Woodland Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Elkhart, Indiana.
- Location
- 343 S Nappanee St, Elkhart, Indiana 46514
- CMS Provider Number
- 155086
- Inspections on file
- 38
- Latest survey
- November 21, 2025
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Woodland Manor during CMS and state inspections, most recent first.
A resident with depression, ADHD, and hemiplegia experienced anxiety and inconsistent care related to colostomy management, with staff failing to consistently perform and document required colostomy care. The care plans did not address the resident's repeated removal of the colostomy bag or related behaviors, and there was a lack of communication with the physician regarding severe depression and colostomy issues. Staff interviews and observations confirmed gaps in care, documentation, and behavioral interventions.
A resident with severe cognitive and physical impairments did not receive scheduled showers as outlined in their care plan, with documentation missing for multiple dates and no record of refusals. Observation noted poor hygiene, and facility staff could not provide further documentation to account for the missed care, resulting in a deficiency related to ADL support.
A resident with diabetes and acute kidney failure experienced blood sugar readings below the physician-ordered threshold for notification. Despite orders to notify the physician for readings under 70 mg/dL, staff did not document or communicate these low values, as confirmed by interviews and facility policy.
Two residents requiring respiratory care were found with improperly stored and undated respiratory equipment, including oxygen tubing, humidification bottles, and masks. Equipment was observed on the floor, in drawers, and visibly soiled, without use of required storage bags or proper dating. Staff interviews and facility policy confirmed that these practices did not meet infection control standards.
Surveyors found that medication carts contained unlabeled, undated, and loose medications, including items for discharged residents and medications without resident identifiers. Staff confirmed that these practices did not meet facility policy, which requires medications to be properly labeled, dated, and stored in a clean and secure manner.
The facility did not ensure residents received their mail on Saturdays, as reported by all residents attending a group meeting. Mail was only distributed Monday through Friday by the receptionist, with no clear process or designated staff for Saturday delivery. Observations confirmed mail accumulated over the weekend, and facility policy lacked guidance for Saturday mail distribution.
Three residents experienced neglect and lack of abuse prevention interventions, including a resident left in soiled clothing and bedding without timely incontinent care, another resident without a required stop sign at the doorway to prevent inappropriate entry, and a third resident with incomplete documentation and supervision following an incident. Staff interviews and observations confirmed failures to follow care plans and required interventions.
Two residents developed advanced pressure injuries due to the facility's failure to consistently perform and document weekly skin assessments, follow physician orders for wound care, and respond promptly to reported symptoms. Staff interviews and record reviews revealed lapses in monitoring, documentation, and adherence to the facility's own skin management policy, resulting in a stage 3 pressure ulcer and unstageable wounds.
The facility did not provide enough nursing staff to meet residents' needs, resulting in two residents experiencing delays and omissions in care, including one who was left soiled and another whose call light was not answered promptly. Staff were observed working over 20 consecutive hours due to inadequate coverage, and the staff-to-resident ratio was significantly below the facility's own standards, directly impacting care delivery.
A resident who was dependent on staff for mobility and hygiene experienced repeated delays in receiving assistance, including waiting up to two hours after a bowel movement before care was provided. The resident's call light was not consistently left within reach, leading her to use her cell phone to request help. These delays resulted in the resident remaining in soiled conditions, causing discomfort and embarrassment, and were confirmed by grievance records and staff interviews.
Staff did not wear required gowns while providing peri-care to a resident with an indwelling urinary catheter on Enhanced Barrier Precautions, despite clear signage and care plan instructions. Both staff members were unaware of the resident's EBP status, even though they had previously received education on EBP protocols.
The facility failed to maintain a sanitary environment, with a strong urine odor in a resident's room due to a urine-soaked mattress that was not documented as offered for replacement. Additionally, maintenance issues such as gouges, unpainted spackle, and dirt on ceilings and walls were observed, with the facility lacking a formal policy for building maintenance.
The facility failed to maintain an effective Pest Control Program, leading to a fruit fly infestation affecting all residents. Observations revealed fruit flies in multiple rooms, and residents reported the issue persisting for over three months. The facility lacked documentation of pest control treatments, and invoices provided were incomplete.
The facility failed to notify physicians of critical changes in resident conditions, including high blood glucose levels for two residents using insulin, burns and a fall for another resident, and a significant change in condition for a resident with low oxygen saturation. These incidents were not communicated in a timely manner, contrary to the facility's policy.
The facility failed to provide transfer/discharge forms and notify the Ombudsman for four residents hospitalized. A resident with cerebral palsy and others with conditions like COPD and heart failure were transferred without necessary documentation. Interviews revealed that the checklist for transfers was not followed, and no forms were found for these residents, indicating a systemic issue.
The facility failed to provide bed hold forms for four residents transferred to the hospital or on therapeutic leave. Despite having a checklist for transfers, the necessary documentation was not completed, as confirmed by the Quality Assurance Administrator and LPNs. The residents involved had various medical conditions, including COPD, congestive heart failure, and cerebral palsy.
A facility failed to maintain a safe environment by not replacing a melted PTAC unit in a resident's room, which had been in use for months despite being a potential hazard. Additionally, the facility did not implement necessary interventions to prevent burns for a resident with physical impairments, resulting in the resident suffering burns from spilled hot coffee. The facility lacked a specific policy for providing a safe environment and did not conduct a timely Hot Liquid Safety Evaluation for the resident.
The facility failed to label over-the-counter medications with resident information and did not maintain proper temperatures for a medication refrigerator. An LPN could not identify the owner of unlabeled medications, and the refrigerator's temperature was consistently below the acceptable range, affecting stored medications.
The facility failed to maintain a sanitary pantry on the 400 unit, affecting 18 residents. Observations revealed a dirty microwave and a stained blanket used to catch water from a leaking sink. The Dietary Director acknowledged the issues, and the Executive Director had informed maintenance about the leak. The facility lacked a specific pantry maintenance policy.
A facility failed to document and follow procedures for hospital transfers of a resident with multiple diagnoses, including Cerebral Palsy. The resident was transferred without necessary physician's orders or documentation, such as transfer/discharge forms and bed hold policies. Interviews with LPNs revealed a checklist existed but was not followed, and the Quality Assurance Administrator confirmed the lack of documentation.
The facility failed to develop comprehensive person-centered care plans for two residents. One resident, with Alzheimer's and other conditions, lacked a care plan for activity preferences, despite being non-responsive and resistant to activities. Another resident, receiving antipsychotic and antidepressant medications, had no care plans for medication use. The facility's policy on care plans was not followed, leading to these deficiencies.
A facility failed to provide a resident with activities tailored to their interests and well-being, as there was no care plan addressing the resident's activity preferences. The resident, diagnosed with Alzheimer's and other conditions, was observed not participating in scheduled activities and was non-responsive to staff encouragement. Interviews revealed a lack of comprehensive activity assessment and individualized care planning.
A resident with congestive heart failure continued to receive extra fluids beyond the prescribed duration, leading to bilateral lower extremity edema and the need for diuretic medication. Despite the resident's heart condition, the additional fluids were not discontinued, contributing to fluid overload symptoms.
A resident with impaired vision and multiple health conditions did not receive necessary optometry follow-up care. Despite a physician's order for optometry visits as needed, there was no record of the resident being seen by an optometrist since admission. The Social Services Director confirmed the lack of documentation and acknowledged the requirement for biennial optometry visits under Medicare regulations.
The facility failed to provide physician-ordered medications to three residents, resulting in multiple missed doses. A resident with various diagnoses did not receive several medications over different months, with no documentation explaining the omissions. Another resident reported not receiving pain medication for a month, with notes indicating the medication was often unavailable. A third resident missed doses of Jardiance, with staff failing to contact the pharmacy or physician for alternatives. The facility's policy on emergency pharmacy service was not effectively followed.
A CNA failed to follow infection control practices during catheter care for a resident. The CNA did not change gloves or wash hands after cleaning feces and before handling clean items and repositioning the resident. The facility's policy on perineal care, which mandates glove removal and handwashing, was not adhered to.
A facility failed to provide a timely pneumococcal vaccination to a resident with multiple health conditions, despite the resident's consent and the Power of Attorney's verbal consent. The resident had previously received the Prevnar 13 vaccine, and CDC guidelines recommend a subsequent pneumococcal vaccine at least one year later. The facility's policy required offering the vaccine unless contraindicated, but this was not followed.
A facility failed to administer a consented COVID-19 booster to a resident with moderate cognitive impairment and multiple health conditions. Despite consent being given upon admission, there was no documentation of the vaccine being administered. The DON was unsure why the resident had not received the vaccination, and the facility could not provide a COVID-19 vaccination policy.
A facility failed to ensure proper dialysis care and monitoring for a resident with End Stage Renal Disease. The resident's care plan required pre- and post-dialysis assessments and regular monitoring of the fistula access site, but these were not documented or conducted. The resident confirmed that staff did not check her fistula after treatments, and the DON admitted the oversight, acknowledging that nurses should have been performing these assessments.
A resident in the Memory Care Unit, who was severely cognitively impaired, experienced a blocked airway after ingesting debris from an incontinence brief. The unit was understaffed, with only one nurse present after a CNA left. The nurse found the resident unresponsive with a white substance in his mouth, leading to an emergency medical response. The facility's staffing policy was not followed, contributing to the incident.
A resident with a traumatic brain injury and cognitive deficits was inadequately supervised during a transport to a physician's office, resulting in the resident leaving the office unnoticed. The van driver, unfamiliar with the resident, left him with the receptionist while parking the van. The resident exited through an alternate door and was not located until several days later. The facility's elopement policy was not effectively followed, and the resident's elopement risk was underestimated.
The facility failed to sanitize a shared glucometer between uses, did not maintain proper catheter care, allowed a resident to retrieve ice with bare hands, and observed poor hand hygiene and glove use by staff. Additionally, a resident's BiPAP mask and tubing were found on the floor and visibly dirty.
The facility failed to ensure food was stored, prepared, served, and delivered in a sanitary manner, affecting all 67 residents. Observations included undated and opened food items, dirty kitchen equipment, improper handling of dinner plates by an LPN, and an uncovered meal tray carried by a QMA. The Dietary Manager confirmed the need for proper dating, discarding, and cleaning practices.
The facility failed to maintain an effective pest control program, as evidenced by the presence of gnats in residents' rooms and common areas. A resident expressed concerns about the gnats and mentioned having complained to the staff. The pest control invoice indicated that the last service was conducted a month prior, and the Director of Housekeeping confirmed the absence of a policy regarding environmental cleaning.
The facility failed to ensure staff spoke to residents respectfully and provided personal dignity. A dietary worker yelled at a resident about telling surveyors the food was cold, and another resident's catheter bag was visibly hanging on the bed frame, which could be seen from the hallway. The facility's policies on respect and dignity were not adhered to in these instances.
The facility failed to develop person-centered care plans for two residents with behavioral issues. One resident, with multiple psychiatric diagnoses, exhibited increased behaviors and confusion, leading to a psychiatric hospital admission. Another resident, diagnosed with dementia and PTSD, exhibited yelling behavior and excessive call light use. Both care plans lacked specific, person-centered interventions for these behaviors.
The facility failed to provide routine care plan meetings for a resident, as required by their policy. The resident indicated he did not have routine care plan meetings, and records showed care plan meetings on three occasions. The Social Service Director confirmed that care conferences should be held quarterly, indicating the resident should have had more frequent meetings.
The facility failed to provide scheduled showers at least twice weekly for three residents, leading to inadequate hygiene and care. Residents with various medical conditions missed multiple scheduled showers, and the Director of Nursing confirmed the deficiencies.
The facility failed to prevent urinary tract infections for a resident with a urinary catheter, as the drainage bag was frequently observed dragging on the floor. Despite the resident's care plan and facility policy requiring the bag to be kept off the floor, staff did not adhere to these protocols.
The facility failed to assess the use of a side rail before maintaining it in the upright position for a resident. The resident, who had multiple diagnoses and was at risk for falls, indicated he had a fall and was supposed to use the siderail to get up. The Director of Nursing confirmed that no side rail assessment was completed prior to the intervention, violating the facility's policy.
The facility failed to post the daily nursing staffing information at the beginning of the shift. The nursing staff posting was observed to be outdated, and the DON confirmed that the night shift is responsible for posting the information by midnight. The facility's policy requires daily posting of nursing personnel numbers for each shift.
The facility failed to ensure narcotics were counted and documented every shift for one of two narcotic count log books reviewed. An observation revealed 30 missing signatures in the narcotic log book over a one-month period. An LPN confirmed the requirement for shift-based documentation, and the DON provided the policy mandating end-of-shift counts by both incoming and outgoing nurses.
Failure to Address Colostomy-Related Behaviors and Mental Health Needs
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident diagnosed with mental disorders and psychosocial adjustment difficulties, specifically related to colostomy care and associated behaviors. The resident, who had diagnoses including depression, ADHD, and hemiplegia, was observed with a colostomy bag that was improperly positioned and ballooning. The resident reported that staff only emptied the colostomy bag when prompted and that he often managed the bag himself, which caused him anxiety. Despite physician orders for staff to perform colostomy care every shift and as needed, documentation showed inconsistent completion of these tasks, and staff interviews confirmed that the resident sometimes removed the colostomy bag and flange without notifying staff. Care plan reviews revealed that while the resident's depression and psychosocial well-being were addressed, there were no specific interventions related to the resident's colostomy behaviors or ADHD diagnosis. The care plans did not address the resident's repeated removal of the colostomy bag or provide strategies to manage these behaviors. Additionally, there was a lack of documentation regarding staff reminders to the resident about not unsealing the colostomy and no evidence of education provided to the resident about proper colostomy care or behavior management. Further, staff failed to notify the physician of the resident's severe depression score and did not document or communicate the resident's colostomy-related behaviors to the physician or in progress notes. Observations and interviews indicated that the resident's actions, such as emptying the colostomy bag on the facility floor, were not adequately addressed in care planning or staff interventions. The facility was unable to provide policies regarding behavior identification and tracking when requested.
Failure to Provide Scheduled Showers and ADL Support
Penalty
Summary
A deficiency was identified when a resident with quadriplegia, epilepsy, blindness, arthritis, and non-Alzheimer's dementia, who required extensive assistance from two staff members for activities of daily living (ADLs), did not receive showers as scheduled. Observation revealed the resident had a large amount of facial hair on her chin and brown substance under her fingernails. The resident's care plan specified a preference for showers on Monday and Thursday evenings with staff assistance, and the shower schedule confirmed these days. However, documentation showed that showers were not provided on several scheduled dates in March and April, and there was no record of the resident refusing showers during this period. Review of the facility's ADL policy indicated that residents unable to perform ADLs independently should receive necessary services to maintain hygiene, including bathing, in accordance with their care plan. The Director of Nursing was unable to provide additional documentation to account for the missed showers, and the Quality Assurance Administrator confirmed the policy in use. The lack of documentation for both the provision of showers and any refusals constituted a failure to provide the required ADL care as outlined in the resident's care plan.
Failure to Notify Physician of Abnormal Blood Sugar Readings
Penalty
Summary
A deficiency occurred when the facility failed to notify the physician of abnormal blood sugar readings for a resident with diabetes mellitus type 2, diabetes with polyneuropathy, and acute kidney failure. The resident, who was cognitively intact and receiving insulin injections, had physician orders specifying that the physician should be notified for blood sugar readings below 70 mg/dL or above 400 mg/dL. Despite this, blood sugar readings of 60 mg/dL and 59 mg/dL were documented, and there was no evidence that the physician had been notified as required by the orders. Interviews with staff confirmed that the physician should have been notified of these low blood sugar readings, and facility policy required nursing staff to contact the physician based on the urgency of the situation. The lack of documentation and notification was acknowledged by both the LPN and the Assistant Director of Nursing, indicating a failure to follow established protocols for monitoring and responding to acute changes in the resident's condition.
Failure to Maintain Sanitary Storage and Handling of Respiratory Equipment
Penalty
Summary
The facility failed to maintain respiratory equipment in a sanitary manner for two residents who required respiratory care. For one resident with severe cognitive impairment and multiple diagnoses including quadriplegia and non-Alzheimer's dementia, observations revealed that the oxygen concentrator humidification bottle was not changed or dated according to physician orders, remaining dated from nearly a month prior and not attached to the concentrator. The nasal cannula tubing was also not dated as required. These deficiencies were observed on multiple occasions, and staff confirmed that the equipment should have been changed, dated, and properly connected. For another resident with chronic respiratory conditions such as COPD and chronic bronchitis, multiple pieces of respiratory equipment, including a portable oxygen tank, oxygen concentrator, nebulizer, and BiPap machine, were found improperly stored. The portable oxygen tank and its nasal cannula were observed on the floor, and the oxygen concentrator tubing was found in a bedside table drawer. The nebulizer mask was visibly soiled and stored in the same drawer, while the BiPap mask was left upright against the wall. There were no respiratory storage bags present for any of the equipment, and the nasal cannulas and masks were not dated as required by facility policy. Interviews with staff confirmed that respiratory equipment should be stored on clean surfaces and in designated respiratory bags when not in use. Facility policy also required that such equipment be dated and stored in plastic bags between uses to prevent infection. The failure to follow these procedures was directly observed and documented by surveyors during the review period.
Medication Storage and Labeling Deficiencies Identified
Penalty
Summary
Surveyors observed multiple deficiencies in medication storage and labeling practices during reviews of two medication carts. On one cart, there was an unopened tube of glucose for a discharged resident, an opened and undated bottle of Milk of Magnesia, an opened bottle of antacid tablets without a resident label, fourteen loose pills, and an opened package of Albuterol inhalation vials with no resident identifier. Additionally, an overflow medication cart contained an unopened box of Omeprazole tablets with no resident identifiers. During interviews, staff confirmed that medications should have been labeled and dated when opened, and that loose pills should not have been present in the carts. A separate observation on the Memory Care Unit revealed four loose pills in the drawers of another medication cart. Staff interviewed at the time acknowledged that loose pills should not be in the cart. The facility's policy on medication labeling and storage, as provided by the Quality Assurance Administrator, requires nursing staff to maintain medication storage areas in a clean, safe, and sanitary manner, and to ensure medications are properly labeled in accordance with federal and state requirements. The observed failures to label, date, and properly store medications directly contravened these established policies.
Failure to Provide Saturday Mail Delivery to Residents
Penalty
Summary
The facility failed to provide mail delivery to residents on Saturdays, affecting all 10 residents who participated in the resident/surveyor group meeting. During the meeting, residents reported that mail was not delivered to them on Saturdays, and one resident who typically delivers mail during the week confirmed she never delivers mail on Saturdays. Observations showed a large accumulation of mail in the outside mailbox on a Monday morning, suggesting mail was not distributed over the weekend. The Business Office Manager stated that mail is delivered to the receptionist Monday through Friday, who then separates and distributes it, but was unsure who, if anyone, retrieved or delivered mail on Saturdays. Occasionally, activity staff might collect the mail, but there was no consistent process. The facility's policy did not specify procedures for providing residents with their personal mail on Saturdays.
Failure to Prevent Neglect and Incomplete Implementation of Abuse Prevention Interventions
Penalty
Summary
The facility failed to protect residents from neglect and did not implement or maintain interventions to prevent abuse and neglect for three residents. One resident was found extensively incontinent of urine and feces, with soiled clothing, bedding, and a saturated brief, and had not received incontinent care for an undetermined period. The resident reported not being changed since the previous day, and staff interviews confirmed that care had not been provided overnight. The resident's care plan required regular toileting and assistance, but documentation showed the last care was provided the evening before the observation. Staff also reported inadequate staffing and failure to check on the resident as required. For another resident, the facility did not maintain a required stop sign across the doorway, an intervention put in place to prevent another resident from entering the room after a prior incident. Observations on multiple occasions confirmed the absence of the stop sign, and staff interviews revealed that documentation of the stop sign being in place was inaccurate. The care plan and interdisciplinary team notes specified the need for this intervention, but it was not consistently implemented or documented. A third resident, who was at risk for emotional distress after being found partially clothed in another resident's room, was to be placed on one-on-one supervision and 30-minute checks. However, documentation of these checks was incomplete or missing for several periods, and observations showed the resident wandering the unit unsupervised. The facility's own abuse policy required protection and supervision to prevent neglect and abuse, but these measures were not reliably carried out for the residents involved.
Failure to Prevent and Identify Pressure Ulcers
Penalty
Summary
The facility failed to prevent and promptly identify pressure injuries in two residents, resulting in the development of a stage 3 pressure ulcer in one resident and unstageable wounds in another. For the first resident, who had multiple risk factors including diabetes, malnutrition, and limited mobility, care plans were in place to address skin integrity and ADL needs. However, documentation showed that weekly skin assessments were either incomplete or failed to identify developing wounds. Physician orders for wound care were not consistently documented as completed, and there were significant gaps in nursing skin evaluations. The resident's pressure ulcer was only identified after it had progressed to stage 3, with evidence that the wound had been present for over two weeks before being documented. For the second resident, who was also at risk for pressure injuries due to malnutrition and muscle weakness, weekly skin reviews were not consistently performed after a certain date. The resident reported pain in the feet and heels, and redness was observed, but there was no follow-up documentation or physician response until several weeks later. When wounds were finally assessed, the resident was found to have unstageable pressure injuries with necrosis on the left heel and plantar foot, as well as a necrotic area on the left great toe. The lack of timely skin assessments and delayed response to reported symptoms contributed to the progression of these wounds. Interviews with facility staff revealed that skin assessments were expected to be completed weekly and that CNAs were responsible for reporting abnormalities. However, documentation did not reflect that these processes were consistently followed. The facility's own policy required ongoing weekly evaluations and documentation of residents' skin, but this was not adhered to for the residents in question. The absence of a specific policy on pressure injury prevention was also noted during the survey.
Insufficient Staffing Leads to Delayed and Missed Resident Care
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the needs of all residents, resulting in delays and omissions in care. On one occasion, a resident was observed to be visibly soiled with urine and bowel movement, saturating their pull-up, bed pad, linens, and blanket, despite being on a scheduled toileting program. Documentation confirmed that the resident had not been toileted as scheduled. Another resident did not have their call light answered in a timely manner, resulting in unmet care needs. Staff interviews confirmed that with only two CNAs assigned to two units with 39 residents, essential care tasks such as showers could not be completed, and this staffing shortage was a recurring issue. Additionally, the facility failed to prevent staff from working excessive hours, as a QMA and an LPN were observed working over 20 consecutive hours due to staff call-offs and lack of replacements. The facility's own assessment indicated a required direct care staff-to-resident ratio of 1:6, but on the day in question, the observed ratio was 1:13. The Quality Assurance Director acknowledged ongoing staffing challenges, including recent absences of key administrative staff and difficulties in finding replacements for call-offs. These staffing deficiencies directly impacted the timely provision of care and the ability to meet residents' needs.
Delayed Response to Call Light and Inadequate Timely Care Compromises Resident Dignity
Penalty
Summary
A resident with diagnoses including cerebral palsy, chronic obstructive pyelonephritis, and morbid severe obesity, who was cognitively intact but required substantial to maximal assistance for bed mobility, toileting, and was dependent for transfers, experienced significant delays in receiving care. The resident was always incontinent of bowel and bladder and required extensive assistance from two staff members for personal hygiene and mobility. On multiple occasions, the resident had to wait extended periods for assistance, including an incident where she waited approximately two hours after a bowel movement before care was provided, resulting in her lying in soiled conditions with associated discomfort and embarrassment. The resident also reported that her call light was not consistently left within reach, necessitating the use of her cell phone to contact staff for help. Grievance records confirmed that the resident had previously waited up to four hours for care, and interviews with staff indicated that on at least one occasion, the charge nurse was aware of the resident's need but was unable to ensure timely care due to other responsibilities. The resident reported repeated instances of waiting longer than 30 minutes for assistance and described feeling undignified and uncomfortable as a result. Facility policy required appropriate assistance with activities of daily living, including hygiene, for residents unable to perform these tasks independently.
Failure to Follow Enhanced Barrier Precautions During Resident Care
Penalty
Summary
Facility staff failed to follow infection control procedures for a resident on Enhanced Barrier Precautions (EBP). During an early morning observation, a CNA and a QMA provided peri-care to a resident with an indwelling urinary catheter. Both staff members donned gloves but did not wear gowns, despite a sign posted outside the resident's room indicating EBP status. Interviews with both staff revealed they were unaware the resident was on EBP, even though the sign was present and the resident had a urinary catheter. Record review showed the resident had significant medical conditions, including hemiparesis, hemiplegia, hydronephrosis with ureteral stricture, chronic obstructive uropathy, and vascular dementia. The resident was severely cognitively impaired, dependent for toileting, and required substantial assistance with bed mobility. Physician orders and the care plan both specified that staff should wear gowns and gloves for personal hygiene and catheter care under EBP. Despite prior education on EBP, staff did not adhere to these requirements during care.
Sanitation and Maintenance Deficiencies in Facility
Penalty
Summary
The facility failed to maintain a sanitary environment, as evidenced by several observations and interviews. A strong smell of urine was detected in a resident's room due to a urine-soaked mattress that the resident brought upon admission. Despite conversations about replacing the mattress, the resident refused, and there was no documentation of the offer until the day of the survey. The cleaning checklists provided by the Director of Housekeeping did not include cleaning resident mattresses, contributing to the persistent odor issue. Additionally, the facility had issues with maintenance and cleanliness in several rooms and hallways. Observations revealed gouges, unpainted spackle, and dirt on ceilings and walls in multiple rooms, which the Maintenance Director was either unaware of or had not yet addressed. The facility lacked a formal policy for maintaining the building and environment, relying instead on a document titled 'Physical Plant Standards.' The Maintenance Director was unable to provide a list of tasks submitted through the TELS system or a list of current tasks, indicating a lack of organized maintenance oversight.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective Pest Control Program, resulting in an infestation of fruit flies that had the potential to affect all 68 residents. Observations on multiple occasions revealed the presence of fruit flies in several rooms, including rooms 110, 111, 112, 114, 118, 120, 229, 402, and 406, as well as a clean utility room behind Nurse's Station 1. During a Resident Council Meeting, several residents reported that fruit flies had been a persistent problem for three months or longer. A review of the Pest Control binder showed no documentation of pest control visits or treatments related to fruit flies in the last three months. The Executive Director (ED) provided an invoice from a Pest Control company dated 11/13/2024, which indicated an inspection of the 100 Hall for fruit flies but did not include treatment for other areas. During an environmental tour, fruit flies were observed in additional rooms not covered by the invoice. The Maintenance Director (MD) claimed regular treatments were being received, but no invoices were available to confirm this, except for the one dated 11/13/2024. The ED mentioned difficulties in obtaining invoices from the Pest Control company, and a representative from the company promised to email any invoices from the last six months, but none were received before the survey exit. The ED later provided three documents identified as invoices, but they lacked details about the Pest Control company or services received.
Failure to Notify Physicians of Critical Changes in Resident Conditions
Penalty
Summary
The facility failed to notify the physician in a timely manner regarding changes in blood glucose levels for two residents using insulin. Resident 30 had multiple instances of blood glucose readings exceeding 400 mg/dL, yet there was no documentation indicating that the physician was notified as required by the care plan. Additionally, there were missed insulin doses for Resident 30 that were not communicated to the physician. Similarly, Resident M had several blood glucose readings above the ordered parameters, but the medical record lacked documentation of physician notification. In another case, Resident 12 experienced burns on her thighs from spilled coffee, which were not immediately reported to the physician or nurse practitioner. The burns were assessed and treated only after a delay, and there was no documentation of timely notification. Furthermore, Resident 12 had an incident where she was wedged between furniture, leading to a fall and subsequent arm pain. The nurse practitioner was not notified of the arm pain until days later, resulting in a delayed x-ray and diagnosis of a fracture. For Resident H, the facility failed to promptly notify the nurse practitioner of a significant change in condition. Resident H was found with low oxygen saturation and confusion, yet the nurse practitioner was not contacted until several hours later. This delay in communication could have impacted the resident's care. The facility's policy requires immediate notification of physicians for changes in condition, but this was not adhered to in these cases.
Failure to Provide Transfer/Discharge Forms and Notify Ombudsman
Penalty
Summary
The facility failed to provide transfer/discharge forms and notify the Ombudsman for four residents who were hospitalized. Resident B, diagnosed with cerebral palsy and other conditions, was transferred multiple times to the hospital without the necessary documentation or notification to the Ombudsman. Interviews with LPNs and the Quality Assurance Administrator revealed that the checklist for transfers was not followed, and no transfer/discharge forms were found for Resident B. Resident 52, who was cognitively intact and had conditions such as COPD and pneumonia, requested hospital transfers on several occasions. However, the facility did not have any transfer forms documented for these events. The Quality Assurance Administrator confirmed the absence of these forms after reviewing un-scanned medical records. Resident 55, with diagnoses including congestive heart failure, and Resident 69, with chronic pancreatitis and other conditions, were also transferred to the hospital without the required documentation. The Quality Assurance Administrator was unable to locate any transfer/discharge forms for these residents, indicating a systemic issue in the facility's process for handling hospital transfers.
Failure to Provide Bed Hold Forms for Hospital Transfers
Penalty
Summary
The facility failed to provide a bed hold form for four residents who were transferred to the hospital or went on therapeutic leave. The deficiency was identified through record reviews and interviews with facility staff. The records for Residents 52, 55, 69, and B lacked documentation that a bed hold policy was provided to the residents or their representatives. This omission was confirmed by the Quality Assurance Administrator, who was unable to locate the necessary forms despite reviewing un-scanned medical records. Resident 52, who had diagnoses including COPD, pneumonia, and acute respiratory failure, was transferred to the hospital multiple times without receiving a bed hold form. Similarly, Resident 55, with diagnoses of congestive heart failure and pneumonia, was readmitted to the facility after a hospital stay without documentation of a bed hold policy being provided. Resident 69, who had chronic pancreatitis, atrial fibrillation, and acute cholecystitis, was also transferred to the hospital without a bed hold form being completed. Resident B, diagnosed with cerebral palsy and other conditions, experienced multiple transfers to the hospital and a leave of absence for surgery, all without receiving a bed hold form. Interviews with LPNs revealed that there was a checklist for transfers that included the bed hold form, but it was not completed. The facility's policy required written notification of the bed hold policy before transferring a resident, but this was not adhered to in these cases.
Facility Fails to Address Safety Hazards and Burn Prevention
Penalty
Summary
The facility failed to maintain a safe environment free from potential hazards in one of its halls, as evidenced by a melted packaged terminal air conditioner (PTAC) unit in a resident's room. The PTAC unit, which was used for heating, had been melted for at least five months due to excessive heat when a resident's comforter was placed in front of it. Despite being aware of the issue, the maintenance department did not replace the unit, and it continued to be used. Interviews with staff and residents revealed that the maintenance department was informed of the issue, but no action was taken to address it. Additionally, the facility failed to implement necessary interventions to prevent burns for a resident with a history of spills and physical impairments. The resident, who had hemiplegia and contractures, suffered burns on her inner thighs after spilling hot coffee while transporting it in her wheelchair. The facility did not conduct a Hot Liquid Safety Evaluation for the resident until after the incident, and there was no care plan in place to address the resident's risk of burns prior to the incident. The resident's care plan was only updated after the incident to include interventions such as using cups with lids and staff assistance for transporting hot liquids. The facility lacked a specific policy related to providing a safe environment, relying instead on a general document titled 'Physical Plant Standards.' The Director of Nursing indicated that the admission nursing assessment included questions about cognitive and functional limb abilities to determine burn risk, but this assessment did not prevent the incident. The facility's failure to address the melted PTAC unit and implement timely interventions for the resident's burn risk contributed to the deficiencies identified in the report.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to properly label over-the-counter medications stored in a medication cart on the 400 Unit. During an observation, an opened bottle of Tylenol and an open bottle of melatonin were found without any resident identifying information. An LPN was unable to identify the owner of these medications and acknowledged that over-the-counter medications should be labeled with the resident's name and room number. The Director of Nursing confirmed that all medications should be labeled with the resident's name, prescriber name, and dosage information. Additionally, the facility did not maintain proper temperatures for a medication refrigerator at Nurses Station 1. The refrigerator was observed to have a temperature of 32 degrees Fahrenheit, which is below the acceptable range of 36 to 46 degrees Fahrenheit as per the facility's policy. The refrigerator contained various medications, including insulin and lorazepam. The temperature log showed out-of-range temperatures for several consecutive days. An LPN responsible for checking the refrigerator's temperature initially believed the temperature was appropriate but later acknowledged it was out of range after reviewing the acceptable parameters.
Sanitation Deficiency in Unit Pantry
Penalty
Summary
The facility failed to maintain one of two unit pantries in a sanitary manner, potentially affecting all 18 residents on the 400 unit. During an observation with the Dietary Director (DD) and the Executive Director (ED), a microwave with dried food splatter inside and a wet white blanket with black and brown stains under the sink were noted. The DD acknowledged the microwave was dirty and needed cleaning, and mentioned the blanket was used to catch water from a leaking sink, but could not recall when it was last changed. The ED stated the blanket should not be used for this purpose and had already informed maintenance about the leak. The facility lacked a specific policy for pantry maintenance, relying instead on a general document titled 'Physical Plant Standards,' which did not address pantry sanitation or equipment upkeep.
Failure to Document and Follow Procedures for Resident Hospital Transfers
Penalty
Summary
The facility failed to ensure proper documentation and procedures were followed for the transfer of a resident, identified as Resident B, to a hospital. Resident B, who had diagnoses including Cerebral Palsy, hydronephrosis, urogenital implants, and obstructive and reflux uropathy, was transferred to the hospital on multiple occasions without the necessary physician's orders or documentation. Specifically, on two occasions, there was no physician's order obtained prior to the transfer, and no transfer/discharge form or bed hold policy was provided to the resident or their representative. Interviews with LPNs revealed that there was a checklist in place for hospital transfers, which included obtaining a physician's order, completing a transfer/discharge form, and providing a bed hold policy. However, these procedures were not followed in the case of Resident B. The Quality Assurance Administrator confirmed the lack of documentation for the required transfer/discharge forms for Resident B, indicating a failure in the facility's process for managing hospital transfers.
Deficiencies in Person-Centered Care Plans for Two Residents
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for two residents, leading to deficiencies in addressing their specific needs. Resident 54, diagnosed with Alzheimer's disease, dementia, anxiety, depression, and other conditions, was observed to have no person-centered care plan for activity preferences. Despite having short and long-term memory issues and receiving hospice services, the resident's care plan did not reflect their activity preferences, as evidenced by their non-responsiveness and resistance to participate in activities. Interviews with the Activities Director and Social Services Director confirmed that activity care plans should be completed upon admission and quarterly, yet Resident 54's care plan lacked this crucial component. Similarly, Resident E, diagnosed with encephalopathy, diabetes, anxiety, and depression, was found to have no care plans regarding the use of antipsychotic and antidepressant medications, despite receiving Risperdal and Sertraline. The Social Service Director acknowledged that care plans should be in place for these medications. The facility's policy on comprehensive person-centered care plans, which involves the Interdisciplinary Team and the resident's family, was not adhered to, resulting in the absence of care plans that incorporate identified problem areas and risk factors associated with the residents' conditions.
Failure to Provide Individualized Activity Program for Resident
Penalty
Summary
The facility failed to provide activities tailored to meet the interests and well-being of a resident diagnosed with Alzheimer's disease, dementia, anxiety, depression, unsteadiness on feet, hallucinations, and hypertension. Observations revealed that the resident was not participating in scheduled activities and was non-responsive to staff encouragement to join. The resident was seen walking in the activity room but resisted sitting down and left the room. Additionally, there was no care plan addressing the resident's activity preferences and needs, and no documentation of the resident attending any group or individual activities over a specified period. Interviews with facility staff indicated that activity attendance was documented in the electronic medical record, and activities were scheduled throughout the day. However, there was no comprehensive activity assessment or individualized care plan for the resident. The facility's policy on activity evaluation did not include guidelines for creating individualized activity programs based on each resident's past and current interests. This lack of documentation and individualized planning contributed to the deficiency in meeting the resident's activity needs.
Failure to Discontinue Extra Fluids Leads to Edema in Resident
Penalty
Summary
The facility failed to discontinue physician orders for extra fluids for Resident M in a timely manner, which led to the development of bilateral lower extremity edema. Resident M, who had diagnoses including diabetes mellitus type 2, congestive heart failure, and vascular dementia, was ordered to receive an additional 240 milliliters of fluids every shift for 72 hours starting on 7/19/2024. However, the Medication Administration Record indicated that Resident M continued to receive these additional fluids through October 2024, well beyond the intended duration. As a result of the continued administration of extra fluids, Resident M developed symptoms consistent with fluid overload, including occasional shortness of breath and edema in the lower extremities. A laboratory test conducted on 7/20/2024 showed elevated BNP levels, indicating heart failure, and Resident M was subsequently started on diuretic medication. Despite the presence of congestive heart failure, the additional fluid intake was not discontinued, which may have contributed to the need for diuretic therapy. The Director of Nursing acknowledged that Resident M should not have been receiving additional fluids due to their heart condition.
Failure to Provide Optometry Follow-Up for Resident with Impaired Vision
Penalty
Summary
The facility failed to ensure that a resident with impaired vision received appropriate follow-up care. The resident, who has multiple diagnoses including multiple sclerosis, depression, and dementia, was noted to have moderate cognitive impairment and impaired vision requiring corrective lenses. A physician's order indicated that the resident could be seen by an optometrist as needed, but there was no record of the resident being seen by an optometrist since their admission to the facility. The resident's care plan included interventions such as wearing glasses and adjusting the tone of voice when communicating, but these did not address the need for optometry follow-up. Interviews with the Social Services Director (SSD) revealed that the optometry service last visited the facility on a date when the resident was not seen, and there were no notes indicating any optometry visits outside the facility. The SSD acknowledged that residents with glasses should be seen by optometry every other year according to Medicare regulations. Despite efforts to determine when the resident was last seen by an eye doctor, the SSD was unable to find any documentation. The facility's policy on sensory impairments required physicians to identify and order appropriate consultations, but this was not followed in the case of the resident.
Medication Availability Deficiency
Penalty
Summary
The facility failed to ensure that physician-ordered medications were available and administered to three residents, leading to multiple missed doses. Resident E, with diagnoses including encephalopathy, diabetes, anxiety, and depression, did not receive several medications as prescribed, including Atorvastatin, Esomeprazole, Ezetimibe, Sitagliptin, Veozah, Metformin, and Risperdal over various dates in September, October, and November. The clinical record lacked documentation explaining why these medications were not administered, and the Director of Nursing indicated that the nurse should have contacted the pharmacy, checked in-house supplies, and called the provider for an alternate medication order if necessary. Resident L, who suffered from kidney failure, diabetes, osteoarthritis, anxiety, and diabetic polyneuropathy, reported not receiving her pain medication for a month. Her physician orders included the application of a Lidoderm Patch for chronic pain, which was not applied or removed on multiple occasions in October and November. Medication Administration Notes indicated that the patches were often unavailable or on order from the pharmacy. Interviews with staff revealed that if a medication was not in the cart, they would notify the unit manager, check the emergency drug kit, and reorder the medication if necessary. Resident M, diagnosed with diabetes mellitus type 2, congestive heart failure, and vascular dementia, missed doses of Jardiance on several dates in November. The Director of Nursing stated that if a medication was unavailable, the nursing staff should have contacted the pharmacy and the physician to determine if alternate orders were necessary. The facility's policy on emergency pharmacy service and emergency kits was provided, indicating that emergency needs for medication should be met using the facility's approved medication supply or by a special order from the pharmacy.
Infection Control Breach During Catheter Care
Penalty
Summary
The facility failed to ensure proper infection control practices during perineal and catheter care for a resident. During an observation, a CNA was seen providing incontinence and catheter care to a resident without following proper glove use and handwashing protocols. After cleaning the urinary catheter and tubing, the CNA, assisted by an LPN, turned the resident and cleaned feces from the resident's buttocks. The CNA then applied a barrier cream without changing gloves or washing hands, and proceeded to handle clean bed pads, briefs, and linens, and repositioned the resident. The CNA only removed her contaminated gloves after completing these tasks. During an interview, the CNA acknowledged the failure to change gloves and wash hands. The facility's policy on perineal care, which requires glove removal and handwashing after cleaning, was not followed.
Failure to Timely Administer Pneumococcal Vaccine
Penalty
Summary
The facility failed to provide a timely pneumococcal vaccination to Resident 11, who was one of the five residents reviewed for vaccinations. Resident 11, diagnosed with multiple sclerosis, anxiety disorder, cerebral infarction, bipolar disorder, hemiplegia and hemiparesis of the left side, and cerebral aneurysm, had previously received the Prevnar 13 vaccine in March 2023. The resident expressed a desire to receive the pneumococcal vaccine, as indicated by a signed consent form in October 2023, and the resident's Power of Attorney/Guardian gave verbal consent for the vaccine in October 2024. However, the facility did not administer the vaccine in a timely manner, despite following CDC recommendations that suggest a pneumococcal vaccine should be given at least one year after the Prevnar 13 vaccine. The facility's policy, dated July 2022, stated that each resident should be offered a pneumococcal immunization unless contraindicated or already immunized, but this was not adhered to in Resident 11's case.
Failure to Administer Consented COVID-19 Vaccination
Penalty
Summary
The facility failed to provide a consented COVID-19 vaccination for one resident, identified as Resident 101, who was reviewed for immunizations. Resident 101 had diagnoses including acute kidney failure, congestive heart failure, and bradycardia, and was assessed to have moderate cognitive impairment. A review of the resident's records revealed that consent for a COVID-19 booster was given upon admission, but there was no documentation in the electronic medical record indicating that the vaccination had been administered. The Director of Nursing (DON) confirmed that residents who consent to vaccinations should have the vaccine ordered immediately and administered upon arrival from the pharmacy, but was unsure why Resident 101 had not received the vaccination. Additionally, the facility was unable to provide a policy for COVID-19 vaccination when requested.
Failure to Monitor Dialysis Care and Fistula Site
Penalty
Summary
The facility failed to provide appropriate dialysis care and monitoring for a resident with End Stage Renal Disease who required hemodialysis. The resident's care plan specified that pre- and post-dialysis assessments, including weight and vital signs, should be conducted, and the fistula access site should be monitored for complications such as infection or bleeding. However, the facility did not document any post-dialysis assessments in the resident's records, and there was no evidence that the fistula was being regularly observed or assessed for complications as required by the facility's policy. During interviews, the resident confirmed that staff did not check her fistula-access site after returning from dialysis treatments. The Director of Nursing acknowledged the oversight, stating that facility nurses should have been conducting post-dialysis assessments and monitoring the fistula every shift. The facility's policy, which mandates monitoring and documentation of dialysis treatments and access site assessments, was not followed, leading to this deficiency.
Inadequate Supervision and Accident Hazard in Memory Care Unit
Penalty
Summary
The facility failed to ensure the Memory Care Unit (MCU) was free from accident hazards and did not provide adequate supervision to prevent accidents, resulting in a serious incident involving Resident C. Resident C, who was severely cognitively impaired and required extensive assistance with all Activities of Daily Living, was found on the floor with a white substance in his mouth, experiencing labored breathing. The nursing staff attempted to perform a finger sweep to clear the airway, but the resident was resistant. Emergency Medical Technicians (EMTs) were called, and during their care, Resident C became pulseless and stopped breathing. The incident occurred when the Memory Care Unit was understaffed. On the evening of the incident, RN 3 was the only nurse on duty after CNA 2, who was not originally scheduled to work, left the facility. CNA 2 had come in to assist with putting residents to bed but left at 10:15 P.M., leaving RN 3 alone on the unit. Prior to leaving, CNA 2 had cleaned up fluff found all over the hall and dining room, which was later identified as pieces of an incontinence brief. After CNA 2's departure, RN 3 briefly left the unit, and upon returning, was informed by another resident that Resident C was eating popcorn. RN 3 found Resident C on the floor, unresponsive, and performed mouth sweeps to remove the fluffy white material from his mouth. The facility's staffing policy, which requires licensed nurses and certified nursing assistants to be available 24 hours a day, was not adhered to, as there was only one staff member present on the Memory Care Unit at the time of the incident. The Corporate Nurse confirmed that there should always be at least one nursing staff member present on the unit. The lack of adequate supervision and the presence of debris from an incontinence brief contributed to the incident, which resulted in Resident C requiring emergent treatment from EMTs.
Failure to Supervise Resident with Cognitive Deficits
Penalty
Summary
The facility failed to ensure adequate supervision and adherence to its elopement policy for a resident with a traumatic brain injury and cognitive deficits. The incident involved a resident who was transported by a van driver to a physician's office for an appointment. The van driver, unfamiliar with the resident, left him in the care of the office receptionist while he parked the van. Upon returning, the van driver waited in the lobby for over an hour, only to discover that the resident had left the office through an alternate exit without his knowledge. The resident, who had a history of severe cognitive deficits and required cueing and reminders for daily care, was not adequately supervised during the appointment. The facility's elopement risk evaluation had previously assessed the resident as a low risk for elopement, despite his cognitive impairments. After the resident's disappearance, the facility staff and local authorities conducted a search, but the resident was not immediately located. The resident was eventually found after several days, having traveled to familiar areas and stayed in a makeshift shelter he had previously occupied. The facility's failure to provide adequate supervision and follow its elopement policy resulted in the resident leaving the physician's office unnoticed. The incident highlighted lapses in communication and supervision, as the van driver was not informed of the resident's potential elopement risk, and there was no documentation of increased supervision upon the resident's return to the facility. The facility's policy required reassessment and additional interventions for residents who successfully elope, but these measures were not effectively implemented in this case.
Infection Control and Hygiene Deficiencies
Penalty
Summary
The facility failed to provide nursing services in a safe and sanitary manner to prevent the transmission of communicable diseases and infections. Specifically, the facility did not sanitize the glucometer between uses for two residents, one of whom had a bloodborne communicable disease. This practice was observed when a Qualified Medication Aide (QMA) used the same glucometer on two different residents without sanitizing it in between. The Director of Nursing confirmed that the proper procedure for blood glucose monitoring was not followed, which included cleaning the glucometer with Microdot bleach wipes after each use. The facility had five residents with bloodborne pathogens, two of whom required blood sugar checks, increasing the risk of disease transmission among residents requiring glucose monitoring. The facility also failed to ensure proper infection control practices in other areas. An indwelling catheter drainage bag for one resident was observed touching the floor, contrary to the care plan that required a basin to keep the bag off the floor. Additionally, a resident was seen retrieving ice with her bare hand from a community ice cooler, and staff did not intervene to prevent this unsanitary practice. Another resident had a foot blister with a dressing that was halfway off and had a foul odor, indicating improper wound care. The Licensed Practical Nurse (LPN) performing the dressing change did not follow proper hand hygiene protocols, failing to wash hands between glove changes. Further observations revealed that a Certified Nursing Assistant (CNA) did not follow proper hand hygiene and glove use while providing perineal care and assisting a resident to the bathroom. The CNA touched various surfaces and items with dirty gloves, increasing the risk of contamination. Additionally, a resident's BiPAP mask and tubing were found on the floor and visibly dirty, indicating poor respiratory care practices. These deficiencies highlight significant lapses in infection control and hygiene practices within the facility, posing a risk to resident safety and health.
Removal Plan
- Inserviced licensed nurses and QMAs regarding proper cleaning of glucometers after use.
- Implemented a system of personal glucometers stored in a labeled bag for each resident.
Sanitation and Food Handling Deficiencies in Kitchen
Penalty
Summary
The facility failed to ensure food was stored, prepared, served, and delivered in a sanitary manner in the kitchen, potentially affecting all 67 residents who consumed food from the kitchen. During an observation, various food items in the freezer were found undated and opened, including waffles, pancakes, pizzas, broccoli, hamburger patties, cereal, and chicken strips. The prep counter, storage bins, delivery cart, and dishwasher were observed to be dirty with crumbs and grease-like substances. Additionally, the cooler contained an undated bowl of fruit and salad. Cook 16 confirmed that the items should have been dated or discarded if expired and that the kitchen equipment should have been cleaned. Further observations revealed that an LPN placed her thumb on the food surface of dinner plates and touched the rim of cups with her fingers while serving food to residents. A QMA was also observed carrying a meal tray without a cover in the hall. The Dietary Manager confirmed that staff should not have their fingers beyond the rim of the plate or cup during meal service and that all meals should be delivered covered. The Dietary Manager provided policies on labeling and dating, and employee sanitary practices, which indicated that all items in storage should be dated and discarded when expired, and that equipment and work units should be cleaned after each use. However, a policy related to correctly delivering meals during dining was not provided.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of gnats in residents' rooms and common areas in one of the four units observed. During an environmental tour, three gnats were observed in the bathroom of room [ROOM NUMBER]. A resident expressed concerns about the gnats and mentioned having complained to the staff. The pest control invoice indicated that the last pest management service was conducted on 4/17/2024, with the next service scheduled for 5/17/2024. Additionally, the Director of Housekeeping confirmed the absence of a policy regarding environmental cleaning, and the Housekeeping Supervisor provided an untitled form outlining daily cleaning tasks for each resident's room, which included emptying trash, cleaning surfaces, and sweeping and mopping.
Failure to Ensure Respectful Communication and Personal Dignity
Penalty
Summary
The facility failed to ensure staff spoke to residents respectfully and provided personal dignity. In one instance, a dietary worker yelled at a resident about telling surveyors the food was cold. The resident, who was cognitively intact and had diagnoses including diabetes mellitus type 2 and bipolar disorder, reported the incident to the surveyor. The dietary assistant was taken off the schedule pending an investigation, and the staff member denied the allegation. The facility's policy indicated that residents should be treated with respect, kindness, and dignity, which was not adhered to in this case. In another instance, a resident with an indwelling urinary catheter had their catheter bag visibly hanging on the frame of the bed, which could be seen from the hallway. The resident had diagnoses including obstructive and reflux uropathy, hydronephrosis, BPH, and hemiplegia affecting the dominant side. The care plan indicated that the catheter bag should be positioned below the level of the bladder and away from the entrance room door. The Director of Nursing indicated that a catheter should be covered with a dignity bag, but the current policy did not address this requirement.
Failure to Develop Person-Centered Care Plans for Behaviors
Penalty
Summary
The facility failed to develop person-centered care plans for behaviors for two residents. Resident 63, diagnosed with vascular dementia, falls, hypertension, and insomnia, was admitted with no behaviors noted initially but later exhibited increased behaviors and confusion, leading to a psychiatric hospital admission. Despite being on multiple psychiatric medications, the care plan for Resident 63 lacked specific, person-centered interventions to address these behaviors. The Social Service staff was unaware of the resident's behaviors, and the care plan did not reflect a person-centered approach as required by the facility's policy. Resident 64, diagnosed with dementia, psychotic disorder, anxiety, and PTSD, exhibited behaviors such as yelling for pain medication and excessive call light use. The care plan for Resident 64 included interventions for depression but did not address the use of antipsychotic medications or the resident's yelling behavior. The Social Service staff confirmed that the care plan was not person-centered. The facility's policy mandates that care plans be developed in conjunction with the resident and their family, incorporating personal and cultural preferences, which was not adhered to in these cases.
Failure to Provide Routine Care Plan Meetings
Penalty
Summary
The facility failed to provide routine care plan meetings for a resident, as required by their policy. During an interview, the resident indicated that he did not have routine care plan meetings. A review of the resident's records showed that care plan meetings were documented on three occasions: March 2023, January 2024, and February 2024. However, the Social Service Director confirmed that care conferences should be held quarterly, indicating that the resident should have had more frequent care plan meetings between March 2023 and January 2024. The facility's policy mandates that each resident's care plan be reviewed at least quarterly, incorporating the resident's strengths, weaknesses, and personal and cultural preferences.
Failure to Provide Scheduled Showers for Residents
Penalty
Summary
The facility failed to provide showers at least twice weekly for three residents reviewed for activities of daily living (ADLs). Resident 20, who was admitted with multiple diagnoses including depression, anxiety, hypertension, hemiplegia, seizures, and diabetes, had not received any showers since admission. The resident's care plan indicated she was totally dependent on staff for bathing and was scheduled to receive showers on Wednesdays and Saturdays. However, documentation showed she only received a bed bath on one occasion and missed several scheduled showers. The Director of Nursing confirmed that the resident should have had more showers. Resident 65, diagnosed with acute kidney failure, dementia, Type 2 diabetes mellitus, and retention of urine, was observed with unshaven whiskers and greasy hair, indicating a lack of proper hygiene. His care plan required maximum assistance with showering, and he was scheduled for showers on Wednesdays and Saturdays. However, records showed he only received one shower and one bed bath, missing several scheduled showers. Similarly, Resident 32, who required partial assistance for bathing due to pain and arthritis, reported not receiving timely showers. His care plan scheduled showers on Tuesdays and Fridays, but documentation indicated he only received a few showers, with many scheduled showers missing. The Director of Nursing confirmed the lack of proper documentation and adherence to the shower schedule for these residents.
Failure to Prevent Urinary Tract Infections Due to Improper Catheter Care
Penalty
Summary
The facility failed to provide appropriate care and services to prevent urinary tract infections for a resident with a urinary catheter. Multiple observations over several days revealed that the resident's urinary catheter drainage bag was frequently dragging on the floor while the resident was in a wheelchair and even when the resident was lying in bed. Staff members were observed pushing the resident with the drainage bag dragging on the floor, and the resident was also seen wandering in his wheelchair with the bag in the same condition. Interviews with staff confirmed that the drainage bag should not be on the floor, indicating a lack of adherence to proper catheter care protocols. The resident in question had a history of urinary tract infection, acute kidney failure, dementia, diabetes mellitus, and urinary retention, necessitating the use of a urinary catheter. The resident's care plan included specific interventions to prevent infections, such as keeping the catheter system closed and the drainage bag off the floor. Despite these interventions, the facility's failure to maintain the drainage bag in a proper position was evident. The facility's policy on catheter care, which aims to prevent catheter-associated urinary tract infections, was not followed, as the drainage bag was repeatedly observed inappropriately positioned on the floor.
Failure to Assess Side Rail Use for Resident
Penalty
Summary
The facility failed to assess the use of a side rail before maintaining the bedrail in the upright position for Resident 42. During an interview, Resident 42 indicated he had a fall and was supposed to use the siderail to get up. A record review showed that Resident 42 had multiple diagnoses, including heart failure, rhabdomyolysis, hypoxemia, and vascular dementia, and was at risk for falls. A Nursing Progress Note indicated that Resident 42 was found sitting on the floor beside his bed after sliding off, with no injuries noted. The Care Plan indicated that Resident 42 was at risk for falls due to cognitive impairment, balance deficits, and other conditions. A Fall Risk Evaluation confirmed that Resident 42's balance was not normal, and he required assistive devices. An IDT Note indicated that a siderail was to be applied to assist with positioning, but no side rail assessment was completed prior to this intervention, as confirmed by the Director of Nursing. The facility's policy on the use of bed rails required an assessment to determine the resident's symptoms, risk of entrapment, and reason for using bed rails. This assessment should include a review of the resident's bed mobility, ability to change positions, transfer to and from bed or chair, potential risks with the use of bed rails, and that the bed's dimensions are appropriate for the resident's size and weight. The Director of Nursing confirmed that no such assessment was completed for Resident 42 before the siderail was applied, which is a violation of the facility's policy and contributed to the deficiency noted in the report.
Failure to Post Daily Nursing Staffing Information
Penalty
Summary
The facility failed to post the daily nursing staffing information at the beginning of the shift. On 5/13/2024 at 7:34 A.M., the nursing staff posting was observed to be dated 5/11/2024. During an interview on 5/17/2024 at 8:26 A.M., the Director of Nursing (DON) indicated that the night shift is responsible for completing the nursing staff posting for the next day and that it should have been posted by midnight. The facility's policy, provided by the DON on 5/17/2024 at 3:43 P.M., states that the facility will post the number of nursing personnel responsible for residents on a daily basis for each shift.
Failure to Document Narcotic Counts
Penalty
Summary
The facility failed to ensure narcotics were counted and documented every shift for one of two narcotic count log books reviewed. During a medication storage observation of the Skilled Hall medication cart, it was found that there were 30 missing signatures in the narcotic log book from 4/16/2024 through 5/15/2024. An LPN confirmed that the narcotic log sheets should be signed every shift. The Director of Nursing provided the facility's policy, which indicated that nursing staff must count controlled medications at the end of each shift, with the nurse coming on duty and the nurse going off duty making the count together.
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Surveyors observed that dietary staff repeatedly worked in kitchen and meal service areas with uncovered facial hair, despite facility policy and state sanitation requirements mandating effective hair restraints. Two dietary aides with short beards or mustaches were seen walking through food preparation areas, taking food temperatures, handling food, and plating meals at steamtables in dining rooms without any facial hair coverings, while the current policy required all hair, including facial hair, to be restrained to prevent contamination.
The facility failed to consistently provide and document required bed-hold policy notices when several residents were transferred to the hospital. In multiple cases, residents with dementia, psychotic disorders, COPD, chronic respiratory failure, altered mental status, and cerebral infarction were sent out for acute changes in condition, and while transfer notes reflected physician and family notifications, they lacked documentation that the bed-hold policy was discussed with the resident or responsible party. Notices of Transfer or Discharge often indicated a copy of the bed-hold policy was sent with the resident, but the records did not show signed and dated acknowledgment by the resident or appropriate representative, including in situations where a resident had moderate cognitive impairment, short-term memory issues, or a documented need for a proxy and a financial POA authorizing an agent for health care decisions.
Surveyors found that the facility failed to provide trauma‑informed and culturally competent care by not incorporating two residents’ extensive trauma histories and specific behavioral triggers into their care plans. One resident with documented homelessness, polysubstance abuse, severe accidents with multiple fractures, viral encephalitis with coma, physical and sexual abuse, loss of family contact, and a past suicide attempt had multiple behavior‑focused care plans that referenced identifying triggers but listed none and did not mention their physical, sexual, medical, or psychosocial trauma. Another resident with TBI from being struck by a truck, an 11‑month coma, long‑term state hospital residence, alleged shooting of a parent, and diagnoses including intermittent explosive disorder and borderline personality disorder had a PASRR identifying a specific trigger and notes of inappropriate sexual behavior, yet their care plans omitted these traumatic events, the identified trigger, and the sexual behavior. Staff interviews confirmed that residents were screened for trauma, but the trauma histories and triggers were not reflected in the individualized plans of care.
A resident with schizophrenia, post‑stroke hemiparesis, and mild cognitive impairment expressed feeling down and wanting to kill himself, but staff did not document asking about a specific plan, did not notify the physician or psychiatric NP as expected, and did not develop or update a care plan addressing depression or suicidal ideation. The SSD documented offering support and initiating 15‑minute checks once, but there was no further follow‑up or documentation of interventions after subsequent suicidal statements made in a care plan meeting with the resident’s father. The DON and Administrator reported that facility policy requires immediate notification of key staff, assessment for a plan and means of self‑harm, and thorough documentation, which were not carried out or reflected in the medical record for this resident.
A resident with schizophrenia, post-stroke hemiparesis, and mild cognitive impairment verbalized suicidal ideation, but the care plan did not address depression or suicidal thoughts, and required assessments and services were not accurately or timely documented. An SSD note recorded the resident saying he wanted to kill himself and referenced 15‑minute checks and a care plan update, yet the active care plan lacked depression/suicidal ideation interventions. Multiple late-entry Social Services notes were later added, describing follow-up visits and the resident denying suicidal ideation, but the SSD later reported she did not typically ask about a suicide plan and did not personally provide individual follow-up visits as described. These practices conflicted with the facility’s policy requiring factual, first-hand, and timely documentation of assessments and services.
A resident was observed with an Albuterol inhaler on an overbed table and later reported keeping the inhaler in a nightstand drawer, with no staff present during these observations. Record review showed the resident had no cognitive impairment on the admission MDS but lacked any documented self-medication administration assessment. The DON acknowledged that the required assessment had not been completed, despite facility policy requiring staff and the practitioner to evaluate each resident’s mental and physical abilities before allowing self-administration of medications.
Surveyors found that the facility submitted inaccurate direct care staffing data to CMS through the PBJ system over multiple days in a quarter. CASPER reports showed apparent gaps in 24-hour licensed nurse coverage, low weekend staffing, and a 1-star staffing rating, while internal staffing sheets documented that licensed nurses were present and the facility was fully staffed on those days. The Administrator reported that the discrepancies were due to PBJ data entry errors, despite a facility policy requiring all PBJ entries to be accurate, auditable, and verifiable against payroll, invoices, or contracts.
Surveyors found that the facility did not provide or document required written transfer/discharge notices and bed-hold policy information for four residents who were sent to the hospital, including individuals with conditions such as dementia, CHF, chronic respiratory failure, and CKD. In each case, progress notes showed that the resident was transferred for acute issues, but the clinical records lacked evidence that written notices were given to the residents or their representatives, and in one case lacked documentation that required information was sent to the receiving provider. Facility leadership, including the ADON, DON, and Administrator, acknowledged that the records did not contain the required documentation, despite a written policy requiring such notices and information exchange.
A resident with Alzheimer’s disease and depression, previously on an antidepressant, exhibited intermittent refusals of medications and care, occasional yelling at staff, and reports of unusual perceptions, such as believing men were in or near her room. Nursing notes over several months documented these refusals and complaints but did not show that the behaviors were evaluated or recorded as dangerous, non-redirectable, or causing significant distress, nor did they document specific non-pharmacological interventions attempted or their outcomes. Despite this, a psychiatric NP later added new diagnoses of schizoaffective disorder, borderline personality disorder, and delusional disorder and ordered an antipsychotic (Seroquel) without a comprehensive evaluation in the record to support these diagnoses. The facility’s psychotropic medication policy, which requires identification and documentation of target behaviors, use of nonpharmacological interventions, and ongoing behavior monitoring, was not followed for this resident.
The facility failed to keep PASARR Level I screenings accurate and current for three residents when new mental health diagnoses and psychoactive medications were initiated. One resident’s PASARR omitted a PTSD diagnosis and an added antidepressant, despite documentation of PTSD on the MDS and care plan and a physician order for Pristiq. Another resident’s PASARR listed only depression and dementia, even after additional diagnoses such as borderline personality disorder, delusional disorder, and schizoaffective disorder were added and an antipsychotic (quetiapine) was ordered, with the MDS later reflecting psychotic disorder, schizophrenia, and depression with antipsychotic and antidepressant use. A third resident’s PASARR did not include a depression diagnosis or newly ordered escitalopram and lorazepam, although the admission MDS documented depression with antianxiety and antidepressant use. These omissions occurred despite facility policy requiring a new Level I review after significant mental status changes, including new mental health diagnoses or new psychotropic medications.
Uncovered Facial Hair During Food Preparation and Meal Service
Penalty
Summary
The deficiency involves the facility’s failure to ensure that food was served in a sanitary and safe manner in accordance with professional standards and facility policy during multiple kitchen and meal service observations. During an initial kitchen observation, two dietary aides were seen walking through the kitchen food preparation area with uncovered facial hair. One aide had facial hair above and below the lip and along the jaw line, approximately one-fourth inch in length, and the other had a mustache of similar length; neither used any facial hair covering. These observations occurred while staff were present in the kitchen area where food was stored and prepared. During subsequent observations on the same day, the same two dietary aides were again observed with uncovered facial hair while directly involved in meal preparation and service. One aide walked through the kitchen while the noon meal was being prepared and placed into a transport cart for service in the south dining room, and later was observed plating the noon meal at the steamtable in that dining room, still without a facial hair covering. The other aide walked through the kitchen while the noon meal was being prepared and placed into the steamtable for the north dining room, took food temperatures, assisted with plating meals at the steamtable, and retrieved food items and supplies from the kitchen, all while having an uncovered mustache approximately one-fourth inch in length. The Dietary Manager stated that staff hair was to be covered when in the kitchen and during meal service, and the facility’s written policy and the cited Indiana Food Establishment Sanitation Requirements both required effective hair restraints, including for facial hair, to prevent contamination of food, equipment, and utensils.
Failure to Provide and Document Bed-Hold Policy at Time of Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure that required bed-hold policy information was provided and documented for four residents transferred to the hospital. For a resident with dementia, psychotic disorder, and autistic disorder who had a BIMS score of 0 indicating severe cognitive impairment, progress notes documented physician notification and guardian notification when the resident was sent to the hospital, but there was no documentation that the bed-hold policy was provided to the responsible party. A Notice of Transfer or Discharge later indicated a copy of the bed-hold policy was sent with the resident. Another resident with COPD and chronic respiratory failure, cognitively intact with a BIMS score of 13, experienced a decline in condition and was transferred to the hospital by ambulance; progress notes documented family notification but did not document any discussion of the bed-hold policy, although a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident. A third resident with altered mental status and cerebral infarction, with a BIMS score of 10 indicating moderate cognitive impairment and documented short-term memory impairment, experienced changes in condition and was transferred to the hospital. Progress notes stated the resident was their own responsible party and that no other notification was completed, and transfer documentation did not include the bed-hold policy, although an untimed Notice of Transfer or Discharge indicated a copy of the bed-hold policy was signed by the resident. A financial power of attorney document in the record showed the resident had designated an agent to act in consent or refusal of health care. For a fourth resident with dementia and osteomyelitis, transfer documentation and a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident, and the transfer form noted the resident required a proxy for decision making. The facility’s policy required that at the time of transfer to a hospital, written notice specifying the duration of the bed-hold policy and information on return to the next available bed be provided, and that a signed and dated copy of the bed-hold notice given to the resident or representative be kept in the resident file, which was not consistently documented for these residents.
Failure to Integrate Trauma Histories and Behavioral Triggers Into Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to identify and incorporate residents’ trauma histories and specific behavioral triggers into their care plans, despite documented histories of significant trauma and behavioral health issues. For one resident, extensive social service and progress notes documented homelessness, polysubstance abuse, major depressive and anxiety disorders, chronic pain, a history of severe car accidents with multiple fractures, viral encephalitis resulting in a three‑month coma, loss of child custody, multiple divorces, physical abuse by a spouse, the death of a fiancé who was struck by a car while in a wheelchair, lack of family contact, and a past suicide attempt by Valium overdose. Additional documentation noted a history of rape by a brother at age eight and prior placement under direct supervision and 15‑minute checks related to suicidal ideation. Despite these documented traumatic events and behavioral health concerns, the resident’s care plans did not identify a history of physical trauma, sexual trauma, homelessness, substance abuse, medical trauma, or attempted suicide. For this same resident, the MDS showed no cognitive deficit and identified behaviors such as verbal aggression and rejection of care, along with diagnoses including seizure disorder, depression, chronic pain syndrome, homelessness, and anxiety disorder. Multiple care plans addressed behaviors such as drug‑seeking, pretending to have seizures for attention or medication, making false allegations, verbal aggression when unable to smoke, and a desire for intimate relationships with consenting male residents. These care plans referenced goals such as effective coping skills, seeking staff support, and compliance with the smoking policy, and they called for identification and reduction of behavioral triggers. However, none of these care plans actually listed any specific triggers. The care plan addressing the resident’s right to consensual intimate relationships focused on assessment and education regarding consent but did not integrate the resident’s extensive trauma history. Staff interviews indicated the resident had displayed sexual behaviors since admission, including an incident where the resident expressed anger at another resident for not buying a soda after engaging in sexual acts. A second resident with a documented history of traumatic brain injury (TBI), dementia, seizure disorder, borderline personality disorder, anxiety, intermittent explosive disorder, tobacco use, and other behavioral/emotional disorders was also affected by the same deficiency. Social history and progress notes documented that this resident sustained a TBI after being hit by a semi‑truck while riding a bicycle at age 18, resulting in an 11‑month coma, followed by 13 years in a state hospital and subsequent residence in a group home. Additional documentation indicated the resident allegedly shot their father at age 26 after being sworn at and had a PASRR identifying TBI, intermittent explosive disorder, and borderline personality disorder, with a specific trigger of hearing the name of the current U.S. President. Progress notes also described inappropriate sexual behavior toward staff, including touching themselves intimately during personal care and refusing to stop when redirected. Despite this, the resident’s care plans, which addressed explosive disorder and history of altercations, risk for decreased psychosocial well‑being, and refusal to bathe or shower, did not list any specific behavioral triggers, did not reference the traumatic events such as being hit by a truck or shooting their father, and did not document the inappropriate sexual behavior. The Administrator and Social Service Director acknowledged that residents were to be screened for trauma and that trauma responses and PTSD should be added to care plans, but the specific trauma histories and triggers for these two residents were not incorporated into their plans of care.
Failure to Assess and Care Plan for Resident Suicidal Ideation
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess, investigate, and care plan for a resident’s suicidal ideation in accordance with its own policy and staff expectations. The resident had diagnoses including schizophrenia, cerebral edema, and hemiparesis/hemiplegia following a cerebral infarction, and a current MDS showed mild cognitive impairment (BIMS score 12). A progress note documented that the resident told the Social Services Director (SSD) he was feeling down and wanted to kill himself; the SSD offered assistance, activities, and initiated 15‑minute checks, and the note stated the care plan was updated. However, the note did not indicate that the SSD asked whether the resident had a plan to kill himself, and there were no additional notes regarding suicidal ideation or follow‑up. Review of the current care plan showed no problem, goal, or interventions addressing depression or suicidal ideation, and progress notes over the following month contained no documentation of physician notification related to the suicidal statement. Further record and interview evidence showed that the care plan conference summary did not document interventions for suicidal ideation, and the SSD acknowledged she did not normally ask residents expressing suicidal ideation if they had a plan. The SSD reported that the resident had admission paperwork mentioning suicidal ideation related to depression after a stroke and that the resident again vocalized suicidal ideation during a care plan meeting with his father, after which emotional support was offered and the father took the resident out on a leave of absence; no further visits or follow‑up were done. The DON stated that, upon notification of suicidal verbalization, staff should assess the resident, ask if there is a plan, remove potential means of self‑harm, immediately notify the psychiatric NP, and document the occurrence, and that a detailed progress note and updated care plan were expected but not present for this resident. The Administrator similarly stated that staff should ask about a plan, document interventions, notify the physician and family, and update the care plan, and indicated the resident should have had a care plan addressing depression with suicidal ideation. The facility’s written policy required immediate notification of the DON, SSD, and physician, an interview including asking about a plan and assessing mood and means for self‑harm, and thorough documentation of mood, behavior, and all actions taken, which were not reflected in the resident’s record.
Incomplete and Inaccurate Documentation of Suicidal Ideation and Follow-Up
Penalty
Summary
The facility failed to ensure accurate, complete, and timely documentation of assessments and services for a resident who verbalized suicidal ideation. Resident 6, who had schizophrenia, cerebral edema, and right-sided hemiparesis/hemiplegia following a cerebral infarction, had a BIMS score of 12 indicating mild cognitive impairment. The resident’s admission paperwork mentioned suicidal ideation related to depression after a stroke, and a Social Services note on 3/11/2026 documented that the resident was feeling down and said he wanted to kill himself. The Social Services Director (SSD) documented that she talked with the resident, coordinated with Activities, advised the resident to contact SSD or nursing if he wanted to talk, and that the resident was scheduled for 15-minute checks and the care plan was updated. However, the current care plan initiated on 2/26/2026 did not address depression or suicidal ideation. Multiple Social Services progress notes were later entered as late entries in April, with effective dates in March, stating that the resident had no plan and no longer had suicidal ideation, that he felt much better after 1:1 time, and that he continued his daily routine and therapy. These late entries described follow-up visits and reassessments of suicidal ideation on several consecutive days, but in interviews the SSD stated she did not normally ask residents about having a plan when they verbalized suicidal ideation and did not recall any other occurrences beyond the initial event. She further indicated she did not personally provide individual follow-up visits with this resident regarding suicidal ideation, despite the late-entry notes describing such visits. The DON acknowledged that late entries had been added to address concern about suicidal verbalization, and the Administrator stated that upon suicidal statements staff should ask about a plan, notify the physician and family, and update the care plan, and that this resident should have had a care plan addressing depression with suicidal ideation. The facility’s documentation policy required factual, first-hand, timely documentation, which was not followed in this case.
Failure to Complete Required Self-Administration Assessment for Inhaler Kept at Bedside
Penalty
Summary
Surveyors identified that a resident was allowed to keep and access an Albuterol inhaler without the facility completing the required self-administration medication assessment. During an initial tour, the resident was observed sitting in a wheelchair with a handheld Albuterol inhaler on the overbed table and no staff present in the room or hallway. On a subsequent observation, the resident again was in a wheelchair and reported that the Albuterol inhaler was stored in the top drawer of the nightstand, where it was found. Review of the clinical record showed an admission MDS indicating no cognitive impairment, but there was no documentation of a self-medication administration assessment. In an interview, the DON confirmed that the resident did not have the required self-medication assessment, despite the facility’s policy stating that staff and the practitioner must assess each resident’s mental and physical abilities to determine whether self-administering medications is clinically appropriate. This failure to complete and document a self-administration medication assessment for a resident who had an Albuterol inhaler kept at bedside constituted noncompliance with the facility’s own policy and with 410 IAC 16.2-3.1-11(a).
Inaccurate PBJ Staffing Data Submission to CMS
Penalty
Summary
The deficiency involves the facility’s failure to electronically submit complete and accurate direct care staffing information to CMS through the Payroll-Based Journal (PBJ) system for 22 days in a fiscal quarter. A CASPER report review on 4/6/26 showed that, according to PBJ data, the facility did not have licensed nursing coverage 24 hours per day on multiple specific dates across three months, had low weekend staffing, and held a 1-star staffing rating. However, review of the facility’s internal staffing sheets for that quarter indicated the facility was fully staffed and had licensed nurse coverage on all of the dates in question. During an interview, the Administrator stated that the PBJ information must have contained data entry errors, as she had verified licensed staff coverage on the timesheets. The facility’s PBJ policy in effect stated that all staffing data entered into the PBJ system would be auditable and verifiable through payroll, invoices, or contracts, but the submitted PBJ data did not accurately reflect the facility’s actual licensed nurse staffing as documented on internal records. No specific residents or clinical conditions were mentioned in the report, and the deficiency centers solely on inaccurate staffing data submission rather than direct resident care events.
Failure to Provide and Document Required Transfer/Discharge and Bed-Hold Notices
Penalty
Summary
The deficiency involves the facility’s failure to provide and document required written notices of transfer/discharge and bed-hold policies, as well as required information to receiving providers, for four residents who were transferred or discharged to the hospital. For a resident with generalized anxiety disorder, major depressive disorder, and dementia, progress notes showed that the resident was sent to the hospital via 911 for chest pain, lower back pain, and shortness of breath and later returned to the facility, but the clinical record lacked documentation that a written Notice of Transfer/Discharge and the bed-hold policy were provided to the resident or representative, and lacked documentation that required information was conveyed to the receiving facility. The ADON and the Administrator both confirmed there was no documentation that these written notices were provided. For a resident with congestive heart failure and muscle weakness who was sent to the emergency room for painful urination and bloody urine, the clinical record lacked documentation that a Notice of Transfer/Discharge or bed-hold policy was given to the resident or representative, which the DON confirmed. Another resident with chronic respiratory failure and diabetes was discharged to the hospital for respiratory failure, and a resident with chronic kidney disease and dementia was discharged to the hospital, but in both cases there was no documentation that a written notice of transfer/discharge or bed-hold policy was provided to the residents or their representatives. Review of the facility’s Transfer and Discharge policy, dated 1/15/26, showed that the policy required the facility to provide written transfer/discharge notices and bed-hold information to residents and representatives and to provide specified information to receiving providers, but the records for these four residents did not contain the required documentation.
Failure to Document Target Behaviors and Non-Pharmacological Interventions Before Initiating Antipsychotic
Penalty
Summary
The deficiency involves the facility’s failure to document how a resident’s behaviors presented danger or distress to self or others, and failure to document non-pharmacological interventions attempted prior to initiating an antipsychotic medication. Resident 6 had documented diagnoses of Alzheimer’s disease, depression, and severe cognitive impairment, and was receiving sertraline for depression. A PASSAR identified only depression and dementia, and the admission MDS listed Alzheimer’s disease and depression as active diagnoses. Over several months, nursing progress notes documented that the resident intermittently reported unusual perceptions, such as believing there were men causing trouble, a man in her room, or a man wanting to marry her and yelling through the walls, but there was no documentation that these episodes caused danger to the resident or others or that they resulted in unmanageable distress. From late April through mid-July, nursing notes primarily described the resident’s frequent refusals of evening and morning medications, blood sugar checks, blood pressure checks, insulin administration, hygiene care, and showers. Staff documented that the resident sometimes yelled at staff, said “Get out!”, was visibly upset by a room move, was leery of staff and asked to see name badges, and became upset about a pillow under her head until it was removed, after which she calmed down. The notes also recorded instances where the resident believed housekeeping had not cleaned her room or that she had not received medications when she had. However, there were no progress notes or assessments indicating that these behaviors were evaluated as dangerous, non-redirectable, or causing significant distress or functional impairment, and no detailed behavior monitoring logs were present as required by facility policy. On a psychiatric NP visit for initial psychotropic medication management, new mental health diagnoses of schizoaffective disorder, borderline personality disorder, and delusional disorder were added, and Seroquel 25 mg, an antipsychotic, was ordered. The clinical record did not contain a comprehensive evaluation to support these new diagnoses, and there was no documentation of target behaviors meeting the facility’s policy criteria for psychotropic use, such as behaviors representing danger to self or others, causing distress and impairment in functional abilities, or clearly attributable to psychosis or mania. The resident’s representative reported that the resident had no prior history of mental health disorders or psychiatric hospitalization and was unaware of the new diagnoses. The facility’s own psychotropic medication policy required identification and documentation of specific target behaviors, use and documentation of nonpharmacological interventions, and ongoing monitoring of behaviors and interventions, which were not reflected in the record for this resident.
Failure to Update PASARR Screens for New Mental Health Diagnoses and Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that Preadmission Screening and Resident Review (PASARR) Level I screenings were accurate and updated when new mental health diagnoses and psychoactive medications were initiated for multiple residents. For one resident with dementia, anxiety, depression, and post-traumatic stress disorder (PTSD), the PASARR completed on admission listed anxiety, depression, and dementia with sertraline and quetiapine, but did not include the PTSD diagnosis or the antidepressant Pristiq, despite the admission MDS and care plan documenting PTSD and a subsequent physician’s order for Pristiq. For another resident with Alzheimer’s disease, borderline personality disorder, delusional disorder, schizoaffective disorder, and depression, the PASARR only reflected depression and dementia with sertraline, even though additional mental health diagnoses were added later and an antipsychotic (quetiapine) was ordered for borderline personality disorder, and the quarterly MDS documented psychotic disorder, schizophrenia, and depression with antipsychotic and antidepressant use. A third resident had diagnoses including Alzheimer’s disease, depression, anxiety disorder, irritability and anger, and nonrheumatic aortic valve stenosis. The PASARR for this resident listed dementia and anxiety with Risperdal but omitted the diagnosis of depression and the medications escitalopram and lorazepam, although physician’s orders were in place for escitalopram for depression and lorazepam for anxiety, and the admission MDS documented depression with antianxiety and antidepressant use. Interviews with the Assistant Director of Nursing confirmed that new Level I PASARR screens should have been completed when new mental health diagnoses and psychoactive medications were added, and that the PASARR for one resident, completed prior to arrival, should have included all mental health diagnoses and medications. The facility’s own policy required notification of the state mental health authority within 14 days after a significant change in mental condition and specified that a new Level I screen is required for new mental health diagnoses or newly prescribed psychotropic medications, which was not followed in these cases.
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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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