Williamsport Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Williamsport, Indiana.
- Location
- 200 Short St, Williamsport, Indiana 47993
- CMS Provider Number
- 155568
- Inspections on file
- 19
- Latest survey
- July 15, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Williamsport Nursing And Rehabilitation during CMS and state inspections, most recent first.
Surveyors found the kitchen in unsanitary condition, with dirty equipment, floors, and food storage areas, and discovered that required cleaning logs had not been completed for several months. Interviews with dietary staff and the DON confirmed that cleaning schedules were not followed and documentation was missing, despite facility policy requiring comprehensive cleaning records.
Surveyors found that the facility did not provide palatable or properly heated food, with residents receiving repetitive meals and food served at incorrect temperatures. Several residents reported cold and unappetizing meals, and a test tray confirmed that both hot and cold items were not within required temperature ranges. The Dietary Manager acknowledged menu substitutions, insufficient caloric intake, and lack of insulated carts for meal delivery.
A resident with moderate cognitive impairment indicated a strong preference for daily morning showers, but was only scheduled for showers twice weekly in the evening. Despite documentation of these preferences and multiple refusals of the offered showers, there was no evidence that her preferences were reassessed or that the care plan was updated to reflect her wishes, resulting in a failure to support resident choice as required.
A resident's MDS assessment was inaccurately coded to indicate anticoagulant use during the look-back period, despite the MAR showing no such medication was administered at that time. The DON confirmed the resident was not on an anticoagulant during the relevant period, and the error was due to incorrect coding.
The facility did not consistently hold or document care plan meetings for two residents, both of whom were cognitively intact and could not recall attending such meetings, with records lacking evidence of required quarterly reviews. Additionally, a resident receiving long-term Macrobid for UTI prevention due to ESBL and recurrent UTIs did not have this therapy addressed in the care plan.
Two residents did not receive showers and shaving as scheduled or per their preferences, despite being dependent on staff for ADLs due to conditions such as hemiplegia and Parkinson's disease. Documentation showed that scheduled showers were frequently missed without evidence of resident refusal, and observations confirmed ongoing issues with grooming and hygiene. Staff interviews revealed uncertainty about grooming routines, and facility policies lacked specific guidance on shower administration.
Staff failed to follow medication administration and disposal protocols for two residents. In one case, a resident was found with multiple pills left at the bedside, contrary to facility policy. In another, an LPN disposed of refused medications in a sharps container instead of the required Drug Buster disposal system. Interviews confirmed that these actions did not align with established procedures.
A resident with a stress fracture and chronic kidney disease requested PRN tizanidine for muscle spasms but was asked by an LPN to wait due to concerns about blood pressure and fall risk, despite being non-weight bearing and in a wheelchair. The resident received Xanax instead, and the LPN did not return to reassess or offer the tizanidine, resulting in increased pain and no further doses documented for that day.
An opened vial of tuberculin solution was found in a medication storage room refrigerator without a date of opening. Both an LPN and the DON confirmed that facility policy requires medications to be dated when opened, and the facility's policy document supports this requirement. This resulted in a deficiency related to proper medication labeling and storage.
A resident with a diabetic foot ulcer experienced improper placement of a wound vac, leading to maceration of the periwound area. The facility had the necessary supplies, but they were not the original brand, causing concern for the resident's wife. The DNS placed the wound vac and was responsible for staff education, but documentation of training was lacking. The DNS re-educated an LPN on proper placement, but this was not documented, resulting in a deficiency.
The facility failed to maintain safe hot water temperatures, with several residents reporting excessively hot water that could cause burns. The new Maintenance Supervisor confirmed the high temperatures but was initially unable to locate temperature logs or calibrate the thermometer. The facility lacked a policy for monitoring water temperatures, and logs for a specific period were missing.
The facility failed to ensure proper food handling and hand sanitization during meal service, affecting all 50 residents who ate meals from the kitchen. Staff were observed placing the ice scoop back into the ice bucket and using ice meant only to keep drinks cold. Additionally, a CNA did not sanitize her hands between assisting two residents with their meals and repositioning them.
The facility failed to ensure a resident was treated with dignity during a dining observation. The SLP was observed standing while assisting the resident with eating and drinking, contrary to the standard practice of sitting down. The resident has multiple diagnoses and requires assistance with daily activities, including eating. Both the DON and SLP acknowledged that staff should sit while assisting residents, in line with the facility's policy on Resident Rights.
The facility failed to conduct quarterly care plan meetings for a resident with moderate cognitive impairment and did not implement an oxygen care plan for another resident with hypoxemia, type 2 diabetes, and obstructive sleep apnea. The resident's oxygen was repeatedly set incorrectly, and staff were unsure of the correct settings.
The facility failed to ensure proper catheter care and placement for a resident, who was observed multiple times with his catheter bag in contact with the floor and other surfaces. Despite specific medical orders and facility policies, the catheter bag was not consistently secured, leading to repeated instances of improper placement.
The facility failed to provide proper respiratory care for two residents. One resident did not receive the prescribed oxygen level, and another resident's nebulizer treatment was not properly administered or assessed. Facility policies for oxygen concentrators and nebulizer treatments were not followed.
The facility failed to provide necessary mental health services to a resident with severe dementia, depression, and a psychotic disorder. Despite exhibiting significant behavioral issues, the resident did not receive timely psychiatric consultation, and there was inadequate documentation of family discussions regarding psychiatric services.
The facility failed to maintain a medication error rate below 5%, with errors including an LPN administering Creon by touching the capsule with an ungloved finger and another LPN administering insulin lispro without ensuring the resident received their meal within the recommended 15-minute window.
Failure to Maintain Kitchen Sanitation and Cleaning Documentation
Penalty
Summary
The facility failed to maintain the kitchen in a sanitary condition and did not ensure that cleaning logs were completed and up to date. During an initial kitchen tour, surveyors observed that the convention oven burners had dark, charred particles caked on them, and the grill had food particles around its rim. The piping and wall behind the oven were dirty with old grease, and the kitchen floor had food crumbs and pieces of paper towel scattered throughout. The walk-in freezer also contained food crumbs and particles on the floor and shelving. No food was being cooked at the time of observation. Interviews with the Dietary Corporate Consultant and the Dietary Manager revealed that the kitchen cleaning logs for April, May, and June were blank and had not been completed. The Dietary Manager, who had recently started, acknowledged that cleaning tasks were not being consistently performed and that staff were not following a daily or deep cleaning schedule. The Director of Nursing confirmed awareness of the incomplete cleaning logs and noted recent management changes in the kitchen. The facility's policy required a comprehensive cleaning schedule and maintenance of cleaning logs, but these procedures were not followed.
Failure to Provide Palatable Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to provide food that was palatable, attractive, and served at safe and appetizing temperatures, as observed during multiple meal services. On one occasion, residents were served a chicken salad sandwich, beets, and pears instead of the scheduled menu of tomato basil soup, hot tuna and cheese sandwich, pickled beets, and sliced pears. Residents expressed dissatisfaction with the repetitive menu and questioned the frequent serving of chicken. The Dietary Manager was unable to explain the menu substitution and acknowledged that the meal provided did not meet adequate caloric intake. Staff interviews confirmed that soup was omitted from the meal due to unavailability, and the Dietary Manager noted ongoing concerns about menu repetition and the lack of a functioning food council. Multiple residents reported that food was often cold, repetitive, and unpalatable, whether eaten in the dining room or delivered to their rooms. The Dietary Manager acknowledged awareness of complaints about cold food and noted the absence of insulated food carts for tray delivery. A test tray revealed that hot food items were below the required temperature, and cold items were above the required temperature, with potato wedges noted as undercooked. The facility's policy requires hot foods to be held at or above 135°F and cold foods at or below 41°F, but these standards were not met during the survey.
Failure to Honor Resident's Shower Preferences
Penalty
Summary
A resident with moderate cognitive impairment expressed a preference to shower every day and to have showers in the morning, which was documented during an interview and in her admission assessment. The resident's preferences were also recorded in a customary routines and activities observation, indicating it was very important for her to choose the type of bath and that she preferred to be bathed more than twice per week in the morning. Despite this, the resident was scheduled for showers only twice weekly on the evening shift, contrary to her stated preferences. Shower reports showed that the resident was offered showers on various dates, with several refusals, but there was no documentation that her preferences were reassessed or that the timing of the showers matched her morning preference. Progress notes did not indicate that the resident was offered a shower daily or that her preferences were revisited after refusals. The care plan did note her preference for daily showers, but this was not reflected in the actual shower schedule or in follow-up actions. Interviews with facility staff, including the DNS, confirmed that the resident's preferences should have been communicated and implemented, but this did not occur. The facility's policy required that resident preferences be identified and shared with the interdisciplinary team, but there was no evidence this process was followed in this case.
Inaccurate MDS Coding for Anticoagulant Use
Penalty
Summary
The facility failed to ensure the accurate coding of a Minimum Data Set (MDS) assessment for one resident. A quarterly MDS assessment indicated that the resident received an anticoagulant medication during the look-back period. However, a review of the Medication Administration Record (MAR) for the same period showed no documentation that the resident received an anticoagulant. The Director of Nursing Services (DNS) confirmed that the resident was not on an anticoagulant during the look-back period, as it had been discontinued prior to that time. The MDS assessment was therefore coded in error, contrary to the requirements outlined in the CMS Resident Assessment Instrument (RAI) manual, which specifies that medication administration records should be reviewed for the 7-day look-back period to ensure accurate coding.
Failure to Document and Conduct Care Plan Meetings and Address Long-Term Antibiotic Use
Penalty
Summary
The facility failed to ensure that care plan meetings were held and properly documented for two residents, and did not develop a care plan for the long-term use of an antibiotic for another resident. One resident, who was cognitively intact, reported not remembering being invited to or attending care plan meetings regularly, and her record showed only two care plan meetings documented over a year, with no evidence of quarterly meetings as required. Another cognitively intact resident also did not recall having a care plan meeting, and her record lacked documentation of invitations being accepted or meetings being held, with only evidence that invitations were mailed. The Social Service Director confirmed that there was no documentation of responses to invitations or that meetings occurred. Additionally, a resident with a history of extended spectrum beta lactamase (ESBL) and recurrent urinary tract infections (UTIs) was prescribed long-term Macrobid therapy for UTI prevention. Despite this, the resident's comprehensive care plan did not include documentation addressing the long-term antibiotic use, nor the resident's history of UTIs and ESBL. The Director of Nursing Services acknowledged that a care plan should have been developed for the resident's long-term antibiotic use.
Failure to Provide Showers and Grooming per Resident Preference
Penalty
Summary
The facility failed to provide care and assistance with activities of daily living (ADLs), specifically in administering showers and shaving, according to resident preferences for two residents. One resident, who was cognitively intact but required assistance due to hemiplegia and poor vision, reported not being regularly shaved or given scheduled showers. Documentation showed that out of 22 scheduled showers, only 10 were administered, with no record of the resident refusing care. Staff interviews revealed uncertainty about shaving frequency and reliance on shower days for shaving, while the Assistant Director of Nursing was unsure about the shaving schedule. Observations confirmed the resident had extensive facial hair and reported not being shaved as preferred. Another resident, dependent for all personal care due to Parkinson's disease and cognitive impairment, was observed multiple times with unshaven facial hair and brown debris under fingernails. Documentation indicated only 6 out of 22 scheduled showers were administered, again with no record of refusals. The facility's policies addressed AM care and fingernail cleaning but did not provide a specific policy for administering showers or bathing. The Director of Nursing confirmed the use of internal shower sheets, which were not retained as part of the medical record.
Failure to Follow Medication Administration and Disposal Protocols
Penalty
Summary
Facility staff failed to follow professional standards for medication administration and disposal for two residents. In one instance, a cognitively intact resident with multiple diagnoses, including COPD, alcoholic cirrhosis, diabetes, GERD, and heart failure, was found with two cups containing several pills left at her bedside. The resident reported that the nurse did not want to wake her and left the medications on her overbed table. The resident's care plan noted a history of rejecting and hiding medications. Interviews with nursing staff and the Director of Nursing confirmed that facility policy prohibits leaving medications at the bedside, and staff stated they do not leave medications with residents. In another instance, an LPN was observed disposing of non-narcotic medications refused by a resident into a sharps container rather than the designated Drug Buster disposal system, as required by facility policy. The LPN acknowledged the error during an interview. The DON provided the facility's medication pass procedure, which specifies that all wasted, dropped, or discarded medications must be disposed of in the Drug Buster disposal system. These actions demonstrate a failure to ensure medications were administered and disposed of according to professional standards.
Failure to Provide Timely PRN Pain Medication for Muscle Spasms
Penalty
Summary
A resident with a history of stress fracture of the right ankle and stage 3 chronic kidney disease requested a PRN dose of tizanidine for muscle spasms during the morning medication pass. The nurse, concerned about the risk of falls due to the medication's potential to lower blood pressure, asked the resident to wait until after lunch. The resident, who was non-weight bearing and used a wheelchair, expressed confusion about the fall risk but reluctantly agreed to wait and instead requested and received Xanax. The nurse did not return after lunch to check on the resident or offer the tizanidine, and the resident later reported increased spasms and pain, with observable signs of discomfort. Record review showed that the resident did not receive any further doses of tizanidine that day, and there was no documentation that the nurse followed up regarding the resident's need for the medication. The facility's pain management policy required pain medication to be given based on pain intensity and for the nurse to monitor the efficacy of pain management. The DON confirmed that the nurse should have followed up with the resident to see if the tizanidine was still needed, but this did not occur.
Failure to Date Opened Medication Vial in Storage Room
Penalty
Summary
Surveyors observed that in one of two medication storage rooms reviewed, an opened vial of tuberculin solution was found in the refrigerator without a date indicating when it was opened. During interviews, both an LPN and the Director of Nurses confirmed that facility policy requires medications to be dated when opened, especially when the medication has a shortened expiration date after opening. The facility's Medication Storage and Expiration policy, provided by the DON, also specifies that staff should record the date opened on the primary medication container. The failure to date the opened tuberculin solution constituted a deficiency in proper medication labeling and storage practices as required by facility policy and professional standards.
Improper Placement of Wound Vac Leads to Deficiency
Penalty
Summary
The facility failed to ensure proper placement of a wound vacuum-assisted closure (vac) for a resident with a diabetic foot ulcer and other medical conditions, including acute osteomyelitis and type 2 diabetes. The resident's care plan required the use of a wound vac, and physician's orders specified the application and maintenance of the device. However, during a wound clinic visit, it was noted that the foam from the wound vac was improperly placed against the resident's skin, leading to maceration of the periwound area. The Medical Records Director acknowledged that the facility had all necessary supplies for the wound vac, although they were not the original brand, which concerned the resident's wife. The Director of Nursing Services (DNS) had placed the wound vac upon the resident's admission and was responsible for educating staff on its use. However, there was no specific documentation of education provided to the staff, and only one nurse was believed to have received training. The DNS checked the placement of the wound vac daily but was unsure if it had been placed improperly. The Executive Director was aware of the concerns regarding the supplies and the placement of the wound vac. The DNS re-educated a Licensed Practical Nurse (LPN) on proper placement following the concerns raised by the resident's wife, but this education was not documented. The facility's policy emphasized the importance of providing care consistent with professional standards to promote healing and prevent complications, but the improper placement of the wound vac foam led to a deficiency in the care provided to the resident.
Failure to Maintain Safe Hot Water Temperatures
Penalty
Summary
The facility failed to ensure hot water temperatures were maintained within a safe range for five residents. During random observations, the water temperatures in the public bathroom and residents' sinks were found to be excessively high, reaching up to 134.4 degrees Fahrenheit. Several residents reported that the water was too hot to hold their hands under without burning their skin. The Maintenance Supervisor, who had just started, confirmed the high temperatures but was initially unable to locate temperature logs or calibrate the thermometer correctly. The Administrator acknowledged the issue and indicated that the water heater had been recently replaced. Further investigation revealed that the facility did not have a policy related to monitoring water temperatures or temperature guidelines. The Maintenance Supervisor later discovered that there were three hot water heaters in the building, each serving different resident wings. Temperature logs for the period between 4/23/24 and 5/9/24 were missing, and it was unclear how long the temperatures had been running high. The Administrator confirmed that no one had been checking the water temperatures after the former Maintenance Supervisor left until the new one started.
Failure to Ensure Proper Food Handling and Hand Sanitization
Penalty
Summary
The facility failed to ensure proper food handling and hand sanitization during meal service, which had the potential to affect all 50 residents who ate meals from the kitchen. During a dining observation, a CNA and the Housekeeping Supervisor were seen placing the ice scoop back into the ice bucket after use, which is against the facility's policy. Additionally, another CNA used ice from a container meant only to keep drinks cold, not for consumption. The Dietary Manager confirmed that staff had been educated on proper procedures, but the issue persisted. In another observation, a CNA failed to sanitize her hands between assisting two residents with their meals and repositioning them. This was observed during the noon meal service in the restorative dining room. Another CNA also failed to sanitize her hands before delivering a meal tray to a resident. The facility's Hand Hygiene Policy clearly states that hand sanitization should occur before and after resident contact, as well as after touching any resident belongings or environmental surfaces. Despite this policy, proper hand hygiene was not followed during the observed meal service.
Failure to Ensure Resident Dignity During Assistance with Eating
Penalty
Summary
The facility failed to ensure that Resident 4 was treated with dignity during a dining observation. The Speech Language Pathologist (SLP) was observed standing while assisting Resident 4 with eating and drinking, rather than sitting down, which is considered a more respectful and dignified approach. Resident 4 has multiple diagnoses, including paraplegia, lack of coordination, muscle contracture, abnormal posture, and mild cognitive impairment, and requires assistance with activities of daily living, including eating. During interviews, the Director of Nursing (DON) and the SLP both indicated that the standard practice is to sit while assisting residents with eating. The DON expressed that she hoped staff would sit in a chair while assisting residents, and the SLP confirmed that she usually sits down next to residents during evaluations. The facility's policy on Resident Rights, updated in 2017, emphasizes the right of residents to be treated with respect and dignity, including reasonable accommodation of their needs and preferences.
Failure to Conduct Quarterly Care Plan Meetings and Implement Oxygen Care Plan
Penalty
Summary
The facility failed to ensure care plan meetings were conducted quarterly for Resident 7 and did not implement an oxygen care plan for Resident 15. Resident 7, who had moderate cognitive impairment, indicated he did not remember attending a care plan meeting. His record showed only two care plan meetings in the past year, despite the requirement for quarterly meetings. The Social Service Director and the Director of Nursing confirmed the lack of quarterly care plan meetings for Resident 7. Resident 15, who had diagnoses including hypoxemia, type 2 diabetes mellitus with hyperglycemia, and obstructive sleep apnea, was observed multiple times with his oxygen meter set incorrectly at 2 liters instead of the prescribed 3 liters. The resident's record lacked a care plan for oxygen use, and staff were unsure of the correct oxygen settings. The Director of Nursing confirmed the oxygen should be set at 3 liters per nasal cannula, and the facility's policy required a comprehensive care plan, which was not followed for Resident 15.
Improper Catheter Care and Placement
Penalty
Summary
The facility failed to ensure proper catheter care and placement for Resident 15, who was observed multiple times with his catheter bag in contact with the floor and other surfaces. On several occasions, the catheter bag was seen touching the floor, the wheel of the wheelchair, and the resident's shoes. The dignity bag, meant to cover the urinary drainage bag, was not fully covering it, making the urine visible. Despite the resident's actions of pulling on the tubing and placing the bag in his lap, the staff did not consistently ensure the catheter bag was properly secured and off the floor until an LPN intervened briefly. The resident's medical records indicated a need for an indwelling urinary catheter due to a bladder/prostate mass, with specific orders to store the collection bag inside a protective dignity pouch and to ensure the tubing or any part of the drainage system did not touch the floor. The facility's policies on catheter care, including the use of a securement device and proper placement of the drainage bag, were not adhered to, as evidenced by the repeated observations of improper catheter bag placement. The Director of Nursing confirmed that the catheter bag and tubing should not touch the floor, yet this standard was not maintained for Resident 15.
Deficiencies in Respiratory Care for Two Residents
Penalty
Summary
The facility failed to ensure proper respiratory care for two residents, leading to deficiencies in their treatment. Resident 15 was observed with a portable oxygen tank set at 2 liters per minute (LPM) instead of the prescribed 3 LPM. The resident reported not receiving any air, and a CNA removed the portable oxygen tank without placing the resident on an oxygen concentrator. The LPN was aware of the situation but did not immediately address it due to being busy with medication pass. The resident's medical record indicated a diagnosis of hypoxemia and other conditions requiring continuous oxygen at 3 LPM, but the care plan lacked documentation for oxygen use. Resident 8 was observed lying in bed with a nebulizer mask removed and placed on the bed. The LPN did not clean the medication chamber after the treatment and failed to assess the resident before or after the nebulizer treatment. The resident confirmed that nurses sometimes did not assess her lungs before or after treatments. The medical record for Resident 8 included diagnoses such as chronic obstructive pulmonary disease and pulmonary hypertension, with physician orders for regular nebulizer treatments and oxygen at 5 LPM. The care plan indicated the resident received continual oxygen and nebulizer treatments as ordered. The facility's policies for oxygen concentrators and nebulizer treatments were not followed. The oxygen concentrator policy required verification of the physician's order and adjustment of the flow meter to the prescribed setting. The nebulizer policy required the nurse to stay with the resident during the entire medication administration and to clean and dry the nebulizer equipment properly. These procedures were not adhered to, leading to deficiencies in the respiratory care provided to the residents.
Failure to Provide Necessary Mental Health Services
Penalty
Summary
The facility failed to provide necessary mental health services to Resident 48, who exhibited significant behavioral health issues. On 5/09/24, during an observation and interview, Resident 48 was found to be very confused, crying, and expressing a desire to leave the facility. The staff indicated that the resident was an elopement risk and had been trying to leave the facility. The resident's medical record, reviewed on 5/14/24, included diagnoses of severe dementia with behavioral disturbances, depression, and a psychotic disorder with delusions. Despite these diagnoses, the resident's care plan and physician orders did not adequately address her behavioral health needs, and there was a lack of documentation regarding consultation with the family about psychiatric services. The Social Services Director acknowledged the need for psychiatric services but noted that the family was reluctant to allow these services, and there was no documentation of discussions with the family about this issue. The facility's policy on behavioral health, provided by the Director of Nursing, indicated that residents should be assessed for behavioral health needs and referred to behavioral health providers when necessary. However, the facility did not follow this policy for Resident 48, as evidenced by the lack of timely psychiatric consultation and inadequate documentation of family discussions. The resident's medical record showed several entries of behaviors including agitation and exit-seeking, yet the quarterly Minimum Data Set (MDS) assessment did not reflect any behavioral symptoms during the look-back period. This discrepancy further highlights the facility's failure to provide appropriate mental health services to Resident 48, leading to the deficiency noted in the report.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure a medication error rate of less than 5%, resulting in an observed error rate of 6.45%. One incident involved an LPN administering Creon to a resident with chronic pancreatitis by touching the capsule with an ungloved finger, which is against the facility's medication administration policy. The Director of Nursing confirmed that medications should not be administered if touched by bare hands, and the facility's policy documents corroborated this procedure requirement. Another incident involved an LPN administering 3 units of insulin lispro to a resident with type 2 diabetes and hyperosmolarity. The insulin was administered at 11:10 a.m., but the resident did not receive their lunch meal until 11:52 a.m., which is beyond the 15-minute window recommended by the manufacturer's guidelines for fast-acting insulin. The Director of Nursing confirmed that residents receiving fast-acting insulin should get their meal within 15 minutes of administration. These actions led to a medication error rate exceeding the acceptable threshold.
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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