers in a resident at moderate risk, as indicated by a Braden scale assessment. The resident, with conditions such as Parkinson's and diabetes, was admitted with a Stage I ulcer and later developed new Stage II and unstageable ulcers. The care plan lacked timely updates with preventive interventions, and documentation of turning and repositioning was insufficient until after the ulcers developed.
The facility failed to serve meals at safe and appetizing temperatures, with observations showing scrambled eggs at 89.0°F and bacon at 76.3°F. Residents reported ongoing issues with food temperature and quality, including cold and undercooked meals. The facility's policy requires hot food to be held at 135°F or greater, which was not met during the observed meal service.
A contracted pharmacy failed to deliver routine medications to residents during a winter storm, resulting in missed doses for four residents. The facility's emergency preparedness and pharmacy policies were insufficient to prevent the deficiency, as emergency supplies were limited and the pharmacy could not fulfill its service obligations.
The facility failed to ensure the food service department was directed by a certified and competent Dietary Manager. The Dietary Manager, who started in January 2023, was not certified and was only enrolled in a certification class starting in November 2023 with a goal completion date of November 2024. The facility lacked a policy for the Dietary Manager position requirements but provided a job description indicating the need for accredited dietetic training and state registration.
The facility failed to employ a qualified Infection Preventionist (IP) as required. The Director of Nursing (DON), who was also the appointed IP, spent fluctuating hours on IP duties without proper documentation. The facility's policy stated that the IP would usually be the DON or ADON, but the job description indicated that the IP reported to the DON, creating a conflict in roles and responsibilities.
The facility failed to provide a bed hold policy to residents or their representatives during hospital transfers for 8 out of 9 residents reviewed. Clinical records lacked documentation of the bed hold policy being given, despite the ADON stating it should be sent with the resident every time.
The facility failed to ensure that nurse aides were certified within the required timeframe and lacked proper documentation and supplies for the CNA training program. Five nurse aides were performing duties independently without certification, and the facility had discontinued CNA training classes due to staff departures.
A resident with multiple diagnoses was found to be receiving narcotic pain medications from an outside physician in addition to those prescribed by the facility's NP. The facility staff were unaware of the additional medications, leading to the resident experiencing withdrawal symptoms and having unauthorized medications in his possession. The lack of coordination and monitoring resulted in the resident receiving unnecessary medications.
The facility failed to store, prepare, and serve food in accordance with professional standards for food service safety. Observations included unlabeled and improperly stored food items, staff adjusting masks with gloved hands and handling food without sanitizing, and improper use of hairnets. The Dietary Manager and DON/IP confirmed these practices were against the facility's policies.
The facility failed to ensure residents were informed of the benefits of vaccines, obtain consents or refusals, and offer vaccines based on resident preference. Multiple residents' records lacked proper documentation and consent forms for administered vaccines, indicating non-compliance with the facility's immunization policy.
The facility failed to ensure residents were informed of the benefits of COVID-19 vaccines and did not obtain consents or refusals for four out of five residents reviewed. This included residents with histories of stroke, depression, fracture, osteoarthritis, Multiple Sclerosis, and hypertension. The facility's policy lacked clear guidance on when to obtain consent, contributing to the deficiencies observed.
The facility failed to provide the required minimum square footage per resident in both double and single occupancy rooms. Specifically, 14 out of 43 resident rooms did not meet the regulatory requirements, with double occupancy rooms having only 77.32 square feet per resident and single occupancy rooms having 90.52 square feet per resident.
A resident with multiple health conditions was found to be self-administering medications without a proper assessment, physician's order, or care plan. The facility's policy on self-administration was not followed, leading to unauthorized access to medications.
The facility failed to ensure accurate MDS Assessments for three residents. One resident on hospice care was inaccurately documented as not receiving hospice services, another resident's MDS did not reflect recent diagnoses of pneumonia and septicemia, and a third resident's MDS incorrectly indicated the use of a hypoglycemic medication.
The facility failed to develop care plans for three residents on various medications and one resident receiving hospice care. The residents lacked care plans for medications such as antidepressants, anticoagulants, diuretics, antiplatelets, and risk for opioid overdose, as well as hospice care.
The facility failed to ensure staff had the necessary knowledge and training for Narcan administration for a resident with a history of substance abuse and overdose. The drug was not available in the facility, and staff were not educated on its use, despite physician's orders and the resident's opioid use.
The facility failed to maintain accurate clinical records and document the destruction of medications for a resident with multiple diagnoses, leading to discrepancies in medication management. The resident's narcotic pain medication was incorrectly documented under the NP's name, and there was no record of destroying found medications, including Percocet, Prestiq, and Haldol.
The facility failed to ensure proper storage and disposal of medications, with observations of unlabeled, expired, and improperly stored medications in medication carts and storage rooms. Medication carts were also found unlocked and unattended.
The facility failed to prevent and contain COVID-19, with staff not performing proper hand hygiene, failing to notify physicians of elevated temperatures, and not enforcing isolation protocols for a COVID-19 positive resident.
The facility failed to post nurse staffing forms in an accessible area and did not update them daily during 3 of 5 days of the survey. The forms were observed in the back hallway, not accessible to residents and visitors, and were outdated on several days. The Administrator confirmed the forms should be updated daily and posted in a prominent location.
Misappropriation of Resident Funds by QMA Using Stolen Checks
Penalty
Summary
Facility staff failed to protect a resident from misappropriation of personal funds when a QMA took multiple checks from the resident’s checkbook and used them without consent. The resident was first alerted to suspicious activity on his bank account when contacted by his bank, and he then notified facility staff. Review of the resident’s checkbook revealed that several checks were missing and unaccounted for, including one that had already been successfully cashed for $700.00. The facility’s own investigation confirmed that the QMA had stolen multiple checks from the resident and used at least one of them to withdraw money from the resident’s account. Further review showed that the QMA attempted to cash another check from the resident’s account for a larger amount of $1,200.00. During this attempt, when the bank requested identification, the QMA fled the bank, leaving behind her driver’s license. Bank staff then contacted the resident, and the facility confirmed that the information on the driver’s license matched the QMA. The incident constituted misappropriation of resident property as defined in the facility’s Abuse Prevention Program policy, which prohibits the deliberate misplacement, exploitation, or wrongful use of a resident’s belongings or money without the cognitively intact resident’s consent.
Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a newly admitted resident with pressure ulcers. The resident, whose diagnoses included aphasia following a nontraumatic intracranial hemorrhage, was admitted on 3/5/26 with physician orders for treatment of coccyx and right buttock wounds, including cleansing with wound cleanser, patting dry, applying calcium alginate with Medihoney, and covering with a border foam dressing. Record review on 3/9/26 showed that the resident’s chart contained no care plan or baseline care plan at that time, despite the active wound care orders. On 3/10/26, further record review showed that a baseline care plan for admission was not entered until 3/9/26 at 4:36 P.M., which was more than 48 hours after the resident’s admission. During interview, the ADON stated that a baseline care plan should be put into place within one to two days after admission. The facility’s written policy, provided by the Administrator, required that every resident have a baseline care plan completed and implemented within 48 hours of admission, with the admitting nurse initiating the baseline care plan assessment upon admission and the IDT assisting to ensure completion within the regulatory timeframe. The failure to have a baseline care plan in place for this resident within 48 hours constituted noncompliance with the facility’s policy and applicable regulation.
Failure to Obtain Timely Wound Orders and Provide Ongoing Care for Existing Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary treatment and services for an existing pressure ulcer and to ensure timely wound care orders and assessments for a resident with significant risk factors. The resident’s diagnoses included muscle wasting and atrophy, protein-calorie malnutrition, anemia, and influenza. An admission MDS indicated the resident had no unhealed pressure ulcers on admission but was at risk for developing them and was dependent for mobility, including rolling side to side in bed. A Braden scale assessment later indicated low risk, but the care plan documented an alteration in skin integrity with an unstageable pressure injury, with interventions to evaluate and change treatment as needed and to observe and report new concerns. On admission, a weekly wound evaluation dated 1/10/26 documented a Stage 1 pressure ulcer on the coccyx measuring 7 cm by 4 cm with no depth, and noted redness on the coccyx with a small open wound toward the right buttocks, with a comment that the wound nurse should evaluate and provide ideas to help with healing. Nursing notes from 1/10/26 described a small open lesion on the coccyx with surrounding redness and irritation, and a 1/12/26 note documented that the resident reported needing to sleep on her side because of a bedsore. The resident was later admitted to the hospital, where a wound/ostomy evaluation on 1/17/26 identified an unstageable pressure injury to the buttocks present on arrival, with 100% slough and a small adjacent Stage 2 pressure injury, and a facility readmission assessment documented a pressure ulcer to the sacrum with specific measurements. Despite these findings, the MAR/TAR showed that the resident did not receive routine wound treatment and had no wound treatment orders to the coccyx from 1/10/26 to 1/14/26 prior to hospital transfer, and again had no routine wound treatment or orders from readmission on 1/21/26 through 2/8/26. A nurse’s note on 2/6/26 indicated that during a skin check a coccyx wound was found and a risk assessment was being submitted. Subsequent wound assessment reports on 2/18/26, 2/25/26, and 3/4/26 documented an unstageable pressure ulcer on the coccyx, present on admission, with varying percentages of granulation and slough and moderate serosanguinous exudate. In interviews, an LPN stated that initial admission or readmission wound assessments should trigger obtaining a wound treatment order and that the wound care nurse should complete weekly assessments, while an RN acknowledged that coccyx wound assessments were not documented from readmission on 1/21/26 until 2/18/26, contrary to the facility’s policy requiring necessary treatment and services for pressure injuries.
Failure to Update Care Plan and Supervise High-Risk Resident Leads to Multiple Falls
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and update the plan of care for a resident with severely impaired cognition and a high risk for falls. The resident experienced multiple falls, including one resulting in major injury with bilateral hip fractures. Despite repeated incidents, the care plan was not consistently updated with new interventions, and the recommended interventions were not always implemented or reviewed for effectiveness. For example, after an initial fall, the intervention to have the resident sit in a recliner in the lobby was not put into practice, and the resident continued to fall from the wheelchair in the lobby multiple times. The resident's clinical record showed a history of dementia with agitation, unsteadiness, and muscle weakness, requiring varying levels of assistance for mobility and daily activities. The resident had a pattern of restlessness and attempts to stand or pick up objects, leading to falls, most of which occurred while seated in a wheelchair in the lobby. The care plan included several interventions over time, such as anti-roll back devices, brake extenders, and reminders to use assistive devices, but these were not always updated or implemented after each fall as required by facility policy. Additionally, the use of a Broda chair, which was observed during the survey, was not included in the care plan. Documentation and follow-up after falls were inconsistent. Interdisciplinary Team (IDT) meetings and root cause analyses were not conducted after every fall, and new interventions were not always introduced. Neurological checks following unwitnessed falls were not completed according to policy, and care plan meetings did not always address changes in the resident's behavior or condition. These lapses in supervision, care planning, and documentation contributed to repeated falls and injuries for the resident.
Kitchen Staff Lacked Required Food Service Certification
Penalty
Summary
The facility failed to employ kitchen staff with the appropriate competencies and skill sets required for food and nutrition services, as evidenced by the kitchen manager not holding a food service certification. During an interview, the kitchen manager confirmed she did not possess any certification in food service. Further, the regional dietary manager stated that she was the only staff member certified with ServSafe, and that all other kitchen staff, including the kitchen manager, were only registered to take the certification class at a future date. The facility's policy indicated that the dietary manager should receive appropriate orientation and training, but there was no evidence that this had occurred for the current kitchen manager.
Failure to Accurately Document Medication and Treatment Administration
Penalty
Summary
The facility failed to ensure accurate documentation of medication and treatment administration for multiple residents, as evidenced by blank entries on Medication Administration Records (MAR) and Treatment Administration Records (TAR). For one resident with encephalopathy and a tracheostomy, required trach care and inner cannula changes were not documented on several shifts, despite physician orders for these treatments to be performed every shift. Nursing staff confirmed that these treatments should have been performed and documented, but the records were left blank on specific dates. Additional residents with diagnoses such as anxiety, depression, GERD, dementia, diabetes, atrial fibrillation, osteoporosis, and congestive heart failure also had blank entries for various medications on their MARs. These included missed documentation for medications such as Gas-X, Pantoprazole, Famotidine, Levothyroxine, Sodium Chloride, Guaifenesin, Wellbutrin, Metformin, Cipro, and Amoxicillin. Interviews with nursing staff and the DON revealed uncertainty about the reasons for the blank entries, with explanations ranging from possible computer errors to shift change issues, but no definitive cause was identified. Facility policy requires that the MAR be initialed by the person administering the medication, but this was not consistently done.
Failure to Meet Minimum Room Size Requirements
Penalty
Summary
The facility failed to provide the required minimum square footage per resident in both double and single occupancy rooms, as determined through interviews and record review. Specifically, 14 out of 43 resident rooms did not meet the regulatory standards of at least 80 square feet per resident in double occupancy rooms and 100 square feet in single occupancy rooms. The rooms in question were identified as having 2 beds with a total of 154.65 square feet, resulting in only 77.32 square feet per resident, and single rooms with only 90.52 square feet per resident. During an interview, the Administrator acknowledged the room size issue and indicated that the facility had room size waivers. A list of the affected rooms and their respective sizes was provided, confirming that these rooms did not meet the required space standards for resident occupancy as specified by regulations.
Failure to Prevent Unnecessary Use of Psychotropic Medications and Chemical Restraints
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from chemical restraints and unnecessary psychotropic medications. A resident with diagnoses including dementia with agitation, anxiety, depression, and unsteadiness was administered Zoloft and Ativan for depression and anxiety/behaviors. Despite the use of these medications, staff documented that Ativan was often ineffective in controlling the resident's restlessness and anxiety, yet additional doses were administered. The resident was observed repeatedly sitting in a Broda chair, appearing confused, fidgeting, and at times drowsy or sedated. Review of the clinical record revealed that the resident received frequent PRN doses of Ativan, with multiple instances documented as ineffective. There was a lack of consistent assessment for the effectiveness of both Ativan and Zoloft, and behavior monitoring was not routinely completed as required. The care plan for anxiety did not include resident-specific non-pharmacological interventions to address anxiety, restlessness, or behaviors prior to administering medication. Additionally, there was no documentation of a thorough assessment by a mental health professional, despite ongoing behavioral concerns and medication adjustments. Progress notes and therapy documentation indicated that the resident experienced increased confusion, functional decline, and drowsiness, which were associated with the increased administration of Ativan. Staff interviews confirmed that psychological consultations were not requested or documented, and that behavior and side effect monitoring were inconsistent. The facility's own policy required non-pharmacological interventions and behavioral programming to be attempted before psychotropic medications were used, but these steps were not documented or implemented for this resident.
Inaccurate MDS Assessments for Three Residents
Penalty
Summary
The facility failed to ensure accurate Minimum Data Set (MDS) assessments for three residents. For one resident, the most recent annual MDS assessment did not indicate that a Level 2 Preadmission Screening and Resident Review (PASRR) had been completed, despite documentation showing the PASRR was completed previously. Another resident's quarterly MDS assessment failed to document a urinary tract infection (UTI) in the last 30 days, even though the clinical record and physician's orders showed the resident had been treated with antibiotics for a UTI during that period. Additionally, a third resident's quarterly MDS assessment incorrectly indicated that the resident received an antibiotic during the 7-day look-back period, but there was no physician's order for an antibiotic in the clinical record for that timeframe. The MDS Coordinator acknowledged these errors during interviews, confirming that the PASRR, UTI, and antibiotic use were not accurately coded in the MDS assessments for the respective residents.
Failure to Provide Individualized Dementia Care and Activity Engagement
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident diagnosed with dementia, resulting in the resident not attaining or maintaining their highest practicable physical, mental, and psychosocial well-being. The resident, who had severe cognitive impairment, agitation, anxiety, depression, unsteadiness, and generalized muscle weakness, was observed repeatedly sitting inactive in a Broda chair in the lobby, often with empty hands and attempting to pull on his blanket. Despite documented interests in activities such as music, animals, current events, group activities, and going outside, the resident was not actively engaged or offered participation in activities, even when activity staff were present and notifying other residents. The care plans indicated the importance of individualized activities and engagement, but interventions were not consistently implemented or updated to reflect the resident's current needs and preferences. The resident's clinical record showed a history of multiple falls, including one resulting in major injury and hospitalization, and a significant decline in function and activity level. Progress notes indicated the resident was restless, attempted to get up unassisted, and was often unable to be redirected, leading to frequent administration of antianxiety medication and increased sedation. Physical therapy evaluations noted functional decline, muscle atrophy due to inactivity, and adverse effects from medication. Despite these findings, there was no evidence of a coordinated approach to address the resident's restlessness or to provide meaningful engagement tailored to his interests and abilities. Interviews with staff revealed a lack of specialized programming or individualized interventions for dementia care. The Activities Director, new to the facility, expressed a desire to implement more engaging activities for dementia residents but had not yet done so. The DON was unaware of any special measures in place for dementia residents, and the resident's wife and therapy staff both noted that the resident's restlessness and attempts to get up were likely due to boredom rather than anxiety. Facility policy emphasized the importance of person-centered care and activity engagement for residents with dementia, but these practices were not observed or documented in the resident's care.
Failure to Post Current Nurse Staffing Sheets Daily
Penalty
Summary
The facility failed to ensure that nurse staffing sheets were posted for the correct day as required, with observations over a five-day period revealing that the posted sheets at the front door were consistently dated for previous days rather than the current day. On multiple occasions, the posted staffing sheets did not reflect the current date, and in one instance, a staffing sheet was posted in a hallway without residents. Interviews with the DON and Scheduler Coordinator confirmed that the first shift begins at 6:00 A.M., but staffing sheets were not posted until 8:00 A.M. and were not posted at all on weekends. The facility's own policy, provided by the DON, requires daily posting of nursing staff at the beginning of each shift, which was not followed during the survey period.
Failure to Prevent Pressure Ulcers in At-Risk Resident
Penalty
Summary
The facility failed to provide adequate pressure ulcer prevention care for a resident identified as being at risk for pressure ulcers. Resident D, who had diagnoses including Parkinson's disease, type 2 diabetes, and dementia, was admitted with a Stage I pressure ulcer and was assessed to be at moderate risk for developing further pressure injuries. Despite this, the resident's care plan was not updated with interventions to prevent new pressure ulcers following a Braden scale assessment indicating increased risk. Additionally, there was no documentation of the resident being turned or repositioned in accordance with physician orders until late January, after new pressure ulcers had developed. Resident D developed a new Stage II pressure ulcer on the right heel and an unstageable pressure ulcer on the bilateral buttock, which were not addressed in the care plan until after their occurrence. The facility's policy required that 'at risk' residents have specific interventions promptly put in place, including turning and repositioning every two hours. However, documentation showed that routine turning and repositioning were not consistently performed or recorded prior to the development of these new pressure ulcers. Interviews with staff confirmed that the care plan should have been updated following the change in risk status, but this was not done in a timely manner.
Failure to Serve Meals at Safe Temperatures
Penalty
Summary
The facility failed to ensure that residents received meals at safe and appetizing temperatures, as evidenced by observations and resident interviews. During a meal service observation, scrambled eggs were found to be at 89.0 degrees Fahrenheit and bacon at 76.3 degrees Fahrenheit, both of which felt cold. Residents expressed ongoing dissatisfaction with the temperature and quality of the food, with one resident noting that meals were often cold, overdone, or raw. Resident grievances from November 2024 indicated similar issues, including undercooked chicken. The facility's Food Temperature Policy requires hot food to be held at 135 degrees Fahrenheit or greater, which was not adhered to during the observed meal service. The Administrator acknowledged the expectation for meals to be served at correct temperatures.
Pharmacy Service Failure During Winter Storm
Penalty
Summary
The facility failed to ensure adequate pharmaceutical services were available to provide physician-prescribed routine medications to four residents. The contracted pharmacy did not deliver the necessary medications due to a winter storm, resulting in residents missing multiple doses of their prescribed medications. Resident B, for instance, did not receive furosemide, potassium chloride, pravastatin sodium, rivaroxaban, and carvedilol on a specific day, as noted in the Medication Administration Record (MAR). Resident C, who has diagnoses including hypertension and heart disease, did not receive aspirin, atorvastatin calcium, and losartan potassium on the same day. Similarly, Resident D, with conditions such as muscle weakness and major depressive disorder, missed several medications over two days, including ascorbic acid, aspirin, cetirizine, and duloxetine, among others. Resident F, diagnosed with conditions like anxiety and Parkinson's disease, also missed multiple medications over two days, including amiodarone, aspirin, duloxetine, and levothyroxine. The facility's emergency preparedness binder and the pharmacy's policy and procedure manual were reviewed, indicating that the facility was aware of the need to provide medications even during emergencies. However, the pharmacy's inability to deliver due to the weather and the lack of sufficient emergency medication supplies in the facility led to the deficiency. The facility's policy required the pharmacy to provide routine and timely pharmacy services, which were not met in this instance.
Uncertified Dietary Manager in Food Service Department
Penalty
Summary
The facility failed to ensure the food service department was directed by a supervisor competent in food service management and knowledgeable in sanitation standards and food handling. The Dietary Manager, who started in January 2023, was not certified. During an interview, the Administrator confirmed that the Dietary Manager was enrolled in a certification class starting in November 2023 with a goal completion date of November 2024. The facility did not have a policy for the Dietary Manager position requirements but provided a job description indicating the need for a graduate of an accredited course in dietetic training and registration as a Food Service Director in the state.
Failure to Employ a Qualified Infection Preventionist
Penalty
Summary
The facility failed to employ a qualified Infection Preventionist (IP) as required. The Director of Nursing (DON), who was also the appointed IP, indicated that she spent about 8 hours earlier in the week on IP duties, although the hours dedicated to these duties fluctuated depending on the number of infections in the facility. The DON's hours spent on both DON and IP duties were not documented. The facility's Infection Prevention and Control policy stated that there would be an appointed person to lead the Infection Prevention and Control Program, usually the DON or Assistant Director of Nursing (ADON). However, the current job description indicated that the IP reported to the DON, creating a conflict in roles and responsibilities.
Failure to Provide Bed Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to ensure that a bed hold policy was provided to residents or their representatives during hospital transfers for 8 out of 9 residents reviewed. The clinical records for these residents lacked documentation of a bed hold policy being given at the time of hospitalization. Specific instances included Resident 7, who was admitted to the hospital and returned without any bed hold policy documentation, and Resident 17, who also lacked such documentation during their hospital stay. Other residents, including Resident 8, Resident 19, Resident 21, Resident 29, Resident 30, and Resident 10, similarly had no records indicating that a bed hold policy was provided during their respective hospitalizations. During an interview, the Assistant Director of Nursing (ADON) indicated that a bed hold policy, along with other necessary documents, should be sent with the resident every time they are transferred to the hospital. However, the review found that this procedure was not followed. An undated Bed Hold Policy provided by the Business Office Manager stated that the policy should be given in written form or via telephone conversation prior to hospital transfer or therapeutic leave and documented in the resident's record, which was not done in these cases.
Failure to Ensure CNA Certification and Training
Penalty
Summary
The facility failed to ensure that nurse aides who had worked more than four months were trained and certified, and that those who had worked less than four months were enrolled in appropriate training. Specifically, five nurse aides who had completed the CNA training program at the facility were not certified within the required timeframe. Employee records showed that these nurse aides had start dates ranging from March 2023 to September 2023 but had not obtained certification. Interviews with the nurse aides and the Administrator confirmed that these aides were performing CNA duties independently without having taken the certification test. The Administrator acknowledged that these aides should have been certified before working on the unit by themselves. Additionally, the facility was no longer conducting CNA training classes due to the departure of the program director and the delegated instructor. The facility lacked individual files for the five students who took the last CNA training class in July 2023, missing essential documentation such as classroom and clinical experience timeframes, assessment tools, PPD testing, physical exams, criminal background checks, and certification information. The DON and Administrator were unaware of the location of the necessary supplies for the training program, indicating a lack of organization and oversight in maintaining the training program's resources.
Failure to Monitor Resident's Drug Regimen
Penalty
Summary
The facility failed to ensure adequate monitoring and supervision of a resident's drug regimen, resulting in the resident receiving unnecessary medications. Resident 29, who had diagnoses including congestive heart disease, atrial fibrillation, edema, pain, morbid obesity, depression, and anxiety, was found to be receiving narcotic pain medications from an outside physician in addition to those prescribed by the facility's Nurse Practitioner (NP). The resident's clinical records indicated that he had not taken any Percocet in November 2023 or March 2024, despite having an order for it. Progress notes revealed that the resident had pain medications in his room that were not prescribed by the facility NP, leading to symptoms of withdrawal and agitation. The facility staff, including the Director of Nursing (DON) and the NP, were unaware of the additional medications being prescribed by the resident's Primary Care Provider (PCP) and had difficulty obtaining records from the PCP to ensure an accurate medication list. Interviews with the DON, a Registered Nurse (RN), and the facility NP indicated that there was confusion and lack of communication regarding the resident's medication regimen. The DON attempted to contact the PCP to reconcile the medications but was unsuccessful. The facility NP educated the resident on the importance of having only one provider, but the resident continued to see both the PCP and the facility NP. This lack of coordination and monitoring led to the resident having unauthorized medications in his possession, including narcotic pain pills and Haldol, which were not on his official medication list. The facility's failure to adequately monitor and supervise the resident's drug regimen resulted in the resident receiving unnecessary medications and experiencing withdrawal symptoms.
Failure to Adhere to Food Safety and Hygiene Standards
Penalty
Summary
The facility failed to store, prepare, and serve food in accordance with professional standards for food service safety. During an initial tour, surveyors observed multiple instances of improper food storage, including unlabeled and open food items in the refrigerator, freezer, and dry storage areas. Specific items included an opened bag of pepperoni, an opened bag of roast beef, and various other food items that were either not labeled or past their best-by dates. Additionally, there were issues with water on the refrigerator floor and freezer-burnt chicken thighs. These observations were confirmed during a second tour, where similar issues with unlabeled and improperly stored food items were noted in the dry storage area. The Dietary Manager confirmed that items should be labeled with the date prepped and what it was if not in its original container, and that meat should not be kept for more than three months in the freezer. The Director of Nursing/Infection Preventionist (DON/IP) also confirmed that food should not be open to air and should be properly labeled and stored away from clothing and other contaminants. The facility's current Food Safety and Sanitation Policy and Employee Health & Personal Hygiene Policy, both dated April 2017, were provided, indicating that the facility should follow safe handling and storage practices for potentially hazardous foods and maintain good personal hygiene among food service employees. Additionally, there were multiple instances of staff failing to maintain proper hygiene and food safety practices. Observations included staff adjusting facial masks with gloved hands and then handling food without sanitizing their hands, holding plate warmer lids and food containers against their clothing, and placing the bottom of a shoe on a shelf where food serving trays were stored. Specific incidents involved Cook 9 and Dietary Aide 21, who were observed with hairnets that did not fully cover their hair, adjusting masks with gloved hands, and handling food and food containers improperly. The DON/IP indicated that after touching a mask, staff should use hand sanitizer or perform hand hygiene, and that hairnets should cover all hair. The DON/IP also stated that food warmer tops should not be placed against clothing, and food should not be carried against clothing or held with the chin. These observations indicate a failure to adhere to the facility's policies and professional standards for food service safety and personal hygiene.
Failure to Obtain and Document Vaccine Consents
Penalty
Summary
The facility failed to ensure residents were informed of the benefits of influenza and pneumococcal vaccines, consents or refusals were obtained for vaccines, and vaccines were offered based on resident preference for five residents. Resident 1's clinical record lacked a consent for the flu vaccine administered, while Resident 15's record lacked an offer for the pneumococcal vaccine since a refusal in 2021. Additionally, Resident 3's record indicated a flu vaccine was administered with a consent form that did not match the resident's signature, and there was no signed consent for the pneumococcal vaccine. Resident 23's record lacked consent forms for both the flu and pneumococcal vaccines, despite the vaccines being administered. Resident 26's record also lacked a consent form for the flu vaccine administered. The facility's current Influenza and Pneumococcal Immunization policy, dated 1/1/17, indicated that residents and/or responsible parties should sign the Immunization Consent or Refusal form. However, this policy was not followed, as evidenced by the missing consent forms and lack of proper documentation for the vaccines administered to the residents. The deficiencies were identified through interviews and record reviews conducted by the surveyors, highlighting the facility's failure to adhere to its own immunization policy and ensure proper consent procedures were followed.
Failure to Obtain and Document COVID-19 Vaccine Consents and Refusals
Penalty
Summary
The facility failed to ensure residents were informed of the benefits of COVID-19 vaccines and did not obtain consents or refusals for four out of five residents reviewed. Resident 1, with a history of stroke and depression, received a COVID-19 booster without a signed consent form. Resident 15, with a history of fracture and osteoarthritis, denied wanting a COVID-19 booster, but the clinical record lacked a signed refusal form. Resident 3, diagnosed with Multiple Sclerosis and moderate cognitive impairment, received a COVID-19 booster without a signed consent form. Resident 23, with hypertension and moderate cognitive impairment, received a COVID-19 booster, but the consent form had a signature that matched another resident's form. Additionally, it was noted that Resident 23 was not cognitively able to provide consent, and staff should have obtained consent from her spouse. The facility's current COVID-19 Vaccine policy, dated 10/5/23, indicated that providers should counsel vaccine recipients, parents, or guardians about expected reactions but did not specify when to obtain consent. This lack of clear guidance in the policy contributed to the deficiencies observed. The failure to properly document consents and refusals for COVID-19 vaccinations indicates a significant lapse in the facility's adherence to regulatory requirements and proper documentation practices.
Facility Fails to Meet Room Size Requirements
Penalty
Summary
The facility failed to provide the required minimum square footage per resident in both double and single occupancy rooms. Specifically, 14 out of 43 resident rooms did not meet the regulatory requirements of at least 80 square feet per resident in double occupancy rooms and 100 square feet in single occupancy rooms. During an interview, the Administrator indicated that the facility had room size waivers and provided a list of rooms and their sizes. However, the listed rooms still did not meet the required square footage per resident, with double occupancy rooms having only 77.32 square feet per resident and single occupancy rooms having 90.52 square feet per resident. The deficiency was identified through interviews and record reviews, revealing that the facility's rooms were not compliant with the space requirements. The specific rooms identified were consistently below the required square footage, impacting the living conditions of the residents. The Administrator's claim of having waivers did not align with the actual measurements provided, leading to the conclusion that the facility was not in compliance with the regulatory standards for room sizes.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident who was self-administering medications was properly assessed for their capability to do so. Resident 29, who had diagnoses including congestive heart disease, atrial fibrillation, edema, pain, morbid obesity, depression, and anxiety, did not have a physician's order, care plan, or assessment to self-administer medications. The resident's clinical record lacked documentation related to self-administration of medications, and the resident was found with various medications in his room, including pain pills and antipsychotics, without proper authorization or oversight from the facility's medical staff. Observations and interviews revealed that the resident had been keeping medications in his room and self-administering them without the facility's knowledge or approval. The Director of Nursing and the Administrator both confirmed that the resident should not have been self-administering medications and that there was no proper assessment or physician's order in place. The facility's policy on self-administration of medications was not followed, leading to the resident having unauthorized access to potentially harmful medications.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure accurate Minimum Data Set (MDS) Assessments for three residents. Resident 21, who was on hospice care, was inaccurately documented as not receiving hospice services in the Significant Change MDS Assessment dated 2/26/24. This discrepancy was noted despite the resident being admitted to hospice on 2/15/24. The MDS Coordinator confirmed that the hospice care should have been marked on the assessment. Additionally, Resident 17's Quarterly MDS on 11/19/23 did not indicate the resident had pneumonia and septicemia, despite hospitalization records showing these diagnoses on 11/13/23. The subsequent MDS on 2/18/24 incorrectly marked these conditions, which the MDS Coordinator acknowledged as an error. Resident 27's Annual MDS inaccurately indicated the resident received a hypoglycemic medication, although the clinical record lacked an order for such medication. The MDS Coordinator admitted that this was a mistake and that their policy is to follow the Resident Assessment Instrument (RAI) manual. These inaccuracies in the MDS assessments highlight the facility's failure to ensure accurate and up-to-date documentation for residents' medical conditions and treatments.
Failure to Develop Care Plans for Medications and Hospice Care
Penalty
Summary
The facility failed to develop care plans for three residents who were on various medications and one resident who was receiving hospice care. Resident 29, who had diagnoses including congestive heart disease, atrial fibrillation, edema, pain, morbid obesity, depression, and anxiety, lacked care plans for taking an antidepressant, anticoagulant, diuretic, antiplatelet, and risk for opioid overdose. Resident 21, who had chronic obstructive pulmonary disease and anxiety, was observed to be on hospice care, but the clinical record lacked a care plan related to hospice care. The Director of Nursing and a Registered Nurse confirmed that a care plan for hospice should be in the electronic health record, but it was missing for Resident 21. Resident 11, who had diagnoses including atrial fibrillation, malignant neoplasm of the sigmoid colon, supraventricular tachycardia, Alzheimer's disease, bipolar disorder, and anxiety disorder, lacked a care plan for anticoagulant use. The Director of Nursing indicated that clinical records should have care plans for residents on different medications, including antipsychotics, antidepressants, diuretics, and anticoagulants. The facility's Baseline Care Plan Assessment/Comprehensive Care Plans Policy indicated that the comprehensive care plan should include measurable objectives and timetables to meet the resident's medical, nursing, physical functioning, mental, and psychosocial needs, but this was not followed for the residents mentioned.
Failure to Ensure Staff Training and Availability of Narcan
Penalty
Summary
The facility failed to ensure that staff had the necessary knowledge and training for the administration of Narcan for a resident with a history of substance abuse and overdose. During an observation, the resident was found asleep in bed, and a review of the clinical record revealed multiple diagnoses, including congestive heart disease, atrial fibrillation, edema, pain, morbid obesity, depression, and anxiety. The resident was taking an opioid, and there was a physician's order for Narcan to be administered in case of unresponsiveness. However, the clinical record lacked a care plan for the risk of opioid overdose, and staff were not educated or inserviced on the use of Narcan. Additionally, the drug was not available in the facility as required by the physician's order. Interviews with the Director of Nursing (DON) and a Registered Nurse (RN) revealed inconsistencies and a lack of awareness regarding the availability and location of Narcan in the facility. The DON indicated that Narcan was not kept at the facility, while the RN believed it was stored in the Pixis system but was unable to locate it. The RN also confirmed that no inservices had been conducted for Narcan administration, despite having residents with Narcan orders. The DON's job description emphasized the responsibility for ensuring staff education and compliance with federal and state regulations, which was not met in this instance.
Failure to Maintain Accurate Clinical Records and Document Medication Destruction
Penalty
Summary
The facility failed to maintain a complete and accurate clinical record for a resident who was receiving unnecessary medications. The resident, who had diagnoses including congestive heart disease, atrial fibrillation, edema, pain, morbid obesity, depression, and anxiety, was found to have discrepancies in his medication records. Specifically, a narcotic pain medication was documented under the name of the Nurse Practitioner (NP) when it was actually ordered by an outside physician. Additionally, there was a lack of documentation regarding the destruction of medications found in the resident's room, including Percocet, Prestiq, and Haldol. The resident's clinical record indicated that he was moderately cognitively impaired and required limited assistance for various activities. Progress notes revealed that the resident had complained about missing pain pills and expressed concerns about medication management. Despite efforts by the Director of Nursing (DON) to contact the resident's Primary Care Provider (PCP) and obtain accurate medication records, the facility was unable to reconcile the discrepancies. The resident continued to see both the facility NP and the PCP, leading to confusion and incomplete medication records. Interviews with the DON, a Registered Nurse (RN), and the facility NP highlighted the communication breakdown and lack of proper documentation. The facility's Controlled Substances policy required the DON and Consultant Pharmacist to maintain accurate records and ensure proper control of Schedule II drugs. However, the progress notes lacked documentation of the destruction of the medications found in the resident's room, and the clinical record was not updated to reflect the correct prescribing physician. This failure to maintain accurate records and properly document medication destruction led to the identified deficiency.
Improper Storage and Disposal of Medications
Penalty
Summary
The facility failed to ensure proper storage and disposal of medications, as observed in two of three medication carts and one medication storage room. During an observation, a plastic pill container in the locked narcotic box was found with only the resident's name and medication type, lacking other required information such as the date of birth, ordering physician, and directions for the medication. Additionally, two medication carts were left unlocked and unattended near the nurses' station, with residents present in the common area nearby. Further inspection of the medication storage room revealed expired medications and medications belonging to deceased or discharged residents. Specific medications were found without proper labeling, and some medications were expired. The facility's policy requires that outdated, contaminated, or deteriorated drugs be immediately withdrawn from stock and disposed of according to drug disposal procedures, which was not followed in this instance. Interviews with staff indicated that the disposal of medications was not conducted in a timely manner, with the responsibility often falling to the night shift nurses. The facility's administrator confirmed that medication carts should be locked at all times when not attended by authorized personnel. The facility's policies on medication storage and labeling were not adhered to, leading to the observed deficiencies.
Infection Control Deficiencies
Penalty
Summary
The facility failed to properly prevent and contain COVID-19, leading to several deficiencies in infection control practices. During an observation, a CNA did not perform hand hygiene between dirty and clean tasks while providing incontinence care to a resident. The CNA used the same gloves to handle both soiled and clean items, and failed to wash hands before donning new gloves. This lapse in protocol was confirmed by the DON, who indicated that hand hygiene should be performed between tasks. Another deficiency was noted when a resident with a COVID-19 diagnosis had elevated temperatures recorded, but the physician was not notified as required by the facility's protocol. The resident's clinical record showed temperature readings of 100 degrees and 99.1 degrees on different shifts, but there was no documentation of physician notification. The DON and Administrator confirmed that they could not locate any record of the required notifications. Additionally, a COVID-19 positive resident was observed multiple times sitting in a common area without a mask, and coughing, which is against the facility's isolation protocols. The resident's care plan indicated that they should be in droplet isolation, but this was not enforced. Staff also failed to wear the appropriate PPE when entering the resident's room. These observations were confirmed by the Administrator and ADON, who acknowledged that the resident should have been in isolation and that staff should have worn full PPE when providing care.
Failure to Post and Update Nurse Staffing Information
Penalty
Summary
The facility failed to ensure nurse staffing forms were posted in an area accessible to residents and visitors, and were not updated daily during 3 of 5 days of the survey. On multiple occasions, the posted nurse staffing forms were observed in the back hallway, which was not accessible to residents and visitors. The forms were also found to be outdated on several days. The Administrator confirmed that the forms should be changed prior to the following shift and by midnight for the next day, and acknowledged that the back hallway was the only place the forms were posted, not by the front door where visitors entered. The facility's current Staffing Posting Requirement policy indicated that the forms must be posted daily at the beginning of each shift in a conspicuous and prominent location accessible to residents and visitors.
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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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