Wesley Manor Health Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Frankfort, Indiana.
- Location
- 1555 N Main St, Frankfort, Indiana 46041
- CMS Provider Number
- 155658
- Inspections on file
- 24
- Latest survey
- December 11, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Wesley Manor Health Center during CMS and state inspections, most recent first.
A resident with multiple medical conditions suffered urethral trauma and urinary obstruction after a foley catheter was improperly inserted by a nursing student. The facility failed to document the catheter procedure, did not specify catheter details in the physician's order, and did not follow up on abnormal urine characteristics or the resident's complaints of pain. The lack of documentation and assessment led to the resident's hospitalization for catheter-related injury.
A resident with multiple medical conditions was discharged to the hospital, but there was no documentation that the required bed hold policy was provided to the resident or their representative at the time of discharge, nor evidence it was sent by email or mail as required by facility policy.
A resident with end stage renal disease did not receive peritoneal dialysis care in accordance with physician orders, as staff failed to consistently use the correct dialysis solution bags based on systolic blood pressure and did not contact the dialysis clinic when the resident's weight exceeded the specified threshold. Documentation of bag concentrations and required communications was also incomplete.
A resident with severe cognitive impairment and a history of falls was placed in a merry walker, considered a restraint, without proper consent or documentation. The facility failed to reassess the appropriateness of the restraint after the resident experienced three falls with major injuries, resulting in emergency room visits and facial fractures. Interviews revealed reliance on verbal discussions rather than documented consent and assessments, highlighting a deficiency in the facility's adherence to its restraint use policy.
A resident with Alzheimer's and reduced mobility suffered an acute hip fracture, potentially due to the use of a Maxi lift. The facility failed to conduct a thorough investigation, including staff interviews, to determine the cause of the injury, and did not follow its policy on investigating potential risks.
A resident with dementia and other health issues was not assisted or cued to eat during meals, contrary to their care plan. Over several days, the resident was observed with untouched meals and no staff assistance, leading to a significant weight loss of 5.54% in four days. The facility failed to document a re-weight or assess the weight change, and the resident was not placed on the Nutrition at Risk list, contrary to facility policies.
A facility failed to document sufficient justification for declining a gradual dose reduction of an antipsychotic medication for a resident with dementia and psychotic disorder. Despite a pharmacy request to reduce the dose, the physician declined, citing intermittent delusions, but no such behaviors were documented in the clinical records. The facility's policy requires documentation of behaviors and interventions, which was not adequately followed.
The facility failed to ensure proper food storage and labeling in its nutrition refrigerators, leading to unsanitary conditions. An LPN's lunch was found in a refrigerator designated for specific items, and other items were found without labels or dates. Staff were unaware of the facility's policies, which required labeling, dating, and daily temperature checks.
Failure to Document and Assess Foley Catheter Placement Resulting in Urethral Trauma
Penalty
Summary
A deficiency occurred when a resident with a history of cerebral infarction, cognitive communication deficit, benign prostatic hyperplasia, and dysuria experienced improper foley catheter care. The facility failed to document the placement of a new foley catheter and did not complete follow-up assessments after a change in urine characteristics was observed. The catheter was inserted by a nursing student under supervision, but neither the student nor the supervising nurse documented the procedure in the resident's medical record. The physician's order for the catheter change did not specify the type, size, or balloon fluid amount, and there was no documentation of the resident's tolerance, urine return, or urine color at the time of insertion. After the catheter change, the resident exhibited signs of complications, including low urine output and red-colored urine, but there was no documentation that the physician was notified of these changes. Later, the resident complained of abdominal pain, and blood was noted in the catheter bag. The resident was subsequently sent to the emergency room, where it was determined that the catheter had been incorrectly placed, resulting in urethral trauma and urinary obstruction. The hospital found the catheter balloon had been inflated in the urethra rather than the bladder, causing a traumatic injury and significant hematuria. The care plan for the resident did not include interventions to prevent pulling on the catheter, despite observations of the resident handling the catheter bag. Facility policy required documentation of catheter size, balloon size, and resident tolerance, but these were not followed. The lack of proper documentation, assessment, and follow-up after the catheter change directly contributed to the resident's injury and subsequent hospitalization.
Failure to Provide Bed Hold Policy Documentation at Discharge
Penalty
Summary
The facility failed to provide required documentation of the bed hold policy to a resident or the resident's representative at the time of discharge to the hospital. Review of the clinical record for a resident with diagnoses including weakness, Crohn's disease, and dementia showed no evidence that the bed hold policy was given at discharge. There was also no documentation that the policy was sent by email or postal service to the resident's representative if needed. Facility policy required that residents or their designated representatives be informed of the bed hold policy in writing at admission, at the time of transfer to a hospital (unless an emergency), or at the time of therapeutic leave exceeding 24 hours. Written notification at the time of transfer was to include the Notice of Transfer and Discharge and a copy of the bed hold policy. In the event of emergency hospitalization, written notice was to be provided within 24 hours. The clinical record lacked documentation that these requirements were met for the resident in question.
Failure to Follow Physician Orders for Peritoneal Dialysis
Penalty
Summary
The facility failed to follow physician's orders for peritoneal dialysis for a resident with multiple diagnoses, including end stage renal disease and dependence on renal dialysis. The orders required staff to take vital signs before and after dialysis, use the resident's morning weight and systolic blood pressure to determine dialysis dose, and to call the dialysis clinic for further instructions if the resident's weight exceeded 216 pounds. Additionally, specific instructions were provided for the use of different dialysis solution bags based on the resident's systolic blood pressure. However, the facility did not clarify conflicting orders regarding which bags to use when the systolic blood pressure was low, and staff did not consistently follow the orders as written. Review of dialysis treatment logs revealed multiple instances where the prescribed protocol was not followed. On several occasions, when the resident's systolic blood pressure was below the specified threshold, the dialysis solution bags used were based on weight rather than blood pressure, contrary to the physician's orders. There were also instances where the concentration of bags used was not documented, and when the resident's weight exceeded 216 pounds, there was no evidence that staff contacted the dialysis clinic for further instructions. Interviews with staff and the DON confirmed that the orders were not always followed and that documentation of required communications with the dialysis clinic was lacking.
Failure to Document and Reassess Restraint Use Leads to Resident Injuries
Penalty
Summary
The facility failed to ensure proper consent and documentation for the use of a physical restraint, specifically a merry walker, for a resident with severe cognitive impairment and a history of falls. The resident, who had multiple diagnoses including dementia with agitation and major depressive disorder, was observed using the merry walker, which was considered a restraint as the resident could not exit it independently. The facility did not complete a consent form with the identified medical reason for the restraint at its initiation, nor did it establish a time frame for its continued use or a plan for its reduction and discontinuation. The resident experienced three falls with major injuries while using the merry walker, resulting in emergency room visits and diagnoses of nasal fractures and facial lacerations requiring sutures. Despite these incidents, there was no documentation in the medical record showing that the facility reassessed the appropriateness of the merry walker after each fall. The facility's policy required that restraints be used only when all other means of keeping a resident safe had been exhausted, and that the use of restraints be carefully monitored to protect resident rights and safety. However, the facility did not adhere to these guidelines, as evidenced by the lack of a written consent and the absence of a documented plan to ensure the restraint was the least restrictive alternative. Interviews with staff and the resident's daughter revealed that the facility relied on verbal discussions rather than documented consent and assessments. The Director of Nursing and the Assistant Executive Director acknowledged the lack of written consent and the absence of a plan to discontinue the restraint. The facility's failure to properly document and reassess the use of the merry walker as a restraint contributed to the resident's repeated falls and injuries, highlighting a significant deficiency in the facility's adherence to its own restraint use policy.
Failure to Conduct Thorough Investigation of Resident Injury
Penalty
Summary
The facility failed to conduct a thorough investigation following an injury of unknown source for a resident with multiple diagnoses, including Alzheimer's disease, dementia, and reduced mobility. The incident report noted bruising and swelling on the resident's right knee, and an x-ray revealed an acute fracture to the right hip. The facility's investigation suggested that the use of a Maxi lift might have caused a pathological fracture, but there was no documentation of a recent fall. Despite this, the Executive Director could not confirm if the Maxi lift was the cause of the fracture. The facility did not conduct interviews with the night shift staff who worked before the injury was noticed, which was a critical oversight in the investigation process. The facility's policy on fall risk identification and investigation was not followed, as it required all falls and potential risks to be investigated. Additionally, the facility did not provide a policy on investigating injuries by the time of the survey exit, further indicating a lack of thorough investigation into the incident.
Failure to Assist Resident with Meals and Monitor Significant Weight Loss
Penalty
Summary
The facility failed to provide adequate assistance and cueing to a resident, identified as Resident 45, during meal times, as per the resident's care plan. Observations over several days revealed that Resident 45, who was diagnosed with dementia, type 2 diabetes mellitus, osteoarthritis, and cerebral infarction, was not being assisted or encouraged to eat by the staff. The resident was often found sitting at the dining table with his silverware still wrapped in a napkin and his food untouched, while staff attended to other residents. Despite the care plan indicating that the resident required supervision and possibly extensive assistance to eat, these needs were not met. Additionally, the facility failed to assess and reweigh Resident 45 following a significant weight loss. The resident's weight dropped from 133.6 pounds to 126.2 pounds within four days, constituting a 5.54% weight loss. However, there was no documentation of a re-weight or assessment for this significant weight change in the electronic health record. The Registered Dietitian (RD) did not trigger a significant weight loss alert because it had not been 30 days, and the resident was not placed on the Nutrition at Risk (NAR) list. The facility's policies on nutrition and weight loss/gain, as well as nutrition risk, were not adequately followed. These policies require interventions when a resident is identified as being at risk for unplanned weight loss, including physician and family notification, and assessment of potential causes for the change. The Assistant Executive Director acknowledged that the Nutrition at Risk notes were missing from the progress notes and that a re-weight request might have been overlooked.
Inadequate Documentation for Antipsychotic Medication Use
Penalty
Summary
The facility failed to provide adequate documentation to justify the decision to decline a gradual dose reduction (GDR) of an antipsychotic medication for a resident diagnosed with unspecified dementia with psychotic disturbance, psychotic disorder with delusions, severe major depressive disorder, and dementia with anxiety. The resident was prescribed risperidone, an antipsychotic, at a dose of 0.75 mg daily. A pharmacy request for a GDR to 0.5 mg daily was declined by the physician, citing intermittent episodes of delusional thinking that could be distressing. However, the clinical records from February to March 2024 did not document any delusions, behaviors, or distress that would support this rationale. The psychiatric progress note from March 19, 2024, indicated that staff reported the resident continued to experience intermittent delusions, but no evidence of delusional thinking or paranoia was observed during the Nurse Practitioner's visit. The Care Tracker Behavior Monitoring and Interventions report documented several instances of the resident expressing frustration, anger, and agitation, but did not include details on interventions used, the duration of behaviors, or the level of distress experienced by the resident. Additionally, there were no corresponding progress notes in the electronic health record for the dates and times of the behaviors listed in the report. The facility's policy on psychotropic medications emphasizes the need for an interdisciplinary approach to limit their use, ensuring they are only prescribed to residents with appropriate diagnoses and documented behavioral symptoms. The policy also requires documentation of attempts to redirect behaviors with less restrictive interventions. In this case, the facility did not adhere to its policy, as there was insufficient documentation to support the continued use of the antipsychotic medication without attempting a GDR, and the specific behaviors and interventions were not adequately recorded in the resident's medical record.
Improper Food Storage and Labeling Practices
Penalty
Summary
The facility failed to maintain proper food storage and labeling practices in its nutrition refrigerators, leading to unsanitary conditions. During an observation, a lunch bag belonging to an LPN was found in the First Floor Unit nutrition refrigerator, which was designated only for specific items like ensures, pudding, and applesauce. Additionally, an open bottle of salad dressing was found without an open date or label. The LPN indicated confusion about the food storage policy, despite a sign on the refrigerator specifying its intended use. The Director of Nursing confirmed that employee food items should be stored in the employee breakroom refrigerator. Further observations revealed additional deficiencies in food storage practices. A refrigerator at the end of the hall contained unlabeled and undated items, such as a gallon of vanilla ice cream and a bag of frozen pastries, and lacked a thermometer. Similarly, a refrigerator/freezer in the common area had an uncovered Styrofoam container of ice cream without a date or label. Interviews with staff indicated a lack of awareness and adherence to the facility's policies, which required labeling and dating of all food items and daily temperature checks of refrigerators. The Assistant Director of Dining was unaware of the refrigerator's presence on the unit, and there was no log for temperature monitoring.
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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