Waters Of Wabash Skilled Nursing Facility East The
Inspection history, citations, penalties and survey trends for this long-term care facility in Wabash, Indiana.
- Location
- 1900 N Alber St, Wabash, Indiana 46992
- CMS Provider Number
- 155006
- Inspections on file
- 34
- Latest survey
- March 17, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Waters Of Wabash Skilled Nursing Facility East The during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, multiple comorbidities (including DM with neuropathy, PVD, CKD, CHF, and malnutrition), and documented risk for pressure ulcers had physician orders and care plan interventions for bilateral heel elevation, use of moon boots, skin protectants, and pressure-reducing devices. Surveyors repeatedly observed the resident in bed on an air mattress with a foot cradle in place but with both feet resting directly on the mattress, covered by blankets, and without moon boots or pillows offloading the heels. Staff interviews showed they believed wound prevention included moon boots, a foot cradle, air mattress, and repositioning, but CNAs relied on printed task sheets that only referenced a “foot buddy” and did not list heel offloading or moon boots. The care plan had been revised for new arterial/ischemic toe ulcers, yet the resident’s wound prevention interventions were not consistently implemented or accurately reflected on CNA documentation tools.
QMAs performed and documented wound care outside their legal scope of practice for a resident with a recurrent left great toe wound involving partial and full thickness loss. The MAR contained orders to cleanse and paint the toe with povidone iodine and leave it open to air on day and evening shifts, and multiple QMAs documented completing these treatments over several months. In interviews, QMAs stated they understood they were only allowed to apply creams and powders and not to treat stage 1 or open wounds, and one QMA admitted signing for treatments she did not perform while another stated she signed after watching a nurse perform the care. The DON believed QMAs could complete the toe treatment because it was open to air, but the state QMA scope of practice limited QMAs to minor skin conditions (including stage I decubitus) and prohibited them from administering treatments for advanced skin conditions such as stage II–IV decubitus ulcers or documenting medications not personally administered.
A resident with dementia, osteoporosis, and high dependence on staff for ADLs was subjected to verbally abusive and rough care by a CNA during toileting and hygiene assistance. While the resident resisted by clamping her legs, the CNA was reported to have pulled forcefully on the resident’s arm and stated, “we can do this the easy way or the hard way,” and to have told the resident to open her “da** legs.” Another CNA present reported feeling uncomfortable with the rude language and rough handling, and an RN was informed that the CNA had cursed and raised her voice toward the resident. The facility’s own incident report documented that the CNA was rude and used the phrase “open your da** legs,” which met the facility’s definition of verbal abuse.
A resident with dementia and major depressive disorder was involved in an incident where a CNA allegedly became aggressive after being scratched by the resident. The event was observed by a dietary manager and reported to the DON, but the Administrator did not report the allegation to the State Agency as required, citing lack of evidence and interpersonal conflicts among staff. The facility did not collect written witness statements or follow its abuse reporting policy, resulting in a deficiency for failure to report suspected abuse.
A facility failed to properly investigate and report an allegation of staff-to-resident abuse involving a resident with dementia. The incident, witnessed by a dietary manager, was not thoroughly documented or reported to the state as required by facility policy. The administrator did not collect written statements from all involved staff and did not separate the alleged perpetrator from resident contact during the investigation.
The facility employed a Dietary Manager who lacked the required certification and had not received any training since being hired. Leadership was aware of the lack of qualifications, and facility policy requiring a qualified Food Service Director was not followed, potentially affecting all residents receiving meals.
Surveyors observed unsanitary conditions in the kitchen, including improper storage of food and chemicals, unclean equipment and surfaces, and staff failing to follow safe food handling practices. These deficiencies had the potential to affect all residents receiving food from the kitchen.
Multiple residents and their representatives reported that meals were frequently cold, lacked flavor, appeared unappetizing, and were served in inconsistent and often insufficient portions. Observations confirmed issues with food temperature, presentation, and portion sizes, while grievances and council minutes documented ongoing dissatisfaction with meal quality and adequacy. Staff interviews and facility records acknowledged these concerns, indicating a systemic failure to meet standards for palatable and properly served meals.
Two residents were observed eating meals while seated in wheelchairs that were too low for the dining tables, causing difficulty in reaching food and drinks and requiring awkward postures. Both residents, who were cognitively intact and required some assistance with eating, experienced undignified dining conditions over multiple meals. Staff did not recognize the issue, and care plans included interventions to ensure proper positioning, but these were not effectively implemented.
The facility did not provide required Skilled Nursing Facility Advance Beneficiary Notices of Non-coverage (SNF ABN) to two residents who remained after their Medicare Part A skilled services ended. The Business Office Manager reported informing residents of private pay amounts but had never issued an ABN form, and clinical records lacked documentation of the required notice.
Two residents were found using wheelchairs that remained visibly soiled with food particles, stains, and unidentified substances over several days, despite a facility policy and cleaning schedule requiring regular deep cleaning. Staff interviews revealed inconsistent understanding of cleaning responsibilities, and the ADON confirmed the wheelchairs should have been cleaned as scheduled.
A resident with a history of repeated falls and severe cognitive impairment experienced multiple falls, but the care plan was not consistently updated with new interventions after each incident. Observations showed that some fall prevention measures, such as non-skid strips and reminder signage, were not properly implemented. Staff interviews confirmed that care plan updates and interventions were not always carried out as required.
A resident with severe cognitive impairment and multiple comorbidities was repeatedly observed lying in bed without the ordered moon boots to offload pressure from the heels, despite care plans and physician orders requiring their use. Staff interviews and documentation review confirmed that the intervention was not consistently implemented, and there was no record of resident refusal. The resident had a stage 3 pressure injury on the heel and additional skin breakdown, indicating a failure to follow prescribed pressure ulcer prevention measures.
A resident with a history of syncope, repeated falls, and a recent seizure did not have proper seizure precautions in place, as only one bed rail was partially padded and staff were unclear on correct procedures. The facility's policy lacked guidance on side rail padding, and maintenance staff were unfamiliar with installation requirements.
A resident with an arterial foot wound and multiple comorbidities did not have required enhanced barrier precautions implemented, including missing door signage and disposal bins for PPE, despite physician orders and care plans. Staff were unaware of the resident's EBP status due to lack of signage and documentation, resulting in noncompliance with facility policy.
A facility failed to maintain infection control practices during catheter care for a resident requiring Enhanced Barrier Precautions. A CNA did not wear a gown as required, despite EBP signage on the resident's door. The ADON confirmed the need for protective gear, as outlined in the facility's policy.
The facility failed to provide palatable food to 23 residents, with issues such as dry and cold meat, mushy vegetables, and inadequate grievance responses. Observations showed staff struggling to cut tough brisket, and residents reported inedible meals. The facility's policy lacked specific guidelines for meat preparation.
A CNA was observed handling bread with bare hands during meal service for 23 residents, violating the facility's infection control policy that prohibits bare hand contact with ready-to-eat foods. The CNA admitted to the oversight, acknowledging that gloves should have been used.
Failure to Implement and Update Wound Prevention Interventions for High-Risk Resident
Penalty
Summary
Surveyors identified a failure to implement ordered wound prevention interventions and to update the care plan for a resident with multiple comorbidities and high risk for skin breakdown. On several observations during the same day, the resident was seen lying on his back on an air mattress with his head elevated, with a foot cradle at the end of the bed, but his feet were directly on the mattress. At various times, his blankets covered one or both feet, and he wore a nonskid sock on the right foot, rather than having his heels elevated or protected as ordered. The foot cradle was in place only to keep blankets off the feet, and there was no evidence that pillows or moon boots were being used to offload the heels while he was in bed. Record review showed the resident had significant diagnoses including permanent atrial fibrillation, pulmonary fibrosis, type II DM with neuropathy, CHF, CKD, PVD, malnutrition, post-polio syndrome, and chronic pain. Physician orders included bilateral heel elevation off the bed with pillows every shift, Aquaphor to bilateral legs/feet twice daily, Pro-heal twice daily, and encouragement of moon boots at all times except for bathing and care. Additional orders were in place for daily wound care to multiple toes on the right foot. The MDS and Braden Scale documented that he was severely cognitively impaired, dependent for mobility and ADLs, at risk for pressure ulcers, and using pressure-reducing devices. A nurse’s note documented new areas on the toes discovered by a CNA during a shower, with wound measurements and treatment initiated. The resident’s care plan for increased risk of impaired skin integrity, revised earlier, included offloading heels at all times in bed, frequent repositioning, good pericare, barrier cream, and use of a pressure-reducing mattress. Later care plans were added for arterial/ischemic ulcers of the right great toe, right second toe distal, and right third toe proximal, with interventions such as daily foot inspection, keeping feet clean and dry, and wound observation and documentation. However, interviews with staff revealed that wound prevention interventions were understood to include moon boots, foot cradle, air mattress, and repositioning, but the resident was observed without heels offloaded and without moon boots in use. The DON stated the resident sometimes refused moon boots and that care plans were in the process of being updated. The ADON indicated CNAs followed printed CNA sheets rather than the electronic care plan, and the CNA sheets for this resident listed a “foot buddy to end of bed” but did not include heel offloading or moon boots, demonstrating that the resident’s wound prevention interventions were not fully implemented or reflected on the CNA task sheets.
QMAs Performed and Documented Wound Care Outside Scope of Practice
Penalty
Summary
Surveyors identified a deficiency in which Qualified Medication Aides (QMAs) performed and/or documented wound treatments outside their legal scope of practice for a resident with a left great toe wound. Resident D had multiple diagnoses, including chronic systolic heart failure, chronic pain syndrome, venous thrombosis history, malnutrition, atherosclerosis of the lower extremities, and restless legs syndrome. A NP wound note from late December documented that an earlier toe wound had resolved but a new wound on the left great toe had developed, initially suspected as an arterial ulcer and later classified as trauma-related. The wound was described as full thickness loss, dry, without drainage, and measured 0.8 cm x 1.2 cm x 0.1 cm. The January MAR ordered cleansing of the left great toe with povidone iodine and leaving it open to air on the day shift, with monitoring for infection or worsening, and QMA 5 documented completion of this treatment on two dates. In late January, nursing documentation indicated the resident’s left toe wound had reopened, was bleeding, and was wrapped with gauze, though the resident would not allow measurement. A February NP wound note recorded that the left great toe wound had reopened with partial thickness loss and measured 0.7 cm x 1.0 cm x 0.1 cm. The February MAR contained orders to cleanse the left great toe with povidone iodine and leave it open to air every day and evening shift, later specifying to cleanse and paint with povidone iodine and leave open to air, with monitoring for signs of infection or worsening. QMAs 5, 7, and 9 documented on multiple dates in February that they completed these wound treatments. A subsequent NP wound note in late February described the wound as stable, scabbed, with partial thickness loss and measuring 0.6 cm x 0.7 cm x 0.1 cm. In March, the MAR continued the order to cleanse and paint the left great toe with povidone iodine and leave it open to air every day and evening shift, with monitoring instructions, and QMAs 5, 7, and 9 again documented completion of these treatments on multiple dates. During interviews, QMA 5 stated that QMAs were allowed to apply creams and powders but not to treat any stage 1 or higher wounds, and acknowledged it was possible she signed for Resident D’s wound treatments even though the wound had worsened and QMAs had stopped doing the treatment. QMA 9 stated QMAs could apply creams and powders but not treat stage 1 or open wounds, and reported that she watched a nurse complete Resident D’s wound treatment but signed it off in the MAR herself, believing she could apply povidone iodine to a wound. QMA 7 similarly indicated QMAs were not allowed to complete treatments above a stage 1 or on open wounds and said she had not completed the resident’s wound treatments because he had a “crater” on his toe. The DON, however, indicated QMAs could not complete wound treatments above stage 2, wounds with bandages, or invasive treatments, but believed QMAs could complete this resident’s wound treatment because the toe was left open to air. The state QMA scope of practice obtained from IDOH specified that QMAs may apply topical medications only to minor skin conditions, including stage one decubitus ulcers, and may not administer treatments involving advanced skin conditions such as stage II–IV decubitus ulcers, and also may only document medications they personally administered, not those given by another person or not administered at all.
Failure to Protect a Dependent Resident From Verbal and Rough Care During ADL Assistance
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from verbal and potential physical abuse during the provision of care. Resident C, who had dementia, osteoporosis, and significant dependence on staff for ADLs including toileting, dressing, and bed mobility, required assistance and redirection as needed. During an episode of care, CNA 4 reported that CNA 3 approached Resident C and began pulling on the resident’s arm in a forceful manner. While Resident C was clamping her legs shut, CNA 3 told the resident to open her “da** legs” and stated, “we can do this the easy way or the hard way.” According to CNA 4, Resident C did not become combative until CNA 3 began roughly yanking on the resident’s arm. CNA 3 acknowledged to the Administrator that she used the phrase “we can do this the easy way or the hard way,” claiming it was said under her breath and that she did not intend harm, and she recalled telling the resident to open her legs but denied using a curse word or pulling the resident’s arm forcefully. CNA 4’s statement indicated that CNA 3 used rude language and had been rough with Resident C, and that CNA 3 firmly grasped the resident’s arm while the resident was combative. RN 5 reported that CNA 4 came to her after the care episode, stating that CNA 3 had cursed and raised her voice toward the resident, which made CNA 4 uncomfortable. The facility’s self-reported incident to the state indicated that CNA 3 was rude to the resident and told the resident to open her “da** legs.” The facility’s abuse policy defined verbal abuse as the use of disparaging or derogatory language within a resident’s hearing, regardless of the resident’s ability to comprehend, and the documented conduct of CNA 3 met this definition.
Failure to Report Alleged Staff-to-Resident Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of staff-to-resident physical and verbal abuse to the State Agency as required. The incident involved a resident with diagnoses of dementia and major depressive disorder, who was severely cognitively impaired and required behavioral monitoring. During a lunch service, a dietary manager observed a CNA become aggressive with the resident after the resident scratched the CNA's hand while both reached for a drink. The CNA reportedly grabbed the resident's wrists and loudly told the resident not to scratch her. The dietary manager reported the incident to the DON and later inquired if her written statement was needed, but was told by the Administrator that it was not necessary. The Administrator, who was ill at the time of the incident, indicated that he did not believe the event was reportable and did not submit a report to the State Agency. He conducted an internal investigation, which included interviews with the involved CNA and other staff, but found no evidence to substantiate the allegation. The Administrator also noted interpersonal conflicts between the dietary manager and the CNA, which influenced his perception of the credibility of the report. The DON confirmed that she had notified the Administrator of the allegation and that no written statements were collected from the witnesses at the time. Facility policy required that all allegations or suspicions of abuse be immediately reported to the Administrator and the State Agency, and that written statements from witnesses be collected within 24 hours. Despite these requirements, the facility did not report the incident to the State Agency, did not collect written statements from all involved parties, and did not document the incident in accordance with policy. The failure to report the allegation and follow established procedures resulted in noncompliance with regulatory requirements for abuse reporting.
Failure to Investigate and Report Alleged Staff-to-Resident Abuse
Penalty
Summary
The facility failed to investigate an allegation of staff-to-resident abuse and did not implement its abuse prevention policy following an incident involving a resident with dementia and major depressive disorder. An anonymous allegation was received by the state regarding a staff member becoming aggressive with a resident during lunch. The Dietary Manager (DM) reported witnessing a certified nursing assistant (CNA) grab the resident's wrists and speak loudly after the resident scratched the CNA. The DM attempted to report the incident to the Director of Nursing (DON) and the Administrator, but the Administrator later indicated there were no findings and did not request a written statement from the DM. Interviews revealed inconsistencies in the facility's response to the allegation. The Administrator stated he was unaware of any abuse reports or grievances in the relevant period and did not consider the incident reportable. He also questioned the reliability of the DM as a witness due to prior conflicts between the DM and the CNA. The DON recalled the DM reporting the incident and attempting to check security cameras, but did not recall collecting written statements from involved staff. The facility's own policy required immediate reporting, separation of the alleged perpetrator, documentation, and notification to the state, none of which were fully followed. The resident involved was severely cognitively impaired and required cues for eating. Clinical records indicated behavioral symptoms related to dementia, but no physical or verbal aggression was documented during the assessment period. The facility's documentation of the incident was created over a month after the event and did not include timely written statements from all witnesses. The facility did not ensure that all required investigative steps were taken or that residents were protected according to policy following the allegation.
Unqualified Dietary Manager Employed Without Required Certification
Penalty
Summary
The facility failed to ensure that the Dietary Manager met the required qualifications and completed the necessary education to serve in that role. The Dietary Manager, who was hired in December 2024, reported during an interview that she did not possess certification qualifying her to act as Dietary Manager and had not received any training at the time of hire or since. Both the Administrator and the Regional Director of Operations confirmed their awareness that the Dietary Manager was not certified and had been employed in the position since December 2024. Facility policy requires the employment of a qualified Food Service Director per regulatory requirements, but this standard was not met, potentially impacting all 56 residents who received meals from the facility kitchen.
Unsanitary Food Storage and Preparation Practices
Penalty
Summary
The facility failed to store and prepare food under safe and sanitary conditions, as evidenced by multiple observations in the kitchen. Surveyors observed an open container of brown sugar with a scoop handle inside the sugar, a microwave with dried food splatters, and upper cabinets with visible food splatters. Discarded kitchen gloves and empty coffee packets were found on the countertop, and the floor beneath was covered with corn flakes. The toaster had crumbs on both the spill tray and countertop, with scissors lying among the crumbs and an uncovered container of melted butter on top. The refrigerator had sticky fingerprints on the exterior and contained a roast beef in a zip lock bag that was past its date. Utensil drawers contained crumbs, a brown substance, and torn paper, and an open bag of panko breadcrumbs was stored improperly under a counter. In the dry storage area, chemicals such as bleach and floor cleaner were stored on the floor beneath electrical panels. Additionally, a kitchen staff member was observed improperly emptying a can of green beans, allowing the lid to repeatedly touch the food, which the Dietary Manager acknowledged was incorrect and attributed to lack of training. The chemicals in the dry storage area remained improperly stored during subsequent observations. Facility policies required clean, sanitary, and safe food storage and preparation, as well as proper cleaning schedules and staff training, but these were not followed, resulting in unsanitary conditions that had the potential to affect all residents receiving food from the kitchen.
Failure to Provide Palatable, Attractive, and Properly Tempered Meals
Penalty
Summary
The facility failed to ensure that meals provided to residents were palatable, attractive, and served at a safe and appetizing temperature for 17 of 31 residents reviewed. Multiple residents and their representatives reported that the food was consistently cold, lacked flavor, was unappetizing in appearance, and was sometimes served in insufficient portions. Specific complaints included hard rolls, unidentifiable or flavorless soups, watered-down drinks, and inconsistent portion sizes. Observations confirmed that food items such as meatloaf appeared grayish and unappealing, mashed potatoes and gravy lacked flavor, and pudding portions varied between residents. Residents also reported receiving meals late, with some meals missing items listed on the menu or being substituted with less desirable options due to shortages. Grievances and resident council minutes further documented ongoing dissatisfaction with the quality, temperature, and quantity of food served. Residents described meals as poorly cooked, insufficient to satisfy hunger, and sometimes inedible, with examples such as undercooked French fries, very small portions of pizza, and missing condiments like butter or sour cream. Several residents indicated they relied on snacks or food brought in by family members to supplement their meals due to the inadequacy of the facility's food service. The issues were persistent, with complaints spanning several months and being raised repeatedly in resident council meetings and formal grievances. Staff interviews and facility records acknowledged the residents' dissatisfaction, with staff noting inconsistent food temperatures, portion sizes, and presentation. The facility's own policy required that food be prepared, held, and served in a manner that maintains its nutritive value and palatability, but observations and resident feedback indicated this standard was not consistently met. The deficiency was evident through direct resident interviews, observations of meal service, review of grievances, and resident council minutes, all pointing to a systemic failure to provide meals that met residents' expectations for palatability, temperature, and adequacy.
Failure to Provide Dignified Dining Experience Due to Improper Table and Wheelchair Positioning
Penalty
Summary
Surveyors observed that two residents were not provided with a dignified dining experience during multiple meal services in the main dining room. Both residents were seated in wheelchairs that were significantly lower than the dining tables, resulting in their chins being at or below the tabletop. This positioning made it difficult for them to eat and required them to reach upward for their food and drinks. One resident was seen eating while hunched over and leaning to the right, and both had to lift their cups from below the table to drink. Staff interviews revealed that CNAs did not perceive the table height as a problem and were unsure if the tables could be adjusted. Neither resident had complained about the table height, and the ADON had not previously considered the issue. The clinical records for both residents indicated they were cognitively intact and required setup or clean-up assistance with eating. One resident had diagnoses including dementia, osteoarthritis, and heart failure, while the other had altered mental status, dysphagia, epilepsy, and adult failure to thrive. Care plans for both residents included supervision and assistance during meals, with interventions to ensure they were close enough to the table to reach food and drink properly. Facility policy stated that residents' needs and preferences should be honored as much as possible, considering their health status and safety.
Failure to Provide Medicare Non-Coverage Notification
Penalty
Summary
The facility failed to provide required notification of Medicare non-coverage to two residents who remained in the facility after their Medicare Part A skilled services ended. For both residents, the clinical records did not contain a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) after their last covered day under Medicare Part A. During an interview, the Business Office Manager stated that she informed residents or their representatives of private pay amounts but had never provided an ABN form to any resident. The facility's current policy referenced providing a detailed explanation of non-coverage, but there was no evidence that the required SNF ABN was issued to the affected residents.
Failure to Maintain Clean Wheelchairs for Two Residents
Penalty
Summary
The facility failed to provide clean and sanitary wheelchairs for two residents, as evidenced by multiple observations over several days. One resident's wheelchair was repeatedly found with smeared dark and reddish-brown substances, as well as honey-colored streaks on the outer panels. Despite a cleaning schedule indicating that deep cleaning should occur every Wednesday night, the wheelchair remained visibly soiled during several observations. Staff interviews revealed inconsistent understanding of cleaning responsibilities, with some indicating that third shift CNAs were responsible for deep cleaning, while others stated it was the responsibility of all staff members. Another resident's wheelchair was observed to have a nickel-sized dark brown substance on the right arm pad, a buildup of food particles and stains on the left side of the seat, and additional unidentifiable streaks and crumbs on various parts of the wheelchair. These conditions persisted over several days, despite the facility's policy requiring durable medical equipment to be clean and in good repair. The Assistant Director of Nursing confirmed that the wheelchairs should have been cleaned according to the schedule, but the deficiencies remained unaddressed at the time of the observations.
Failure to Update Care Plan and Implement Fall Precautions After Multiple Falls
Penalty
Summary
The facility failed to implement fall precautions and update care plan interventions following multiple falls for a resident with significant risk factors. The resident had diagnoses including syncope, repeated falls, chronic kidney disease, and severe cognitive impairment. Despite a history of falls and specific care plan interventions in place, the care plan was not consistently updated with new interventions after each fall event, as required by facility policy and regulatory standards. Several incidents were documented where the resident experienced falls, including being found on the floor in another resident's room, in front of her wheelchair, and by her bed. After some of these falls, such as those on 12/21/25, 4/13/25, and 5/19/25, there was no evidence that new interventions were added to the care plan. In one instance, a new intervention (pommel cushion) was added after a fall, but this was not consistently done after subsequent incidents. Staff interviews confirmed that new interventions should be implemented after each fall, but this was not always carried out. Observations also revealed that some existing interventions were not properly implemented, such as the use of non-skid strips and signage to remind the resident to ask for assistance. The non-skid strips were smaller than intended, and the required signage was missing from the resident's room. Staff interviews corroborated these findings, indicating a lack of adherence to the care plan and facility policy regarding fall prevention and care plan updates.
Failure to Consistently Implement Pressure Ulcer Prevention Interventions
Penalty
Summary
The facility failed to implement prescribed interventions to prevent and promote the healing of a pressure injury for one resident. Multiple observations over several days showed that the resident, who was severely cognitively impaired and dependent on staff for mobility and care, was repeatedly found lying on his back in bed without his ordered moon boots, which are designed to offload pressure from the heels. Despite physician orders and care plan interventions specifying the use of moon boots while in bed and the need to float the resident's heels, staff did not consistently apply these devices. The moon boots were frequently observed on a chair or chest of drawers rather than on the resident, and his heels were not floated as required. Interviews with staff confirmed that the resident was supposed to have the moon boots on while in bed, and that this was a standing order signed off every shift. However, there was no documentation of the resident refusing the intervention, and staff acknowledged that the boots were not always applied. The resident's representative also reported that the resident was not repositioned for extended periods and that the moon boots were only used about half the time. The resident had a history of pressure injuries, including a stage 3 pressure injury on the left heel that developed after admission, as well as sores on his back and buttocks. Clinical record review indicated ongoing wound care treatments and preventative interventions, including the use of a pressure-relieving mattress, hydrophilic wound dressings, and regular wound assessments. Despite these measures, the lack of consistent application of the moon boots and failure to float the heels as ordered contributed to the deficiency. Facility policy required the use of specialty boots or floating heels for residents at high risk for skin breakdown, but this was not consistently followed for this resident.
Failure to Implement Seizure Precautions for Resident
Penalty
Summary
The facility failed to implement appropriate seizure precautions for a resident with a history of syncope, repeated falls, and a recent seizure episode. The resident, who was severely cognitively impaired and required significant assistance with activities of daily living, experienced an unwitnessed fall and a witnessed seizure within the same day. Medical orders and care plans specified the use of two, one-half padded side rails as a seizure precaution, and interventions included ensuring proper body alignment and padding of side rails as needed. Upon observation, only one side rail was partially padded with a pool noodle, leaving parts of the rail exposed, while the other rail was not padded at all. Interviews with staff revealed uncertainty regarding the correct application of padding for seizure precautions, and the Director of Nursing confirmed that maintenance staff were unfamiliar with the installation of side rail pads due to the infrequent use of seizure precautions in the facility. The facility's policy on seizure precautions did not provide instructions for side rail pad application.
Failure to Implement Enhanced Barrier Precautions for Resident with Wound
Penalty
Summary
The facility failed to consistently implement its policy for enhanced barrier precautions (EBP) for a resident with a wound requiring such precautions. Multiple observations over several days showed that the resident, who had an arterial wound on his right foot and was under orders for EBP, did not have the required signage for transmission-based precautions on his door. Additionally, the necessary bins for disposal of personal protective equipment (PPE), trash, and laundry were not present in the resident's room until after the deficiency was identified. Staff interviews revealed that certified nursing assistants (CNAs) relied on door signage and assignment sheets to identify residents on EBP, but the resident in question was not listed or marked appropriately, leading to confusion about his precaution status. The resident had significant medical conditions, including chronic diastolic heart failure, peripheral vascular disease, multiple myeloma, and a protein calorie deficit, and required substantial staff assistance for daily activities. Despite care plans and physician orders indicating the need for EBP due to his wound, the infection preventionist had not placed the required signage, and staff were unaware of the resident's EBP status. The facility's policy, revised in December 2022, required proper signage and receptacles for EBP, but these measures were not implemented as ordered for this resident.
Infection Control Lapse During Catheter Care
Penalty
Summary
The facility failed to maintain appropriate infection control practices during urinary catheter care for a resident who required Enhanced Barrier Precautions (EBP). During an observation, a Certified Nursing Assistant (CNA) performed hand hygiene with soap and water before donning gloves but failed to wear a gown before starting the catheter care for the resident. The resident had EBP signage displayed on the door, indicating the need for additional protective measures during care. Interviews conducted during the observation revealed that the CNA acknowledged the failure to don a gown before providing catheter care. The Assistant Director of Nursing (ADON) confirmed that staff members were required to wear a gown, gloves, goggles, and a mask before performing catheter care on residents requiring EBP. The facility's EBP sign and catheter care policy outlined the necessary infection prevention and control techniques, which were not adhered to in this instance.
Deficiency in Food Quality and Palatability
Penalty
Summary
The facility failed to provide palatable food to 23 residents in the main dining room during meal service. Observations and interviews revealed that residents experienced issues with the quality and temperature of the food. Resident 19 reported that the meat was dry and there were delays in service. Resident 12 mentioned that the meat was hard and the food was often cold when served in her room. During meal observations, a CNA struggled to cut brisket with a butter knife, indicating the meat's toughness. Resident 16 found her meal inedible and requested a salad instead. A test tray confirmed that the brisket was dry and the green beans were mushy and flavorless. The facility's grievance binder showed previous complaints about the food quality, including grievances from Resident 47 about cold meat and Resident 16 about dry meat and other food issues. The responses to these grievances were inadequate, as they did not fully address the concerns. The Regional Nurse Consultant acknowledged the difficulty in providing perfectly cooked food daily. The facility's policy on general preparation and cooking practices did not specifically address meat preparation or ensuring palatable food, contributing to the deficiency.
Infection Control Breach During Meal Service
Penalty
Summary
The facility failed to adhere to infection control practices during meal service for 23 residents in the main dining room. During a meal observation, a CNA was seen handling bread with bare hands on two separate occasions, contrary to the facility's policy that prohibits bare hand contact with ready-to-eat foods. This incident was confirmed during an interview with the CNA, who acknowledged that gloves should have been used when handling the bread. The facility's policy on meal service, provided by the Administrator, clearly states that there should be no bare hand contact with ready-to-eat foods.
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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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