Waters Of Scottsburg, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Scottsburg, Indiana.
- Location
- 1350 N Todd Dr, Scottsburg, Indiana 47170
- CMS Provider Number
- 155494
- Inspections on file
- 39
- Latest survey
- March 18, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Waters Of Scottsburg, The during CMS and state inspections, most recent first.
Surveyors found that kitchen staff with visible facial hair were working in food preparation and dishwashing areas without required beard guards, despite posted signage and a written policy mandating hairnets and beard guards in all food prep, processing, and storage areas. The Dietary Manager acknowledged that beard guards had run out but confirmed they were required by facility policy, which states that all facial hair must be fully covered when in these areas. This resulted in a cited deficiency related to food safety and hygiene standards.
The facility failed to prevent and adequately respond to multiple episodes of resident-to-resident abuse. A resident with schizophrenia and dementia verbally threatened another resident, and the threat was reported to the DON and Social Services, but no effective protective action is described. The next day, the same resident physically grabbed and shoved the threatened resident in the hallway, with staff witnesses describing grabbing by the neck and repeated shoving, while documentation minimized the contact as a slight push. In a related incident, another resident with a history of TBI admitted to pushing her rollator into the same resident’s legs due to perceived intrusion into personal space, after which staff had to separate them. These events occurred amid ongoing reports that the victim resident was pacing halls, entering others’ rooms, and disturbing residents, leading to repeated physical altercations that met the facility’s own definition of abuse.
A resident with hypotension had a physician’s order for Midodrine 10 mg via G-tube three times daily, with instructions to hold the dose if systolic blood pressure (SBP) was greater than 110. Review of the MAR showed that staff administered the medication on several occasions when the resident’s SBP was above this parameter, including readings of 122, 126, and 119. In an interview, an LPN acknowledged that physician orders should be followed, confirming that the medication should have been held when SBP exceeded the ordered limit.
Surveyors found that meal service failed to provide adequate food temperature, quality, and portion sizes. Observations showed overcooked meatloaf with very small portions and soup bowls filled only a quarter of the way. Multiple residents reported being consistently hungry after meals and described portions as suitable for a young child. Residents also stated that food, especially breakfast items and meals served in rooms, was often cold. A tray temperature check confirmed substandard temperatures for scrambled eggs and sausage links, despite a facility policy requiring TCS foods to be held at or above 135°F.
Surveyors found that between-meal snacks were not consistently available or nutritionally adequate, with observations showing only a jar of peanut butter, a few peanut butter or peanut butter and jelly sandwiches on hard bread with minimal filling, and limited snack options such as small bags of Cheez-Its. Several residents reported that snacks were not always offered, especially at night, and that when provided, the sandwiches lacked substance. A staff member confirmed that dietary repeatedly sent sandwiches with only a small clump of peanut butter that was not spread. These practices did not follow facility policies requiring three meals daily plus an evening or bedtime snack and a variety of high-nutritional-value snacks stocked in each service area.
The facility failed to keep residents and their representatives informed about key aspects of care and treatment. A resident with a recent above-knee amputation and chronic pain had a prescribed narcotic pain medication dose reduced without being informed, only discovering the change when the medication appeared different, and there was no documentation of notification in the record. The same resident had a hospital-ordered vascular follow-up appointment for suture management that was missed, with no documented effort by the facility to notify the resident of the appointment or to reschedule after a no call/no show. In a separate case, another resident with dementia was discharged from therapy after about a month when max potential was deemed reached, but the PT did not notify the family and relied on nursing staff, and the record contained no documentation that the resident’s representative was informed of the discontinuation of therapy.
The facility failed to ensure complete, accurate, and timely reporting of multiple resident-to-resident abuse allegations to the abuse coordinator and Administrator. A staff member overheard a male resident threaten to kill a female resident if she entered his room and, after reporting this to the DON and Social Services, no clear abuse report followed and the Administrator later stated she was unaware of the threat. The next day, the same male resident physically grabbed and shoved the same female resident in the hallway; staff witnesses described grabbing at the neck and shoulder, twisting an arm, and repeated shoving, but the written incident report minimized the contact as a slight push after she entered his room. In a separate event, another resident admitted to striking the same female resident’s legs with a rollator walker due to perceived intrusion into personal space, yet this was not promptly or fully reported as abuse. These actions and omissions conflicted with the facility’s abuse policy requiring immediate reporting of all incidents and allegations of potential mistreatment and prompt initiation of an investigation.
Surveyors found that multiple residents on anticoagulants and insulin were not consistently monitored or had no documented monitoring for bleeding or hypo/hyperglycemia, despite physician orders for aspirin, Xarelto, apixaban, and various insulin regimens. Records for several residents with diabetes, cardiovascular disease, and thromboembolic conditions lacked required assessments for bleeding and blood sugar-related symptoms over extended periods. An LPN acknowledged that residents on blood thinners and insulin should be monitored and that this monitoring should be recorded on the MAR, consistent with the facility’s medication administration policy.
A resident with COPD was found to have a room closet that was not properly maintained, with the sliding closet door off its track and leaning against the closet side, and extensive gray/black spotted areas identified by staff as mold on the closet walls and above the closet entrance. Facility records showed the room had been marked as deep cleaned, and the housekeeping supervisor later acknowledged that housekeeping was responsible for cleaning closets and that this closet had likely been missed during deep cleaning.
Surveyors found that a resident with significant neurologic impairments had multiple discrepancies between the MAR and controlled substance records for Modafinil, including undocumented doses on the narcotic log and additional or duplicate doses without corresponding physician orders, along with no documented physician or NP visits in the chart. Other residents with complex conditions, including cancer, liver transplant, diabetes, respiratory failure, paraplegia, traumatic brain injury, and CHF, lacked timely or ongoing physician and NP progress notes in their records. Staff interviews confirmed that medications are expected to be given only with orders and that controlled substances must be documented at the time of administration, and facility policies required current, complete health records and properly maintained MARs and physician visit documentation.
A resident with depression and anxiety, who was cognitively intact, reported that a Social Services Designee (SSD) entered her room with a new roommate, abruptly pulled open the privacy curtain without knocking or identifying herself, and told the roommate that the resident was a woman, then told the resident in front of the roommate that she needed to shave her face. The resident stated she felt humiliated and cried after the incident. The SSD later documented that she entered with the roommate to address the roommate’s concern about not wanting to sleep in a room with a man and that she pulled the curtain, introduced the residents, and explained that the resident was a woman who had facial hair, offering help with shaving, but did not document identifying herself or obtaining permission before opening the curtain. The facility’s resident rights document included the right to be treated with dignity and respect.
A resident with a history of atrial fibrillation had a physician’s order for Propranolol 20 mg TID with instructions to hold the dose if systolic BP was below 110, but nursing staff repeatedly administered the medication when the resident’s BP readings were below the ordered parameter. Record review showed multiple administrations at times when SBP values were documented under 110, contrary to the order. An RN acknowledged that physician-set parameters must be followed, and the facility’s medication administration policy required medications to be given as prescribed, including adherence to ordered parameters.
A resident with anoxic brain injury, acute respiratory failure with hypoxia, hypercapnia, and anxiety, who was care planned as a fall risk with instructions to keep the call light within reach, was observed resting in bed without an accessible call light, while the only call cord in the room was positioned for the roommate. A CNA confirmed there was no call light available for this resident and noted a split call cord should have been present, and an LPN stated all residents should have a call light within reach. The facility’s call light policy, provided by the regional nurse consultant, requires a functioning, accessible call system in each resident room, but this was not in place for the resident involved.
A resident with end stage renal disease and psychiatric diagnoses, but documented intact cognition, was moved to a secured memory care unit and had his cell phone removed from his possession without his consent or documented discussion with him. He reported that after independently going outside to the front porch, staff later placed a monitor on him, moved him to the secured unit, and took his phone, leaving him feeling like a prisoner and unsure why he was on the unit. Facility records showed that the IDT and Social Services discussed exit seeking and impulsive or manic behaviors with the resident’s family, who agreed to the room change and phone restriction, but behavior logs did not document exit seeking or related behaviors during the reviewed period, and there was no documentation that the resident himself was informed of or involved in these decisions, despite a policy affirming residents’ rights to dignity and respect.
A resident with bipolar disorder, major depressive disorder, dementia, and exit-seeking behaviors was transferred to a secured memory care unit, but the facility did not initiate a secured unit baseline care plan at the time of the move. Documentation shows the room change occurred, yet the first secured unit care plan entry was not made until weeks later. The DON acknowledged that the care plan for the secured unit should have been started when the resident was moved. Facility policy indicated that comprehensive care plans must address resident risks, goals, and interventions using a person-centered approach and be updated based on assessed needs, but this was not followed for this resident’s timely care planning.
A resident with diagnoses including diabetes, end-stage renal disease, major depressive disorder, anxiety, and bipolar disorder was placed on a secured memory care unit based on a physician order and a care plan that cited dementia and exit seeking, despite the clinical record lacking any diagnosis of dementia, Alzheimer’s disease, or other irreversible dementia or documentation of clinical need for a secured unit. The former primary care physician reported that the resident did not have a dementia diagnosis and that he would not have initiated an order for dementia unit placement. This conflicted with the facility’s Memory Springs admission criteria, which require a diagnosis of Alzheimer’s or irreversible dementia and a physician determination of clinical need for a secured unit.
Surveyors observed unsanitary conditions in the kitchen and nourishment rooms, including food and equipment stored directly on the floor, accumulation of crumbs and unknown substances, and undated or expired food items in refrigerators. Cleaning schedules were missing, and staff interviews confirmed that cleaning responsibilities and documentation were not maintained according to facility policy.
A resident with a history of falls and impaired mobility was physically restrained in a wheelchair using a gait belt for approximately 15 minutes by a CNA, who did so to prevent the resident from falling while staff were busy with another resident. The restraint was not part of the care plan and was reported by staff during shift change, with the gait belt found still attached in a restraining position. The CNA stated she was unaware this action constituted abuse, despite prior education on abuse and restraints.
Staff and resident interviews, along with direct observation, revealed that snacks were frequently unavailable, with nursing staff often purchasing snacks themselves due to inadequate supply from dietary services. Essential food items were out of stock, and the nourishment pantry was poorly stocked, resulting in residents—including those with specific dietary needs—not consistently receiving snacks as required by facility policy.
Two residents with hypertension received blood pressure medications despite physician orders to hold the medications for SBP less than 120. The EMAR showed multiple instances where atenolol and metoprolol were administered when SBP readings were below the ordered threshold, contrary to facility policy and physician instructions.
A resident with generalized anxiety received additional doses of Lorazepam without a physician's order, as documented in controlled drug records. The medication, ordered for bedtime use, was also administered in the morning on several dates without proper documentation or authorization. Staff confirmed that medications should only be given as prescribed, in accordance with facility policy.
A resident with orders for double portions at all meals, due to conditions including Parkinson's disease and prostate cancer, did not receive the required double portions during a meal service. The meal ticket clearly indicated the need for double portions, and facility policy requires accuracy in meal service, but the dietary staff did not follow the order.
A resident with vascular dementia and a severe intellectual disorder, who required a pureed consistent carbohydrate diet with an inner lip plate, was served a meal without the necessary assistive device, despite clear orders and care plan instructions. The meal was served in individual bowls, and dietary staff did not follow the meal ticket or facility policy for therapeutic diet accuracy.
The facility failed to provide 8-hour consecutive RN coverage from July to December 2024, affecting all 60 residents. The nursing schedule showed multiple days with only 6 hours of RN coverage. The Executive Director and Corporate Nurse Consultant were unaware of the requirement, while the DON knew but acknowledged the lack of coverage every other weekend. The Facility Assessment required 6 licensed nurses and 4 CNAs per 12-hour shifts, but the facility did not meet the RN coverage requirement.
The facility failed to properly document narcotic medication counts and remove expired insulins from medication carts. Discrepancies were found in narcotic counts, with staff admitting to not signing out medications immediately. Expired insulin vials were also found in use, contrary to facility policy. These issues were observed across multiple medication carts, affecting the safe care of residents.
A resident with multiple health issues was not properly secured in a wheelchair van, resulting in a fall during transport. The van driver did not follow the facility's emergency procedures, and the incident was not immediately reported. The resident later experienced pain and required medical assessments.
A facility failed to monitor a resident's dialysis site after returning from the hospital, as the physician's order was not reinstated. The resident, with end-stage renal disease, continued dialysis without proper monitoring of their AV fistula for two months. Interviews revealed the oversight was due to the order not being re-entered into the system.
A facility failed to properly store and dispose of insulin pens in the Eagle Court Hall Medication Cart. A resident's Humalog kwikpen was found without a pharmacy label and had an incorrect open date, despite the order being discontinued. Other insulin pens were also improperly stored, lacking proper labeling and documentation. These actions violated the facility's policies on medication storage and disposal.
The facility failed to provide snacks to residents, with several residents and staff reporting that snacks were not available, leading to residents purchasing their own. The dietary department did not supply snacks, and the Director of Nursing confirmed the issue since a new company took over. Observations showed limited pantry supplies, and the dietary service manager acknowledged the lack of specific items. The facility's policy indicated snacks should be available 24/7, but this was not adhered to.
A resident with end-stage heart failure and anxiety was not informed in a timely manner about the cancellation of her pain management appointment after hospice took over her care. The resident only learned of the cancellation on the day of the appointment, leading to distress. Staff interviews confirmed the lack of communication, violating the resident's rights to be informed of her health status.
An LPN in a facility verbally abused two residents, one with schizoaffective disorder and another with anxiety and chronic respiratory failure. The LPN used derogatory language, dismissed residents' concerns, and escalated situations, causing distress. These actions violated the facility's Abuse Prevention Program policy.
The facility failed to report and document incidents of abuse and inappropriate conduct involving two residents. An LPN was heard using inappropriate language and upsetting a resident with schizoaffective disorder. Another resident with anxiety and chronic respiratory failure experienced a delay in care and was subjected to derogatory remarks by the same LPN. Despite reports to the DON, the incidents were not documented as required by the facility's Abuse Prevention Program policy.
A facility failed to implement a care plan for a resident after all her teeth were extracted. Despite the resident's significant health change, the clinical record lacked documentation of a care plan addressing the extraction. The DON assumed a care plan would be in place, but the RDO provided a policy indicating care plans should be updated with health changes.
A resident with hypertension and end-stage heart disease had all her teeth extracted, but the facility delayed implementing a necessary diet change. The resident's clinical record lacked documentation of dietary adjustments until four days after the procedure, despite the significant impact on her ability to eat. Interviews indicated that no paperwork was provided by the dentist, and there was a failure to promptly clarify the new diet.
A facility failed to provide a prescribed therapeutic diet for a resident with diabetes, anxiety, and major depressive disorder. The resident was supposed to receive prune juice with lunch daily, as per a physician's order. However, the resident reported never receiving it, and the facility lacked prune juice, as confirmed by the Regional Director of dietary services.
The facility failed to change PICC line dressings as ordered for two residents. One resident with acute osteomyelitis and another with bacteremia had dressings that were not changed weekly as required. Observations showed dressings dated from October, despite records indicating changes. An LPN confirmed the need for weekly changes, and the DON provided documentation supporting this protocol.
A resident with anxiety and COPD did not receive her routine Lorazepam as ordered, with significant gaps in administration noted in October and November. Interviews revealed frequent delays or missed doses, and controlled drug records lacked documentation. An RN confirmed the need for proper documentation, as outlined in the facility's medication administration policy.
The facility failed to serve meals at appropriate temperatures and times on [NAME] Hall. Observations showed that food temperatures were not consistently appetizing or safe, with residents expressing dissatisfaction over cold and late meals. Resident council minutes from September and October 2024 also highlighted concerns about breakfast and dinner service.
A facility failed to accurately document the administration of PRN Morphine Sulfate for a resident with end-stage heart failure and other conditions. The controlled drug records showed multiple administrations, but the medication administration record lacked documentation for these instances. An RN confirmed the procedure for documenting PRN narcotics, and the DON provided a document outlining safe medication administration practices.
Failure to Enforce Beard Guard Use for Kitchen Staff
Penalty
Summary
The facility failed to ensure kitchen staff used required facial hair coverings while working in food preparation and dishwashing areas. On 3/15/26 at 12:14 p.m., signage on the kitchen door stated that staff must have hairnets and beard guards in place to enter the kitchen. During an observation at 12:16 p.m., a dietary aide and a dishwasher, each with 1/2 inch or longer facial hair on their lip and chin areas, were seen working in the kitchen dish and food preparation areas without beard guards. In an interview at 12:19 p.m., the Dietary Manager stated they had just run out of beard guards, but confirmed that facility policy required beard guards to be worn while in the kitchen. The Executive Director later provided the facility’s written policy, last reviewed on 6/2/25, which specified that all personnel must wear approved beard guards in food preparation, processing, or storage areas, and that beard guards must fully cover all facial hair. This deficiency was cited under 410 IAC 16.2-3.1-21(i)(3) and related to multiple complaint intakes, indicating noncompliance with state requirements for food procurement, storage, preparation, distribution, and service in accordance with professional standards.
Failure to Prevent and Respond to Resident-to-Resident Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from resident-to-resident abuse despite clear warning signs and prior incidents. Resident B, who had diagnoses including schizophrenia, depression, suicidal ideations, and vascular dementia, verbally threatened Resident C on one day, telling her he would kill her if she came into his room. Staff Member 8 overheard this threat and reported it to the Director of Nursing, who instructed her to inform Social Services. When the incident was reported to Social Services, the staff member was asked what she wanted Social Services to do about it. The Administrator later stated she was unaware of this threat when she initially reported the subsequent physical incident and had not yet obtained staff statements. The following day, Resident C, who had a history of traumatic subarachnoid hemorrhage, traumatic brain injury, affective mood disorder, and anxiety, continued to pace the halls, enter other residents’ rooms, rummage through belongings, and disturb other residents, and was described as difficult to redirect and agitated. Around that time, Resident C approached the area near Resident B’s room. Multiple staff interviews indicated that Resident B came out of his room, grabbed Resident C by the neck and shoulder area, twisted her arm behind her back, and pushed her into a geriatric chair in the hallway, shoving her multiple times as she tried to get away. Staff Member 9 intervened and separated the residents, and both Staff Member 9 and Staff Member 17 reported what they witnessed to the Director of Nursing. The incident report and progress note, however, documented the event as Resident B placing his hands on Resident C’s shoulders, turning her around, and slightly pushing her from the back. In a separate but related incident, Resident D, who had a history of traumatic brain injury and anxiety, admitted to pushing her rollator walker into Resident C’s legs because Resident C had entered her personal space. Staff Member 9 reported that she had to separate Resident C and Resident D after Resident D rammed her walker into Resident C’s legs and reported this to the Director of Nursing. An incident report later documented that Resident D made contact with Resident C’s legs with her rollator walker. These events occurred in the context of Resident C’s ongoing behavior of pacing the halls, entering other residents’ rooms, and disturbing them, and demonstrate multiple instances of resident-to-resident physical contact that met the facility’s own definition of physical abuse under its Abuse Prevention Program, which states the facility will not tolerate abuse by anyone, including other residents.
Failure to Follow Blood Pressure Parameters for Midodrine Administration
Penalty
Summary
Surveyors found that the facility failed to follow a physician’s ordered blood pressure parameter for administration of Midodrine for one resident. Resident K had a diagnosis that included hypotension and a physician’s order, dated 2/14/26, for Midodrine 10 mg via gastrostomy tube three times daily at 6:00 a.m., 2:00 p.m., and 10:00 p.m., with instructions to hold the medication if the systolic blood pressure (SBP) was greater than 110. Review of the February 2026 medication administration record showed that staff administered Midodrine despite SBP readings above the ordered parameter on multiple occasions: on 2/16/26 at 10:00 p.m. when SBP was 122, on 2/17/26 at 6:00 a.m. when SBP was 126, on 2/17/26 at 10:00 p.m. when SBP was 119, and on 2/19/26 at 6:00 a.m. when SBP was 119. In an interview, an LPN stated that physician’s orders should be followed, confirming that the medication should not have been given when the SBP exceeded the ordered threshold.
Inadequate Food Temperature, Quality, and Portion Sizes During Meal Service
Penalty
Summary
The deficiency involves the facility’s failure to provide palatable, adequately portioned food at safe and appetizing temperatures during meal service. During a kitchen observation, meatloaf on the steam table was noted to have blackened areas across the top and along the edges, and the portion size being served measured approximately 3 inches by 1 inch by 1 inch. Multiple residents reported that soup bowls at supper and dinner were only filled a quarter of the way, and that meatloaf portions were equivalent to two or three bites. Several residents stated that after every meal they were still hungry because the portion sizes were so small and described the quantity of food as what would be served to a young child. Residents also reported and observations confirmed that food was frequently served cold, particularly breakfast items and meals delivered to rooms. One resident stated that the previous night’s soup and the morning’s hash brown and sausage links were cold when served. Another resident reported that food served in rooms, especially eggs, was always cold. A random tray temperature check showed scrambled eggs at 98.8°F and sausage links at 86.4°F, while oatmeal measured 149.2°F. Residents described the food as generally cold, overcooked or undercooked at times, and of poor quality, with one resident stating the meatloaf was way overcooked and another reporting that twice they had been served undercooked food. The facility had a written policy requiring TCS foods to be held at 135°F or above and temperatures to be recorded before service, but the observed temperatures and resident reports showed this was not consistently achieved.
Inadequate Availability and Quality of Nutritional Snacks
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a variety of snacks with nutritional value were consistently available and properly prepared for residents, as required by facility policy. Surveyors observed the snack pantry containing only one jar of peanut butter, no bread, and a tray with a small number of peanut butter and peanut butter and jelly sandwiches in baggies, with hard bread crusts and no other snacks available except those purchased by residents themselves. The snack cart was observed to have only small bags of Cheez-Its as snacks. On another observation of snack sandwiches sent from dietary, surveyors found several peanut butter and peanut butter and jelly sandwiches with hard crusts and such minimal fillings that the peanut butter and jelly had saturated into the bread, leaving no substance to the sandwiches. Multiple residents reported that snacks were not always available or offered, particularly at night, because staff did not have anything to provide. One resident stated that the peanut butter and jelly sandwiches had barely any filling, with only thinly spread peanut butter and jelly that soaked into the bread, which was hard. Another resident reported that the only snacks available were peanut butter sandwiches on hard bread with very little peanut butter. A staff member confirmed that dietary had repeatedly sent peanut butter sandwiches with only a small clump of peanut butter, about the size of a quarter, placed in the middle of the bread and not spread. Another resident indicated that nursing staff had to go out and buy peanut butter and bread so residents could have snacks because the dietary department rarely sent snacks. These findings were inconsistent with the facility’s written policies stating that each resident shall receive three meals daily plus an evening or bedtime snack, and that a variety of snacks of high nutritional value will be stocked in each service area by dining services.
Failure to Inform Residents of Treatment Changes and Missed Follow-Up Care
Penalty
Summary
The facility failed to ensure residents were fully informed about their health status, care, and treatments, and failed to arrange a necessary follow-up appointment. One resident with intact cognition and diagnoses including diabetes, chronic pain, depression, and a recent left above-knee amputation was discharged from the hospital with orders for a follow-up appointment with a vascular nurse practitioner and was prescribed Oxycodone-Acetaminophen 7.5-325 mg every 6 hours for pain. A subsequent physician order decreased this pain medication to 5-325 mg every 6 hours, but the clinical record contained no documentation that the resident was notified of this change. The resident reported he only realized his pain medication had been decreased when he noticed the pills were a different color and was then told by a nurse that the nurse practitioner had decreased the dose. The clinical record also lacked documentation that the resident was informed of the original follow-up appointment, the need to reschedule it, or any related communication. The same resident’s hospital discharge orders included a follow-up appointment on 2/16/26 with the vascular provider, but the vascular center reported the facility made no contact to reschedule after the resident was listed as a no call/no show for that appointment. The appointment was later rescheduled after involvement from an external social worker, and the resident ultimately arrived late but was still seen for suture removal. In a separate case, another resident with dementia and lack of coordination had been receiving therapy services. The resident’s representative stated she had requested therapy to help increase the resident’s strength and had not observed any therapy being provided, nor had she been notified about the status of therapy. The physical therapist reported working with the resident for about a month, stated that maximum potential had been reached, and that the resident was discharged from therapy, but he did not notify the family and instead relied on nursing staff to do so. The clinical record lacked documentation that the resident or representative was notified of the discontinuation of therapy services.
Failure to Accurately and Timely Report Resident-to-Resident Abuse Allegations
Penalty
Summary
The deficiency involves the facility’s failure to ensure complete and accurate information was provided to the abuse coordinator, failure to report an allegation of resident-to-resident abuse to the abuse coordinator, and failure to timely report an allegation of verbal abuse for multiple residents. On one day, a staff member overheard a male resident (Resident B) threaten to kill a female resident (Resident C) if she entered his room. This staff member reported the threat to the DON, who instructed the staff member to inform Social Services; when informed, Social Services questioned what they were supposed to do about it. The Administrator later stated she was unaware of this threat. The following day, Resident C was ambulating down a hall when Resident B exited his room, grabbed her by the neck and shoulder, twisted her arm behind her back, and pushed her into a geriatric chair in the hallway, continuing to push her as she tried to get away. A staff member intervened and reported the incident to the DON, who said it would be reported to the Administrator. Another staff member witnessed Resident B grab Resident C at the top of her left shoulder and neck area, swivel her around, and shove her three times down the hallway. However, the incident report documented only that Resident C entered Resident B’s room and that Resident B, upset, placed his hands on her shoulders to turn her around and slightly pushed her from the back. The Administrator indicated she reported only what she had been told, had not yet obtained staff statements, and did not have the full story when she reported the incident. The deficiency also includes a separate resident-to-resident physical contact incident that was not fully reported to the abuse coordinator. A staff member reported that she had to separate Resident C from another resident (Resident D) after Resident D rammed her walker into Resident C’s legs. The Administrator later indicated that Resident D admitted to hitting Resident C in the leg with her walker because Resident C was in her personal space, and Resident D herself confirmed she pushed her walker into Resident C and hit her legs for the same reason. An incident report dated two days after the event indicated it was reported to the Administrator that Resident D made contact with Resident C’s legs with her rollator walker. The facility’s Abuse Prevention Program policy requires supervisors to immediately inform the Administrator or person in charge of all reports of incidents or allegations of potential mistreatment and requires the Administrator or designee to initiate an incident investigation upon learning of a report. The survey findings show that these requirements were not followed for the verbal threat, the physical altercation between Residents B and C, and the walker incident between Residents C and D.
Failure to Document Monitoring for Anticoagulant and Insulin Therapy
Penalty
Summary
The deficiency involves the facility’s failure to ensure appropriate monitoring and documentation for residents receiving anticoagulant and insulin therapy, as required by its medication administration policy. For one resident with diabetes and a history of left above-knee amputation, admission orders included aspirin 81 mg daily, Xarelto 20 mg daily with breakfast, and insulin lispro 5 units subcutaneously with meals. Review of this resident’s medication administration records for January, February, and March 2026 showed no documentation that nursing staff monitored for signs or symptoms of bleeding related to the blood thinners or for signs or symptoms of hypoglycemia or hyperglycemia related to the insulin. Another resident with diabetes had an order for Lantus 25 units subcutaneously twice daily at 9:00 a.m. and 9:00 p.m., but the clinical record lacked documentation that nursing staff monitored for signs or symptoms of hyperglycemia or hypoglycemia. Two additional residents receiving anticoagulant therapy also lacked documented monitoring for bleeding. One resident with chronic embolism and thrombosis of the right upper extremity had an order for apixaban 5 mg twice daily at 8:00 a.m. and 8:00 p.m., yet the clinical record showed no documentation of bleeding assessments from March 12 through March 16, 2026. Another resident with hypotension and cardiovascular disease had an order for apixaban 5 mg twice daily at 8:00 a.m. and 8:00 p.m. for cardiovascular health, but the record similarly lacked documentation of monitoring for signs of bleeding. During an interview, an LPN confirmed that residents on blood thinners should be monitored for signs of bleeding and residents on insulin should be monitored for hyperglycemia and hypoglycemia, and that such monitoring should be documented on the medication administration record. The facility’s Medication Administration Policy Guideline stated that medications are to be administered as prescribed and in accordance with good nursing principles and practices.
Environmental Deficiency in Resident Closet Cleanliness and Maintenance
Penalty
Summary
The facility failed to maintain a safe, clean, and intact environment in a resident’s room closet, specifically for Resident B. Resident B’s clinical record showed diagnoses including chronic obstructive pulmonary disease. During observation of the resident’s room, the sliding closet door was found off its track and leaning against the right side of the closet rather than being properly installed. Inside the closet, the right upper wall contained multiple gray/black spotted areas extending across the width of the wall and approximately 10 inches downward, and the interior wall above the closet entrance had a large vertical area of gray/black spotting with two streaked areas and a larger dark gray/black area measuring about 3 inches by 1.5 inches. A staff member identified these gray/black spotted areas as mold. Review of the deep cleaning schedule showed the room was documented as deep cleaned on 2/25/26, and the housekeeping supervisor later indicated that housekeeping was responsible for ensuring closets were mopped, cleaned, and free of debris and that this closet had likely been missed during deep cleaning. This deficiency was cited under 410 IAC 16.2-3.1-19(f) and relates to Intake 2730662.
Medication Documentation Errors and Missing Physician Visit Notes
Penalty
Summary
The deficiency involves failures in medication documentation and medical record maintenance for multiple residents. For one resident with diagnoses including subarachnoid hemorrhage with loss of consciousness, paraplegia, and traumatic brain injury, the physician ordered Modafinil 100 mg daily at 8:00 a.m. Review of the November, December, and January medication administration records (MARs) and controlled substance records showed multiple discrepancies. On several dates, the MAR reflected administration of Modafinil, but the corresponding controlled substance record was not signed to show it was given. On other dates, the controlled substance record showed additional doses at 8:00 p.m. or duplicate 8:00 a.m. doses without any physician order for those extra administrations. The resident’s clinical record also lacked documentation of any physician or nurse practitioner visits. Additional deficiencies were identified in the timeliness and completeness of physician and nurse practitioner documentation for other residents. One resident with malignant neoplasm of the larynx, liver transplant, diabetes, and acute respiratory failure had an admission date earlier in the year, but the first physician or nurse practitioner progress note in the record was dated several months later. For another resident with paraplegia and traumatic brain injury, the clinical record lacked physician and nurse practitioner visit documentation after a specific date in the spring. A further resident with acute and chronic respiratory failure and congestive heart failure had no documented physician or nurse practitioner visit after a date in the fall. Interviews with staff confirmed expectations and highlighted gaps in practice. An RN stated that medications could not be administered without a physician’s order and that narcotic medications should be signed out on the narcotic sheet when pulled and then signed as administered on the MAR at the time of administration. The DON reported that both the physician and nurse practitioner had been in to see residents but was unsure why the notes were not present in the records. An LPN reported that the nurse practitioner indicated notes had been uploaded on their end and needed to be retrieved by the facility. Facility policies provided by the Regional Nurse Consultant required that each dose of controlled substances be recorded at the time of administration, that medications be administered as prescribed, that physicians or non-physician practitioners write, sign, and date progress notes at each required visit, and that each resident have a current, complete, and available health record including a MAR with date, time, and person administering each medication.
Failure to Maintain Resident Dignity and Privacy During Room Interaction
Penalty
Summary
The facility failed to maintain a resident’s dignity and respect for privacy when a Social Services Designee (SSD) entered the room of Resident F without proper identification or permission and exposed her to another resident. Resident F had diagnoses including depression and anxiety, and her quarterly MDS dated 12/23/25 indicated intact cognition. According to an incident report dated 1/28/26, Resident F reported that the SSD entered her room with her new roommate, Resident G, and hastily pulled open Resident F’s privacy curtain. The SSD then stated to Resident G, “see, she is a woman,” and told Resident F that she needed to shave her face. Resident F stated she did not know the SSD had entered until the curtain was flung open and that other staff typically knock and identify themselves before entering. In an interview, Resident F reported that after Resident G moved into the room, she had introduced herself to Resident G earlier. Later, the SSD came in with Resident G, abruptly opened the privacy curtain, and told Resident G that Resident F was not a man, then told Resident F in front of Resident G that she needed to shave. Resident F reported feeling humiliated, horrible, and that she cried after the incident. A written interview from the SSD indicated that it had been reported to her that Resident G refused to sleep in a room with a man, and that the SSD went into the room with Resident G, pulled the privacy curtain, introduced the residents to each other, and told Resident G that Resident F was a woman, adding that Resident G may have thought Resident F was a man due to facial hair. The SSD stated she told Resident F she could get someone to help her shave, but her written account did not document that she identified herself to Resident F upon entering or that she asked permission before pulling back the privacy curtain. The facility’s resident rights document provided by the Regional Nurse Consultant included the right to be treated with dignity and respect.
Failure to Follow Blood Pressure Parameters for Ordered Cardiac Medication
Penalty
Summary
The deficiency involves the facility’s failure to follow a physician’s parameter order for a resident with atrial fibrillation who was prescribed Propranolol HCL 20 mg three times daily at 8:00 a.m., 12:00 p.m., and 5:00 p.m. The physician’s order, dated 10/9/25, directed that the medication be held if the resident’s systolic blood pressure (SBP) was less than 110. Review of the resident’s clinical record and medication administration records for November 2025, December 2025, and January 2026 showed that the Propranolol was administered despite SBP readings below the ordered threshold on multiple occasions. Specifically, the medication was given when the SBP was 106 at 8:00 a.m., 12:00 p.m., and 5:00 p.m. on 11/17/25; 105 at 12:00 p.m. on 12/24/25; 107 at 12:00 p.m. on 12/30/25; 109 at 5:00 p.m. on 01/06/26; and 107 at 5:00 p.m. on 01/16/26. During an interview, an RN stated that all parameters set by the physician must be followed. The facility’s Medication Administration Policy Guideline, dated 5/17/21 and provided by the Regional Nurse Consultant, stated that medications are to be administered as prescribed and in accordance with written physician orders, including parameters. The documented administration of Propranolol outside the ordered SBP parameters constituted the basis for the cited deficiency.
Failure to Provide Accessible Call Light for Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s room was adequately equipped with an individual call system device, as required by facility policy. Resident C’s clinical record, reviewed on 1/23/26, showed diagnoses including anoxic brain injury, acute respiratory failure with hypoxia, hypercapnia, and anxiety. The resident’s care plan dated 1/13/26 identified a risk for falls and directed that the resident’s call light be placed within reach. During an observation on 1/28/26 at 1:26 p.m., Resident C was found resting in bed with eyes closed and without a call light in place. In the same observation, only a single call cord was present in the room, and it was positioned for the use of the resident’s roommate, leaving Resident C without access to a call system. When CNA 5 entered the room at 1:27 p.m., she confirmed that she did not see a call light for Resident C and stated there should have been a split call cord in the room. At 1:29 p.m., an LPN stated that all residents should have a call light within reach. The Regional Nurse Consultant later provided the facility’s undated “Call Lights” policy, which states that the facility will have a system in place to allow staff to respond promptly to residents’ calls for assistance and that a functioning call light must always be available and accessible to the resident in their room. This deficiency was cited under 3.1-19(u) and related to intakes 2712868, 2713745, and 2718083.
Failure to Involve Cognitively Intact Resident in Room Change and Phone Restriction
Penalty
Summary
The deficiency involves the facility’s failure to ensure a cognitively intact resident was informed of and involved in decisions about his care, specifically a room change to a secured memory care unit and the temporary removal of his cell phone from his possession. Resident B had diagnoses including end stage renal disease, major depressive disorder, bipolar disorder, and anxiety, but his quarterly MDS assessment documented intact cognition. His care plan noted that he enjoyed independent activities, walking, and being outdoors. Despite this, he was moved from his prior location to the secured memory care unit and had his cell phone removed from his possession without his consent. According to the resident’s account, he had gone outside to the front porch for fresh air, as he had done multiple times before, without being aware of any rule requiring him to ask permission. Staff brought him back inside, later placed a monitor on his ankle, and about a week later moved him to the memory care unit and took his phone, all without asking him or obtaining his permission. He reported feeling like he had no freedom, felt like a prisoner, and stated he would prefer to be around higher functioning people. At the time of surveyor observation, he was well groomed and alert and oriented to person, place, time, and situation, and he continued to express that he did not know why he had been placed on the secured unit. Facility documentation showed that staff and the IDT discussed the resident’s exit seeking, impulsive, anxious, pacing, and manic behaviors with his spouse and other family members, and that the family agreed to the room change and to having his cell phone kept at the nurse’s station. However, behavior tracking logs for the months reviewed lacked documentation of exit seeking, impulsive behaviors, anxiousness, pacing, restlessness, or manic behaviors, and progress notes did not document any conversations with the resident about the room move or his permission for removal of his phone. The Social Services Designee confirmed she had not spoken with the resident about the move or his phone and was unsure if any other IDT members had done so, and acknowledged that nursing staff did not document behaviors as they should. The facility’s Resident Rights policy stated that each resident has the right to be treated with dignity and respect, but the record lacked evidence that this resident was informed of or involved in these significant care decisions.
Failure to Timely Initiate Care Plan After Transfer to Secured Memory Care Unit
Penalty
Summary
The deficiency involves the facility’s failure to timely implement a care plan for a resident who was moved to a secured memory care unit. Resident B, whose diagnoses included bipolar disorder and major depressive disorder, was transferred to the memory care unit as documented on a room change notice dated 7/18/25. Although the resident was residing on a secure unit due to dementia and exit-seeking behaviors, the clinical record did not contain a secured unit baseline care plan until 8/30/25, approximately two weeks after the room change. The care plan dated 8/30/25 indicated the resident resided on a secure unit due to dementia and exit seeking, but there was no earlier documentation of a secured unit baseline care plan in the record. During an interview, the Director of Nursing stated that the resident’s care plan for the secured unit should have been initiated at the time of the move. The Administrator provided a current policy document titled “Baseline Care Plan Assessment/Comprehensive Care Plans,” dated 3/23/21, which stated that the comprehensive care plan would expand on the resident’s risks, goals, and interventions using a person-centered plan of care with measurable goals and timetables, and that additional changes would be made to the comprehensive care plan based on the assessed needs of the resident. Despite this policy, the resident’s secured unit baseline care plan was not initiated until weeks after the transfer, resulting in noncompliance with care plan timeliness requirements.
Resident Placed on Secured Memory Care Unit Without Dementia Diagnosis or Documented Need
Penalty
Summary
The facility failed to ensure that a resident placed on the secured memory care unit had an appropriate dementia-related diagnosis or documented clinical need for that placement. The resident, who had diagnoses including diabetes, end-stage renal disease, major depressive disorder, anxiety, and bipolar disorder, was ordered by a physician on 7/18/25 to reside on the secured unit. The resident’s care plan dated 8/30/25 documented that the resident lived on the secured unit related to dementia and exit seeking, with interventions such as activities per schedule, secured unit per physician order, and review and assessment of appropriate placement. However, the clinical record lacked any diagnosis of dementia, Alzheimer’s disease, or other irreversible dementia, and there was no documentation supporting a clinical need for a secured unit. The resident’s former primary care physician stated that the resident did not have a dementia diagnosis and that he would not have initiated an order for placement on the dementia unit. The facility’s Memory Springs admission/discharge criteria required that individuals have a diagnosis of Alzheimer’s or irreversible dementia and be deemed by a physician to be in clinical need of a secured unit, criteria that were not supported by the documentation in this resident’s record.
Failure to Maintain Sanitary Kitchen and Proper Food Storage
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen environment and did not store food items appropriately, as observed during two separate kitchen inspections and reviews of two snack refrigerators. Surveyors found the main kitchen door propped open, food service areas unattended, and significant accumulations of crumbs and unknown substances on floors, carts, and equipment. Food items, including cabbages and milk crates, were stored directly on the floor in the walk-in refrigerator, and dry storage areas had bags of food placed on the floor with visible debris around the shelves. The reach-in refrigerator contained undated and opened food items, sticky residue on handles, and spilled substances inside. Cleaning schedules were missing at the time of inspection, and the Dietary Manager could not provide them when requested. In the Main Hallway Nourishment Room and Dementia Unit Nourishment Room, snack refrigerators contained undated and expired food items, including sandwiches, salads, chicken strips, and yogurts. Some items belonged to specific residents and were past their labeled dates, while others were unmarked and undated. The refrigerators also had visible spills and residue, and staff interviews confirmed that kitchen staff were responsible for cleaning but had not maintained proper cleaning records or schedules. The Dietary Manager and Administrator acknowledged the lack of cleaning documentation and the presence of unclean surfaces and improperly stored food. Facility policies required all food contact and non-food contact surfaces, equipment, and utensils to be kept clean and free of residue, and for all leftovers and opened foods to be labeled and dated. However, these policies were not followed, as evidenced by the observations of unclean conditions, undated and expired food items, and missing cleaning schedules. The deficiencies had the potential to affect nearly all residents receiving food from the kitchen.
Resident Restrained with Gait Belt for Staff Convenience
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including chronic obstructive pulmonary disease, muscle weakness, impaired mobility, and a history of falls, was physically restrained in a wheelchair using a gait belt. The care plan for the resident included interventions such as a high back wheelchair for comfort and positioning, keeping the call light within reach, and ensuring the resident was within sight of staff when up in the wheelchair. However, during an incident, a CNA used a gait belt to restrain the resident in the wheelchair for approximately 15 minutes to prevent the resident from falling while staff were occupied with another resident. The CNA stated the restraint was applied for the resident's safety and was not aware it constituted abuse. The use of the gait belt as a restraint was reported by staff during shift change, and the nurse on duty, as well as the DON, were notified. The gait belt was found still attached to the wheelchair in a restraining position. The facility's abuse prevention policy defines unreasonable confinement as abuse, and the CNA involved had previously received education on abuse and restraints. The incident was documented and discussed among staff, and the resident did not exhibit any immediate effects from the restraint.
Failure to Provide Consistent and Adequate Snack Availability for Residents
Penalty
Summary
The facility failed to ensure that snacks were consistently available and provided to residents in accordance with their needs, preferences, and requests. Staff interviews revealed that it was common for nursing staff to purchase snacks out-of-pocket because the dietary department frequently did not supply adequate food or drink items. The Dietary Manager confirmed ongoing shortages of essential items such as pasteurized eggs, bread, oatmeal, and coffee, with some items completely unavailable at the time of survey. Observations showed that there were no hydration or snack carts present in the hallways, and the nourishment pantry was inadequately stocked, containing only minimal items such as a small jar of peanut butter, a squeeze container of jelly, a half box of crackers, applesauce, and a single sandwich and small bag of deli meat, both unlabeled or undated. Multiple residents reported that they were often unable to receive snacks, with some stating they had to purchase their own or were only offered snacks a few times a week. One resident, who is diabetic and supposed to receive a bedtime snack, indicated that staff told him there was nothing available when he requested a snack in the evening. The facility's policy stated that between-meal snacks should be available for all residents and that snacks for specific residents should be labeled and prepared by dining services, but these procedures were not being followed, as evidenced by the lack of available snacks and inconsistent provision to residents.
Failure to Follow Physician Orders for Blood Pressure Medication Hold Parameters
Penalty
Summary
The facility failed to follow physician orders regarding medication hold parameters for two residents diagnosed with hypertension. For one resident, the physician ordered atenolol 25 mg daily to be held if the systolic blood pressure (SBP) was less than 120. Despite this, the medication was administered on multiple occasions when the resident's SBP was below the specified threshold, with recorded SBP values ranging from 89 to 118 on several dates. The medication administration records (EMAR) confirmed these instances, and staff interviews indicated an understanding that blood pressure medications should be held if readings fall outside physician-ordered parameters. Similarly, another resident with hypertension was prescribed metoprolol 12.5 mg twice daily, also to be held for SBP less than 120. The EMAR showed that this medication was administered on several occasions when the resident's SBP was below 120, with values between 111 and 119. Facility policy requires medications to be administered as prescribed and in accordance with physician orders, but these orders were not followed in the cases reviewed.
Administration of Unordered Anxiety Medication Dose
Penalty
Summary
A deficiency occurred when a resident with a diagnosis of generalized anxiety received additional doses of Lorazepam without a corresponding physician's order. The resident's care plan indicated a risk for anxiousness and directed that medications be administered as ordered by the physician. However, the clinical record showed that Lorazepam, prescribed for administration at bedtime, was also given at 8:00 a.m. on multiple dates. There was no documentation of a physician's order authorizing these additional morning doses. Further review of the controlled drug records for May and June revealed that the medication was administered twice daily on several occasions, despite the absence of an order for the morning dose. The medication administration records did not document these extra doses. During interviews, staff confirmed that medications should not be administered without a physician's order, and facility policy required medications to be given only as prescribed.
Failure to Provide Prescribed Double Portions for Therapeutic Diet
Penalty
Summary
The facility failed to ensure that a resident with physician orders for double portions at all meals received the prescribed diet. The resident, who had diagnoses including Parkinson's disease and malignant neoplasm of the prostate, had a physician's order dated 10/10/24 specifying double portions at all meals. During a lunch meal service observation, the resident did not receive double portions as indicated on their meal ticket, which clearly stated the requirement in capital letters. The Dietary Manager confirmed that dietary staff are expected to follow the meal tickets when serving meals. Facility policy requires all meals to be checked for accuracy, including proper portion sizes and adherence to therapeutic diet extensions, prior to serving.
Failure to Provide Required Assistive Eating Device During Meal Service
Penalty
Summary
A deficiency occurred when a resident with vascular dementia and a severe intellectual disorder, who was prescribed a pureed consistent carbohydrate diet with an inner lip plate (divided plate) at meals, was not provided with the required assistive device during a lunch observation. Despite physician orders, care plan directives, and the resident's meal ticket all specifying the need for an inner lip plate, the resident was served lunch in individual bowls without the assistive device. The Dietary Manager confirmed that dietary staff should have followed the meal ticket instructions. Facility policy also required accuracy in following therapeutic diet extensions, but this was not adhered to in this instance.
Failure to Provide Consecutive RN Coverage
Penalty
Summary
The facility failed to provide 8-hour consecutive Registered Nurse (RN) coverage for six months, from July to December 2024. The review of the nursing schedule revealed multiple instances where only 6 hours of consecutive RN coverage were provided on specific days across these months. This deficiency had the potential to affect all 60 residents residing in the facility. The Executive Director was unaware of the requirement for 8 consecutive hours of RN coverage, and the Corporate Nurse Consultant also indicated a lack of awareness regarding this requirement. However, the Director of Nursing was aware of the requirement but acknowledged that the facility lacked the necessary RN hours every other weekend. The Facility Assessment dated June 28, 2024, indicated the need for 6 licensed nurses providing direct care and 4 Certified Nursing Aides per 12-hour shifts. Despite this, the facility did not meet the required RN coverage, leading to a deficiency. Interviews with the facility's leadership revealed a lack of understanding and compliance with the regulatory requirement for consecutive RN coverage, contributing to the deficiency observed by the surveyors.
Medication Documentation and Expired Insulin Management Deficiencies
Penalty
Summary
The facility failed to ensure proper documentation and management of narcotic medication counts and expired insulins across multiple medication carts. During observations, discrepancies were noted in the narcotic drawers of the medication carts, where the Controlled Drug Receipt Record/Disposition sheets did not match the actual count of medications. For instance, Resident 53's Tramadol count was off by one tablet, and similar discrepancies were found with other residents' medications, such as clonazepam and Pregabalin. Licensed Practical Nurse (LPN) 6 admitted to administering medications without signing them out immediately, which contributed to the discrepancies. Additionally, expired insulin vials were found in the medication carts, which were not removed in a timely manner. Resident 5's Admelog vial and Resident 63's Lispro kwikpen were both past their expiration dates, yet they remained in use. The facility's policy required insulin pens to be dated upon opening and considered expired after 28 days, but this was not adhered to, leading to the administration of potentially ineffective insulin. The Memory Care Unit also exhibited similar issues with narcotic documentation. The Controlled Drug Receipt Record/Disposition sheets did not match the actual medication counts for several residents, including alprazolam and lorazepam. Qualified Medication Aide (QMA) 9 acknowledged a habit of not signing out narcotics immediately after administration, which resulted in inaccurate records. These lapses in documentation and medication management highlight significant deficiencies in the facility's pharmaceutical services, impacting the safe and effective care of residents.
Failure to Secure Resident in Wheelchair Van Leads to Accident
Penalty
Summary
The facility failed to adequately secure a resident in the facility van during transport, leading to an accident. The resident, who had multiple diagnoses including chronic osteomyelitis, muscle weakness, and impaired mobility, was being transported in a wheelchair van. During the transport, the van driver rounded a corner, causing the resident and the wheelchair to fall to the right side. The resident was assessed for injuries and initially reported no pain, but later complained of pain in the right hip and knee, and a bump on the head. The incident was not immediately reported or documented by the facility's Executive Director, who was on vacation at the time. The corporate Executive Director did not fill out an incident report, and the facility's Executive Director was unaware of the need to do so, as she was informed that the resident was not injured. The incident report was completed several days later. The facility's Director of Nursing confirmed that the bus driver had not secured the resident correctly, which led to the wheelchair turning over. The facility's Transportation Policy and Procedure manual, which outlines emergency procedures and safety measures during transport, was not followed. The policy requires that in the event of a fall during transport, 911 should be called, and the resident should not be moved or transported by the facility staff. However, the bus driver did not call 911 and instead assisted the resident back into an upright position and returned her to the facility. The resident later required medical assessments and imaging due to complaints of pain and a headache following the incident.
Failure to Monitor Dialysis Site for Resident
Penalty
Summary
The facility failed to ensure proper monitoring and assessment of a dialysis site for a resident who required such services. Resident 24, who had diagnoses including dependence on renal dialysis, end-stage renal disease, and diabetes mellitus, was supposed to have their AV fistula monitored for signs of infection, bleeding, and bruit/thrill every shift as per a physician's order dated 5/13/24. This order was discontinued when the resident was sent to the hospital on 12/29/24. Upon the resident's return, the order was not reinstated, resulting in a lack of documentation and monitoring of the fistula for two months, despite the resident continuing to receive dialysis three times a week. Interviews with facility staff, including an LPN and the DON, revealed that the oversight occurred because the physician's order was not re-entered into the computer system after the resident's return from the hospital. The facility's policy on the care of residents receiving dialysis treatments, which includes monitoring for infection or clotting of the access area, was not followed. The staff failed to confirm the resident's dialysis orders, leading to the deficiency in care for Resident 24.
Improper Storage and Disposal of Insulin Pens
Penalty
Summary
The facility failed to properly store and dispose of discontinued insulin pens in the Eagle Court Hall Medication Cart. During an observation, Resident 18's Humalog kwikpen was found without a pharmacy label, only bearing a sticker with the resident's name, and had an open date of 2/17/25 despite the order being discontinued on 1/16/25. The resident's medical record showed a diagnosis of type 2 diabetes mellitus with diabetic neuropathy, and the last documented administration of Humalog was on 1/16/25. There was no documentation of a current physician's order for Humalog in February, and RN 7 confirmed that the resident was only receiving Lantus at bedtime, with no insulin administered during the day. Additionally, other insulin pens were improperly stored in the medication cart. An Aspart kwikpen with an illegible name had an open date of 1/3/25 and an expiration date of 2/3/25, while another Insulin Aspart kwikpen lacked a name, physician's order, or pharmacy label, with an open date of 11/18/24 and an expiration date of 12/18/24. These findings indicate a failure to adhere to the facility's policies on insulin pen storage and disposal, which require that outdated or improperly labeled medications be immediately withdrawn from stock and disposed of according to drug disposal procedures.
Failure to Provide Snacks to Residents
Penalty
Summary
The facility failed to ensure that snacks were provided and available for residents, affecting 8 out of 10 residents reviewed for dietary services. Residents reported that they had to purchase their own snacks as the kitchen did not provide any. Certified Nurse Aides confirmed that they had to buy snacks themselves because the dietary department did not supply them. The Director of Nursing acknowledged the issue, stating that the dietary department had not been providing snacks since a new company took over. Observations of the nourishment pantry revealed limited supplies, with no meats or peanut butter available. Residents expressed dissatisfaction with the lack of snacks, with some indicating they were not receiving snacks as ordered by their physicians. The Manager of the dietary service company mentioned that they provide bulk snacks but do not follow specific snack times, and acknowledged the lack of prune juice and peanut butter, which they planned to purchase. The facility's meal schedule was reviewed, and a policy document indicated that snacks should be available 24 hours a day, but this was not being followed. This deficiency was related to complaints IN00452715 and IN00453276.
Failure to Inform Resident of Appointment Cancellation
Penalty
Summary
The facility failed to ensure that Resident B was informed in a timely manner about the cancellation of her pain management appointment. Resident B, who had diagnoses including end-stage heart failure and anxiety, was upset and angry upon discovering that her appointment was canceled. The cancellation occurred because hospice services had taken over her care, including pain management. However, there was no documentation in the clinical record indicating that Resident B was notified of the cancellation before the day of the appointment. Interviews with the resident and staff revealed that Resident B was not informed of the cancellation until she was dressed and waiting for her ride on the day of the appointment. LPN 7 confirmed that the appointment was canceled without notifying the resident, and CNA 13 was unaware of the cancellation until the day of the appointment, as the original appointment was still listed on the transportation log. This oversight violated the resident's rights to be fully informed of her health status and care, as outlined in the facility's Resident Rights document.
Verbal Abuse by LPN Towards Residents
Penalty
Summary
The facility failed to protect residents from verbal abuse by a staff member, specifically involving two residents, Resident D and Resident L. Resident D, diagnosed with schizoaffective disorder, psychotic disorder with delusions, and major depressive disorder, reported concerns about the behavior of an LPN. The LPN was described as argumentative and using a mean tone, which agitated Resident D. An incident was observed where the LPN was cursing and speaking rudely to Resident D, escalating the situation. Despite an investigation, the facility was unable to substantiate the allegations of abuse. Resident L, who has diagnoses including anxiety, chronic respiratory failure with hypoxia, and diabetes, also experienced verbal abuse from the same LPN. The LPN referred to Resident L as a 'cry baby' and dismissed her concerns as lies during a phone conversation with the resident's family member. This conversation was overheard by Resident L, causing her distress. The LPN's behavior included using inappropriate language and dismissing the resident's needs, which was witnessed by other staff members. The facility's Abuse Prevention Program policy was not adhered to, as it mandates that residents receive care in a person-centered environment free from verbal abuse. The incidents involving the LPN's interactions with both Resident D and Resident L demonstrate a failure to uphold this policy, as the LPN's actions were derogatory and disrespectful, contributing to the residents' distress.
Failure to Report Abuse and Inappropriate Conduct
Penalty
Summary
The facility failed to implement policies and procedures for reporting a reasonable suspicion of a crime in accordance with 1150B of the Act for two residents, Resident D and Resident L. Resident D, who was diagnosed with schizoaffective disorder, psychotic disorder with delusions, and major depressive disorder, reported concerns about care provided by an LPN. An incident occurred where the LPN was heard using inappropriate language and purposefully upsetting Resident D. Although RN 15 witnessed the incident and submitted a written statement to the Director of Nursing (DON), the facility's reportables lacked documentation of this incident. Resident L, diagnosed with anxiety, chronic respiratory failure with hypoxia, and diabetes, experienced a delay in care and was subjected to derogatory remarks by the same LPN. The LPN was overheard making inappropriate comments about Resident L to her family member and in the presence of Resident L. Despite the incidents being reported to the DON by CNA 13 and RN 5, the facility failed to document these incidents in their reportables. The facility's Abuse Prevention Program policy requires immediate reporting of abuse incidents, which was not adhered to in these cases.
Failure to Implement Care Plan After Dental Extractions
Penalty
Summary
The facility failed to implement a care plan for a resident after all of the resident's teeth were extracted. The resident, who had diagnoses including end-stage heart failure and anxiety, had all her teeth removed on January 10, 2025. Despite this significant change in her condition, the clinical record lacked documentation of a care plan addressing the extraction and its implications for her care. The resident was observed without teeth and mentioned she was awaiting dentures. A physician's order dated January 31, 2025, indicated dietary preferences related to the extraction, but no comprehensive care plan was documented. During an interview, the Director of Nursing expressed an assumption that a care plan would have been implemented following the extractions. The Regional Director of Operations provided a policy document indicating that comprehensive care plans should be reviewed and updated quarterly or more frequently based on changes in the resident's condition. This deficiency was related to complaints IN00451851 and IN00452480, highlighting the facility's failure to adhere to its policy of updating care plans in response to significant health changes.
Delayed Diet Change for Resident Post-Dental Procedure
Penalty
Summary
The facility failed to timely implement a diet change for a resident who had all her teeth extracted. Resident B, diagnosed with hypertension and end-stage heart disease, underwent a dental procedure on 1/10/25, resulting in the extraction of all her teeth. Despite this significant change in her ability to eat, the clinical record did not document any dietary adjustments until 1/14/25, when a physician's order was made for a modified diet of chicken noodle soup, ice cream, pudding, and milk. Interviews revealed that the resident did not return with any paperwork from the dentist, and there was a lack of immediate action to clarify the new diet with the dentist upon her return.
Failure to Provide Prescribed Therapeutic Diet
Penalty
Summary
The facility failed to adhere to a therapeutic diet order for a resident, identified as Resident H, who was diagnosed with diabetes, anxiety, and major depressive disorder. The physician's order, dated March 12, 2024, specified that Resident H was to receive prune juice with her lunch every day. However, during an interview on February 6, 2025, Resident H reported that she had never received the prune juice with her lunch tray. Further investigation revealed that the facility did not have prune juice available, as confirmed by the Regional Director of the dietary service, who stated that they would need to purchase some. This deficiency was noted during a review of the resident's clinical record and interviews conducted with the resident and facility staff.
Failure to Change PICC Line Dressings as Ordered
Penalty
Summary
The facility failed to ensure that dressing changes for peripherally inserted central catheter (PICC) lines were completed as ordered for two residents, Resident B and Resident D. Resident B, diagnosed with acute osteomyelitis of the right foot and ankle, had a physician's order to change the PICC line dressing weekly and as needed. However, observations on November 1st and 2nd revealed that the dressing, dated October 24th, had not been changed as per the order. The medication administration record inaccurately indicated that the treatment was completed on November 1st, and an LPN confirmed that PICC line dressings should be changed every seven days. Similarly, Resident D, diagnosed with bacteremia, had a physician's order to change the transparent dressing to the PICC line on admission and then weekly. Observations on November 1st and 2nd showed that the dressing was still dated October 24th, despite the medication administration record indicating a change on October 31st. The Director of Nursing provided a document outlining the process for dressing changes, which confirmed that transparent dressings should be changed every seven days. These findings indicate a failure to adhere to physician orders and facility protocols for PICC line dressing changes.
Failure to Administer Lorazepam as Ordered
Penalty
Summary
The facility failed to ensure that a resident's routine Lorazepam, a narcotic antianxiety medication, was administered as ordered by the physician. The resident, identified as Resident E, had diagnoses including anxiety and chronic obstructive pulmonary disease. The care plan indicated an increased risk for anxiousness and required the administration of anxiety medication as ordered. However, the medication administration records for October and November 2024 showed that the resident did not receive the medication at the prescribed times, with significant gaps in administration noted. Interviews and record reviews revealed that Resident E frequently experienced delays or missed doses of her anxiety medication. The controlled drug records lacked documentation of the administration of Lorazepam on several occasions. An RN confirmed that routine narcotics should be signed off on the controlled drug record when removed and documented on the medication administration record after administration. The facility's medication administration policy, provided by the Director of Nursing, emphasized the importance of documenting medication administration appropriately.
Inadequate Meal Temperature and Timeliness
Penalty
Summary
The facility failed to ensure that food was served at appropriate temperatures, as observed during a survey on [NAME] Hall. On November 1, 2024, lunch trays were delivered at 12:58 p.m., and food temperatures were recorded shortly after. The cheesy grits with shrimp were at 145 degrees, collard greens at 126 degrees, and garlic toast at 108.6 degrees. These temperatures suggest that some items were not served at an appetizing or safe temperature. Additionally, the resident council minutes from September and October 2024 indicated ongoing concerns about breakfast being served cold and dinner being served late. Multiple residents expressed dissatisfaction with the temperature and timeliness of their meals. Resident B noted that food was hot in the dining room but cold and late when served on the hall. Resident D shared a similar experience, preferring the dining room to avoid cold meals. Resident K described the food as consistently late and cold, while Resident L echoed these sentiments, stating that meals were usually late and cold by the time they reached the hall. These observations and resident testimonies highlight a pattern of inadequate meal service on [NAME] Hall.
Inaccurate Documentation of PRN Narcotic Administration
Penalty
Summary
The facility failed to ensure that a resident's medication administration record accurately reflected the administration of as-needed narcotic pain medication. Specifically, the clinical record for a resident with diagnoses including end-stage heart failure, anxiety, and chronic obstructive pulmonary disease was reviewed, revealing discrepancies in the documentation of Morphine Sulfate administration. The physician's order prescribed 0.75 mg of Morphine Sulfate every two hours as needed for pain. However, the October and November 2024 controlled drug records indicated multiple instances where the medication was administered, but the medication administration record lacked corresponding documentation for these dates and times. During an interview, an RN confirmed that when a PRN narcotic is administered, it should be signed out on the controlled drug record and initialed on the medication administration record by the nurse. Additionally, the resident should be followed up on after 30 minutes to assess the effectiveness of the pain medication. The Director of Nursing provided a document titled Medication Administration, which outlined the procedure for administering medications safely and appropriately, including documenting medication administration with initials in the appropriate spaces.
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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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