Waters Of Syracuse Skilled Nursing Facility, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Syracuse, Indiana.
- Location
- 500 E Pickwick Dr, Syracuse, Indiana 46567
- CMS Provider Number
- 155581
- Inspections on file
- 22
- Latest survey
- February 10, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Waters Of Syracuse Skilled Nursing Facility, The during CMS and state inspections, most recent first.
Two residents at a facility experienced falls due to inadequate implementation of fall prevention interventions. One resident, with a history of falls and high fall risk, suffered a brain hemorrhage after an unwitnessed fall, while another resident rolled out of bed due to the absence of planned interventions. Staff interviews revealed a lack of awareness and communication regarding necessary interventions.
The facility's kitchen was found to have multiple sanitation deficiencies, including unsealed and undated food items, expired foods, and dirty cooking utensils, affecting all 44 residents receiving meals. Observations included dirty freezer seals, improperly stored food, and unsanitary food handling practices. The facility's policies on food storage and equipment cleaning were not followed.
A resident with a history of bladder dysfunction and kidney failure was observed multiple times without a dignity cover on her urinary drainage bag, allowing urine to be visible. Despite a physician's order for the bag to be covered, the facility's policy did not specify this requirement, and a CNA confirmed that the bags should be covered.
The facility did not provide a SNF-ABN to two residents after their Medicare services ended, despite having remaining Medicare A days. The Business Office Manager confirmed the oversight, and the facility lacked a policy for ABN administration and documentation.
A facility failed to complete a timely PASARR for a resident with serious mental illness and/or intellectual disability. The initial PASARR Level 1 screening authorized a 60-day convalescence care, requiring re-screening by the 60th day if the resident remained in the facility. However, no new Level 1 screen was documented before the expiration date. The Social Service consultant noted that the Business Office Manager was instructed to initiate the process, but it was not completed as per the facility's policy.
The facility failed to initiate proper baseline care plans for two residents, one requiring dialysis and another at high risk for falls. Both residents' care plans lacked necessary goals and interventions, contrary to facility policy. This deficiency was confirmed through record reviews and staff interviews.
The facility failed to maintain comprehensive care plans for three residents, leading to deficiencies in their care. A resident with cerebral infarction and COPD lacked an active care plan for ADLs, while another with a Foley catheter had no plan for catheter care. Additionally, a resident receiving medication for hypothyroidism did not have a care plan for this condition. The MDS Coordinator confirmed the absence of necessary care plans, contrary to facility policy.
The facility failed to conduct timely care plan meetings for three residents, resulting in gaps in care planning. One resident had no documented meetings after April, another missed a quarterly meeting, and a third had a significant gap between meetings. The Corporate Social Service Director and Regional MDS Consultant confirmed these oversights.
A resident with a history of bladder dysfunction and urinary tract infections was observed with an indwelling urinary catheter without documented necessity. Despite being cognitively intact and frequently incontinent, the facility did not complete a structured toileting program evaluation. The Nurse Practitioner did not attempt alternative interventions before catheter placement, and the Director of Nursing could not provide documentation for a neurogenic bladder diagnosis.
A facility failed to ensure proper nutritional management for three residents, leading to deficiencies in care. A resident with significant weight loss did not have their supplement intake documented, while another experienced delayed implementation of dietician recommendations and was not included in a weight assessment program. Additionally, a resident with chronic kidney disease was served meals not aligned with their dietary restrictions. The facility's oversight in documentation and meal service contributed to these deficiencies.
The facility failed to properly store respiratory equipment for two residents, leading to deficiencies in care. A resident's C-PAP mask was found unbagged and on the floor, while another resident's nasal cannula tubing was improperly stored on the floor. Staff interviews confirmed the equipment should have been stored in respiratory bags, but the facility's policy lacked specific guidelines for storage.
A facility failed to monitor the effectiveness of pain medication for a resident with multiple diagnoses, including diabetes and polyneuropathy, who was prescribed Tramadol for pain management. Despite the care plan's requirement to monitor medication effectiveness, the MARs for several months lacked documentation. A nurse confirmed the oversight, and the facility's policy required documentation of medication effectiveness, which was not followed.
A facility failed to complete pre and post dialysis assessments for a resident with chronic kidney disease, missing several assessments over a period of time. The resident's care plan required monitoring for fluid volume changes, but the absence of these assessments indicates non-compliance with the care plan. A nurse confirmed the necessity of these assessments for communication with the dialysis center.
A resident with multiple diagnoses was prescribed a high dose of cholecalciferol, resulting in elevated vitamin D levels. Despite lab results indicating levels above the normal range, the nurse practitioner did not adjust the medication dosage. The facility's policy for monitoring lab results was not effectively followed, leading to a deficiency in ensuring the drug regimen was free from unnecessary drugs.
A resident with major depressive disorder and moderate cognitive impairment received Xanax beyond the 14-day limit for PRN psychotropic medications without proper documentation or physician evaluation. Facility staff were unaware of the time limits, and drug reviews were conducted every six months. The resident had multiple emergency room visits, and the emergency room physician prescribed Xanax for shortness of breath, but no progress note justified the extended use.
The facility failed to maintain the nutritive value and flavor of pureed diets for two residents. The Dietary Manager prepared pureed carrots without adding chicken base as per the instructions, which were taped inside a cabinet door. The omission was acknowledged during an interview, and the facility's policy on consistency-modified foods was provided.
The facility failed to ensure proper infection control practices for residents on Enhanced Barrier Precautions (EBP). A nurse administered medication to a resident with a PEG tube without wearing a gown, and two CNAs did not use appropriate PPE while providing care to residents on EBP. The facility's policy required gloves and gowns during high-contact activities, which was not followed.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to develop and implement interventions to reduce the risk of falls for two residents, resulting in a fall that required hospitalization for one of them. Resident 247, who was admitted with a history of falls and a high risk for future falls, did not have any interventions in place to prevent falls despite being identified as high risk. The resident experienced an unwitnessed fall, leading to a brain hemorrhage and subsequent hospitalization. Observations revealed that the resident continued to walk unassisted without any assistive devices or reminders to use the call light, even after returning from the hospital. Resident 27, who was severely cognitively impaired and required extensive assistance, also experienced a fall due to rolling out of bed. Although a new intervention was planned to place the bed in the lowest position with a fall mat beside it, this intervention was not consistently implemented. Observations showed that the resident's bed was not in the lowest position, and the fall mat was not in place during multiple checks. Interviews with staff indicated a lack of awareness and communication regarding the interventions for both residents. The Director of Nursing acknowledged that new interventions should be communicated through the electronic record and during shift change huddles, but there was a failure to ensure these interventions were consistently applied. The facility's policy required a site investigation and new care plan interventions for each fall, but this was not adequately followed for the residents involved.
Sanitation Deficiencies in Kitchen Affecting Resident Meals
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, which had the potential to affect all 44 residents receiving meals. During an initial tour, several issues were observed, including unsealed and undated food items in the freezer and cooler, expired foods in use, and dirty cooking utensils and appliances. Specific observations included dirty seals and food debris in the reach-in freezer, improperly sealed sausage links and Salisbury steak, and opened and undated food items such as dill pickles and chicken gravy. Additionally, personal items were found in the walk-in cooler, and the kitchen floor was stained and littered with food debris. Further inspections revealed additional unsanitary conditions, such as a metal spoon and dish rag found under food prep areas, and a cook resting plates against his uniform during food plating. A revisit to the kitchen showed a dirty microwave plate, stained drinking glasses, and improperly cleaned or damaged cooking utensils, including a greasy metal pan and a spatula with burnt areas. The facility's policies on food storage, labeling, and equipment cleaning were not adhered to, as evidenced by the lack of sanitizing solution in the cleaning bucket and the presence of undated and improperly stored food items.
Failure to Provide Dignity Cover for Urinary Catheter
Penalty
Summary
The facility failed to provide a dignity cover for a urinary indwelling catheter for Resident 34, who was observed multiple times without a dignity cover on her urinary drainage bag. On several occasions, the urinary drainage bag was visible and not covered, allowing urine to be seen through the clear side of the bag. This was observed while the resident was in her recliner, during transport to the therapy room, and while in the therapy room. Additionally, the drainage bag was noted to be leaking on the floor during one observation. Resident 34 has a history of neuromuscular dysfunction of the bladder, kidney failure, and urinary tract infections, and is cognitively intact. The facility's policy did not specify the need for dignity covers for indwelling urinary catheters, despite a physician's order indicating that the catheter drainage bag should be covered. A CNA confirmed that Foley catheter drainage bags should be covered, highlighting a discrepancy between staff understanding and facility policy.
Failure to Provide SNF-ABN to Residents Post-Medicare Discharge
Penalty
Summary
The facility failed to provide a Skilled Nursing Facility-Advanced Beneficiary Notice (SNF-ABN) to two residents who were discharged from Medicare services but remained in the facility. Resident 9 was given a Notice of Medicare Non-Coverage (NOMNC) indicating that Medicare coverage would end on August 28, 2024, despite having 34 Medicare A days remaining. Similarly, Resident G received a NOMNC stating that Medicare coverage would end on June 6, 2024, with 57 Medicare A days left. The Business Office Manager confirmed that both residents were not issued an SNF-ABN after their Medicare A services ended. Additionally, the facility lacked a policy for the administration and documentation of ABN notices, as confirmed by the Executive Director.
Failure to Complete Timely PASARR for Resident
Penalty
Summary
The facility failed to ensure a timely completion of a PASARR (Pre-Admission Screening and Resident Review) for a resident, identified as Resident B. Resident B's medical history included fractured ribs, cancer, end-stage renal disease, bipolar disorder, and malnutrition. A PASARR Level 1 screening was initially completed on June 16, 2024, which identified the resident as having a serious mental illness and/or intellectual disability, placing them in the Convalescence category with a 60-day convalescence care approval. The screening indicated that a re-screening was required by or before the 60th day if the resident was expected to remain in the nursing facility beyond the authorized timeframe. However, the facility's records lacked documentation of a new Level 1 screen being completed before the expiration date of September 14, 2024. During an interview, the Social Service consultant acknowledged that another Level of Care PASARR form should have been completed in September and indicated that the Business Office Manager was instructed to initiate the process. The facility's policy, provided by the Corporate MDS consultant, outlined that the Business Office Manager should initiate a new Level 1 and Level of Care 7-14 days prior to the expiration date, but this was not adhered to in Resident B's case.
Failure to Initiate Baseline Care Plans for Residents
Penalty
Summary
The facility failed to ensure baseline care plans were properly initiated for two residents, leading to deficiencies in care planning. Resident B, who had diagnoses including fractured ribs, cancer, end-stage renal disease, bipolar disorder, repeated falls, and malnutrition, was admitted and required dialysis. However, the baseline care plan for Resident B, dated the same day as the admission, lacked specific goals, interventions, and special needs to address the resident's conditions. This omission was confirmed during an interview with the MDS coordinator, who acknowledged that the care plan summary should have included these elements. Similarly, Resident 247, who was admitted with conditions such as subarachnoid hemorrhage, cardiomegaly, falls, insomnia, and polyneuropathy, was identified as being at high risk for falls. Despite this, the baseline care plan for Resident 247, created two days after admission, did not include goals or interventions for fall prevention. The comprehensive care plan addressing falls was not completed until much later, while the resident was hospitalized. The facility's policy required the admitting nurse to initiate a baseline care plan to identify potential problems and establish appropriate goals and interventions, which was not adhered to in these cases.
Deficiencies in Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to maintain comprehensive care plans for three residents, leading to deficiencies in their care. Resident 18, who had diagnoses including cerebral infarction, spinal stenosis, and COPD, was observed with facial hair stubble, indicating a lack of assistance with personal hygiene. The care plan for activities of daily living (ADLs) for this resident was not active, as it had been resolved prematurely. The MDS Coordinator confirmed that Resident 18 should have had an active care plan addressing his ADL needs. Resident 20, who had a Foley catheter due to conditions such as chronic kidney disease and congestive heart failure, did not have an active care plan for catheter care. The care plan had been resolved earlier, leaving the resident without a documented plan for this critical aspect of care. Similarly, Resident 32, diagnosed with conditions including underweight and osteoarthritis, was receiving medication for hypothyroidism, yet lacked a care plan for this condition. The MDS Coordinator acknowledged the absence of a care plan for hypothyroidism, which should have been in place. The facility's policy requires comprehensive care plans to be developed and maintained, but these were not adhered to for the residents in question.
Failure to Conduct Timely Care Plan Meetings
Penalty
Summary
The facility failed to ensure timely care plan meetings for three residents, leading to deficiencies in care planning. Resident 27, diagnosed with arthritis, hypertension, obstructive and reflux uropathy, and glaucoma, had a care plan meeting in April 2024, but no subsequent meetings were documented, despite the requirement for additional meetings. The Corporate Social Service Director confirmed that two additional meetings should have occurred but did not. Resident 38, with a history of femur fracture, hemiplegia, hemiparesis, muscle contracture, malnutrition, stroke, depression, and dysphagia, had a care plan meeting in July 2024, but no further meetings were documented. The resident's POA was unaware of the need for quarterly meetings, and the Corporate Social Service Director acknowledged that a meeting should have been held in October. Resident 30, who reported never attending a care plan conference, had a gap in documented care plan meetings between November 2023 and December 2024, which the Regional MDS Consultant confirmed should not have occurred.
Failure to Justify Indwelling Catheter Use for Incontinent Resident
Penalty
Summary
The facility failed to ensure that a resident, who was incontinent, remained free from an indwelling urinary catheter. During an observation, the resident was seen with urinary drainage tubing over her thigh and a drainage bag attached to her wheelchair. The resident had a history of neuromuscular dysfunction of the bladder, kidney failure, and urinary tract infections. Despite being cognitively intact and frequently incontinent of bladder, the resident was noted to have an indwelling urinary catheter without a documented diagnosis justifying its necessity. The facility's policy requires that residents not be catheterized unless clinically necessary, and that appropriate treatment and services be provided to prevent urinary tract infections and restore continence. The resident's medical records indicated a Foley catheter was placed due to constant urine leakage, but there was no supporting documentation for a neurogenic bladder diagnosis. A Bowel and Bladder Incontinence Screener suggested further evaluation for a structured toileting program, which was not completed. Interviews revealed that the Nurse Practitioner did not attempt alternative interventions such as medication, bladder scans, or a toileting program before catheter placement. Additionally, the Director of Nursing claimed a full medical examination for neurogenic bladder was conducted, but no documentation was available to support this claim.
Nutritional Management Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure proper nutritional management for three residents, leading to deficiencies in their care. Resident 1, who had a history of diabetes, anxiety, kidney failure, and polyneuropathy, experienced significant weight loss. Despite a physician's order for nutritional supplements, the facility did not consistently document the percentage of supplements consumed, and the Director of Nursing acknowledged the oversight in the electronic charting system. This lack of documentation hindered the ability to monitor the resident's nutritional intake effectively. Resident 27, diagnosed with arthritis, hypertension, obstructive and reflux uropathy, and glaucoma, also experienced significant weight loss. The facility did not promptly implement the dietician's recommendations for nutritional supplements, resulting in a delay of nine days. Furthermore, the facility failed to document the consumption of these supplements, which was crucial for assessing their effectiveness. The resident was not included in the Skin-Weight-Assessment-Team program, despite meeting the criteria for significant weight loss. Resident 20, who had chronic kidney disease, mild protein-calorie malnutrition, diabetes mellitus type 2, and gastroparesis, was not served the appropriate diet for his condition. The facility provided meals that did not align with the dietary restrictions for a renal diet, such as serving mashed potatoes instead of rice and providing larger portions of peach cobbler. The Dietary Manager admitted to not realizing the main menu diet differed from the renal diet, leading to inappropriate meal service for the resident.
Improper Storage of Respiratory Equipment for Two Residents
Penalty
Summary
The facility failed to properly store oxygen therapy and C-PAP equipment for two residents, leading to deficiencies in respiratory care. For Resident 18, observations revealed that the C-PAP mask was repeatedly found unbagged on top of a personal refrigerator and even on the floor. Despite a physician's order for the resident to use the C-PAP at bedtime and for naps, the mask was not stored according to guidelines. Interviews with staff indicated a lack of proper storage practices, as the C-PAP mask should have been stored in a respiratory bag when not in use. Similarly, Resident 20's nasal cannula tubing was observed improperly stored, with the tubing and respiratory storage bag found on the floor and intertwined. The resident was ordered to wear oxygen continuously, yet the equipment was not maintained in a sanitary manner. Staff interviews confirmed that the oxygen tubing should not have been dragging on the floor and should have been stored in a respiratory bag. The facility's policy did not include specific guidelines for the storage of oxygen and C-PAP equipment, contributing to the improper handling of these devices.
Failure to Monitor Pain Medication Effectiveness
Penalty
Summary
The facility failed to ensure the effectiveness of pain medications was monitored for a resident who required such services. The resident, who had diagnoses including diabetes, anxiety, kidney failure, and polyneuropathy, reported experiencing pain upon movement and was prescribed Tramadol 50 mg every 6 hours for pain management. Despite the resident's care plan indicating the need to monitor the effectiveness of pain medications, the Medication Administration Records (MAR) for November, December, and January lacked documentation showing that the effectiveness of Tramadol was monitored. The effectiveness box on the MAR was marked out for the entire duration of these months. During an interview, a registered nurse confirmed that the effectiveness of the pain medication should have been documented. The facility's policy on pain management, provided by the Assistant Director of Nursing, stated that the effectiveness of administered pain medication should be documented 1-2 hours post-administration. However, this policy was not adhered to, leading to the deficiency in monitoring the resident's pain management effectively.
Failure to Complete Pre/Post Dialysis Assessments
Penalty
Summary
The facility failed to ensure that pre and post dialysis assessments were completed for a resident who required dialysis services. The resident, who had chronic kidney disease stage 4, anemia in chronic kidney disease, and acute kidney failure, was scheduled to attend dialysis sessions three times a week. Despite this, there were multiple instances where pre and post dialysis assessments were not completed, as evidenced by missing assessments on specific dates in November and December 2024. This lack of documentation was confirmed during an interview with a registered nurse, who stated that these assessments were necessary for communication between the facility and the dialysis center. The resident's care plan highlighted the risk of fluid volume deficit and excess related to dialysis treatment, with specific interventions to monitor for symptoms such as hypotension, tachycardia, and weight gain. However, the absence of pre and post dialysis assessments indicates a failure to adhere to these care plan interventions. The facility's policy on post hemodialysis care outlined conditions under which a physician should be notified and described emergency situations related to dialysis patients, emphasizing the importance of continuous management of the disease causing renal failure. The failure to complete these assessments could potentially compromise the resident's health and safety, as critical signs and symptoms may go unnoticed.
Failure to Adjust Medication Based on Lab Results
Penalty
Summary
The facility failed to adjust a resident's medication regimen in response to laboratory results, leading to a deficiency in ensuring the drug regimen was free from unnecessary drugs. Resident 32, who had diagnoses including underweight, disorientation, muscle weakness, and osteoarthritis, was prescribed cholecalciferol 10,000 units daily for vitamin D deficiency. A laboratory test conducted on the resident showed a vitamin D level greater than 120 ng/mL, which exceeded the normal range of 30-100 ng/mL. Despite this elevated level, the nurse practitioner's progress notes did not address the high vitamin D level, and the medication dosage was not adjusted accordingly. During an interview, the nurse practitioner stated a preference for vitamin D levels between 30-80 ng/mL and indicated that she would decrease the medication if levels exceeded 100 ng/mL. However, she also mentioned that a high vitamin D level was not harmful, which contradicts professional references indicating potential harm from excessive vitamin D. The facility's policy required the charge nurse to monitor lab results and ensure they were reported to the physician, but this process was not effectively followed, contributing to the deficiency.
Failure to Limit PRN Psychotropic Medication Use
Penalty
Summary
The facility failed to adhere to the 14-day limit for as-needed (PRN) psychotropic medication use for a resident diagnosed with major depressive disorder and adjustment disorder with depressed mood. The resident, who had moderate cognitive impairment, was prescribed Xanax for anxiety on an as-needed basis. However, the medication was administered beyond the 14-day limit without proper documentation or evaluation by a physician to justify the extended use. The Medication Administration Record showed that the resident received Xanax on multiple occasions beyond the 14-day period. Interviews with facility staff revealed a lack of awareness regarding the time limits for PRN psychotropic medications. The RN interviewed was unaware of the limitations, and the facility's drug reviews for psychotropic medications were conducted every six months, which may not have been sufficient to address the issue in a timely manner. Additionally, the Nurse Practitioner and Director of Nursing acknowledged that the resident had been to the emergency room multiple times, and the emergency room physician had prescribed Xanax for shortness of breath, but no progress note was completed to justify the continued use of Xanax beyond the 14-day limit. The facility's policy required PRN orders for psychotropic drugs to be limited to 14 days unless a physician documented the rationale for extending the medication, which was not done in this case.
Failure to Maintain Nutritive Value in Pureed Diets
Penalty
Summary
The facility failed to ensure the nutritive value and flavor of pureed diets for two residents who received such diets. During an observation of food preparation, the Dietary Manager was seen preparing pureed carrots by blending cooked carrots with water but failed to add chicken base as per the instructions. The instructions, which were taped inside a cabinet door, specified the addition of chicken base, hot water, and thickener for pureed vegetables. The Dietary Manager acknowledged the omission of the chicken base during an interview. The facility's policy on consistency-modified foods was provided, indicating that recipes should be prepared as given unless otherwise stated.
Inadequate Infection Control Practices for Residents on EBP
Penalty
Summary
The facility failed to ensure proper infection control practices for residents on Enhanced Barrier Precautions (EBP). During a medication administration observation, a registered nurse entered the room of a resident with an EBP sign and an isolation cart, wearing only gloves and not a gown, as required. The resident had a PEG tube, and the care plan indicated the need for EBP due to the device. The nurse admitted to not wearing the necessary gown during the medication administration. Additionally, two certified nursing assistants (CNAs) were observed not following EBP protocols. One CNA entered a resident's room without any personal protective equipment (PPE) and provided morning care, despite a sign indicating the need for PPE. Another CNA handled a resident's urinary catheter drainage bag, which was leaking, wearing only gloves and not changing them between tasks. Both CNAs acknowledged the requirement for additional PPE when providing care to residents on EBP but failed to comply. The facility's policy, provided by the Regional MDS Consultant, outlined the need for gloves and gowns during high-contact activities, which was not adhered to in these instances.
Latest citations in Indiana
Surveyors observed that dietary staff repeatedly worked in kitchen and meal service areas with uncovered facial hair, despite facility policy and state sanitation requirements mandating effective hair restraints. Two dietary aides with short beards or mustaches were seen walking through food preparation areas, taking food temperatures, handling food, and plating meals at steamtables in dining rooms without any facial hair coverings, while the current policy required all hair, including facial hair, to be restrained to prevent contamination.
The facility failed to consistently provide and document required bed-hold policy notices when several residents were transferred to the hospital. In multiple cases, residents with dementia, psychotic disorders, COPD, chronic respiratory failure, altered mental status, and cerebral infarction were sent out for acute changes in condition, and while transfer notes reflected physician and family notifications, they lacked documentation that the bed-hold policy was discussed with the resident or responsible party. Notices of Transfer or Discharge often indicated a copy of the bed-hold policy was sent with the resident, but the records did not show signed and dated acknowledgment by the resident or appropriate representative, including in situations where a resident had moderate cognitive impairment, short-term memory issues, or a documented need for a proxy and a financial POA authorizing an agent for health care decisions.
Surveyors found that the facility failed to provide trauma‑informed and culturally competent care by not incorporating two residents’ extensive trauma histories and specific behavioral triggers into their care plans. One resident with documented homelessness, polysubstance abuse, severe accidents with multiple fractures, viral encephalitis with coma, physical and sexual abuse, loss of family contact, and a past suicide attempt had multiple behavior‑focused care plans that referenced identifying triggers but listed none and did not mention their physical, sexual, medical, or psychosocial trauma. Another resident with TBI from being struck by a truck, an 11‑month coma, long‑term state hospital residence, alleged shooting of a parent, and diagnoses including intermittent explosive disorder and borderline personality disorder had a PASRR identifying a specific trigger and notes of inappropriate sexual behavior, yet their care plans omitted these traumatic events, the identified trigger, and the sexual behavior. Staff interviews confirmed that residents were screened for trauma, but the trauma histories and triggers were not reflected in the individualized plans of care.
A resident with schizophrenia, post‑stroke hemiparesis, and mild cognitive impairment expressed feeling down and wanting to kill himself, but staff did not document asking about a specific plan, did not notify the physician or psychiatric NP as expected, and did not develop or update a care plan addressing depression or suicidal ideation. The SSD documented offering support and initiating 15‑minute checks once, but there was no further follow‑up or documentation of interventions after subsequent suicidal statements made in a care plan meeting with the resident’s father. The DON and Administrator reported that facility policy requires immediate notification of key staff, assessment for a plan and means of self‑harm, and thorough documentation, which were not carried out or reflected in the medical record for this resident.
A resident with schizophrenia, post-stroke hemiparesis, and mild cognitive impairment verbalized suicidal ideation, but the care plan did not address depression or suicidal thoughts, and required assessments and services were not accurately or timely documented. An SSD note recorded the resident saying he wanted to kill himself and referenced 15‑minute checks and a care plan update, yet the active care plan lacked depression/suicidal ideation interventions. Multiple late-entry Social Services notes were later added, describing follow-up visits and the resident denying suicidal ideation, but the SSD later reported she did not typically ask about a suicide plan and did not personally provide individual follow-up visits as described. These practices conflicted with the facility’s policy requiring factual, first-hand, and timely documentation of assessments and services.
A resident was observed with an Albuterol inhaler on an overbed table and later reported keeping the inhaler in a nightstand drawer, with no staff present during these observations. Record review showed the resident had no cognitive impairment on the admission MDS but lacked any documented self-medication administration assessment. The DON acknowledged that the required assessment had not been completed, despite facility policy requiring staff and the practitioner to evaluate each resident’s mental and physical abilities before allowing self-administration of medications.
Surveyors found that the facility submitted inaccurate direct care staffing data to CMS through the PBJ system over multiple days in a quarter. CASPER reports showed apparent gaps in 24-hour licensed nurse coverage, low weekend staffing, and a 1-star staffing rating, while internal staffing sheets documented that licensed nurses were present and the facility was fully staffed on those days. The Administrator reported that the discrepancies were due to PBJ data entry errors, despite a facility policy requiring all PBJ entries to be accurate, auditable, and verifiable against payroll, invoices, or contracts.
Surveyors found that the facility did not provide or document required written transfer/discharge notices and bed-hold policy information for four residents who were sent to the hospital, including individuals with conditions such as dementia, CHF, chronic respiratory failure, and CKD. In each case, progress notes showed that the resident was transferred for acute issues, but the clinical records lacked evidence that written notices were given to the residents or their representatives, and in one case lacked documentation that required information was sent to the receiving provider. Facility leadership, including the ADON, DON, and Administrator, acknowledged that the records did not contain the required documentation, despite a written policy requiring such notices and information exchange.
A resident with Alzheimer’s disease and depression, previously on an antidepressant, exhibited intermittent refusals of medications and care, occasional yelling at staff, and reports of unusual perceptions, such as believing men were in or near her room. Nursing notes over several months documented these refusals and complaints but did not show that the behaviors were evaluated or recorded as dangerous, non-redirectable, or causing significant distress, nor did they document specific non-pharmacological interventions attempted or their outcomes. Despite this, a psychiatric NP later added new diagnoses of schizoaffective disorder, borderline personality disorder, and delusional disorder and ordered an antipsychotic (Seroquel) without a comprehensive evaluation in the record to support these diagnoses. The facility’s psychotropic medication policy, which requires identification and documentation of target behaviors, use of nonpharmacological interventions, and ongoing behavior monitoring, was not followed for this resident.
The facility failed to keep PASARR Level I screenings accurate and current for three residents when new mental health diagnoses and psychoactive medications were initiated. One resident’s PASARR omitted a PTSD diagnosis and an added antidepressant, despite documentation of PTSD on the MDS and care plan and a physician order for Pristiq. Another resident’s PASARR listed only depression and dementia, even after additional diagnoses such as borderline personality disorder, delusional disorder, and schizoaffective disorder were added and an antipsychotic (quetiapine) was ordered, with the MDS later reflecting psychotic disorder, schizophrenia, and depression with antipsychotic and antidepressant use. A third resident’s PASARR did not include a depression diagnosis or newly ordered escitalopram and lorazepam, although the admission MDS documented depression with antianxiety and antidepressant use. These omissions occurred despite facility policy requiring a new Level I review after significant mental status changes, including new mental health diagnoses or new psychotropic medications.
Uncovered Facial Hair During Food Preparation and Meal Service
Penalty
Summary
The deficiency involves the facility’s failure to ensure that food was served in a sanitary and safe manner in accordance with professional standards and facility policy during multiple kitchen and meal service observations. During an initial kitchen observation, two dietary aides were seen walking through the kitchen food preparation area with uncovered facial hair. One aide had facial hair above and below the lip and along the jaw line, approximately one-fourth inch in length, and the other had a mustache of similar length; neither used any facial hair covering. These observations occurred while staff were present in the kitchen area where food was stored and prepared. During subsequent observations on the same day, the same two dietary aides were again observed with uncovered facial hair while directly involved in meal preparation and service. One aide walked through the kitchen while the noon meal was being prepared and placed into a transport cart for service in the south dining room, and later was observed plating the noon meal at the steamtable in that dining room, still without a facial hair covering. The other aide walked through the kitchen while the noon meal was being prepared and placed into the steamtable for the north dining room, took food temperatures, assisted with plating meals at the steamtable, and retrieved food items and supplies from the kitchen, all while having an uncovered mustache approximately one-fourth inch in length. The Dietary Manager stated that staff hair was to be covered when in the kitchen and during meal service, and the facility’s written policy and the cited Indiana Food Establishment Sanitation Requirements both required effective hair restraints, including for facial hair, to prevent contamination of food, equipment, and utensils.
Failure to Provide and Document Bed-Hold Policy at Time of Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure that required bed-hold policy information was provided and documented for four residents transferred to the hospital. For a resident with dementia, psychotic disorder, and autistic disorder who had a BIMS score of 0 indicating severe cognitive impairment, progress notes documented physician notification and guardian notification when the resident was sent to the hospital, but there was no documentation that the bed-hold policy was provided to the responsible party. A Notice of Transfer or Discharge later indicated a copy of the bed-hold policy was sent with the resident. Another resident with COPD and chronic respiratory failure, cognitively intact with a BIMS score of 13, experienced a decline in condition and was transferred to the hospital by ambulance; progress notes documented family notification but did not document any discussion of the bed-hold policy, although a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident. A third resident with altered mental status and cerebral infarction, with a BIMS score of 10 indicating moderate cognitive impairment and documented short-term memory impairment, experienced changes in condition and was transferred to the hospital. Progress notes stated the resident was their own responsible party and that no other notification was completed, and transfer documentation did not include the bed-hold policy, although an untimed Notice of Transfer or Discharge indicated a copy of the bed-hold policy was signed by the resident. A financial power of attorney document in the record showed the resident had designated an agent to act in consent or refusal of health care. For a fourth resident with dementia and osteomyelitis, transfer documentation and a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident, and the transfer form noted the resident required a proxy for decision making. The facility’s policy required that at the time of transfer to a hospital, written notice specifying the duration of the bed-hold policy and information on return to the next available bed be provided, and that a signed and dated copy of the bed-hold notice given to the resident or representative be kept in the resident file, which was not consistently documented for these residents.
Failure to Integrate Trauma Histories and Behavioral Triggers Into Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to identify and incorporate residents’ trauma histories and specific behavioral triggers into their care plans, despite documented histories of significant trauma and behavioral health issues. For one resident, extensive social service and progress notes documented homelessness, polysubstance abuse, major depressive and anxiety disorders, chronic pain, a history of severe car accidents with multiple fractures, viral encephalitis resulting in a three‑month coma, loss of child custody, multiple divorces, physical abuse by a spouse, the death of a fiancé who was struck by a car while in a wheelchair, lack of family contact, and a past suicide attempt by Valium overdose. Additional documentation noted a history of rape by a brother at age eight and prior placement under direct supervision and 15‑minute checks related to suicidal ideation. Despite these documented traumatic events and behavioral health concerns, the resident’s care plans did not identify a history of physical trauma, sexual trauma, homelessness, substance abuse, medical trauma, or attempted suicide. For this same resident, the MDS showed no cognitive deficit and identified behaviors such as verbal aggression and rejection of care, along with diagnoses including seizure disorder, depression, chronic pain syndrome, homelessness, and anxiety disorder. Multiple care plans addressed behaviors such as drug‑seeking, pretending to have seizures for attention or medication, making false allegations, verbal aggression when unable to smoke, and a desire for intimate relationships with consenting male residents. These care plans referenced goals such as effective coping skills, seeking staff support, and compliance with the smoking policy, and they called for identification and reduction of behavioral triggers. However, none of these care plans actually listed any specific triggers. The care plan addressing the resident’s right to consensual intimate relationships focused on assessment and education regarding consent but did not integrate the resident’s extensive trauma history. Staff interviews indicated the resident had displayed sexual behaviors since admission, including an incident where the resident expressed anger at another resident for not buying a soda after engaging in sexual acts. A second resident with a documented history of traumatic brain injury (TBI), dementia, seizure disorder, borderline personality disorder, anxiety, intermittent explosive disorder, tobacco use, and other behavioral/emotional disorders was also affected by the same deficiency. Social history and progress notes documented that this resident sustained a TBI after being hit by a semi‑truck while riding a bicycle at age 18, resulting in an 11‑month coma, followed by 13 years in a state hospital and subsequent residence in a group home. Additional documentation indicated the resident allegedly shot their father at age 26 after being sworn at and had a PASRR identifying TBI, intermittent explosive disorder, and borderline personality disorder, with a specific trigger of hearing the name of the current U.S. President. Progress notes also described inappropriate sexual behavior toward staff, including touching themselves intimately during personal care and refusing to stop when redirected. Despite this, the resident’s care plans, which addressed explosive disorder and history of altercations, risk for decreased psychosocial well‑being, and refusal to bathe or shower, did not list any specific behavioral triggers, did not reference the traumatic events such as being hit by a truck or shooting their father, and did not document the inappropriate sexual behavior. The Administrator and Social Service Director acknowledged that residents were to be screened for trauma and that trauma responses and PTSD should be added to care plans, but the specific trauma histories and triggers for these two residents were not incorporated into their plans of care.
Failure to Assess and Care Plan for Resident Suicidal Ideation
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess, investigate, and care plan for a resident’s suicidal ideation in accordance with its own policy and staff expectations. The resident had diagnoses including schizophrenia, cerebral edema, and hemiparesis/hemiplegia following a cerebral infarction, and a current MDS showed mild cognitive impairment (BIMS score 12). A progress note documented that the resident told the Social Services Director (SSD) he was feeling down and wanted to kill himself; the SSD offered assistance, activities, and initiated 15‑minute checks, and the note stated the care plan was updated. However, the note did not indicate that the SSD asked whether the resident had a plan to kill himself, and there were no additional notes regarding suicidal ideation or follow‑up. Review of the current care plan showed no problem, goal, or interventions addressing depression or suicidal ideation, and progress notes over the following month contained no documentation of physician notification related to the suicidal statement. Further record and interview evidence showed that the care plan conference summary did not document interventions for suicidal ideation, and the SSD acknowledged she did not normally ask residents expressing suicidal ideation if they had a plan. The SSD reported that the resident had admission paperwork mentioning suicidal ideation related to depression after a stroke and that the resident again vocalized suicidal ideation during a care plan meeting with his father, after which emotional support was offered and the father took the resident out on a leave of absence; no further visits or follow‑up were done. The DON stated that, upon notification of suicidal verbalization, staff should assess the resident, ask if there is a plan, remove potential means of self‑harm, immediately notify the psychiatric NP, and document the occurrence, and that a detailed progress note and updated care plan were expected but not present for this resident. The Administrator similarly stated that staff should ask about a plan, document interventions, notify the physician and family, and update the care plan, and indicated the resident should have had a care plan addressing depression with suicidal ideation. The facility’s written policy required immediate notification of the DON, SSD, and physician, an interview including asking about a plan and assessing mood and means for self‑harm, and thorough documentation of mood, behavior, and all actions taken, which were not reflected in the resident’s record.
Incomplete and Inaccurate Documentation of Suicidal Ideation and Follow-Up
Penalty
Summary
The facility failed to ensure accurate, complete, and timely documentation of assessments and services for a resident who verbalized suicidal ideation. Resident 6, who had schizophrenia, cerebral edema, and right-sided hemiparesis/hemiplegia following a cerebral infarction, had a BIMS score of 12 indicating mild cognitive impairment. The resident’s admission paperwork mentioned suicidal ideation related to depression after a stroke, and a Social Services note on 3/11/2026 documented that the resident was feeling down and said he wanted to kill himself. The Social Services Director (SSD) documented that she talked with the resident, coordinated with Activities, advised the resident to contact SSD or nursing if he wanted to talk, and that the resident was scheduled for 15-minute checks and the care plan was updated. However, the current care plan initiated on 2/26/2026 did not address depression or suicidal ideation. Multiple Social Services progress notes were later entered as late entries in April, with effective dates in March, stating that the resident had no plan and no longer had suicidal ideation, that he felt much better after 1:1 time, and that he continued his daily routine and therapy. These late entries described follow-up visits and reassessments of suicidal ideation on several consecutive days, but in interviews the SSD stated she did not normally ask residents about having a plan when they verbalized suicidal ideation and did not recall any other occurrences beyond the initial event. She further indicated she did not personally provide individual follow-up visits with this resident regarding suicidal ideation, despite the late-entry notes describing such visits. The DON acknowledged that late entries had been added to address concern about suicidal verbalization, and the Administrator stated that upon suicidal statements staff should ask about a plan, notify the physician and family, and update the care plan, and that this resident should have had a care plan addressing depression with suicidal ideation. The facility’s documentation policy required factual, first-hand, timely documentation, which was not followed in this case.
Failure to Complete Required Self-Administration Assessment for Inhaler Kept at Bedside
Penalty
Summary
Surveyors identified that a resident was allowed to keep and access an Albuterol inhaler without the facility completing the required self-administration medication assessment. During an initial tour, the resident was observed sitting in a wheelchair with a handheld Albuterol inhaler on the overbed table and no staff present in the room or hallway. On a subsequent observation, the resident again was in a wheelchair and reported that the Albuterol inhaler was stored in the top drawer of the nightstand, where it was found. Review of the clinical record showed an admission MDS indicating no cognitive impairment, but there was no documentation of a self-medication administration assessment. In an interview, the DON confirmed that the resident did not have the required self-medication assessment, despite the facility’s policy stating that staff and the practitioner must assess each resident’s mental and physical abilities to determine whether self-administering medications is clinically appropriate. This failure to complete and document a self-administration medication assessment for a resident who had an Albuterol inhaler kept at bedside constituted noncompliance with the facility’s own policy and with 410 IAC 16.2-3.1-11(a).
Inaccurate PBJ Staffing Data Submission to CMS
Penalty
Summary
The deficiency involves the facility’s failure to electronically submit complete and accurate direct care staffing information to CMS through the Payroll-Based Journal (PBJ) system for 22 days in a fiscal quarter. A CASPER report review on 4/6/26 showed that, according to PBJ data, the facility did not have licensed nursing coverage 24 hours per day on multiple specific dates across three months, had low weekend staffing, and held a 1-star staffing rating. However, review of the facility’s internal staffing sheets for that quarter indicated the facility was fully staffed and had licensed nurse coverage on all of the dates in question. During an interview, the Administrator stated that the PBJ information must have contained data entry errors, as she had verified licensed staff coverage on the timesheets. The facility’s PBJ policy in effect stated that all staffing data entered into the PBJ system would be auditable and verifiable through payroll, invoices, or contracts, but the submitted PBJ data did not accurately reflect the facility’s actual licensed nurse staffing as documented on internal records. No specific residents or clinical conditions were mentioned in the report, and the deficiency centers solely on inaccurate staffing data submission rather than direct resident care events.
Failure to Provide and Document Required Transfer/Discharge and Bed-Hold Notices
Penalty
Summary
The deficiency involves the facility’s failure to provide and document required written notices of transfer/discharge and bed-hold policies, as well as required information to receiving providers, for four residents who were transferred or discharged to the hospital. For a resident with generalized anxiety disorder, major depressive disorder, and dementia, progress notes showed that the resident was sent to the hospital via 911 for chest pain, lower back pain, and shortness of breath and later returned to the facility, but the clinical record lacked documentation that a written Notice of Transfer/Discharge and the bed-hold policy were provided to the resident or representative, and lacked documentation that required information was conveyed to the receiving facility. The ADON and the Administrator both confirmed there was no documentation that these written notices were provided. For a resident with congestive heart failure and muscle weakness who was sent to the emergency room for painful urination and bloody urine, the clinical record lacked documentation that a Notice of Transfer/Discharge or bed-hold policy was given to the resident or representative, which the DON confirmed. Another resident with chronic respiratory failure and diabetes was discharged to the hospital for respiratory failure, and a resident with chronic kidney disease and dementia was discharged to the hospital, but in both cases there was no documentation that a written notice of transfer/discharge or bed-hold policy was provided to the residents or their representatives. Review of the facility’s Transfer and Discharge policy, dated 1/15/26, showed that the policy required the facility to provide written transfer/discharge notices and bed-hold information to residents and representatives and to provide specified information to receiving providers, but the records for these four residents did not contain the required documentation.
Failure to Document Target Behaviors and Non-Pharmacological Interventions Before Initiating Antipsychotic
Penalty
Summary
The deficiency involves the facility’s failure to document how a resident’s behaviors presented danger or distress to self or others, and failure to document non-pharmacological interventions attempted prior to initiating an antipsychotic medication. Resident 6 had documented diagnoses of Alzheimer’s disease, depression, and severe cognitive impairment, and was receiving sertraline for depression. A PASSAR identified only depression and dementia, and the admission MDS listed Alzheimer’s disease and depression as active diagnoses. Over several months, nursing progress notes documented that the resident intermittently reported unusual perceptions, such as believing there were men causing trouble, a man in her room, or a man wanting to marry her and yelling through the walls, but there was no documentation that these episodes caused danger to the resident or others or that they resulted in unmanageable distress. From late April through mid-July, nursing notes primarily described the resident’s frequent refusals of evening and morning medications, blood sugar checks, blood pressure checks, insulin administration, hygiene care, and showers. Staff documented that the resident sometimes yelled at staff, said “Get out!”, was visibly upset by a room move, was leery of staff and asked to see name badges, and became upset about a pillow under her head until it was removed, after which she calmed down. The notes also recorded instances where the resident believed housekeeping had not cleaned her room or that she had not received medications when she had. However, there were no progress notes or assessments indicating that these behaviors were evaluated as dangerous, non-redirectable, or causing significant distress or functional impairment, and no detailed behavior monitoring logs were present as required by facility policy. On a psychiatric NP visit for initial psychotropic medication management, new mental health diagnoses of schizoaffective disorder, borderline personality disorder, and delusional disorder were added, and Seroquel 25 mg, an antipsychotic, was ordered. The clinical record did not contain a comprehensive evaluation to support these new diagnoses, and there was no documentation of target behaviors meeting the facility’s policy criteria for psychotropic use, such as behaviors representing danger to self or others, causing distress and impairment in functional abilities, or clearly attributable to psychosis or mania. The resident’s representative reported that the resident had no prior history of mental health disorders or psychiatric hospitalization and was unaware of the new diagnoses. The facility’s own psychotropic medication policy required identification and documentation of specific target behaviors, use and documentation of nonpharmacological interventions, and ongoing monitoring of behaviors and interventions, which were not reflected in the record for this resident.
Failure to Update PASARR Screens for New Mental Health Diagnoses and Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that Preadmission Screening and Resident Review (PASARR) Level I screenings were accurate and updated when new mental health diagnoses and psychoactive medications were initiated for multiple residents. For one resident with dementia, anxiety, depression, and post-traumatic stress disorder (PTSD), the PASARR completed on admission listed anxiety, depression, and dementia with sertraline and quetiapine, but did not include the PTSD diagnosis or the antidepressant Pristiq, despite the admission MDS and care plan documenting PTSD and a subsequent physician’s order for Pristiq. For another resident with Alzheimer’s disease, borderline personality disorder, delusional disorder, schizoaffective disorder, and depression, the PASARR only reflected depression and dementia with sertraline, even though additional mental health diagnoses were added later and an antipsychotic (quetiapine) was ordered for borderline personality disorder, and the quarterly MDS documented psychotic disorder, schizophrenia, and depression with antipsychotic and antidepressant use. A third resident had diagnoses including Alzheimer’s disease, depression, anxiety disorder, irritability and anger, and nonrheumatic aortic valve stenosis. The PASARR for this resident listed dementia and anxiety with Risperdal but omitted the diagnosis of depression and the medications escitalopram and lorazepam, although physician’s orders were in place for escitalopram for depression and lorazepam for anxiety, and the admission MDS documented depression with antianxiety and antidepressant use. Interviews with the Assistant Director of Nursing confirmed that new Level I PASARR screens should have been completed when new mental health diagnoses and psychoactive medications were added, and that the PASARR for one resident, completed prior to arrival, should have included all mental health diagnoses and medications. The facility’s own policy required notification of the state mental health authority within 14 days after a significant change in mental condition and specified that a new Level I screen is required for new mental health diagnoses or newly prescribed psychotropic medications, which was not followed in these cases.
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