Waters Of Wakarusa Skilled Nursing Facility, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Wakarusa, Indiana.
- Location
- 300 N Washington St, Wakarusa, Indiana 46573
- CMS Provider Number
- 155582
- Inspections on file
- 27
- Latest survey
- March 16, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Waters Of Wakarusa Skilled Nursing Facility, The during CMS and state inspections, most recent first.
A resident with a history of strokes, who was cognitively intact and required moderate assistance for bathing and shower transfers, was care planned and scheduled to receive two showers per week on specific evenings, with staff instructed to honor his preference for a shower or bath. Review of documentation over two consecutive months showed multiple missed scheduled showers, with only a few showers and one complete bed bath provided instead of the planned twice-weekly showers. In an interview, the DON confirmed that the resident was scheduled for two weekly showers and that facility policy required showers or baths at least twice weekly per the posted shower schedule, but acknowledged that the documented care did not meet these scheduled expectations.
A resident with ESRD on dialysis and dementia returned from dialysis after treatment was stopped early due to hypotension, restlessness, agitation, and concern for possible sepsis, as documented by the dialysis RN on a communication form. Facility nursing staff did not document reviewing this form, did not perform or document an immediate assessment on return, and did not notify the NP/MD of the dialysis staff’s concern. Later that day, an LPN, unaware of the early termination of dialysis, assessed the resident for abdominal pain, obtained a STAT abdominal x-ray per NP order, and was instructed to monitor closely and send the resident to the hospital if symptoms worsened. Although an SBAR for change in condition was initiated, required follow-up assessments every shift for 72 hours were not documented, and there were no further notes until two days later when the resident again had severe abdominal pain and was sent to the hospital. This sequence reflects a failure to complete timely and ongoing assessments after a documented change in condition.
Surveyors found that food items in the kitchen's walk-in cooler and freezer were not stored according to professional standards, with several opened items not tightly sealed and some foods either expired or lacking use by dates. Staff confirmed that these practices did not meet facility policy, potentially impacting all residents who received meals from the kitchen.
Staff did not follow recipes or measure ingredients when preparing pureed meals, resulting in meals that were watery and not consistent with facility policy. A resident received a pureed meal where food items ran together, and staff acknowledged that recipes should have been used.
Staff, including CNAs and the DON, did not consistently use required PPE such as gowns and gloves when entering rooms of residents on Enhanced Barrier Precautions or contact precautions, despite posted signage and care plan directives. In several cases, staff were unaware of precaution requirements or failed to follow them during direct care activities. Additionally, the facility did not maintain up-to-date documentation for infection surveillance, with no tracking or trending of infections recorded for several months.
Multiple residents did not receive care according to physician orders, including the administration of medications outside of prescribed parameters, lack of required documentation for a hospice patient, failure to provide recommended skin care, and missed doses of sliding scale insulin for a diabetic resident. Facility staff and leadership acknowledged that these actions did not comply with established orders and policies.
A resident with a history of cystectomy and dementia was admitted with a urostomy, but the facility failed to have physician orders, a care plan, or necessary urostomy supplies in place. The resident experienced a leaking urostomy bag and was found lying in urine, with the family ultimately providing the required supplies. Documentation inconsistently described the resident's urinary status, and the deficiency was confirmed through internal review and staff interviews.
A resident's advance directive and code status were inconsistently documented across the medical record, with conflicting information found on the face sheet, physician orders, POST form, and care plan. Staff interviews confirmed they were aware of the discrepancies, and the DON acknowledged the clinical record did not match the resident's current wishes.
Two residents requiring non-invasive mechanical ventilation did not receive appropriate respiratory care: one resident's Bi-Pap equipment was not provided for use as ordered, with no documentation of refusal or care plan, while another resident's C-Pap mask was stored uncovered instead of in a dated respiratory bag, contrary to facility policy. The DON confirmed these lapses in care and equipment storage.
A resident with chronic kidney disease and a left wrist dialysis fistula did not have required assessments of the fistula performed or documented each shift, as outlined in the care plan and facility policy. Staff confirmed there was no physician's order or documentation for these assessments.
Surveyors found that medications and biologicals on two medication carts were not properly labeled, dated, or stored. Multiple opened and undated medications, items without resident identifiers, expired products, and loose pills were observed. Both an LPN and an RN confirmed that medications should have been labeled and dated when opened, but this was not consistently done. The facility's policy on medication storage was provided, but a specific policy for dating and labeling was not available at the time of the survey.
A resident with multiple medical conditions returned from a hospital stay with physician orders for a CBC and renal panel to be completed within one week. There was no documentation that these lab tests were performed or that results were obtained, and the DON confirmed the orders should have been completed.
A resident with complex medical needs, including a gastrostomy/jejunostomy tube, was unsafely discharged from a facility to a hospital waiting area without prior arrangements or means to obtain nutrition. The facility failed to provide a written discharge notice, complete discharge planning, or ensure continuity of care, leaving the resident feeling hopeless and abandoned.
The facility failed to maintain sanitary food handling practices and proper food temperatures during meal service. Staff used the same gloved hands to handle food and touch surfaces without changing gloves, and meals served on room trays were not kept at appropriate temperatures. The kitchen lacked sufficient plate warmers, contributing to the issue.
A facility failed to provide a written notice of discharge to a resident with complex medical needs, leading to an improper discharge. The resident, who was approved for skilled care through a specific date, was incorrectly informed that his insurance would not cover his stay. Discharge planning was inadequate, with no 30-day notice or physician's order for discharge. The resident was transported to a hospital without proper coordination, and no community resources were arranged. Interviews with staff revealed a lack of communication and understanding of the discharge process.
A resident with complex medical needs was discharged from an LTC facility without proper preparation or orientation, leading to a deficiency in discharge planning. The resident, who required enteral tube feedings, was informed abruptly of his discharge due to insurance issues, without prior notice or documentation. The facility failed to coordinate with community resources or the local hospital, leaving the resident without a safe transition plan.
The facility failed to provide scheduled bathing opportunities for two residents, leading to inconsistencies in showering and hygiene care. One resident reported not receiving a shower or hair shampoo in weeks, while another resident's son raised concerns about the lack of showers. Documentation inconsistencies and missing records were noted, and the facility lacked a specific policy on showering opportunities.
The facility failed to properly document and administer tube feedings for two residents as ordered by their physicians. One resident, admitted after surgery for pancreatitis, had no documentation of enteral feedings on the MAR/TAR, while another resident with Alzheimer's and dysphagia missed multiple scheduled feedings. Additionally, equipment management protocols were not followed, as observed with undated piston syringes and water bottles. The facility's policies lacked specific guidance on documentation, contributing to these deficiencies.
The facility did not post daily nurse staffing information as required by CMS. The posted form was outdated, dated November 18, 2024, and was the only one displayed near the entrance. The DON confirmed the lapse, noting it was the scheduler's job to update it, but the facility lacked a scheduler. The Administrator stated the responsibility was with the DON and Assistant DON. The facility's policy confirmed the daily posting requirement.
A resident with multiple health conditions experienced significant weight gain, but the facility failed to notify the physician as required by the care plan and physician's orders. The DON confirmed the lack of documentation for physician notification, which is against the facility's policy.
The facility failed to provide necessary ADL services for two residents, including nail care, facial hair removal, and showers. One resident reported not receiving scheduled showers, and documentation showed inconsistencies. Another resident was observed with long, dirty fingernails and facial hair, indicating a lack of assistance with personal hygiene.
A resident with severe cognitive deficits and wandering behaviors exited the facility and fell outside. The resident, wearing a wander guard, managed to push open a door with an alarm that was not loud enough to be heard by staff. The resident was found outside by a visitor and brought back inside with abrasions. Staff interviews revealed they did not hear any alarms or see the resident attempting to exit before.
The facility failed to provide medical doctor visits every 60 days for a resident with severe cognitive impairment and significant weight loss. The Medical Director did not see the resident within the required timeframe, relying instead on the Nurse Practitioner, contrary to the facility's policy.
Failure to Provide Scheduled Showers per Resident Care Plan
Penalty
Summary
The deficiency involves the facility’s failure to provide showers according to a resident’s care plan and stated preferences. A cognitively intact resident with a history of strokes required moderate staff assistance for transferring in and out of the shower and for bathing, as documented on a quarterly MDS dated 1/26/26. The resident’s care plan, revised on 2/9/26, specified that he required assistance with ADLs, including bathing and transferring, and that staff were to honor his specific daily preferences, such as choosing a shower or bath. A master shower schedule showed he was to receive two showers per week on Wednesday and Saturday evenings. Documentation Survey Reports for February and March 2026 showed multiple missed scheduled showers. In February, the resident received showers only on 2/18/26 and 2/25/26 and a complete bed bath on 2/19/26, while scheduled showers were not provided on 2/4, 2/7, 2/11, 2/14, 2/21, or 2/28/26. In March, the resident received showers on 3/5 and 3/11/26, but scheduled showers were not provided on 3/7/26 or 3/14/26. In a confidential interview, it was alleged that the resident had not received showers per his preference and care plan. During an interview on 3/16/26, the DON confirmed the resident was scheduled for two showers per week and acknowledged that, according to the documentation, the resident had not received showers as scheduled, despite facility policy requiring showers or baths at least twice weekly according to the shower schedule.
Failure to Perform Timely and Ongoing Assessments After Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely and thorough assessments following a change in condition for a resident with end-stage renal disease on dialysis and dementia. The resident’s care plan required attendance at dialysis three times weekly and monitoring for pain, with staff to observe for signs and symptoms of pain and notify the physician of uncontrolled pain. On a dialysis day, the dialysis RN documented that the resident experienced an unusual drop in blood pressure requiring extra fluids to maintain systolic pressure above 100, was more restless and agitated than usual, wanted to stop treatment early, and raised concern for developing sepsis, instructing that the resident be seen by a nurse or doctor to rule out sepsis. The dialysis communication form reflected these concerns, but upon the resident’s return, there was no documentation that the unit manager or day-shift nurse reviewed the dialysis form, performed an assessment, or notified the NP or physician of the dialysis staff’s concern for sepsis. Later that same day, the evening-shift LPN, who had not been informed that dialysis was stopped early and had not seen the dialysis communication form, found the resident refusing supper and complaining of abdominal pain. The LPN assessed the resident, attempted repositioning without relief, administered Tylenol per orders, and notified the NP, who ordered a STAT abdominal x-ray and instructed that the resident be sent to the hospital if symptoms persisted. Progress notes documented the resident repeatedly calling out with abdominal pain and stating she could hardly breathe, with a rounded, soft abdomen, right upper quadrant tenderness, normal bowel sounds, and a bowel movement earlier that day. After the abdominal x-ray showed no acute abdominal issues, the NP ordered close monitoring and transfer to the hospital if fever or worsening pain developed. The last documented observation that night indicated the resident was sleeping, easily arousable, and without obvious signs of pain. Following this documented change in condition and initiation of an SBAR form, the facility’s process required follow-up assessments every shift for 72 hours, but the record contained no such follow-up assessments after an early-morning note indicating the resident was resting without complaints of stomach pain. There were no further assessments or progress notes from the early morning of the next day until two days after the initial event, when another SBAR documented severe abdominal pain, with the resident yelling out and reporting increased lower abdominal and severe right lower abdominal pain, prompting transfer to the hospital. A nurse who worked the intervening day shift reported being told the resident had stopped dialysis early due to feeling sick and nauseous and had decreased appetite for several days, but she did not perform an assessment because there were no further reports of abdominal pain and the abdominal x-ray had been negative. The absence of documented follow-up assessments and failure to act on the dialysis center’s sepsis concern and early termination of dialysis constituted the failure to ensure timely assessments following a change in condition.
Improper Food Storage and Handling in Kitchen
Penalty
Summary
Surveyors observed that the facility failed to store food under sanitary conditions in the kitchen, as evidenced by multiple instances of opened food items in both the walk-in cooler and freezer that were not tightly sealed, as well as several opened food items that were either past their use by date or lacked a use by date. Specifically, items such as sausage gravy, tomato soup, lettuce, shredded cheddar cheese, hot dogs, beef patties, and green beans were found either not sealed tightly or outdated. During interviews, staff acknowledged that these items should have been properly sealed and expired foods should have been discarded. The facility's policy required opened products to be labeled, stored in tightly covered containers, and used by their use by date, but these procedures were not followed during the survey, potentially affecting all residents receiving food from the kitchen.
Failure to Follow Recipes for Pureed Meals
Penalty
Summary
Staff failed to follow recipes when preparing pureed meals for residents, as observed on multiple occasions. During meal preparation, a staff member used unmeasured amounts of water and did not refer to a recipe when pureeing cauliflower and mixed vegetables. The staff member indicated that she added water as needed to achieve the desired consistency and would add thickener if the mixture appeared too thin. The facility's policy specified that foods should be thickened to a pudding or mashed potato consistency using commercial thickeners or food items, and that water should not be used as it causes flavor loss and poor intake. However, water was used, and recipes were not followed as required. During meal service, a resident received a pureed meal that was watery in appearance, with individual food items running together. The staff member acknowledged during an interview that she should have used a recipe when preparing the pureed meals. The facility's policy was provided, confirming the expectations for preparing pureed diets, which were not met during the observed meal preparations.
Failure to Follow Enhanced Barrier Precautions and Maintain Infection Surveillance
Penalty
Summary
Staff members failed to follow established infection prevention and control practices, specifically regarding Enhanced Barrier Precautions (EBP) and contact precautions. Certified Nursing Assistants (CNAs) and the Director of Nursing (DON) were observed entering rooms of residents on EBP or contact precautions without wearing required personal protective equipment (PPE) such as gowns and gloves, despite clear signage indicating the need for these precautions. In one instance, a CNA entered a resident's room with an EBP sign and performed tasks such as gathering trash and making the bed without a gown. The DON also entered a resident's room on EBP, provided perineal care, and assisted with toileting while wearing gloves but not a gown. Another CNA provided toileting assistance to a resident with multiple skin tears, who had a physician's order for EBP, but was unaware of the precautions due to the absence of a sign on the door. Additionally, staff, including a housekeeper and CNAs, were observed entering and providing care in a room of a resident on contact precautions for a multidrug-resistant organism without donning gloves or gowns, contrary to posted instructions and care plan requirements. The facility also failed to maintain an ongoing infection surveillance program as required by policy. Review of the infection log book revealed that documentation for tracking and trending resident infections had not been completed since December of the previous year, with no evidence of monitoring in the current year. The DON confirmed that infection surveillance should have been documented but was not. Facility policies for EBP and infection prevention and control were in place, but staff did not consistently adhere to them, and surveillance activities were not maintained as required.
Failure to Follow Physician Orders and Provide Required Care
Penalty
Summary
The facility failed to follow physician orders and provide appropriate care for multiple residents, resulting in several deficiencies. For one resident with pulmonary hypertension and orthostatic hypotension, midodrine was administered repeatedly despite physician orders to hold the medication when systolic blood pressure (SBP) exceeded 120. Medication administration records showed that the medication was given dozens of times when the SBP was above the specified threshold, and both the regional nurse and an LPN confirmed that the medication should not have been administered under those circumstances. Another resident receiving hospice care did not have a complete hospice binder as required. The binder was missing documentation of medications, physician orders, a signed DNR, and records of communication between the facility and the hospice provider. The DON confirmed that these documents should have been present according to facility policy and the care plan, which required ongoing communication and documentation with the hospice provider. Additional deficiencies included the administration of antihypertensive medication to a resident when blood pressure readings were below the physician-ordered parameters, failure to obtain an order for an emollient for a resident with documented dry and atrophic skin despite a nurse practitioner's recommendation, and failure to provide sliding scale insulin for two days to a resident with diabetes mellitus due to a delay in implementing a pharmacy interchange order. In each case, facility staff and leadership acknowledged that the care provided did not align with physician orders or facility policy.
Failure to Provide Urostomy Care and Supplies
Penalty
Summary
The facility failed to provide appropriate urostomy care and necessary supplies for a resident with a urostomy. Upon admission, the resident, who had a history of chronic kidney disease, bladder cancer, cystectomy, and dementia, did not have any physician orders or care plans addressing urostomy care. Nursing documentation inconsistently described the resident's urinary status, sometimes noting continence and at other times referencing the presence of a urostomy. The facility did not have urostomy supplies available upon the resident's arrival, and the family had to provide the needed supplies the following day. During this period, the resident experienced a urostomy bag leak and was found lying in urine, as reported by the family. Internal reviews and progress notes confirmed that the facility was aware of the lack of supplies and the incident of leakage. The Assistant DON replaced the urostomy bag after the issue was identified, and the facility attempted to obtain supplies from the hospital and the family. Despite these actions, the initial failure to have supplies and a care plan in place resulted in inadequate care for the resident's urostomy needs. The care plan only addressed urinary incontinence and did not mention the urostomy, further contributing to the deficiency.
Failure to Consistently Document and Communicate Resident Advance Directive
Penalty
Summary
The facility failed to ensure that a resident's advance directive and code status were documented consistently across the medical record and that staff were aware of the resident's current wishes. During a review of the resident's records, conflicting information was found: the face sheet listed the resident as Do Not Resuscitate (DNR), while physician's orders included both DNR and Full Code instructions. Additionally, the Indiana Physician Orders for Scope of Treatment (POST) form indicated the resident wanted to be a Full Code, but the care plan documented a DNR status. Interviews with staff confirmed the inconsistencies. An LPN acknowledged that the code status information was conflicting across the face sheet, physician orders, and POST form. The DON stated that the resident had recently changed her code status and confirmed that the clinical record did not accurately reflect the resident's current wishes. The facility's policy requires honoring residents' rights to accept or refuse treatment and to formulate advance directives, but this was not followed in this instance.
Failure to Provide and Store Non-Invasive Ventilation Equipment Appropriately
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents requiring non-invasive mechanical ventilation. For one resident with diagnoses including acute respiratory failure with hypoxia, rib fracture, panic disorder, and emphysema, Bi-Pap equipment was observed in her room but not in use, despite a physician's order to apply the Bi-Pap mask while sleeping. The resident reported not having worn the Bi-Pap mask since admission and stated it had not been offered to her. There was no documentation of any refusal to use the Bi-Pap, and no baseline care plan was in place addressing her obstructive sleep apnea or Bi-Pap use. For another resident with Parkinson's disease, shortness of breath, and obstructive sleep apnea, the C-Pap mask was repeatedly observed stored uncovered in the top drawer of her bedside table, contrary to facility policy requiring storage in a dated respiratory bag when not in use. Both residents had physician orders for the use of their respective respiratory devices at bedtime and during naps, and care plans identified risks related to their respiratory conditions. The DON confirmed the required practices for use and storage of the equipment were not followed.
Failure to Assess Dialysis Fistula as Required
Penalty
Summary
The facility failed to assess a dialysis fistula for a resident with chronic kidney disease stage 4 and a left wrist fistula. The resident's care plan identified a risk for the dialysis fistula to become non-functioning and included interventions requiring assessment of the fistula every shift and as needed for bruit and thrill, with instructions to notify the physician if absent. However, the resident's record did not contain a physician's order for staff to assess the fistula, and there was no documentation that staff had been performing or recording these assessments. Interviews with facility staff confirmed that the required assessments and documentation were not completed, despite facility policy stating that a licensed nurse should palpate the fistula daily and assess the site each shift.
Failure to Properly Store and Label Medications on Medication Carts
Penalty
Summary
Surveyors observed that medications and biologicals were not stored in accordance with professional standards on two of three medication carts. On the Peach Pod medication cart, there were multiple instances of opened and undated medications, including Zinc Caps, Vitamin C, Lantus insulin vials, a Lispro insulin pen, and Tussin cough syrup. Several items lacked resident identifiers, such as a bottle of betadine for a discharged resident, a tube of Neosporin ointment, and a bottle of ammonium lactate lotion with the label torn off. Additionally, a loose white pill was found, and four opened and undated containers of laxative were present. The LPN interviewed confirmed that medications should have been labeled and dated when opened. On the Maple Pod medication cart, similar deficiencies were found, including an unlabeled Flutisone Propionate inhaler, an unopened bottle of timolol eye drops without resident identifiers, and an opened and undated vial of Humalog insulin. Expired items, such as two boxes of assure prism solution, were also present. There were containers of Aquaphor for a deceased resident and one without a label, as well as an opened and undated bottle of cough syrup and four opened and undated bottles of Miralax. The RN interviewed acknowledged that medications should have been labeled and dated when opened. The facility's policy on medication storage was provided, but a specific policy for dating and labeling medications was not made available before the survey exit.
Failure to Complete Physician-Ordered Lab Tests After Hospitalization
Penalty
Summary
The facility failed to obtain a physician-ordered laboratory test for a resident following their return from hospitalization. The resident, who had diagnoses including epilepsy, depression, hypertension, atrial fibrillation, hernia, and cardiomegaly, was hospitalized after complaining of abdominal pain related to a protruding hernia. Upon return from the hospital, a post-acute transfer order specified that a complete blood count (CBC) and a renal panel were to be drawn within one week. However, there was no documentation that these laboratory tests were completed or that results were obtained. The Director of Nursing confirmed that the lab orders should have been carried out.
Unsafe Discharge of Resident with Complex Medical Needs
Penalty
Summary
The facility failed to provide a written notice of discharge, complete discharge planning, and ensure a safe discharge with continuity of care for a resident. The resident, who had complex medical needs including a gastrostomy/jejunostomy tube for enteral feedings, was discharged to a hospital waiting area without prior admission arrangements or means to obtain nutrition. This resulted in the resident feeling hopeless and expressing that others wanted him to die. The resident was admitted to the facility from an acute care setting for short-term rehabilitation following surgical repair of necrotizing pancreatitis. Despite being cognitively intact and dependent on staff for feeding due to enteral feedings, the resident was informed by the Social Service Director that he needed to leave the facility because his insurance would not cover his stay. The resident's family was unable to take him in, and the facility discharged him to a hospital without notifying the hospital or providing necessary discharge documentation. The facility's discharge process was inadequate, as there was no physician order for discharge, no written notice provided to the resident or family, and no arrangements made for the resident's continued care. The resident was left at the hospital without any community resources or equipment for his tube feedings, leading to a situation where he was unable to receive nutrition and felt abandoned. The facility's actions resulted in an unsafe discharge and a failure to ensure the resident's well-being.
Improper Food Handling and Temperature Maintenance
Penalty
Summary
The facility failed to ensure that food was served and maintained in a sanitary and safe manner during meal service. During a dinner service, the Dietary Manager and a Dietary Aide were observed using the same gloved hands to handle food and touch other surfaces, such as ladles and counters, without changing gloves. This practice was contrary to the facility's policy, which required gloves to be changed whenever hand washing would be necessary, such as after touching non-food contact surfaces. The Dietary Manager acknowledged the improper handling of food and indicated that tongs should have been used instead of gloved hands. Additionally, the facility did not maintain proper food temperatures for meals served on room trays. During an observation, the meal cart delivered to a unit contained food items that were not at the appropriate temperatures. The Italian sausage was recorded at 116 degrees, which was below the minimum required temperature of 145 degrees, and the fruit punch was warmer than the desired cold serving temperature. The Dietary Manager noted that the kitchen had insufficient plate warmers to accommodate all residents who ate in their rooms, which contributed to the failure to maintain proper food temperatures.
Failure to Provide Proper Discharge Notice and Planning
Penalty
Summary
The facility failed to provide a written notice of discharge to Resident E prior to a facility-initiated discharge. Resident E was admitted to the facility from an acute care setting following surgical repair of necrotizing pancreatitis and had several complex medical conditions, including a gastrostomy tube for enteral feeding. Despite being approved for long-term care skilled services through 12/26/24, the resident was informed on 12/23/24 that he needed to leave the facility because his insurance would not cover his stay, which was incorrect information. The discharge planning for Resident E was inadequate, with no documented recommendations or follow-up from the initial care plan meeting. The Social Service Director (SSD) informed the resident and his sister that the facility could not continue to provide skilled services, leading to the resident's discharge on 12/24/24. However, there was no documentation of a 30-day written notice of discharge, nor was there a physician's order for discharge. The resident was transported to a local hospital without proper notification or coordination with the hospital, and no community resources were arranged for his continued care. Interviews with facility staff, including the SSD, Director of Nursing (DON), and Administrator, revealed a lack of communication and understanding of the discharge process. The SSD was unaware of the requirement for a 30-day notice and did not provide any written documentation to the resident or his family. The DON and Administrator also failed to ensure proper discharge planning and communication with the hospital. The facility's policy required a 30-day notice for non-emergency discharges, which was not followed in this case.
Inadequate Discharge Planning for Resident
Penalty
Summary
The facility failed to ensure proper preparation and orientation for a resident's discharge, leading to a deficiency in discharge planning. Resident E, who was admitted for short-term rehabilitation following surgical repair of necrotizing pancreatitis, was informed abruptly that he needed to leave the facility due to insurance issues. The resident, who was dependent on enteral tube feedings and had complex medical needs, was not given prior notice or documentation regarding his impending discharge. The facility did not provide a 30-day discharge notice or a Notice of Medicare/Medicaid Non-Coverage form, and there was no physician's order for discharge. The discharge planning for Resident E was inadequate, as there were no nursing or social service progress notes addressing his discharge needs until the day before he was informed of his discharge. The Social Service Director informed the resident and his sister that he needed to leave because his insurance would not cover his stay, but there was no follow-up or coordination with community resources to ensure a safe transition. The resident expressed that he would be homeless and planned to go to the local hospital, but there was no documentation of communication with the hospital or arrangements for his continued care. The facility's discharge process was further compromised by the lack of coordination among staff. The Director of Nursing completed the discharge forms and instructions but was unaware of the discharge planning completed by the Social Service Director or the Assistant Director of Nursing. The resident was discharged without a proper plan for his tube feedings or medications, and he was left at the hospital without any paperwork or notification to the hospital staff. The facility's failure to provide appropriate preparation and orientation for Resident E's discharge resulted in a deficiency in ensuring a safe and orderly discharge process.
Failure to Provide Scheduled Bathing Opportunities
Penalty
Summary
The facility failed to ensure that dependent residents received bathing opportunities according to their preferences, as evidenced by the cases of Resident R and Resident X. Resident R reported not having received a shower or hair shampoo in 2-3 weeks, despite her preference for showers on Wednesdays and Saturdays. The clinical record review confirmed that Resident R required assistance with activities of daily living, including bathing, and had no documented pattern of care refusal. The Shower Report indicated multiple instances where Resident R refused showers, but there were inconsistencies in the documentation, such as missing records for certain dates and discrepancies in the reported completion of hair shampooing. Resident X's son expressed concerns about the lack of showers provided to his mother. Observations noted an odor of stool in Resident X's room, and the resident required assistance with changing. The clinical record indicated that Resident X preferred showers twice a week, but the care plan did not specify the days for these showers. Documentation showed that Resident X received showers and bed baths inconsistently, with missing reports for January 2025. The facility's policy on bathing was provided, but there was no specific policy related to showering or bathing opportunities. This deficiency was related to a complaint investigation.
Deficiency in Tube Feeding Documentation and Administration
Penalty
Summary
The facility failed to ensure proper documentation and administration of tube feedings for two residents, Resident E and Resident S, as ordered by their physicians. Resident E, who was admitted following surgical repair of necrotizing pancreatitis, had a gastrostomy/jejunostomy tube for nutrition. Despite physician orders for enteral feedings and specific instructions on the timing and volume of feedings, there was a lack of documentation on the Medication Administration Record (MAR) and Treatment Administration Record (TAR) indicating that the feedings were administered as ordered. The Director of Nursing confirmed the absence of documentation for Resident E's enteral feedings. Resident S, diagnosed with Alzheimer's Disease, diabetes, and dysphagia, also had a gastrostomy tube for nutrition. The facility's records showed multiple instances where Resident S did not receive the prescribed enteral feedings at the scheduled times. Additionally, during an observation, it was noted that the resident's piston syringe and water bottle were not dated as required, indicating a lapse in following the facility's protocol for equipment management. The Licensed Practical Nurse (LPN) confirmed that the resident did not refuse any feedings, and the Director of Nursing acknowledged that the lack of documentation suggested the feedings were not administered as ordered. The facility's policy on enteral feeding did not specify where or when to document the feedings, and the nursing documentation policy emphasized the importance of recording all actions, stating, "If you did not write it down, you did not do it." The Regional Nurse Consultant and the Administrator provided these policies, which were currently in use at the facility. The deficiencies in documentation and administration of tube feedings were identified during a survey, and the facility's failure to adhere to physician orders and documentation protocols was noted.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information was posted daily for residents and their families to review, as required by Medicare and Medicaid Services (CMS). On January 2, 2025, it was observed that the posted form titled 'Nursing Staff Directly Responsible For Resident Care' was dated November 18, 2024, indicating that the information had not been updated daily. The form was located near the entrance to the facility behind a glass case. The Director of Nursing (DON) confirmed that this was the only location where the form was displayed and acknowledged that it was the scheduler's responsibility to update the posting daily. However, the facility did not have a scheduler at the time, and the Administrator indicated that the responsibility fell to the DON and Assistant Director of Nursing. The facility's policy, titled 'Guidelines for BIPA Staffing Posting Requirement,' dated July 24, 2023, was provided by the DON, confirming the requirement for daily posting of nursing staff information.
Failure to Notify Physician of Significant Weight Gain
Penalty
Summary
The facility failed to notify the physician of a significant weight gain in a resident as per the parameters set in the physician's orders. Resident 60, who has diagnoses including Parkinson's Disease, type 2 diabetes, chronic systolic congestive heart failure, and cardiomyopathy, experienced a weight gain of 2.2 pounds in one day and 5 pounds over five days. Despite these changes, there was no documentation in the electronic medical record indicating that the physician was notified of these weight gains on the specified dates. The resident was observed with elevated and wrapped legs, indicating ongoing issues with edema, which should have prompted immediate physician notification as per the care plan and physician's orders. During an interview, the Director of Nursing confirmed that the physician should have been notified and that such notifications should be documented in the progress notes. However, the review of the electronic medical record showed no such documentation. The facility's policy on physician notification of resident change of condition was provided, which mandates that licensed personnel notify the attending physician of any change in a resident's condition and document this in the nurse's notes. This policy was not followed in the case of Resident 60, leading to the deficiency noted in the report.
Failure to Provide Necessary ADL Services
Penalty
Summary
The facility failed to provide necessary ADL services related to nail care, facial hair removal, and showers for two residents. Resident 1, who has diagnoses including epilepsy, diabetes mellitus type 2, and major depressive disorder, reported not receiving his scheduled showers despite being dependent on assistance for bathing. Documentation showed inconsistencies in shower records, with missing entries on specific dates. The Executive Director and Director of Nursing confirmed that showers were scheduled twice a week and should be documented in the electronic medical record, but there were gaps in the documentation provided to the surveyor. Resident 82, diagnosed with chronic obstructive pulmonary disease, a non-pressure chronic ulcer of the right heel, and rheumatoid arthritis, was observed with long fingernails containing a brown substance and facial hair under her chin. She indicated that staff had not offered assistance with trimming her nails or shaving her facial hair, which she preferred to be done. Multiple observations over several days confirmed that her nails and facial hair remained unaddressed. Interviews with CNAs revealed that while they provided various aspects of personal care, there was no specific mention of nail trimming or facial hair removal. The facility's policies on ADL care and shaving were reviewed, indicating that residents should receive routine daily care to promote hygiene and comfort. However, the observations and interviews demonstrated that these policies were not consistently followed, leading to deficiencies in the care provided to Residents 1 and 82. The Director of Nursing confirmed the policies but did not provide evidence that the required care was consistently documented or performed.
Failure to Supervise Resident with Wandering Behaviors
Penalty
Summary
The facility failed to supervise a resident with severe cognitive deficits and wandering behaviors, resulting in the resident exiting the facility and falling. The incident occurred when the resident, who was wearing a wander guard, managed to push open the rehabilitation unit door and gain access to the assisted living entrance and facility parking lot. The alarm on the door was not loud enough to be heard by staff, and the resident was found outside on the ground by a visitor. The resident was assessed for injuries and brought back inside the facility. The initial investigation indicated that the rehabilitation exit door might not have been shut correctly, possibly due to air pressure or other doors, and did not lock properly. The facility checked the exit doors and the alarm/wanderguard system, but no issues were noted. The resident was placed on 15-minute safety checks after the incident. The resident's diagnoses included neurocognitive disorder with Lewy Bodies, hallucinations, altered mental status, and muscle weakness. An Admission Minimum Data Set (MDS) Assessment indicated the resident was severely cognitively impaired and utilized a wheelchair for mobility. A Progress Note indicated the resident was found outside on the ground with abrasions on the right cheek and chin. An Elopement Risk Assessment and a Wandering Risk Scale Assessment indicated the resident was at risk for wandering. The facility's Elopement Book included pictures and face sheets of residents who wore a wander guard, including the resident involved in the incident. Interviews with staff members revealed that they did not hear any alarms and had not seen the resident attempting to exit before. The facility's policy on missing residents and elopement was provided, indicating that the facility aims to provide a safe and secure environment for all residents and to implement policies and procedures in the event of a missing resident. The policy also emphasized the importance of staff awareness of resident safety and security. The facility's Elopement Book included pictures and face sheets of residents who wore a wander guard, including the resident involved in the incident. Interviews with staff members revealed that they did not hear any alarms and had not seen the resident attempting to exit before. The facility's policy on missing residents and elopement was provided, indicating that the facility aims to provide a safe and secure environment for all residents and to implement policies and procedures in the event of a missing resident. The policy also emphasized the importance of staff awareness of resident safety and security.
Failure to Provide Required Medical Doctor Visits
Penalty
Summary
The facility failed to provide medical doctor visits every 60 days as required for a resident with diagnoses including protein-calorie malnutrition, mild cognitive impairment, and localized edema. The resident had a documented weight loss of five percent or more in the past month or ten percent or more in the past six months and had severe cognitive impairment. The facility's Nurse Practitioner (NP) documented visits on multiple dates, but the Medical Doctor only documented visits on two occasions, significantly outside the required 60-day interval. The Executive Director indicated that the Medical Director believed that if the NP had seen the resident, then he did not need to, even for the regulatory visits. The Medical Director did not document agreement with the NP assessments, and the NP was an employee of the facility, not the Medical Director. The Medical Director signed the Care Summary monthly and oversaw the NP's care in this way, but did not see the residents within the required 60-day timeframe alternating with the NP. The Director of Nursing and the Executive Director confirmed that the Medical Director followed a list for visits provided by the Medical Records Supervisor, which was rotated every other month between the House NP, Insurance NP, and the Medical Director. The Medical Records Supervisor indicated that the Medical Director preferred the NP to complete acute visits and did not see the residents within the 60-day timeframe. The facility's policy stated that residents should be seen by a physician within 30 days of admission, every 30 days for the first 90 days after admission, and then at least every 60 days thereafter. The policy allowed for certain tasks to be designated to a non-physician practitioner, but the Medical Director did not comply with the required visit schedule.
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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