Westside Retirement Village
Inspection history, citations, penalties and survey trends for this long-term care facility in Indianapolis, Indiana.
- Location
- 8616 W 10th St, Indianapolis, Indiana 46234
- CMS Provider Number
- 155606
- Inspections on file
- 41
- Latest survey
- March 20, 2026
- Citations (last 12 mo.)
- 34
Citation history
Health deficiencies cited at Westside Retirement Village during CMS and state inspections, most recent first.
A resident with bipolar disorder, anxiety, and mild cognitive impairment, documented as cognitively intact and independent with ADLs, was transferred under an Emergency Detention Order to a psychiatric facility after refusing to go and being escorted by police. Facility staff reported to the psychiatric facility that the resident had recent physical and verbal aggression, including cursing at a roommate and spraying a staff member with chemicals, but these behaviors and alleged medication refusals were not supported by nursing documentation in the clinical record and were based on secondhand reports from social services. The DON later stated the resident had not shown aggressive behaviors, there was no documented medication refusal, and she was unsure why the resident was sent to a psychiatric hospital, while the resident reported she did not understand why she was transferred and that the reason was never explained to her, demonstrating a failure to ensure the resident was fully informed of and able to choose her treatment.
A cognitively intact resident with a history of brain neoplasm, muscle weakness, and depression reported that her roommate, who had bipolar disorder and a documented pattern of escalating behaviors and verbal aggression, became angry over use of a shared landline phone and threatened to kill her and her sister during a phone call. The resident told staff that the roommate kept threatening her, and the sister confirmed hearing explicit death threats, but the DON later characterized the event as only an altercation between the roommate and the sister and did not initiate an abuse investigation or timely report it as abuse. The resident subsequently reported that the roommate continued to intimidate her by walking past her door and making a finger gun gesture, contributing to her staying in her room and avoiding activities, while the SSD acknowledged being told of the gestures but did not interview staff, and the facility’s own abuse policy defining mental/verbal abuse as intimidating conduct was not applied to this situation.
A cognitively intact resident who required assistance with ADLs reported that her roommate became angry over use of a landline phone and repeatedly threatened to kill her and her sister, with the sister corroborating the threats during a phone call. The resident told a CNA that the roommate "keeps threatening me," and the CNA reported this to a UM. The SSD was informed that one resident was threatening and verbally aggressive toward another, directed that the resident be moved, and filed an APS report describing threats and listing the alleged victim as an endangered adult. The DON, however, understood the situation only as an altercation between the roommate and the resident’s sister over the phone, did not recognize it as resident abuse, did not initiate an abuse investigation, did not interview staff or residents about the threats, and did not report the allegation to the state agency as required by facility policy and regulations.
A cognitively intact resident who required assistance with ADLs reported that her roommate became angry over use of a shared landline phone and threatened to kill her and her sister, with the sister confirming she overheard these threats. The resident told a CNA and was moved to another room, but later reported that the roommate continued to intimidate her by making finger gun gestures when passing her door. The SSD was notified by a CNA of verbal threats and filed an APS report, but did not clearly ensure that the DON was informed or that staff were interviewed about ongoing gestures. The DON believed the incident involved only a phone altercation with the sister, concluded there was no resident abuse, and therefore did not initiate an investigation or report the allegation to the state agency, resulting in a failure to document, report, and thoroughly investigate the verbal abuse allegation.
A resident with cirrhosis and heart failure was admitted with a physician's order for a 1500 ml fluid restriction, but staff did not document fluid intake or include a care plan for the restriction. The ADON indicated the order was viewed as a dietary recommendation rather than a direct order, resulting in the fluid restriction not being tracked or implemented as required.
A resident with multiple health conditions, including COPD and a history of stroke, was left without access to her ordered oxygen and call light after staff assisted her with dressing. The oxygen equipment and call light were both out of reach, contrary to facility policy and the resident's care plan, which required staff assistance and accessibility to these essential items.
Surveyors observed that a shower room was not maintained in a clean and orderly condition, with feces, debris, and a used nicotine patch found on the floor and wall, as well as a persistent black substance around the shower base. Both the ADON and Lead Housekeeper confirmed the room was unclean, and the Administrator stated there was no specific cleaning policy or checklist in place.
Multiple residents received cold or unpalatable meals due to delays in tray delivery, inadequate food transport methods, and lack of accessible reheating options. Food was often left sitting in hallways before being served, and residents reported not receiving ordered meals or alternative menu options. Staff interviews and facility records confirmed ongoing complaints about food temperature and quality, with current practices failing to maintain food at safe and appetizing temperatures.
A resident's room and bathroom were found to be unclean, lacking basic supplies, and emitting foul odors due to infrequent cleaning and spills. Observations revealed soiled carpets, dust accumulation, and debris in both resident rooms and common areas, with insufficient housekeeping staff present to maintain cleanliness. Interviews confirmed that cleaning routines were inconsistently followed and some areas were left unattended, contrary to facility policy.
A resident with end stage renal disease and a dialysis port was not provided showers during her stay, despite her preference and ability to shower with her port covered. Staff delayed providing a dressing to cover the port, citing the need for a physician's order, but did not document attempts to obtain one or accommodate her request. The DON later confirmed that the necessary dressing was available without a physician's order, yet the resident only received sponge baths and was not assisted to shower as she preferred.
The facility did not adequately follow up, investigate, or resolve grievances related to cold meals, insufficient showers, and poor room cleaning for several residents, as well as ongoing food concerns raised in Resident Council meetings. Documentation of actions taken was vague, and residents reported persistent issues with food quality and dietary accommodations.
The facility failed to ensure residents who wanted to vote in the 2024 Presidential Election were registered and able to vote. Five residents faced obstacles, such as not being registered, not receiving absentee ballots, or not being assisted to vote. The Activity Director attempted to coordinate with the Mobile Voting Board, but issues persisted, and the Director of Nursing was unaware of the residents' voting needs.
The facility failed to respond to call lights in a timely manner, affecting all 11 residents who participated in a resident council meeting. Despite reeducation efforts, residents reported waiting 1 to 2 hours for responses, especially at night and on weekends. Grievance logs from February to September 2024 highlighted ongoing issues, with resolutions typically involving staff meetings or coaching. Interviews with the ED and DON revealed that monthly in-services and reeducation were the primary responses, but the problem persisted.
The facility failed to maintain a clean and homelike environment in the memory care unit's dining room and in two residents' rooms. Remnants of feces were not cleaned up after a resident's incontinent episode in the dining room, and stains remained despite cleaning attempts. Additionally, two residents' rooms had large areas of staining on the floors due to incontinent episodes, with no special cleaning or replacement requests made.
The facility failed to prevent falls for a resident with a history of falls, resulting in a nasal fracture. A resident with dementia exhibited intrusive wandering, entering other residents' rooms, causing distress. The Elopement Binder was outdated, missing residents at risk for elopement, and medications were left at the bedside without proper orders, posing potential risks.
A QMA failed to perform hand hygiene between administering medications to multiple residents and did not wear gloves while administering ear drops to a resident, violating the facility's infection control policy.
A facility failed to treat residents with dignity, as one resident was left waiting for over 20 minutes for restroom assistance, resulting in incontinence, while another resident experienced harsh treatment during a transfer and had privacy-compromising photographs displayed. The incidents reflect deficiencies in care practices and staff attentiveness.
The facility failed to document advanced directives for residents, leading to discrepancies and omissions in their medical records. A resident with multiple diagnoses lacked an advanced directive order upon admission, while another had conflicting code status documentation. A third resident was not asked about creating an advanced directive until later in their stay. The DON acknowledged issues with the process, indicating it was now everyone's responsibility to ensure completion.
The facility failed to accurately code MDS assessments for two residents, leading to deficiencies in care plans. One resident, observed wandering aimlessly, was not coded for wandering behaviors despite multiple notes indicating such tendencies. Another resident's MDS assessment omitted a significant mental health diagnosis, despite a PASRR Level II assessment identifying a major mental illness. These errors highlight lapses in assessment and documentation processes.
The facility failed to ensure accurate PASRR Level I screenings for two residents. One resident's Level I did not reflect her diagnoses of dementia and psychotic disorder, potentially requiring a Level II screen. Another resident admitted under a 30-day exclusion did not have a new Level I completed after the period expired. Staff were unable to explain the documentation lapses.
A facility failed to use a resident's G-tube for medications and nutrition as intended. The resident, who had a G-tube placed after a stroke, reported that it was not used for medications or feeding supplements. LPNs confirmed this, stating they only flushed the tube. The resident's MAR showed Glucerna was given despite her eating over 50% of meals. The DON and RDCS acknowledged the oversight and incorrect orders for G-tube use.
The facility failed to ensure proper oxygen administration and equipment hygiene for two residents. One resident's oxygen concentrator was set incorrectly, and her nasal cannula and humidifier bottle were not maintained properly. Another resident's oxygen concentrator was also set incorrectly, and his bipap mask and tubing were found uncovered and contaminated. The facility did not adhere to its policy on oxygen administration, compromising respiratory care for residents.
A facility failed to obtain a blood pressure reading before administering prazosin HCL to a resident, as required by the medication order. The resident had multiple diagnoses, including GERD, COPD, osteoporosis, and schizoaffective disorder. The order specified holding the medication if the systolic blood pressure was less than 100 or the pulse was less than 60, but did not include instructions to check blood pressure prior to administration. The DON acknowledged the omission, and the facility's policy emphasized the need to note parameters around drug administration.
The facility failed to manage medication storage and expiration properly, as observed in two medication rooms. A resident's lorazepam bottle lacked an opening date, and an expired aplisol bottle was found in the 100-medication room. In the 300-medication room, a resident's chlorpactin bottle was expired despite being claimed otherwise by an RN. The facility did not follow its policy on medication storage and expiration dating.
Two residents' wheelchairs were not maintained in safe conditions. One resident's wheelchair had a broken left arm, and despite claims of repair, the issue persisted due to a broken bolt. Another resident's wheelchair had a missing brake handle, leaving a hollow bar exposed, which was a safety concern. The facility lacked a specific policy for wheelchair maintenance, although a checklist and preventative maintenance policy were available.
A facility failed to update the care plan for a resident with dementia, who was observed without a required brace despite instructions in her room. The care plan, which was over a year old, indicated the need for a left edema glove and wrist orthotic, which were no longer necessary. The Director of Therapy confirmed the resident no longer required these interventions, but the care plan and room instructions had not been revised.
A resident with multiple health conditions did not receive necessary podiatry care, resulting in extremely long and jagged toenails causing discomfort. Despite being dependent on staff for ADLs, the resident was not seen by a podiatrist during scheduled visits. The facility's process for ensuring routine podiatry care was not followed, violating the resident's rights to reasonable accommodation.
A resident with dementia and a history of aggressive behavior was involved in multiple altercations with peers, resulting in injuries and police involvement. The facility failed to provide adequate supervision and did not update the resident's care plan with specific interventions after each incident, despite having a policy emphasizing person-centered care. The lack of individualized care planning contributed to ongoing aggressive behaviors.
The facility failed to properly label, store, and destroy medications, with several opened bottles lacking open dates and discrepancies in medication administration records. Over-the-counter medications were not properly labeled, and biologicals were stored incorrectly. The DON acknowledged these issues, indicating a lack of consistent adherence to facility policies.
A resident was not provided showers according to his preference of twice a week, as documented in his care plan. Despite being cognitively intact and having a preference for showers on specific days, the facility failed to document any refusals or interventions, resulting in the resident receiving fewer showers than scheduled. Staff interviews revealed that showers were prescheduled by room number, not individual preference, and there was a lack of documentation regarding the resident's refusal of care.
A facility failed to follow infection control practices during catheter care for a resident with a suprapubic catheter. A QMA changed the resident's catheter bag without sanitizing the catheter tip or washing hands after glove removal. The resident had a history of prostate cancer and was at risk for infections. Staff interviews revealed inconsistencies in following proper procedures, despite facility policies requiring aseptic techniques and hand hygiene.
The facility failed to address and track grievances from residents and their families over several months. Concerns included missed showers, delayed call light responses, and missing laundry items. Despite a process for documenting grievances, there was no follow-up or resolution provided. Interviews with residents and a family member confirmed ongoing issues with personal care and hygiene, with no feedback or resolution from the facility.
The facility failed to revise care plans for two residents. One resident had multiple pressure ulcers that were not addressed in the care plan until after a surveyor's review. Another resident had a worsening wound on the coccyx that was not documented in the care plan despite being noted upon admission.
A facility failed to ensure effective wound management for a resident admitted with an open area on the coccyx, which worsened into a stage 3 pressure ulcer. The resident's care plan was not effectively implemented, and the wound was not promptly assessed or documented, leading to significant deterioration. Staff interviews revealed inconsistencies in wound assessment and documentation practices, and the facility's policy on wound care was not followed.
Failure to Inform Resident and Obtain Consent for Involuntary Psychiatric Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was fully informed of and able to choose her treatment when she was transferred to a psychiatric facility against her will. The resident had diagnoses of bipolar disorder, anxiety disorder, and mild cognitive impairment, and a recent MDS assessment documented that she was cognitively intact, independent with all ADLs, and had no behaviors or rejection of care during the assessment period. An Emergency Detention Order (EDO) was completed stating that the resident had a psychiatric condition impairing her judgment, was unwilling to accept treatment voluntarily in the facility, and had demonstrated impaired judgment and the physical capacity to cause grave harm to herself and others, including verbal aggression, threats, and spraying chemicals. The order directed law enforcement to take her into custody and transport her to a psychiatric facility. A care management note documented that the resident was taken to a psychiatric hospital under a court order after she refused to go, and that she was escorted by police. On readmission, an NP note recorded that the resident was irritable and stated she intended to sue the facility for sending her to another facility without her permission. At the psychiatric facility, a progress note indicated the sending facility had reported that over the prior 72 hours the resident had been physically and verbally aggressive, cursing and yelling at her roommate, refusing to remove her belongings from the roommate’s side of the room, and spraying a staff member in the face with chemicals to cover a bowel movement odor. The psychiatric facility note also documented that the resident reported she was unclear why she had been sent there and that the reason for the transfer had never been explained to her. Interviews with facility staff showed discrepancies and lack of documentation supporting the behaviors and refusals cited in the EDO. The DON stated the resident had become manic, was pacing the halls, and refusing medications, and that she initially agreed to go to the hospital but refused when she learned it was a psychiatric hospital; the DON also stated the resident had not displayed aggressive behaviors and that documentation of refused medications and manic behaviors was only in the court order. Review of the MAR and progress notes revealed no nursing documentation of medication refusals, with refusals only noted by the SSD. The SSD reported she verbally relayed behavior information, including the alleged spraying incident, to the psychiatric facility based on staff reports that were not specifically documented in the clinical record and could not identify who was sprayed. The NP stated she completed the EDO using information provided by the SSD and that certain wording was needed to qualify for emergency detention; she acknowledged her own clinical notes did not support the description of the resident as verbally abusive to others and that she was not personally aware of specific behavior incidents. The DON later indicated she was unsure why the resident had been sent to a psychiatric hospital and had not been fully informed of the resident’s behaviors, underscoring that the resident’s transfer occurred without clear documentation and without the resident understanding or consenting to the psychiatric transfer.
Failure to Protect Resident From Verbal Abuse and to Investigate Abuse Allegations
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from verbal abuse and to recognize and investigate an allegation of abuse involving two roommates. Resident C, who was cognitively intact and required staff assistance with mobility, dressing, transfers, and personal hygiene, was admitted with diagnoses including a history of malignant brain neoplasm, muscle weakness, depression, and a need for assistance with personal care. After Resident B, who had a documented history of bipolar disorder and recent escalating behaviors including verbal aggression, verbal abuse of a roommate, and spraying a substance at a CNA, was sent to a psychiatric facility, Resident C used the landline phone in their shared room to communicate with her sister because her cell phone and charger were not working. When Resident B returned from the psychiatric facility, she became upset that Resident C was using the landline phone and an argument ensued. During this argument, Resident C reported that Resident B told her, "if anyone touches my stuff, I'm going to kill you," and also told Resident C’s sister over the phone that she was going to kill her as well. Resident C indicated to staff that Resident B kept threatening her, and Resident C’s sister confirmed hearing Resident B say that if she called the phone again, she would kill her, and that she heard Resident B tell Resident C, "If you touch my things, I will kill you. I will kill anyone who touches my things." CNA 5 responded to the roommates’ call light and heard Resident C say she needed to get out of the room because Resident B was being mean and kept threatening her; CNA 5 then reported the allegation to the Unit Manager. Despite these reports, the DON later stated she believed the incident was only an altercation between Resident B and Resident C’s sister and did not involve resident-to-resident abuse, and therefore no abuse investigation was initiated. Resident C reported that she remained fearful of Resident B after the incident, stayed in her room, and did not attend activities because of her fear. She stated that when Resident B walked by her door, Resident B would look at her and make a finger gun gesture. Resident C reported this behavior to the SSD, who acknowledged being told that Resident B would walk by Resident C’s room and make a finger gun gesture, but the SSD did not interview staff about these gestures and indicated she had not personally observed them. The SSD also indicated she had witnessed Resident B being verbally aggressive with other residents in the past but did not know her to have threatened to kill anyone and was unsure if the DON had been informed of the threats. The DON stated she was unaware of any threats to kill Resident C, was not aware that APS had been notified or that police were supposed to have been contacted, and did not consider the situation to be resident abuse, so she did not conduct staff or resident interviews. This sequence of events, combined with the facility’s own policy defining mental or verbal abuse as conduct causing or having the potential to cause fear or intimidation, led to the finding that the facility failed to protect Resident C’s right to be free from verbal abuse and failed to appropriately identify, report, and investigate the alleged abuse. The facility’s abuse policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish, and defined mental or verbal abuse as verbal or nonverbal conduct that causes or has the potential to cause humiliation, intimidation, fear, or agitation. Despite this policy and the known behavioral history of Resident B, including documented episodes of verbal aggression and verbal abuse of a roommate prior to this incident, the DON indicated she believed Resident B did not have a prior history of resident agitation or concerns that would preclude assigning her a new roommate. The DON also indicated that, because she believed the incident involved only Resident C’s sister, she did not treat it as an abuse allegation and did not initiate an investigation or report it to the state agency within two hours as would have been required if she had known of threats to kill Resident C. As a result, the facility did not fully recognize or respond to the reported threats and intimidating gestures directed at Resident C, and did not ensure that the resident was protected from verbal abuse as required by regulation and facility policy.
Failure to Report and Investigate Resident-to-Resident Verbal Abuse and Death Threats
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff reported and investigated an allegation of resident-to-resident verbal abuse, including death threats, in accordance with abuse reporting requirements. A cognitively intact resident, identified as Resident C, was newly admitted and required staff assistance with mobility, dressing, showering, transfers, and personal hygiene. After her cell phone and charger stopped working, staff arranged for her to use her roommate’s landline phone while the roommate, Resident B, was out of the room at a psychiatric facility. When Resident B later returned, she became upset that Resident C was using her landline phone and, according to Resident C and her sister, threatened to kill Resident C and her sister if they touched or used her belongings or called the phone again. Resident C reported that Resident B told her, “If anyone touches my stuff, I’m going to kill you,” and made similar threats toward her sister over the phone. Resident C stated she informed a CNA about the threats, and the CNA confirmed that Resident C said Resident B “keeps threatening me” and that Resident C’s sister reported ongoing threats over the phone. The CNA reported the allegation to the Unit Manager. Resident C was moved to another room the same evening, but she later reported that she did not feel safe and that Resident B continued to walk by her new room and make a finger-gun gesture toward her. Resident C’s sister corroborated hearing Resident B threaten to kill both Resident C and herself during the phone call. The Social Services Director (SSD) stated she was called at home after hours by a CNA and informed that Resident B was threatening Resident C and being verbally aggressive. She instructed staff to move Resident C and to contact the police, and she submitted an Adult Protective Services (APS) report listing Resident C as an endangered adult and Resident B as the perpetrator, with the allegation described as battery and threats to physically harm Resident C. However, the DON reported that she was only told there had been an altercation between Resident B and Resident C’s sister over the phone and believed the issue did not involve resident abuse. The DON stated there was no investigation because she understood the incident to be between Resident B and the sister, not involving Resident C as a victim, and she was unaware of any threats, APS report, or police involvement. She did not conduct staff or resident interviews related to the threats, and there was no report made to the state agency within the required timeframe for alleged abuse. The facility’s abuse-reporting policy required associates who suspect a crime against a resident to immediately notify the Executive Director, but the DON remained uninformed of the full nature of the threats and no formal abuse investigation was initiated.
Failure to Investigate and Report Resident-to-Resident Verbal Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to document, report, and conduct a thorough investigation of an allegation of resident-to-resident verbal abuse. Resident C, who was cognitively intact and required staff assistance with mobility, dressing, showering, transfers, and personal hygiene, reported that after her admission she used her roommate’s landline phone while the roommate (Resident B) was out of the facility. When Resident B returned, she became upset that Resident C was using her phone and threatened Resident C, stating that if anyone touched her belongings she would kill them. Resident C and her sister, who was on the phone at the time, both reported that Resident B threatened to kill Resident C and Resident C’s sister if they continued to use or call the phone. Resident C stated she informed a CNA about the threats and was moved to another room that evening, but she did not report the threats directly to a nurse. She later reported that Resident B continued to intimidate her by walking past her new room and making a finger gun gesture toward her. Resident C discussed these concerns with the Social Services Director (SSD) and expressed that she did not feel safe with Resident B in the facility, and she had considered finding another facility. An Adult Protective Services (APS) online report identified Resident C as an endangered adult and Resident B as the perpetrator, with the allegation described as battery and including threats of physical harm made on the night Resident B returned from a psychiatric hospital stay. The SSD reported that she was notified after hours by a CNA that Resident B was threatening Resident C and being verbally aggressive, and she instructed staff to move Resident C and to contact the police. However, she did not recall who called her, was unsure if the DON was informed, and did not interview staff about the reported ongoing finger gun gestures. The DON indicated she was only aware of an altercation between Resident B and Resident C’s sister over the phone and believed there had been no resident abuse, so no investigation was initiated. The DON was unaware of the reported death threats, the APS report, or any police contact, and later learned from law enforcement that no police report had been filed. As a result, the facility did not complete required documentation, did not report the alleged threats to the state agency within the required timeframe, and did not conduct a thorough investigation into the allegation of resident-to-resident verbal abuse.
Failure to Document and Implement Physician-Ordered Fluid Restriction
Penalty
Summary
A deficiency occurred when the facility failed to complete a physician's order for a resident with cirrhosis of the liver, diastolic congestive heart failure, and obesity, who was on a restricted fluid intake. The resident was admitted with a hospital discharge note and a current physician's order specifying a 1500 ml fluid restriction. However, the clinical record lacked documentation of fluid intake and did not include a care plan addressing the fluid restriction. During an interview, the ADON stated that the fluid restriction was considered a dietary recommendation rather than a direct order, leading to the order not being tracked or implemented as required. Facility policy on fluid-restriction diets was available but not followed in this case.
Failure to Ensure Resident Access to Oxygen and Call Light
Penalty
Summary
A resident with a history of stroke with left-sided weakness, chronic obstructive pulmonary disease, diastolic congestive heart failure, and depression was observed without access to her prescribed oxygen and call light. The resident had recently received assistance from staff to get dressed but was left without her oxygen reapplied. The oxygen concentrator and nasal cannula were placed on the opposite side of the bed, out of the resident's reach. The resident attempted to reach her call light to request staff assistance, but it was found coiled on the floor next to the bed, also out of reach. Facility policy requires that the call light be positioned within reach of the resident and that oxygen therapy be administered and stored safely. During the observation, the administrator confirmed that both the oxygen and call light were not accessible to the resident as required. The resident's care plan indicated she needed assistance with dressing and transferring, but staff failed to ensure her oxygen was reapplied and her call light was accessible after providing care.
Failure to Maintain Cleanliness in Shower Room
Penalty
Summary
The facility failed to maintain a clean and orderly shower room for resident use, as observed in one of three shower rooms. During an inspection of the 100 Hall shower room, surveyors found feces in three separate areas on the floor outside the shower, along with a used plastic bag, wet paper towels, and a used nicotine patch on the floor. The floor was visibly dirty throughout the room, and a used nicotine patch was also stuck to the shower wall. Additionally, a black substance was noted around the base of the shower area where the wall and floor meet. Both the ADON and the Lead Housekeeper acknowledged the unclean condition of the room during interviews, with the Lead Housekeeper stating that the floors should be swept and mopped and all debris removed, but that the dark substance remained despite cleaning attempts. The Administrator reported there was no specific policy or checklist for cleaning the bathrooms.
Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to ensure that food and drink were served at safe and appetizing temperatures, resulting in multiple residents receiving cold or unpalatable meals. Observations revealed that residents who ate in their rooms frequently received food that was cold by the time it reached them, with some residents reporting that staff would not reheat their meals due to the lack of accessible microwaves. Several residents indicated that their food was often cold, and some left meals uneaten or sought food outside the facility as a result. Trays were observed sitting in hallways for extended periods before being distributed, and the plastic coverings intended to maintain temperature were sometimes removed prematurely. Dietary staff attempted to keep food warm using plate warmers and heated plates, but these measures were insufficient, as food lost heat quickly after plating. The facility relied on open metal carts for food transport, and delays in tray delivery by nursing staff further contributed to the problem. Residents also reported not always receiving the food they ordered, not being offered alternative menu options, and not always being served the prescribed diet. Resident council minutes and grievance logs documented ongoing complaints about cold food, limited choices, and poor food quality over several months. Interviews with dietary and administrative staff confirmed awareness of the issue, with acknowledgment that heated transport carts had only recently been approved and would not be available for some time. In the interim, there were no additional measures from the kitchen to keep food hot, and the process for timely meal delivery was inconsistently followed. The facility's own policy required food to be served at acceptable temperatures, but observations and resident feedback indicated this standard was not being met.
Failure to Maintain Clean and Sanitary Environment Due to Inadequate Housekeeping
Penalty
Summary
The facility failed to maintain a safe, clean, and sanitary environment on one of two units observed for cleanliness. Multiple observations revealed that a resident's bathroom was not stocked with toilet paper or paper towels, the bathroom sink was loose, and the carpet was stained and emitted a foul odor due to frequent spills of bodily fluids. The resident reported that his room was not regularly cleaned, with dust accumulation on surfaces and debris, including food and paper, remaining on the floor for extended periods. The resident also indicated that staff did not prioritize his room's cleanliness, and debris he swept into the hallway remained unaddressed. Further observations on the same and following day showed that several resident rooms and bathrooms had soiled floors with unidentified dried substances, heavily stained carpets, and various debris such as used tissues, paper scraps, and food items. Common areas, including the front entry, hallways, and ice cream shoppe, were noted to have visible dust and dirt buildup, particularly on baseboards. Housekeeping staff were observed to be insufficiently present, with only one housekeeper seen working in certain areas and no staff observed cleaning other assigned areas during the survey period. Interviews with housekeeping staff and the supervisor revealed that the department was understaffed, with some housekeepers absent and no coverage for their assignments. Cleaning routines were inconsistently followed, with some areas only cleaned as needed and dusting in common areas performed weekly rather than daily. The facility's housekeeping policy required daily cleaning of high-touch areas and regular cleaning of carpets and bathrooms, but these standards were not met during the survey period, resulting in unsanitary conditions in resident rooms and common areas.
Failure to Accommodate Resident's Showering Preference Due to Inadequate Coordination for Port Dressing
Penalty
Summary
The facility failed to provide or document showers for a resident who was admitted with end stage renal disease requiring dialysis, a malignant neoplasm of the left breast, and a need for assistance with personal care. Despite the resident's expressed preference and ability to shower with her dialysis port covered, she did not receive a shower during her stay. The resident reported that prior to admission, she managed to shower safely by covering her port with a product from a pharmacy, but after admission, staff repeatedly told her they were waiting for a physician's order for a dressing to cover her port, which was never obtained or documented. The resident denied ever refusing a shower, stating she only needed her port covered to do so. Observations confirmed that the resident's shower was unused, and her towels remained dry and folded. Record review showed that the resident only received sponge baths and that documentation indicated refusals for showers, but there was no evidence of attempts to contact the physician for a dressing order or to accommodate her showering preference. The DON later confirmed that Tegaderm dressings, which could be used to cover the port, were available in stock and did not require a physician's order, and that the resident could have had a shower at any time. The facility's policy required that residents receive care in accordance with their choices and professional standards, but there was no documentation that the resident's preference for showers was accommodated or that appropriate steps were taken to enable her to shower safely.
Failure to Properly Investigate and Resolve Resident Grievances
Penalty
Summary
The facility failed to ensure that resident grievances were properly followed up, investigated, and resolved for three residents and over three months of Resident Council meetings. Specific grievances included complaints about cold and sometimes frozen meals, inadequate showering opportunities, and insufficient room cleaning. The facility's grievance logs showed that while some resolutions were noted, such as conducting audits, temperature checks, and instructing staff to offer showers or clean rooms, the documentation of follow-up actions and investigations was vague and lacked detail. Resident Council minutes also reflected ongoing concerns about food quality, temperature, and variety, with repeated issues being raised over several months. Confidential interviews with residents further corroborated these concerns, with reports of consistently cold and inedible food, lack of alternative meal options, and improper diets being served. The Administrator acknowledged that responses to grievances and Resident Council concerns were not specific and that staff documentation did not clearly outline the actions taken to address the complaints. The facility's own grievance policy required prompt efforts to resolve grievances, thorough documentation of investigations, and communication of resolutions, but these standards were not met in the reviewed cases.
Failure to Facilitate Resident Voting Rights
Penalty
Summary
The facility failed to ensure that residents who wanted to register to vote were registered and that those who were registered were able to vote in the 2024 Presidential Election. This deficiency affected five residents who expressed a desire to vote but encountered various obstacles. Resident B indicated that his democratic right was violated because he was not registered to vote. Resident E did not receive his absentee ballot, and Resident F was not assisted in getting up to vote. Resident D expected someone to come to the facility to assist with voting, but this did not happen. Resident C signed papers to vote but did not receive an absentee ballot. The Activity Director (AD) attempted to facilitate the voting process by contacting the voting board, which sent representatives to register residents. However, the AD did not maintain a list of residents who wanted to register, leading to some residents being upset about not being able to vote. The Mobile Voting Board (MVB) visited the facility to register residents and was supposed to return to assist with absentee voting, but this did not occur as planned. The Executive Director's investigation noted that Resident B was the only known resident who did not get a chance to vote because he was not registered. Further interviews revealed that the MVB had left applications for voter registration and travel board voting at the facility, but some residents did not complete or return these applications. The Director of Nursing was unaware of the residents' desire to vote and the issues they faced. The facility's policy on resident rights, which includes the right to vote, was not effectively implemented, resulting in the residents' inability to exercise their voting rights.
Deficient Call Light Response Times
Penalty
Summary
The facility failed to ensure a timely and appropriate response to grievances related to answering call lights, affecting all 11 residents who participated in a resident council meeting. The issue was first documented in the resident council meeting minutes from July 2024, where residents reported waiting 1 to 2 hours for call lights to be answered, with the situation worsening at night. Despite reeducation efforts, the problem persisted, as noted in subsequent meetings in October and November 2024, where residents continued to report delays, particularly during night and weekend shifts. The residents expressed that the issue was a recurring topic in their meetings and that grievances had been filed multiple times, with only temporary improvements observed. The grievance logs from February to September 2024 further highlighted the ongoing issue, with multiple grievances filed by residents and their families regarding delayed call light responses. Resolutions to these grievances typically involved meetings with staff or coaching, but the problem persisted. Interviews with the Executive Director and Director of Nursing revealed that the facility's primary response to the issue was monthly in-services and reeducation, but no additional measures were identified. The facility's policy on call light response, dated January 2023, emphasized the importance of staff being aware of and responding to call lights, but the policy was not effectively implemented, as evidenced by the continued grievances and resident feedback.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment in the memory care unit's main dining room and in two residents' rooms. During an initial tour, remnants of feces were observed in the dining room corner, which were not cleaned up after a resident's incontinent episode. Despite attempts to clean the area with an industrial carpet cleaner, the stains and debris remained. A Certified Nursing Aide identified the stains as likely being from a resident with a history of using the bathroom in inappropriate places. The Floor Tech acknowledged that the area needed spot cleaning, which had not been done. Additionally, the facility failed to ensure the floors in two residents' rooms were free from large areas of staining due to incontinent episodes. In one room, a crumpled pile of linens with a large yellow/brown stain was observed, and the room smelled strongly of urine. The floor tiles were deeply discolored due to urine seeping under a fall mat. A similar situation was observed in another resident's room, where the tiles were also discolored. The Floor Tech admitted that the tiles needed special cleaning, but no request for work or replacement had been made.
Deficiencies in Fall Prevention, Supervision, and Medication Management
Penalty
Summary
The facility failed to implement adequate interventions to prevent falls for a resident with a history of falls, resulting in a nasal fracture. Resident H, who had diagnoses including abnormalities of gait and mobility, lack of coordination, muscle weakness, difficulty in walking, and a history of falling, was observed without necessary safety measures such as a reachable call light and padded side rails. Despite having a care plan that required these interventions, they were not in place, leading to a fall that resulted in significant injury. The resident was found with bruising and was later diagnosed with a nasal fracture at the hospital. Another deficiency involved a resident with dementia who exhibited intrusive wandering behaviors, entering other residents' rooms and causing distress. Despite being on a secured memory care unit, Resident 193 was observed wandering without purpose and entering other residents' rooms, which led to altercations. The staff attempted to redirect her, but she continued to wander, indicating a lack of effective supervision and intervention to manage her behavior. Additionally, the facility's Elopement Binder was not up to date, failing to include current residents at risk for elopement. This oversight included residents with documented risks for elopement who were not listed in the binder, compromising their safety. Furthermore, medications were left at the bedside for two residents without proper orders or assessments, posing a potential risk for accidents. These deficiencies highlight the facility's failure to ensure a safe environment and adequate supervision for its residents.
Infection Control Breach During Medication Administration
Penalty
Summary
The facility failed to adhere to proper infection prevention and control protocols during medication administration. On the morning of January 14, 2025, a Qualified Medication Aide (QMA) was observed administering medications to multiple residents without performing hand hygiene between each resident. Specifically, the QMA did not wash her hands after administering medications to three residents before proceeding to the next. Additionally, when administering ear drops to a resident, the QMA used an ungloved hand to manipulate the resident's ear and did not wear gloves on the other hand while administering the drops. This was contrary to the facility's policy on ear drop instillation, which requires the use of gloves to comply with standard precautions.
Failure to Ensure Resident Dignity and Timely Assistance
Penalty
Summary
The facility failed to ensure residents were treated with dignity, as evidenced by two separate incidents involving Resident 40 and Resident 1. In the first incident, Resident 40, who resides in a secure memory care unit and requires assistance with personal care due to severe dementia and anxiety, was not assisted to the restroom in a timely manner. Despite multiple requests for assistance, Resident 40 was left waiting for over 20 minutes, resulting in incontinence. Staff members, including an LPN and two CNAs, were aware of the resident's need but failed to provide timely assistance. In the second incident, Resident 1, who has hemiplegia and hemiparesis following a stroke, was subjected to harsh treatment during a transfer from the toilet to her wheelchair. The resident expressed pain and distress during the transfer, and a staff member responded inappropriately by speaking harshly. Additionally, photographs of Resident 1 in her wheelchair, intended to guide staff on proper positioning, were displayed in a manner that compromised her privacy and dignity, as they were visible from the public hallway. The facility's failure to address these issues reflects a lack of adherence to policies that promote respect and dignity for residents. The Executive Director and Director of Nursing acknowledged the inappropriate actions and the need for staff to be attentive to residents' concerns, but the incidents highlight deficiencies in the facility's care practices.
Failure to Document Advanced Directives for Residents
Penalty
Summary
The facility failed to ensure that residents had advanced directives or code statuses documented in their medical records. Resident 250, who was admitted with multiple diagnoses including GERD, COPD, osteoporosis, and schizoaffective disorder, did not have an order or care plan addressing her advanced directive wishes upon initial review. The Director of Nursing (DON) later provided a care plan and order for her advanced directive, indicating that the documentation was not present until requested. The DON acknowledged that advanced directives should be obtained upon admission. Resident 48, with diagnoses including stroke, diabetes, hypertension, and major depressive disorder, had conflicting documentation regarding her code status. While a physician's order indicated a full code status, her care plan listed a DNR status. Resident B, admitted with COPD, diabetes, chronic kidney disease, and respiratory failure, did not have a physician's order or care plan for his advance directive status upon admission. He reported not being asked about creating an advance directive until later. The DON admitted to issues with creating residents' advance directive statuses, noting that it was now everyone's duty to ensure completion.
Inaccurate MDS Coding for Residents
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) assessments for two residents, leading to deficiencies in their care plans. Resident 193, who was observed wandering aimlessly and entering other residents' rooms without purpose, was not coded for wandering behaviors in her MDS assessment. Despite multiple nursing progress notes indicating her confusion and wandering tendencies, the admission MDS inaccurately reflected no wandering behaviors during the assessment's 7-day look-back period. This discrepancy highlights a failure in accurately assessing and documenting the resident's behaviors, which are crucial for her care and safety. Similarly, Resident 81's MDS assessment failed to include his mental health diagnosis in the PASRR section, despite having a significant change in his condition with a new diagnosis of bipolar disorder with manic and psychotic features. The PASRR Level II assessment had previously identified him as having a major mental illness, yet this was not accurately reflected in the MDS. The Social Service Director acknowledged these coding errors, indicating a lapse in the facility's assessment and documentation processes, which are essential for providing appropriate care to residents with complex needs.
PASRR Screening Deficiencies for Two Residents
Penalty
Summary
The facility failed to ensure accurate information was submitted on a Pre-Admission Screen and Resident Review (PASRR) Level I for Resident 68. This resident, who was observed in the secured memory care unit, had diagnoses including psychotic disorder with delusions and unspecified dementia. However, the PASRR Level I indicated that Resident 68 did not require a Level II screen because it inaccurately stated she did not have a major mental illness or neurocognitive or dementia diagnoses. The Social Service Director acknowledged that the Level I should have included these diagnoses to determine if a Level II screen was necessary. Additionally, the facility failed to complete a new PASRR Level I for Resident 90, who was admitted under a 30-day exclusion for pre-admission screening. Resident 90 had diagnoses including schizophrenia, depression, and anxiety. Her initial Level I was completed, allowing a 30-day stay, but a new Level I was not completed after the 30 days expired. The Social Service Assistant and the Director of Nursing were unable to provide an explanation for the missing documentation. The facility's policy requires that a Level I PASRR screening be completed prior to admission and retained in the resident's medical record.
Failure to Utilize G-tube for Medications and Nutrition
Penalty
Summary
The facility failed to provide appropriate services and documentation for a resident with a gastrointestinal tube (G-tube). Resident 295, who had a G-tube placed after a cerebrovascular accident (stroke), was observed and reported that the G-tube was not being used for medications or feeding supplements. Interviews with multiple Licensed Practical Nurses (LPNs) confirmed that the G-tube was not utilized for its intended purposes, and the staff only followed orders to flush it. The resident was on a regular diet and had orders for Glucerna to be administered if she consumed less than 50% of her meals, but this was not necessary as she regularly ate over 50% of her meals. The medical record review revealed discrepancies in the administration of medications and nutritional supplements via the G-tube. The resident's Medication Administration Record (MAR) indicated that Glucerna was administered on several occasions, despite the resident's consistent meal consumption. Additionally, there was confusion regarding the resident's weight gain, initially suggesting a significant increase, which was later clarified with documentation from a previous healthcare provider. The Director of Nursing (DON) and the Regional Director of Clinical Services acknowledged the oversight in the resident's medical record and the incorrect orders for medication administration via the G-tube.
Deficiencies in Oxygen Administration and Equipment Hygiene
Penalty
Summary
The facility failed to ensure proper oxygen administration for two residents using nasal cannulas. Resident Z, who had a history of idiopathic peripheral autonomic neuropathy, diabetes mellitus, edema, and pneumonia, was observed with her oxygen concentrator set incorrectly at 1 liter per minute (lpm) instead of the prescribed 2 lpm. Her oxygen saturation levels were below the recommended threshold, and she experienced shortness of breath and dizziness. The nasal cannula was not dated, and the humidifier bottle had not been changed since 12/31/24, indicating a lapse in maintaining equipment hygiene and functionality. Resident B, diagnosed with chronic obstructive pulmonary disease (COPD), diabetes mellitus, chronic kidney disease, and obstructive sleep apnea, also experienced improper oxygen administration. His oxygen concentrator was set at 3 lpm instead of the prescribed 2 lpm. Additionally, his bipap mask and tubing were found uncovered and contaminated with dust, dirt, and debris, compromising their cleanliness and safety. Resident B reported delays in receiving his bipap mask at night, sometimes having to sleep without it, which could exacerbate his respiratory conditions. The facility's policy on oxygen administration, which requires humidifier bottles to be changed every 7 days and respiratory supplies to be stored properly, was not adhered to. The Director of Nursing confirmed that the bipap mask should be covered when not in use, and the tubing should not be on the floor. These deficiencies highlight a failure in maintaining proper respiratory care and equipment hygiene for residents requiring oxygen therapy.
Failure to Obtain Blood Pressure Before Administering Medication
Penalty
Summary
The facility failed to obtain a blood pressure reading as indicated in a medication order before administering a blood pressure medication to one of the residents reviewed. The resident, identified as Resident 250, had multiple diagnoses including gastro-esophageal reflux disease (GERD), chronic obstructive pulmonary disease (COPD), age-related osteoporosis, and schizoaffective disorder. The resident had an order for prazosin HCL, a blood pressure medication, to be administered at bedtime with instructions to hold the medication if the systolic blood pressure (SBP) was less than 100 or the pulse was less than 60. However, the order did not include instructions to obtain a blood pressure reading prior to administering the medication. During an interview, the Director of Nursing (DON) acknowledged that a blood pressure reading should have been included in the order. The facility's policy on medication administration emphasized the importance of noting the resident's history and any parameters around drug administration.
Medication Storage and Expiration Management Deficiency
Penalty
Summary
The facility failed to properly manage and store medications in accordance with accepted professional principles, as observed in two medication rooms. In one instance, a bottle of lorazepam belonging to a resident was found in the refrigerator without a date indicating when it was opened. This lack of proper labeling could lead to the use of expired or compromised medication. Additionally, in the 100-medication room, an opened bottle of aplisol, used for tuberculosis testing, was found with an expiration date that had already passed. Further observations in the 300-medication room revealed an opened bottle of chlorpactin belonging to another resident, which was sent by the pharmacy with an expiration date of 12/30/24. Despite the RN's assertion that the medication was still valid, it was determined that the medication had expired as it was only good for 10 days in the refrigerator. The facility's policy on the storage and expiration dating of medications was not adhered to, as expired medications were not separated from other medications for destruction or return to the pharmacy.
Wheelchair Maintenance Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain two residents' wheelchairs in safe operating conditions. Resident 1's wheelchair had a broken left arm that moved freely forward and backward, which was observed on multiple occasions. Despite the Regional Director of Clinical Services indicating that the wheelchair was fixed, the Certified Occupational Therapy Assistant noted that a bolt was completely broken, and a replacement part had been ordered but not yet received. The Maintenance Director mentioned that the wheelchair could be fixed within an hour if another wheelchair was available for temporary use. However, the alternative wheelchair was not suitable for Resident 1, leading her to sit on the bed while repairs were made. The Director of Nursing indicated that the broken wheelchair should have been reported to the Maintenance Director by the Certified Nursing Aides or therapy staff. Resident 14's wheelchair had a missing right brake handle, leaving a hollow metal bar exposed, which was a safety concern as the brake could not engage properly. This issue persisted throughout the survey week. Although a wheelchair extension bar was eventually replaced, it remained uncapped, posing a risk of skin tears. The Director of Therapy was unaware of the uncapped handle, and the Executive Director did not have a specific policy related to wheelchair maintenance, although a wheelchair inspection checklist and a preventative maintenance policy were provided. The policy indicated that wheelchairs with broken or missing parts should be taken out of use immediately and reported for repair.
Failure to Update Care Plan for Resident with Dementia
Penalty
Summary
The facility failed to ensure that comprehensive care plans were reviewed and revised as needed for a resident with updated interventions. Resident 14, who resides in a secured memory care unit and has a diagnosis of dementia, was observed without a brace or splint throughout the survey week, despite a picture in her room instructing that a brace should be worn at all times. Her care plan, dated over a year prior, indicated the need for a left edema glove and wrist orthotic at all times, which was no longer necessary according to the Director of Therapy. The care plan had not been updated to reflect the resident's current needs, and the outdated instructions remained in her room.
Failure to Provide Routine Podiatry Care for Resident
Penalty
Summary
The facility failed to ensure that a resident's activities of daily living (ADLs) were completed, specifically in the case of a resident with multiple health conditions including chronic obstructive pulmonary disease, diabetes mellitus with chronic kidney disease, acute and chronic respiratory failure with hypoxia, and obstructive sleep apnea. The resident was dependent on staff for emotional, intellectual, physical, and social needs, as well as assistance with mobility and ADLs. On a specific date, the resident's toenails were observed to be extremely long and jagged, causing discomfort and preventing the resident from placing them under a blanket. The facility's records indicated that the resident was not seen by a podiatrist during scheduled visits on multiple occasions, despite being added to a recall list. The Director of Nursing acknowledged that residents should be seen routinely by the podiatrist, and the process involves nurses notifying the Social Services Director, who then compiles a list of residents to be seen. The facility's policy on resident rights emphasizes the right to reasonable accommodation of resident preferences, which was not upheld in this instance.
Inadequate Supervision and Care Planning for Aggressive Resident with Dementia
Penalty
Summary
The facility failed to provide adequate supervision, monitoring, and interventions for a resident diagnosed with dementia and a history of aggressive behaviors. This deficiency resulted in multiple incidents of verbal and physical threats, as well as resident-to-resident altercations. The resident, identified as having severe cognitive impairment, exhibited physical behavioral symptoms directed toward others, which significantly interfered with care and posed a risk to both the resident and others. The resident was involved in several incidents where they physically assaulted other residents, leading to injuries and the need for police involvement. Despite these incidents, the facility's care plan for the resident lacked specific interventions tailored to the resident's needs and did not adequately address the behavioral health needs. The care plan was not updated with new interventions following each incident, and the facility's response was limited to separating residents and placing them on safety monitoring. The facility's policy on dementia care emphasized the need for person-centered care and individualized interventions, but the implementation was lacking. The resident's medical record did not reflect person-centered, individualized care, and the facility failed to revise care plans effectively after each incident. This lack of appropriate care planning and intervention contributed to the ongoing aggressive behaviors and altercations involving the resident.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling, storage, and destruction of medications and biologicals across multiple medication carts. During observations, several opened bottles of eye drops and nasal sprays were found without open dates, which is against the facility's policy that requires medications to be dated when opened. Additionally, some medications were found to be almost full despite records indicating they were administered daily, suggesting discrepancies in medication administration or documentation. The Director of Nursing (DON) acknowledged that medications should be dated and replaced according to the manufacturer's instructions. Further observations revealed that over-the-counter medications were not properly labeled with resident names or instructions for use. Some medications were found with worn and faded labels, and there were inconsistencies between the number of doses documented as administered and the remaining medication count. The DON indicated that residents could have multi-dose bottles provided by family members, but these should have been labeled with the resident's initials, drug name, and physician's order for use. Additionally, the storage of medications was not in compliance with facility policy. Biologicals such as PeriGuard ointment were found unbagged and stored among oral medications, which is against the policy that requires treatments to be stored separately in the treatment cart. Nebulizer vials were also improperly stored, and there was a lack of proper labeling and storage for these items. The DON and other staff members acknowledged these issues, indicating that night shift nurses were responsible for checking and cleaning the medication carts, but these tasks were not consistently performed.
Failure to Provide Showers as Per Resident's Preference
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident B, was provided showers according to his preference, which was twice a week on Mondays and Thursdays. Observations and interviews revealed that Resident B was not receiving showers as scheduled. The medical record review showed that Resident B had only received one shower in June, six in July, and three from August 1 to 16. Despite the resident's preference for two showers per week, there was a lack of documentation in the care plans regarding any specific refusal of showers or interventions to address this issue. Interviews with staff, including a CNA and the Director of Nursing (DON), indicated that if a resident refused a shower, the nurse was supposed to verify and offer a bed bath. However, the showers were prescheduled according to room numbers, not individual preferences. The DON acknowledged that there was no documentation in the medical record indicating the resident refused showers, except for one entry in the nurse's notes. The facility's policy on resident rights emphasized the resident's right to participate in care planning and receive services included in the plan of care, which was not adhered to in this case.
Infection Control Lapse in Catheter Care
Penalty
Summary
The facility failed to adhere to proper infection control practices during catheter care for a resident with a suprapubic catheter. During an observation, a Qualified Medication Aide (QMA) changed the resident's foley catheter leg drainage bag to a regular urinary drainage bag without sanitizing the tip of the drain tube or catheter before connecting them. Additionally, the QMA did not wash or sanitize her hands after removing gloves and before handling the resident's drinking cup. The resident had a history of prostate cancer, diabetes with neuropathy, obstructive and reflux uropathy, bladder neck obstruction, and was at risk for infections. Interviews with staff revealed inconsistencies in following proper procedures for changing catheter bags. The QMA did not acknowledge the need to wash hands or sanitize the catheter drain tip, while other staff members, including a Registered Nurse (RN) and a Licensed Practical Nurse (LPN), described correct procedures that included hand hygiene and sanitizing the catheter tubing. The facility's policies on hand hygiene and urinary catheter management were provided, indicating the need for aseptic techniques and hand hygiene, but these were not followed during the observed incident.
Failure to Address and Track Resident Grievances
Penalty
Summary
The facility failed to adequately address and track grievances raised by residents and their families over a five-month period. The Resident Council meetings highlighted several unresolved concerns, including residents not receiving scheduled showers, delayed response times to call lights, and missing laundry items. Despite a process in place where the Activity Director was supposed to fill out grievance cards and distribute them to the appropriate department managers and the Executive Director, there was no evidence of follow-up or resolution. The Activity Director confirmed that she had not received any responses from the Executive Director or department managers regarding the grievances documented on the blue cards. Interviews with residents and a family member revealed ongoing issues with personal care and hygiene, such as residents not receiving their scheduled showers. Residents E, K, and Q reported not receiving the showers they were scheduled for, and Resident R's family member expressed concerns about the resident's hygiene and room cleanliness. Despite completing grievance cards, these individuals did not receive any feedback or resolution from the facility. The Executive Director, who had just started working at the facility, acknowledged the lack of a response system for grievances, which was contrary to the facility's policy that required follow-up on all complaints and suggestions presented at Resident Council meetings.
Failure to Revise Care Plans for Residents
Penalty
Summary
The facility failed to revise care plans for two residents, GG and H, as required. Resident GG was observed on 4/16/24 with multiple pressure ulcers, including an unstageable pressure ulcer on the right ischium and deep tissue injuries on both heels. Despite these observations, a review of Resident GG's care plan on 4/17/24 revealed that it did not address the current status of her skin integrity, specifically the right ischium wound. The care plan was only updated after the surveyor's review on 4/17/24. Resident H was admitted on 4/5/24 with diagnoses including late-onset Alzheimer's disease and a traumatic hemorrhage of the cerebrum. Upon admission, Resident H had a pink open lesion on the coccyx, which was documented as worsening by 4/6/24. Despite this, the care plan dated 4/8/24 only indicated that the resident was at risk for skin integrity issues and did not document the existing wound. The facility's policy required comprehensive care plans to be reviewed and revised by the interdisciplinary team after each assessment, but this was not followed for Resident H.
Failure to Ensure Effective Wound Management
Penalty
Summary
The facility failed to ensure effective wound management for a resident admitted with an open area on the coccyx that worsened into a stage 3 pressure ulcer. Upon admission, the resident had a pink open lesion on the coccyx, but the documentation lacked detailed descriptions, measurements, or staging of the wound. The resident's care plan included interventions such as keeping the skin clean and dry, using a pressure-reducing mattress, and applying Calmoseptine ointment, but these measures were not effectively implemented or documented. The wound was not included in the wound tracking log, and the wound nurse did not follow up on the resident's condition promptly, leading to the deterioration of the wound to a stage 3 pressure ulcer with full-thickness tissue loss and serous drainage. The resident's responsible party expressed dissatisfaction with the care provided, noting delays in rehabilitative services, the resident being left in bed, and the room smelling of urine. Observations confirmed that the resident was often left lying flat in bed without proper positioning devices to offload pressure from the coccyx. The wound nurse and wound MD were not promptly notified or involved in the resident's wound care, and the wound was not assessed or documented accurately until it had significantly worsened. The facility's internal wound tracking log initially did not include the resident, and there was a lack of consistent documentation and communication regarding the resident's wound status. Interviews with staff revealed inconsistencies in wound assessment and documentation practices. Licensed Practical Nurses (LPNs) and Registered Nurses (RNs) indicated that they were not responsible for staging wounds and that the wound nurse or DON should handle this task. However, the wound nurse and DON failed to ensure timely and accurate documentation and follow-up. The wound MD confirmed that the resident was not on the wound list during his previous visit, and the resident's wound was not assessed until it had worsened. The facility's policy on wound documentation and assessment was not followed, resulting in inadequate treatment and monitoring of the resident's pressure ulcer.
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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