WATERS OF LAGRANGE SKILLED NURSING FACILITY, THE
For profit - Corporation
100 Beds
INFINITY HEALTHCARE CONSULTING
Data: November 2025
Trust Grade
25/100
#399 of 505 in IN
Last Inspection: October 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
The Waters of LaGrange Skilled Nursing Facility has received a Trust Grade of F, indicating significant concerns about its operations and care quality. It ranks #399 out of 505 facilities in Indiana, placing it in the bottom half, and #2 out of 2 in LaGrange County, meaning only one other local facility is available and it is better. While the facility is showing improvement, reducing its issues from 21 in 2024 to just 2 in 2025, it still has a long way to go. Staffing is a notable weakness, with a low rating of 1 out of 5 stars and a high turnover rate of 60%, which is concerning compared to the state average of 47%. Specific incidents include a failure to properly identify and treat a resident's pressure injury, and inadequate staffing levels that resulted in CNAs being overwhelmed, potentially compromising resident safety. On a positive note, the facility has not incurred any fines, which is a good sign, but the overall care quality still raises red flags.
- Trust Score
- F
- In Indiana
- #399/505
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 60% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Indiana facilities.
- Skilled Nurses ⚠ Watch
- Each resident gets only 21 minutes of Registered Nurse (RN) attention daily — below average for Indiana. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 34 deficiencies on record. Higher than average. Multiple issues found across inspections.
25/100
Bottom 21%
Review needed
21 → 2 violations
★★☆☆☆
2.0
Overall Rating
★☆☆☆☆
1.0
Staff Levels
★★★★★
5.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 21 issues
2025: 2 issues
The Good
-
5-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in quality measures, fire safety.
The Bad
2-Star Overall Rating
Below Indiana average (3.1)
Below average - review inspection findings carefully
Staff Turnover: 60%
14pts above Indiana avg (46%)
Frequent staff changes - ask about care continuity
Chain: INFINITY HEALTHCARE CONSULTING
Part of a multi-facility chain
Ask about local staffing decisions and management
Staff turnover is elevated (60%)
12 points above Indiana average of 48%
The Ugly 34 deficiencies on record
1 actual harm
Feb 2025
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to ensure residents were free from verbal abuse for 1 of 3 residents reviewed (Resident J).
The deficient practice was corrected on 1/22/25 pri...
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Based on interview and record review the facility failed to ensure residents were free from verbal abuse for 1 of 3 residents reviewed (Resident J).
The deficient practice was corrected on 1/22/25 prior to the start of the survey and was therefore past non-compliance.
Findings include:
A facility reported incident to the Indiana Department of Health, dated 1/21/25, indicated an allegation of verbal abuse had occurred and was being investigated by the facility. The allegation involved verbal abuse from a Certified Nurse Aid (CNA) to a resident.
On 2/3/25 at 12:53 P.M., Resident J's record was reviewed. Diagnoses included Alzheimer's disease with late onset.
A significant change Minimum Data Set assessment, dated 1/8/25, indicated the resident had severely impaired cognition and required maximal to dependent care for her activities of daily living. She had no behaviors or rejection of care.
A care plan, dated 1/8/25, indicated Resident J had cognitive impairments related to dementia and short term memory loss. Her goals were to have her needs met and anticipated. Interventions included: if upset/or distressed check for any unmet needs; give resident two choices when presenting decisions; and observe and report changes in cognitive status.
On 2/3/25 at 12:30 P.M., the Administrator was interviewed. He indicated on 1/21/25, he was notified that CNA 8 had been overheard by staff, being rude to Resident J and calling her a bitch in front of her. CNA 8 was asked to write and sign a statement and immediately suspended pending investigation. Resident J was assessed, found with no injury, and was monitored for psychosocial distress. The Administrator interviewed witnesses and contacted the police. A thorough investigation was completed, the facility reeducated all staff and began quality reviews to prevent further verbal abuse.
A current facility policy, titled Abuse Prevention Program, provided by the Director of Nursing on 2/3/25 at 3:46 P.M., indicated: It is the policy of this facility to prohibit and prevent resident .Verbal abuse: any use of oral, written, or gestured language that includes disparaging and derogatory terms to residents or their families, or within their hearing distance, to describe residents, regardless of their age, ability to comprehend or disability
The past non-compliance deficiency began on 1/21/24 and deficient practice corrected on 1/22/25 after the facility suspended CNA 8's employment, reported the incident to IDOH as required, re-inserviced all staff on abuse prevention, and began quality monitoring to prevent recurrance. Resident J was assessed for injury with none found and psychosocial monitoring put into place.
This Citation relates to Complaint IN00451712.
3.1-27(a)(b)
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0602
(Tag F0602)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to ensure residents were free from misappropriation of property for 4 of 4 residents reviewed (Resident K, Resident L, Resident M, and Residen...
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Based on interview and record review, the facility failed to ensure residents were free from misappropriation of property for 4 of 4 residents reviewed (Resident K, Resident L, Resident M, and Resident N).
The deficient practice was corrected on 1/22/25 prior to the start of the survey and was therefore past non-compliance.
Findings include:
A facility-reported incident was submitted to the Indiana Department of Health on 1/10/25, which indicated potential misappropriation of resident property had occurred and the facility was investigating the allegation.
On 2/3/25 at 3:10 P.M., the Director of Nursing (DON) was interviewed. She indicated she had been conducting routine compliance audits of controlled medication records when she noticed a pattern of administration. Licensed Practical Nurse 5 (LPN) administered opioid pain medications to residents with as needed orders for pain medication consistently and without assessment of pain prior to administration. The DON indicated LPN 5's documentation of administration was not completed according to facility policy and the administration records hadn't matched the controlled medication records but should have. During the compliance audits, the DON was notified, 1 opioid medication for Resident N hadn't been accounted for and the controlled medication record was off by 1 pill.
1. On 2/3/25 at 2:15 P.M., Resident K's record was reviewed. Diagnoses included status post pelvis fracture (9/24) and dementia.
A physician order, dated 9/30/24, was for Oxycodone 5 milligrams (mg)-give 2 tablets every 4 hours as needed for moderate to severe pain.
A Controlled Drug Record, initiated 10/18/24, indicated Oxycodone had been administered as ordered, 1 time on 10/23/24 by LPN 2. LPN 5 administered Oxycodone as ordered on 10/23/24, 11/3, 11/16, 11/20, 12/4, 12/7, 12/9, 12/15, 12/18, 12/23/24, 1/6/25, and 1/8/25. No other nurses administered Oxycodone to the resident.
The Medication Administration Records (MAR), dated October 2024, November 2024 and December 2024 had no documentation to indicate Oxycodone had been administered to Resident K on dates the medication was signed out on the controlled drug record by LPN 5.
2. On 2/3/25 at 2:30 P.M., Resident L's record was reviewed. Diagnoses included heel wound.
A physician order, dated 12/6/24, was for Hydrocodone-Acetaminophen 5-325 mg tablets-take 1 tablet every 6 hours as needed for moderate pain.
A Controlled Drug Record, initiated 12/16/24, indicated LPN 5 administered Hydrocodone as ordered on 12/28/24 at 8:00 a.m., 1/6/25 at 8:00 a.m. and 1:30 p.m., and on 1/8/25 at 7:30 a.m.
Medication Administration Records, dated December 2024 and January 2025, had no documentation to indicate Hydrocodone had been administered to the resident on dates the medication was signed out on the controlled drug record by LPN 5.
Resident L was interviewed by staff and police during the investigation. The resident indicated he hadn't asked for pain medication on 1/6/25 and hadn't remembered getting any. He indicated he only requested pain medication in the evenings/night time due to pain in his heel during those times.
3. On 2/3/25 at 3:00 P.M., Resident M's record was reviewed. Diagnoses included arthritis and chronic pain.
A physician order, dated 3/1/23, was for Hydrocodone 10-325 mg-give 1 tablet by mouth every 4 hours as needed for moderate pain.
A Controlled Drug Record, initiated 12/31/24, indicated Hydrocodone had been administered by LPN 5, on 1/8/25 at 3:30 p.m.
A MAR, dated January 2025, had not indicated on 1/8/25 Hydrocodone had been administered by LPN 5. The MAR indicated no doses of Hydrocodone had been administered on 1/8/25.
When questioned by staff, Resident M indicated she had not been give Hydrocodone on 1/8/25. Her last dose had been given on 1/7/25 around 9:00 p.m. by Nurse 3. The MAR and Controlled Drug Record indicated Hydrocodone had been signed out and administered on 1/7/25 at 9:07 p.m.
4. On 2/3/25 at 3:48 P.M., Resident N's record was reviewed. Diagnoses included pressure wound to back and buttocks.
A physician order, dated 11/16/24, was for Norco 5-325 mg tablets-give 1 tablet every 8 hours as needed for severe pain.
A Controlled Drug Record, initiated 11/22/24, indicated LPN 5 signed out Norco 1 tablet at 8:00 a.m. and 1:00 p.m. on 1/6/25 and on 1/8/25 at 10:30 a.m. The record indicated on 1/6/25 at 1:00 p.m., a Norco tablet was dropped and then wasted. LPN 5 signed their name but there was no second nurse signature as required for disposing of a controlled substance.
An email sent to the DON, dated 1/9/25, indicated LPN 7 worked on 1/6/25 and had counted the controlled medications with off-going nurse, LPN 5. LPN 7 indicated the record had been off for Resident N's Norco. There were supposed to be 25 tablets but there were only 24 tablets in the card holding the medication. LPN 7 questioned LPN 5 about the discrepancy. She indicated she wasn't sure if she'd accidentally pulled it and given to someone else in place of theirs but all other narcotics were accounted for. LPN 5 indicated to LPN 7 she would just write that it had been dropped and ask the unit manager or DON to sign for it later. Both the unit manager and DON were seated at the desk by the medication cart where the 2 nurses were counting but LPN 5 hadn't asked either to sign for her at that time. LPN 7 reported the discrepancy to the DON and unit manager after LPN 5 left the building.
A MAR, dated January 2025, had not indicated Norco had been administered by LPN 5 on 1/6/25 at 8:00 a.m. or at 1:00 p.m. The MAR hadn't indicated Norco had been administered by LPN 5 on 1/8/25 at 10:30 a.m. as signed out on the controlled drug record.
On 2/3/25 at 3:59 P.M., the Administrator was interviewed. He indicated the DON had notified him of the discrepancy with the controlled medication count and the pattern of administration by LPN 5. The police were contacted and report completed. LPN 5 was immediately suspended. The facility pharmacy conducted a facility wide reconciliation of all controlled medications on all units/residents with no further discrepancies found.
A current facility policy, titled Abuse Prevention Program, provided by the DON on 2/3/25 at 3:46 P.M., indicated: It is the policy of this facility to prohibit and prevent .misappropriation of resident property .is the deliberate misplacement, exploitation, or wrongful, temporary, or permanent, use of a resident's belongs or money without the resident's consent
The past non-compliance deficiency began on 1/10/24 and deficient practice corrected on 1/22/25 after the facility suspended LPN 5, then reported the incident to IDOH as required. Resident K, Resident L, Resident M, and Resident N were assessed for pain with no adverse effects, all nursing staff were inserviced on misappropriation of property, reporting, and drug diversion and quality monitoring initiated to prevent recurrance.
This Citation relates to Complaint IN00451002.
3.1-28(a)
Oct 2024
14 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure an advance directive (code status) was accurate for 1 of 7 r...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure an advance directive (code status) was accurate for 1 of 7 residents reviewed (Resident 4).
Findings include:
Resident 4's record was reviewed on [DATE] at 10:09 AM. Diagnoses included chronic obstructive pulmonary disease, (emphysema) unspecified dementia, schizoaffective disorder and bipolar disorder.
Resident 4's Quarterly Minimum Data Set, (MDS) dated [DATE], indicated their Brief Interview for Mental Status (BIMS) score was 15 (no cognitive deficit). The MDS indicated Resident 4 required substantial to maximum assistance for activities of daily living.
Resident 4's Care Plan, dated [DATE], indicated their code status was Do Not Resuscitate (DNR).
A physician order, revision date [DATE], indicated DNR status had been discontinued.
A Cardiopulmonary Resuscitation (CPR) Status Form, signed by Resident 4's representative on [DATE] indicated the resident's code status was to have CPR initiated. Resident 4's physician signed the form on [DATE].
In an interview on [DATE] at 12:01 PM, the DON indicated they were not aware of Resident 4's CPR code status. The DON indicated resident code status should be the same throughout each document in the resident's record.
A current undated facility policy, provided by the Regional Nurse Consultant on [DATE] at 11:51 AM, indicated each resident's choice of advance directive would be honored and incorporated into their plan of care. The policy indicated advance directive choices would be reviewed annually and as needed.
3.1-4(d)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure family notification of an episode of resident-to-resident co...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure family notification of an episode of resident-to-resident contact for 1 of 2 residents reviewed (Resident 63).
Findings include:
Resident 63's record was reviewed on 9/30/24 at 1:13 PM. Diagnoses included dementia with mood disturbance, Parkinson's Disease, major depressive disorder, anxiety disorder and visual hallucinations.
Resident 63's Quarterly Minimum Data Set (MDS), dated [DATE], indicated the resident's Brief Interview for Mental Status (BIMS) score was 3 (severe cognitive impairment). The MDS indicated Resident 63 required substantial to maximal assistance to roll left and right, to move from a lying to a sitting position and to move from a sitting to a standing position.
Resident 63's Care Plan, dated 12/8/23, indicated the resident did not participate in many activities. The Care Plan Indicated Resident 63 mostly sat in the background and watched others. The target goal was for the resident to participate in activities of interest at least 2 times a week through 12/9/24. Interventions included the determination that religious beliefs and religious activities were important to Resident 63.
A Behavior Charting note, dated 9/18/24 at 5:19 PM, indicated Resident 63 kissed another resident (Resident 49) on the lips in the dining room. Separation of the residents was effective.
Resident 63's progress notes, dated 9/18/24 through 9/30/24, did not indicate the resident's family representative had been made aware of the resident kissing another resident. The progress notes did not indicate the episode had been reported to the family or the resident's physician.
In an interview, on 10/1/24 at 1:36 PM, The Social Service Director (SSD) indicated the kiss between Resident 63 and Resident 49 was a brief peck on the lips. The SSD indicated the incident was not reportable as both the residents had a diagnosis of dementia. The SSD indicated the kiss was not sexual. The SSD indicated Resident 63 was a willing participant. The SSD indicated although Resident 49 currently displayed sexual behaviors the kiss was friendly. The SSD indicated Resident 49's sexual behaviors had improved with medication and was now easily redirected. The SSD indicated they were not aware of further information related to the kissing episode as they were not at work that day. The SSD indicated the Administrator may have further information in their office.
In an interview, on 10/1/24 at 2:05 PM, the Administrator indicated they had not been made aware of Resident 63 and Resident 49 kissing and did not believe they had any further information related to family and/or physician notification of the incident.
A current policy titled, Guidelines for Incidents/Accidents/Falls dated 6/30/23, provided by the Registered Nurse (RN) 27 on 9/27/24 at 11:51 AM, indicated the facility would ensure any incident/accident/fall that met reporting criteria would be identified and reported accurately and timely to appropriate persons and agencies which included follow-up reporting.
3.1-5(a)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure contents of a urinary catheter bag were not vis...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure contents of a urinary catheter bag were not visible from the hallway for 1 of 2 residents reviewed (Resident 44).
Findings include:
During an observation, on 9/25/24 at 9:42 AM, Resident 44 was lying in bed in a semi-reclined position with a catheter bag attached to the bedframe and facing the door. Resident 44's door was open, his bag was in plain sight and visible from the hallway. The bag was about half full of yellow liquid.
During an observation on 9/26/24 at 6:44 PM, Resident 44 was lying in bed with a catheter bag attached to the bedframe and facing the door with about 200 milliliters of yellow liquid in the bag. The bag was in plain sight from the hallway.
During an observation, on 9/27/24 at 2:50 PM, Resident 44 was lying in bed with a catheter bag attached to the bedframe and facing the hallway about two-thirds full of yellow liquid.
During an interview, on 9/27/24 at 2:50 PM, Licensed Practical Nurse (LPN) 25 indicated catheter bags should be emptied at the end of the traditional day shift, around 2:00 PM. She indicated catheter bags should be anchored on the other side of the bed so it would not be visible from the hallway, protecting resident privacy. She indicated a privacy cover should be in place on the bag to keep urine from being visible to the casual observer.
Resident 44's record was reviewed on 9/27/24 at 3:19 PM. Diagnoses included benign prostatic hyperplasia with lower urinary tract symptoms, retention of urine, and neuromuscular dysfunction of the bladder.
Resident 44's current quarterly Minimum Data Set (MDS), dated [DATE], indicated their Basic Interview for Mental Status (BIMS) score was 7 (cognitively impaired). The MDS indicated the resident used an indwelling urinary catheter.
Resident 44's current care plan titled Catheter indicated the resident had a problem of requiring the use of an indwelling catheter, with a goal date of 11/19/24. Interventions included ensuring a dignity bag was in place.
In an interview, on 9/27/24 at 3:11 PM, Regional Nurse Consultant 27 indicated the catheter bag containing urine should have been covered and its contents should not be visible from the hallway.
A current policy titled Catheters, undated, provided by Regional Nurse Consultant 27 on 9/27/24 at 3:20 PM, did not address providing privacy by covering the catheter bag to prevent visibility of the contents by casual observers. No other policies pertaining to maintaining privacy for a resident requiring an indwelling catheter were available for review.
3.1-3(p)(2)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to prevent abuse for 1 of 2 residents reviewed (Resident 41).
Findings...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to prevent abuse for 1 of 2 residents reviewed (Resident 41).
Findings include:
An Indiana State Department of Health Survey Report System Incident Number 189, dated 9/13/24 at 2:45 PM, indicated Resident 41's family member got loud with the resident during a visit at the facility. Immediate action taken was the removal of Resident 41's visitor from the facility. A preventative measure was the visitor not being permitted at the facility during the investigation. Follow up on 9/20/24 indicated on 9/13/24 a verbal altercation was overheard in Resident 41's room. The visitor was identified as Resident 41's Power of Attorney (POA). The visitor seemed intoxicated as evidenced by their appearance and smell. The visitor was asked to leave the facility immediately. Resident 41 voiced concern the visitor would return. Adult Protective Services recommended a visit restriction and a possible guardianship change. Resident 41's visitation was to be monitored for the next 30 days. Resident 41's Care Plan was reviewed and updated.
Resident 41's record was reviewed on 9/27/24 at 3:00 PM. Diagnoses included systemic lupus erythema, adult failure to thrive, anxiety disorder, bipolar disorder, schizophrenia, cognitive communication deficit, obsessive compulsive disorder, depression, agoraphobia with panic disorder and posttraumatic stress disorder (PTSD).
Resident 41's Quarterly Minimum Data Set, (MDS) dated [DATE], indicated their Brief Interview for Mental Status (BIMS) score was 6 (severe cognitive impairment). The MDS indicated Resident 41had a gastrointestinal (g tube) feeding tube.
Resident 41's Care Plan, dated 5/22/24, indicated the resident had a history of trauma and Resident 41's triggers were still being determined. Resident 41 coped by speaking with their boyfriend (the visitor and POA who had been restricted from visitation). The target goal was for the resident to feel safe and comfortable through 11/22/24. Interventions included findings things of comfort and encouraging the resident to use them.
Resident 41's Care Plan did not indicate Resident 41's visitation was to be monitored. The Care Plan did not indicate Resident's POA could not visit. The Care Plan did not indicate the facility had witnessed the abuse of Resident 41 on 9/13/24.
A progress note, dated 9/13/24 at 4:11 PM, indicated Resident 41's boyfriend had been verbally abusive. The boyfriend was noted to use a loud voice and told Resident 41 they should stop crying and to get up and walk. Resident 41 had been crying and reported they were afraid of their boyfriend. The boyfriend left the facility after being asked to calm down.
A progress note, dated 9/22/24 at 1:27 PM, indicated Resident 41's POA was observed sitting in a chair in the resident's room while the resident was in the dining room. Resident 41's POA left the facility when reminded they were not allowed to visit.
Resident 41's [NAME] (care plan summary for direct care staff) did not indicate the resident's visitation was to be monitored. The [NAME] did not indicate the resident's POA was not permitted to visit.
In an interview, on 10/1/24 at 11:40 AM, Qualified Medication Aide (QMA) 28 indicated they were not aware of Resident 41's visitation monitoring. QMA 28 indicated they did not work Resident 41's unit very often. QMA 28 indicated they were aware of Resident 41's boyfriend being nasty to the resident in the past.
In an interview, on 10/1/24 at 1:36 PM, The Social Service Director (SSD) indicated Resident 41 had an extensive history of trauma that included multiple sexual assaults. The SSD indicated Resident 41's boyfriend had left Resident 41 unattended at home for an undetermined length of time. The SSD indicated Resident 41's boyfriend was their Power of Attorney. The SSD indicated the facility was aware of Resident 41's boyfriend's past abusive episodes at the facility. The SSD indicated the episode on 9/13/24 was the first time Resident 41 had asked for help. The SSD indicated they had provided copies of all Resident 41's documentation available.
A current facility policy, dated 10/22/22, indicated the facility would identify residents with increased vulnerability for neglect, abuse or mistreatment. The facility would identify risk factors and incorporate the factors into the care plan to monitor and reevaluate.
3.1-27(a)(b)
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 19's record was reviewed on 9/27/24 at 10:00 AM. Diagnoses included bipolar disorder, anxiety disorder, delusional d...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 19's record was reviewed on 9/27/24 at 10:00 AM. Diagnoses included bipolar disorder, anxiety disorder, delusional disorders, complete traumatic amputation of right lower leg, idiopathic peripheral autonomic neuropathy, muscle weakness, and lack of coordination.
Resident 19's current quarterly Minimum Data Set (MDS), dated [DATE], indicated her Basic Interview for Mental Status (BIMS) score was 8, moderate cognitive impairment. The MDS indicated for 7 to 11 days in a period of 14 days, she felt tired or had little energy, had trouble concentrating, poor appetite and was on an antidepressant. The MDS indicated she had lost weight of 5% in the last month or 10% in last 6 months and was not on Physician prescribed weight loss regimen. The MDS indicated the resident was impaired on 1 side of her lower extremity and used a wheelchair. The MDS indicated she required substantial/maximal assist with rolling left to right, transfers, and toileting.
Resident 19's current care plan, initiated 2/12/24, indicated her care plan focus was high risk for elopement/wandering related to her bi-polar disorder. The goal of her focus area was the resident would not wander out of the facility or off the floor with a target date of 11/7/24. Interventions included wanderguard in placed initiated 6/10/24, assess/record/report to Medical Doctor (MD) risk factors for potential elopement initiated 2/12/24, and supervise closely and make regular compliance rounds whenever the resident was in her room initiated 2/12/24.
A Care Plan Meeting progress note, dated 5/2/24 at 8:54 AM, indicated when Resident 19 wouo ld outside she was to be monitored. The note indicated the resident was not able to physically sign for herself anymore. The note indicated the facility was requesting the MD to evaluate Resident 19 to see if guardianship (a legal process that gives a person or entity the authority to make decisions for another person, called a ward, who is considered incompetent) was appropriate.
A Progress note, dated 6/9/24 at 1:11 PM, indicated Resident 19 was found by activity personnel outside on the pavement of the parking lot lying on her right side. The resident told the staff a visitor let her out of the building. The resident indicated she fell from the sidewalk curb and reported hitting her head. Abrasions were found on the resident's left knee, redness found on her right elbow/shoulder, and swelling/discoloration on the right side of her forehead/temple. Resident 19 reported slight pain to her head and right hip immediately after the incident; ice was applied to the area.
In an interview, on 10/2/24 at 1:42 PM, the Director of Nursing (DON) indicated Former Employee 45, working on the Assisted Living unit, was looking out the large main window in the Facility's Assisted living (located midway down the unit) and observed Resident 19 exit the building. The DON indicated Employee 45 went to find the Resident 19 (through half the corridor of the Assisted living, through the facility's lobby, through one set of doors, through anti-room, through second set of doors, and to the outside of the building). The DON indicated Former Employee 45 indicated before she could reach Resident 19 she fell out of her wheelchair outside the facility. The DON indicated the incident was reviewed and it was decided it was not an elopement (a resident who leaves a healthcare facility without authorization or supervision).
In an interview, on 9/30/24 at 11:40 AM, the Administrator indicated Resident 19's elopement had not been reported to the proper agencies.
A current policy titled, Guidelines for Incidents/Accidents/Falls dated 6/30/23, provided by the Registered Nurse (RN) 27 on 9/27/24 at 11:51 AM, indicated the facility would ensure any incident/accident/fall that met reporting criteria would be identified and reported accurately and timely to appropriate agencies which included follow-up reporting.
3.1-28(c)
Based on interview and record review, the facility failed to ensure unusual incidents were reported to the appropriate agencies for 2 of 2 residents reviewed (Resident 63 and Resident 19).
Findings include:
1. Resident 63's record was reviewed on 9/30/24 at 1:13 PM. Diagnoses included dementia with mood disturbance, Parkinson's Disease, major depressive disorder, anxiety disorder and visual hallucinations.
Resident 63's Quarterly Minimum Data Set (MDS) dated [DATE], indicated the resident's Brief Interview for Mental Status (BIMS) score was 3 (severe cognitive impairment). The MDS indicated Resident 63 required substantial to maximal assistance to roll left and right, to move from lying to a sitting position and to move from a sitting to standing position.
A Behavior Charting note, dated 9/18/24 at 5:19 PM, indicated Resident 63 kissed another resident (Resident 49) on the lips in the dining room. Separation of the residents was effective.
Resident 63's progress notes, dated 9/18/24 through 9/30/24, did not indicate the resident's family representative had been made aware of the resident kissing another resident. The progress notes did not indicate the episode had been reported to the appropriate agencies.
Resident 63's Care Plan, dated 12/8/23, indicated the resident did not participate in many activities. The Care Plan Indicated Resident 63 mostly sat in the background and watched others. The target goal was for the resident to participate in activities of interest at least 2 times a week through 12/9/24. Interventions included the determination that religious beliefs and religious activities were important to Resident 63.
In an interview on 10/1/24 at 1:36 PM, The Social Service Director (SSD) indicated the kiss between Resident 63 and Resident 49 was a brief peck on the lips. The SSD indicated the incident was not reportable as both the residents had a diagnosis of dementia. The SSD indicated the kiss was not sexual. The SSD indicated Resident 63 was a willing participant. The SSD indicated although Resident 49 currently displayed sexual behaviors the kiss was friendly. The SSD indicated Resident 49's sexual behaviors had improved with medication and was now easily redirected. The SSD indicated they were not aware of further information related to the kissing episode as they were not at work that day. The SSD indicated the Administrator may have further information in their office.
In an interview, on 10/1/24 at 2:05 PM, the Administrator indicated they were not aware of the kissing episode between Resident 63 and Resident 49 so had not reported it.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the elopement of a resident was investigated f...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the elopement of a resident was investigated for 1 of 2 residents reviewed (Residents 19).
Findings include:
Resident 19's record was reviewed on 9/27/24 at 10:00 AM. Diagnoses included bipolar disorder, anxiety disorder, delusional disorders, complete traumatic amputation of right lower leg, idiopathic peripheral autonomic neuropathy, muscle weakness, and lack of coordination.
Resident 19's current quarterly Minimum Data Set (MDS), dated [DATE], indicated her Basic Interview for Mental Status (BIMS) score was 8, moderate cognitive impairment. The MDS indicated for 7 to 11 days in a period of 14 days, she felt tired or had little energy, had trouble concentrating, poor appetite and was on an antidepressant. The MDS indicated she had lost weight of 5% in the last month or 10% in last 6 months and was not on Physician prescribed weight loss regimen. The MDS indicated the resident was impaired on 1 side of her lower extremity and used a wheelchair. The MDS indicated she required substantial/maximal assist with rolling left to right, transfers, and toileting.
Resident 19's current care plan, initiated 2/12/24, indicated her care plan focus was high risk for elopement/wandering related to her bi-polar disorder. The goal of her focus area was the resident would not wander out of the facility or off the floor with a target date of 11/7/24. Interventions included a wanderguard was placed initiated 6/10/24, assess/record/report to Medical Doctor (MD) risk factors for potential elopement initiated 2/12/24, supervise closely and make regular compliance rounds whenever the resident was in her room initiated 2/12/24.
A Care Plan Meeting progress note, dated 5/2/24 at 8:54 AM, indicated when Resident 19 would go outside she was to be monitored. The note indicated the resident was not able to physically sign for herself anymore. The note indicated the facility was requesting the MD to evaluate Resident 19 to see if guardianship (a legal process that gives a person or entity the authority to make decisions for another person, called a ward, who is considered incompetent) was appropriate.
A Progress note, dated 6/9/24 at 1:11 PM, indicated Resident 19 was found outside by activity personnel on the pavement of the parking lot lying on her right side. The resident indicated a visitor her out of the building. The resident fell from the sidewalk curb and reported hitting her head. Abrasions were found on the resident's left knee, redness found on her right elbow/shoulder, swelling/discoloration on the right side of her forehead/temple. Resident 19 reported slight pain to her head and right hip immediately after the incident; ice was applied to the area.
In an interview, on 10/2/24 at 1:42 PM, the Director of Nursing (DON) indicated Former Employee 45, working on the Assisted Living unit, was looking out the large main window in the Facility's Assisted living (located midway down the unit) and observed Resident 19 exit the building. The DON indicated Employee 45 went to find the Resident 19 (through half the corridor of the Assisted living, through the facility's lobby, through one set of doors, through anti-room, through second set of doors, and to the outside of the building). The DON indicated Former Employee 45 indicated before she could reach Resident 19 she fell out of her wheelchair outside the facility. The DON indicated the incident was reviewed and was decided it was not an elopement (a resident who leaves a healthcare facility without authorization or supervision) and was not investigated as an elopement.
A current policy titled, Guidelines for Incidents/Accidents/Falls dated 6/30/23, provided by the Registered Nurse (RN) 27 on 9/27/24 at 11:51 AM indicated the facility would ensure any incident/accident/fall would be identified, reported accurately and timely to appropriate agencies, investigated, and resolved.
3.1-28(c)
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
Based on interview, and record review the facility failed to ensure showers were consistently offered for 1 of 6 residents reviewed (Resident 76).
Findings include:
During an interview, on 9/26/24 at ...
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Based on interview, and record review the facility failed to ensure showers were consistently offered for 1 of 6 residents reviewed (Resident 76).
Findings include:
During an interview, on 9/26/24 at 10:08 AM, Resident 48 indicated he was not getting showers on a regular basis. He indicated he was supposed to have a shower on Wednesdays and Saturdays at 3:00 pm. He indicated when staff did not show up to give him a shower, he would frequently go to the nurses' station to find out what was going on and was told they were short staffed.
Resident 48's record was reviewed on 9/30/24 at 10:25 AM. Diagnoses included cerebral infarction due to thrombosis of right posterior cerebral artery, hemiplegia and hemiparesis following cerebral infarction affecting left, non-dominant side, and diabetes mellitus, type 2 without complications.
Resident 48's current quarterly Minimum Data Set (MDS) indicated their Basic Interview for Mental Status (BIMS) score was 15 (cognitively intact). The MDS indicated Resident 48 required moderate assistance with bathing and rejection of care was not exhibited.
Resident 48's current care plan titled Preferences indicated Resident 48 expressed choices regarding his personal care was important to him, with a goal date of 10/4/24. Interventions included showering twice weekly around 3:00 PM.
Resident 48's current care plan titled ADL (Activity of Daily Living) Self-Care Performance indicated the resident had a problem of a self-care deficit related to a cerebral infarction, with a goal date of 10/4/24. An intervention titled Personal Hygiene Routine indicated the resident prefered being shaved weekly and hands washed. Interventions did not include specifications on assistance provided for showering or any other hygiene.
Progress notes, dated 8/6/24 at 6:11 PM, indicated Resident 48's skin was dry over his entire body and at high risk for skin breakdown. The notes indicated Nurse Practitioner (NP) 34 recommended Resident 34 receive good hygiene and skin care to prevent skin breakdown.
An undated document titled Southwest Shower List indicated Resident 48 should receive showers on evening shift on Wednesdays and Saturdays.
Shower/Skin Alteration Worksheets, dated September 2024, indicated Resident 48 received showers on 9/6/24, 9/11/24 and 9/25/24. A worksheet for 9/15/24 indicated Resident 48 refused his shower. No other showers or offerings of a shower were recorded between 9/11/24 and 9/25/24.
A form titled I would like to know . provided by the Director of Nursing on 9/26/24 at 9:10 AM, indicated on 9/5/24, Resident 48 indicated he was concerned about missing showers. The Administrator's response noted on the form, dated 9/9/24, indicated Resident 48 received the first shower that week and had refused the second shower. He indicated the resident should receive showers on Wednesdays and Saturdays and he would review all shower schedules.
In an interview, on 9/26/24 at 7:06 PM, Licensed Practical Nurse (LPN) 22 indicated evening shift showers were not being done consistently for the prior few months due to lack of staff to complete them.
In an interview on, 10/1/24 at 10:16 AM, the Director of Nursing indicated she could not find any documentation of showers being provided or offered and refused between 9/11/24 and 9/25/24, except for a refusal recorded on a shower worksheet on 9/15/24. She indicated when staff were unable to provide a shower for a resident, it should be offered to the resident as soon as possible. She indicated habitual refusals would have been documented in a progress note and care planned. She indicated she was not aware of habitual refusals by Resident 48.
A current policy titled Guidelines for Bathing, provided by the Administrator on 10/1/24 at 1:42 PM indicated bathing should occur to cleanse the skin and promote circulation.
This citation is related to complaint IN00443976.
3.1-38(b)(3)
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) During an observation on 9/26/24 at 6:43 PM, a loud male voice was heard yelling for help. Resident 5 was lying on the floor ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) During an observation on 9/26/24 at 6:43 PM, a loud male voice was heard yelling for help. Resident 5 was lying on the floor on his right side next to a piano located across the hall from the dining room at the far end of the hall. Resident 5 was lying on his back turned slightly to the left on the floor with his feet near the piano positioned along the wall, his torso and head positioned toward the hallway. Licensed Practical Nurse (LPN) 22, LPN 25, and Registered Nurse (RN) 46 approached Resident 5 and asked him if he had any pain. Resident 5 indicated he had pain in his bottom. LPN 22, LPN 25, and RN 46 began to assist Resident 5 away from the piano bench, Resident 5 yelled out and complained of pain.
Resident 5's current quarterly Minimum Data Set (MDS), dated [DATE], indicated their Basic Interview for Mental Status (BIMS) score was 4 (cognitively impaired). The MDS indicated the resident required moderate assistance to mobilize his wheelchair 50 feet with two turns and substantial assistance to mobilize his wheelchair 150 feet.
Resident 5's current care plan, titled Pain indicated the resident had a problem of pain/discomfort, with a goal date of 11/5/24. Interventions included assess pain, notify physician as needed, acknowledge presence of pain and discomfort, listen to the resident's concerns, and document and report complaints and nonverbal signs of pain.
Progress notes, dated 9/26/24 at 8:31 PM, indicated Resident 5 was heard yelling down the hall. He was found lying on the floor by the dining room with his head toward the dining room doors and feet toward the piano in lounge area. The notes indicated the resident was assessed for injuries with none found and assisted by 3 staff back into his chair. The resident was then assisted to the nurses' station for close monitoring. Vital signs and neurological checks were normal for the resident. The physician, family and Director of Nursing were notified.
Progress notes, dated 9/27/24 at 1:49 PM, indicated two nurses attempted to assist Resident 5 to the toilet. When he stood while receiving the usual amount of assistance, he yelled out complaining of pain and indicated the pain was in his right hip. The physician was contacted with orders received to send to the emergency room for evaluation and treatment.
Progress notes, dated 9/27/24 at 9:15 PM, indicated the nurse had received report from the hospital at about 5:00 PM and the resident was expected to return to the facility. The notes indicated the resident returned to the facility with new orders around 8:30 PM. No pain assessments were available for review.
Emergency Department (ED) notes, dated 9/27/24 at 1:42 PM, indicated Resident 5 was brought into the ED with a complaint of right hip pain after a fall the previous evening.
A hospital Xray report, dated 9/27/24 at 2:30 PM, indicated Resident 5 had a comminuted nondisplaced fracture of the right ischial tuberosity (part of the bone in the lower pelvis).
No progress notes or assessments related to pain interventions between 9/27/24 and 9/28/24 were available for review.
Progress notes, dated 9/29/24 at 4:46 PM, indicated Resident 5 had a fractured pelvis. No pain assessments were available for review.
A medication administration record (MAR), dated 9/29/24 at 2:52 PM, indicated Resident 5 received a one-time dose for oxycodone 5 mg, one tablet by mouth for pain. No pain assessment was available for review.
Progress notes, dated 9/30/24 at 5:51 PM, indicated Resident 5 had increased pain and discomfort. New orders for oxycodone 5 mg, two tablets by mouth every four hours as needed for pain was received.
Resident 5's record was reviewed on 10/1/24 at 11:15 AM. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, weakness, vascular dementia, and impulse disorder.
In an interview, on 10/1/24 at 11:30 AM, LPN 47 indicated residents should be checked for injuries prior to moving when found on the floor. When a resident would report pain, the doctor would be notified, and his orders should be followed before moving the resident.
A current policy titled Guidelines for Incidents/Accidents/Falls, dated 6/30/23, provided by Regional Nurse Consultant 27 on 9/30/24 at 2:25 PM, indicated upon the occurrence of a fall, a nurse should assess the resident for pain and notify the provider. The policy indicated documentation of the resident's physical and mental status should be completed at least every shift over the next 72 hours or until the condition improved.
3.1-37(a)
Based on observation, interview and record review the facility failed to ensure supervision and maintain seizure precautions for 2 of 6 residents reviewed (Resident 32 and Resident 5).
Findings include:
During an observation, on 9/26/24 at 11:12 AM, upon entering the memory Care unit, a voice was heard calling for help. A staff member was observed entering the shower room. A voice was heard asking who the nurse was. The Director of Nursing (DON) wsa observed entering the shower room.
On 9/26/24 at 11:55 AM, Resident 32 was observed leaving the unit on a gurney escorted by 2 paramedics. Resident 32 was covered with a blanket.
In an interview, on 9/26/24 at 11:57 AM, Certified Nurse Aide (CNA) 30 indicated they had started working at the facility on 9/12/24 and they were being trained by CNA 35. CNA 30 indicated they entered the shower room after hearing the resident call for help. CNA 30 observed Resident 32 sitting on the floor in the shower with their right arm stuck in the handrail. CNA 30 indicated they were unable to remove Resident 32's arm from the handrail. CNA indicated Resident 32 had been in the shower room alone since 10:55 AM. CNA 30 indicated they were directed to place Resident 32 in the unsupervised by CNA 35. CNA 30 indicated they were not permitted to provide direct care to the residents until their training was complete but had been providing direct care due to a staffing shortage. CNA 30 indicated they were directed by CNA 35 to provide direct care due to low staffing.
In an interview, on 9/26/24 at 12:05 PM, CNA 35 indicated Resident 32 was unsupervised in the shower room due to low staffing. CNA 35 indicated the unit had been short staffed for a few months. CNA 35 indicated the unit was often staffed with 1 CNA and 1 Qualified Medication Aide (QMA) (A CNA with medication training). CNA 35 indicated the unit QMA was on a break due to having stayed over from night shift. CNA 35 indicated the facility management was aware of the short staffing issues. CNA 35 indicated the corporate office would not allow the facility to use a staffing agency due to the cost. CNA 35 indicated CNAs in training were not supposed to provide resident care. CNA 35 indicated the Unit Manager had directed the CNA in training to provide direct care to residents due to low staffing. CNA 35 indicated the Unit Manager had directed the unsupervised shower of Resident 32.
Resident 32's record was reviewed on 9/26/24 at 2:10 PM. Diagnoses included dementia, osteoarthritis, osteoporosis, and seizure disorder.
Resident 32's Annual Minimum Data Set, (MDS) dated [DATE], indicated their Brief Interview for Mental Status (BIMS) score was 13 (no cognitive impairment). The MDS indicated the resident required partial to moderate assistance with showering or bathing. The MDS indicated the resident had 2 or more recent falls.
Resident 32's Care Plan, dated 12/28/23, indicated the resident had a self-care deficit. The target goal was for the resident to participate in self-care with supervision through 9/17/24. Interventions included assisting the resident according to the resident's level of need and offering frequent rest breaks.
Resident 32's Care Plan, dated 8/22/24, indicated the resident was at risk for falls. The target goal was to reduce risks to avoid significant injury from falls through 9/17/24. Interventions included increasing supervision and referring the resident to therapy.
Resident 32's Care Plan, dated 9/7/24, indicated the resident required therapy due to decreased leg strength, impaired balance, decreased walking ability and a recent fall. The target goal was for the resident to receive therapy services through 9/17/24. Interventions included gait training, therapeutic exercise and neuromuscular re-education.
Resident 32's Care Plan did not address their diagnosis of a seizure disorder.
An Incident Description, dated 5/5/24 at 4:45 PM, indicated Resident 32 had a seizure while walking in the dining room.
A Fall Risk Review, dated 5/6/24 at 12:50 PM, indicated Resident 32 had a fall risk of 10. The resident had normal gait and balance.
An IDT note, dated 5/6/24 at 9:15 AM, indicated Resident 32 had a fall due to increased seizure activity. A new intervention was for the resident to be assisted by a staff member while walking until the resident was evaluated by a neurologist.
An Incident Description, dated 7/9/24 at 6:30 PM, indicated Resident 32 had a seizure in their bathroom and had a laceration to their lip.
An IDT note, dated 7/9/24 at 12:19 PM, indicated the resident had a fall due to seizure activity. A new intervention was to encourage the resident to call for assistance with toileting.
A physician order, dated 5/16/24, indicated Resident 32 may have a camera in their room for safety due to a diagnosis of seizure disorder.
Resident 32's physician orders did not indicate they were to have any other seizure or fall precautions.
Resident 32's current [NAME], (care plan summary for CNAs), dated 9/26/24, indicated the resident had a camera in their room. The [NAME] did not indicate the resident was at risk for falls. The [NAME] did not indicate the resident had a seizure disorder or what interventions should be inplace to prevent falls.
In an interview, on 9/30/24 at 2:50 PM, the DON indicated Resident 32 should not have been unsupervised in the shower room. The DON indicated Resident 32's Care Plan should have included interventions for seizure and fall precautions. The DON indicated seizure precautions and fall risk precautions should have been included on the resident's [NAME] and omplemented from the care plan.
An undated current facility policy, provided by the Regional Nurse Consultant on 9/27/24 at 11:51 AM, indicated residents were to never be left unattended in the shower room.
A current facility policy, dated 6/20/23, provided by the Regional Nurse Consultant on 9/27/24 at 11:51 AM, indicated internal risk factors for falls included confusion, unstable joints, confusion, and weakness of the legs. The policy indicated external risk factors for falls included wet floors. The policy indicated the resident's [NAME] would be updated as indicated.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0699
(Tag F0699)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide trauma informed care by identifying triggers t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide trauma informed care by identifying triggers to minimize re-traumatization for 1 of 2 residents reviewed (Resident 41).
Findings include:
Resident 41's record was reviewed on 9/27/24 at 3:00 PM. Diagnoses included systemic lupus erythema, adult failure to thrive, anxiety disorder, bipolar disorder, schizophrenia, cognitive communication deficit, obsessive compulsive disorder, depression, agoraphobia with panic disorder and posttraumatic stress disorder (PTSD).
Resident 41's Quarterly Minimum Data Set, (MDS), dated [DATE], indicated their Brief Interview for Mental Status (BIMS) score was 6 (severe cognitive impairment). The MDS indicated Resident 41had a gastrointestinal (g tube) feeding tube.
Resident 41's Care Plan, dated 5/20/24, indicated the resident had a diagnosis of PTSD. The target goal was for Resident 41 to be symptom free through 11/22/24. Interventions included sensitivity to the resident's feelings, encouragement of healthy coping strategies, open discussion, administration of psychoactive medications, observance and documentation of behaviors. The Care Plan did not indicate potential triggers for behaviors. The Care Plan did not indicate specific PTSD symptoms.
Resident 41's Care Plan, dated 5/22/24, indicated the resident had a history of trauma. Resident 41's triggers were still being determined. Resident 41 coped by speaking with their boyfriend. The target goal was for the resident to feel safe and comfortable through 11/22/24. Interventions included findings things of comfort and encouraging the resident to use them.
A Trauma Screening, dated 5/21/24, indicated Resident 41's trauma score was 4. The screening indicated the score was determined by the number of yes answers. The screening indicated a score of 5 or more was high risk for trauma related symptoms.
A progress note, dated 5/28/24 at 9:40 AM, indicated Resident 41 had a history of tobacco use, alcohol use and elicit drug use. Resident 4 1 had been found in an unresponsive state at home by their boyfriend. Resident 41 had been covered with urine and stool for an unknown amount of time.
A progress note, dated 9/13/24 at 4:11 PM, indicated Resident 41's boyfriend had been verbally abusive. The boyfriend was noted to use a loud voice and told Resident 41 they should stop crying and to get up and walk. Resident 41 had been crying and reported they were afraid of their boyfriend. The boyfriend left the facility after being asked to calm down. Adult Protective Services (APS) were notified.
Resident 41's [NAME] (care plan summary for direct care staff) did not indicate the resident had PTSD. The [NAME] indicated Resident 41 would be symptom free through 11/22/24. Interventions included being sensitive to feelings, encouraging healthy coping mechanisms, acknowledgment by the resident of safety, open discussion by the resident, psychoactive medications and observation and documentation of behaviors.
A progress note, dated 924/24 at 2:40 AM, indicated Resident 41 had been calling out for their boyfriend.
A progress note, dated 9/20/24 at 2:42 PM, indicated Resident 41had been lying in bed yelling out. Resident 41 was calling for help and had stated he said I am going to lose my apartment if I don't go home and work.
A progress note, dated 9/15/24 at 11:16 AM, indicated Resident 41 had been screaming and crying. Resident 41 kept referring to a traumatic event that had occurred on Friday.
A new medication for panic disorder was ordered by the Psychiatric Nurse Practitioner.
On 9/27/24 at 3:00 PM, Resident 41 was observed sitting in their wheelchair near the nurse station crying. Resident 41 indicated they did not have a car and asked to borrow a car or get a ride with someone to leave the facility.
In an interview, on 10/1/24 at 11:40 AM, Qualified Medication Aide (QMA) 28 indicated they were not aware of Resident 41's visitation monitoring. QMA 28 indicated they did not work Resident 41's unit very often. QMA 28 indicated they were aware of Resident 41's boyfriend being nasty to the resident in the past.
In an interview, on 10/1/24 at 1:36 PM, The Social Service Director (SSD) indicated Resident 41 had an extensive history of trauma that included multiple sexual assaults. The SSD indicated Resident 41's boyfriend had left Resident 41 unattended for an undetermined time. The SSD indicated they were not aware of any specific triggers or stressors. The SSD indicated the facility was aware of Resident 41's abusive episodes in the past. The SSD indicated Resident 41's boyfriend was the resident's Power of Attorney (POA). The SSD indicated the episode on 9/13/24 was the first time Resident 41 had asked for help. The SSD provided Resident 41's Adult Protective Services (APS) Case Manager contact information. The SSD indicated they had provided copies of all Resident 41's documentation.
A current facility policy, dated 12/6/16, provided by the Regional Nurse Consultant on 9/30/24 at 9:30 AM, indicated all individuals should be treated as if they may have experienced trauma. The policy indicated trauma is primary to the development of addiction and mental health problems. The policy indicated the facility must ensure culturally competent, trauma informed care with professional standards of practice in order to eliminate or mitigate triggers that may cause re-traumatization.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0744
(Tag F0744)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure specific resident behaviors were identified, in...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure specific resident behaviors were identified, investigated and communicated with individualized interventions for a resident with dementia for 1 of 1 resident reviewed (Resident 49).
Findings include:
On 9/26/24 at 11:15 AM, Resident 49 was observed standing up from dining room table. Resident 49 was observed walking while pushing their locked wheelchair. Resident 49 spoke in an agitated voice when they were being followed.
Resident 49's record was reviewed on 9/27/24 at 11:36 AM. Diagnoses included alcohol dependence with alcohol induced dementia, anxiety disorder, major depressive disorder, psychotic disorder with hallucinations and mild cognitive impairment.
Resident 49's admission Minimum Data Set (MDS), dated [DATE], indicated Resident 49's Brief Interview for Mental Status (BIMS) was 10 (moderate cognitive impairment). The MDS indicated Resident 49 required partial to moderate assistance with mobility, bathing and dressing. The MDS indicated Resident 49 had diagnoses of non-Alzheimer's dementia, anxiety and depression.
Resident 49's Care Plan, dated 7/29/24, indicated the resident displayed behaviors of hitting, kicking, pinching, throwing things, delusions, hallucinations, raising of voice, making sexual comments, irritability, lashing out and being nervous around other people. The target goal was the resident would have no side effects from medications and their needs would be met without injury to self or others through 12/10/24. Interventions included calling family, minimize private interactions with another specific resident, redirection, watch TV, discuss archery and play music. Resident 49's Care Plan did not include resident specific stressors or triggers to their behaviors. The Care Plan interventions did not include attempting to identify resident specific triggers or stressors.
Resident 49's Care Plan did not address their diagnosis of dementia.
An Incident Description, dated 7/14/24 at 7:00 AM, indicated Resident 49 allegedly touched another resident's breast. A facility staff member indicated Resident 49 had adjusted the other resident's blanket. A Resident Witness indicated Resident 49 had indicated the resident had pulled the other resident's shirt to expose them. A Resident Witness indicated Resident 49 was touching the other resident's breasts. Camera footage indicated Resident 49 had adjusted the other resident's blanket.
An Incident Description, dated 7/15/24 at 2:00 PM, indicated Resident 49 had punched a staff member in the ear. Resident 49 had been delusional thinking another resident was being killed by visitors.
An Interdisciplinary (IDT) Note, dated 7/22/24 at 9:01 PM, indicated Resident 49 had been triggered at the same time of day (3-5 pm), but the trigger had been unknown at that time. A new intervention was for activity staff to engage with resident during the trigger time.
Resident 49's [NAME] (summary care plan for direct care staff) indicated the resident resided on a secure dementia unit. The [NAME] did not indicate the resident displayed behaviors of hitting, kicking, pinching, throwing things, delusions, hallucinations, raising of voice, making sexual comments, irritability, lashing out and being nervous around other people. The [NAME] indicated staff were to minimize private interactions with another specific resident.
A progress note, dated 8/11/24 at 3:22 PM, indicated Resident 49 thought they were having a mental breakdown no intervention was documented.
A progress note, dated 9/4/24 at 11:19 PM, indicated Resident 49 was found in bed with a female resident. Resident 49 was only wearing a brief.
A progress note, dated 9/5/24 at 4:51 PM, indicated Resident 49 had placed their hand on their penis and stated the penis had different flavors for different staff.
A progress note, dated 9/13/24 at 5:01 PM, indicated Resident 49 had become agitated at another resident due to the other resident attempting to push the resident's wheelchair. Resident 49 pushed the other resident's hands away.
An IDT note, dated 9/16/24 at 11:17 AM, indicated Resident 49 believed their personal space was being invaded on 9/13/24 when they pushed another resident's hands away.
A progress note, dated 9/18/24 at 5:14 PM, indicated Resident 49 had kissed another resident on the mouth in the dining room.
In an interview on, 10/1/24 at 11:40 AM, Qualified Medication Aide (QMA) 28 indicated direct care staff members were made aware of only new behaviors during shift report. QMA 28 indicated the facility learned the residents' specific behaviors as they got to know the residents. QMA 28 indicated they had not been educated to observe for specific events or stressors that had happened prior to resident behaviors.
In an interview on, 10/1/24 at 1:36 PM, The Social Service Director (SSD) indicated the kiss between another resident and Resident 49 on 9/18/24 was a brief peck on the lips. The SSD indicated the incident was not reportable as both the residents had a diagnosis of dementia. The SSD indicated the kiss was not sexual. The SSD indicated the other resident was a willing participant. The SSD indicated although Resident 49 has displayed sexual behaviors the kiss was friendly. The SSD indicated Resident 49's sexual behaviors had improved with medication and the resident was now easily redirected.
A current facility policy, dated 8/18/23, provided by the Regional Nurse Consultant on 9/30/24 at 9:30 AM, indicated the facility would investigate resident behaviors in an effort to determine the root cause of the behavior.
An undated current facility policy, provided by the Regional Nurse Consultant on 9/30/24 at 9:30 AM, indicated the facility memory care unit could not accept residents who displayed behaviors that may result in harm to self or others.
3.1-37
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3) During an observation, on 9/26/24 at 9:05 AM, Resident 76 was observed seated on a bench, smoking a pipe in front of the buil...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3) During an observation, on 9/26/24 at 9:05 AM, Resident 76 was observed seated on a bench, smoking a pipe in front of the building about 50 feet from the front door.
During an interview, on 9/26/24 at 10:22 AM, Resident 76 indicated he was required to sign out at the nurses' station each time he goes out to smoke . He indicated he was supposed to turn in his smoking materials for staff to lock up, but he would occasionally keep them in his room when staff was not around or too busy. He indicated he did not have a way to lock the materials up in his room.
Resident 76's record was reviewed on 9/26/24 at 10:28 AM. Diagnoses included diabetes mellitus type 2, acute systolic heart failure, and muscle weakness.
Resident 76's current quarterly, Minimum Data Set (MDS), dated [DATE], indicated their Basic Interview for Mental Status (BIMS) score was 15 (cognitively intact).
A smoking assessment, dated 9/5/24, indicated a smoking apron was recommended for Resident 76, he was educated on its use, and he did not wish to use it.
Resident 76's current care plan did not include identification of risk factors, gals, or interventions pertaining to Resident 76's smoking activities.
During an interview, on 9/30/24 at 1:34 PM, the Social Services Director (SSD) indicated upon admission, when a resident had a history of smoking, a smoking evaluation should be performed by therapy. The resident's ability to open and close the facility door and handle smoking materials appropriately would be assessed. The SSD indicated staff was aware of who smoked by common knowledge and by reading the [NAME]. Residents must follow smoking assessment recommendations to be allowed to continue to smoke. She indicated a care plan should be in place to inform the staff of a resident's smoking status and any special instructions, such as signing out of the building to smoke, care of smoking materials and any devices needed to smoke safely.
A current policy titled Smoking Policy, dated 6/10/23, provided by Regional Nurse Consultant 27 on 9/30/24 at 2:15 PM, indicated residents should be assessed for safe smoking behavior prior to smoking at the facility. The policy indicated education should be provided to the resident and staff based on the results of the smoking assessment. The policy indicated the care plan and certified nurse aide assignment sheets.
4) Resident 64's record was reviewed on 9/26/24 at 10:51 AM. Diagnoses included dementia, severe with other behavioral disturbances, delusional disorders, major depressive disorders, and muscle weakness.
Resident 64's current quarterly Minimum Data Set (MDS), dated [DATE], indicated their Basic Interview for Mental Status (BIMS) score was 4 (cognitively impaired). The MDS indicated the resident required substantial assistance to move from sitting to standing positions and transferring in and out of a chair.
A fall investigation, dated 8/27/24 at 1:21 PM, indicated Resident 64 slid down her wheelchair onto her calf cushion and tipped her wheelchair forward, causing her to change planes. The form indicated Resident 64 had impaired memory and decreased safety awareness. No additional care plan interventions were added on the document.
A fall risk review, dated 8/27/24, indicated Resident 64 was at high risk for falls.
A fall investigation, dated 9/17/24 at 2:15 AM, indicated Resident 64 was sleeping in a recliner in the lounge when the nurse heard a noise, checked on the resident and found her sitting on the floor in front of the recliner.
A fall investigation, dated 9/17/24 at 9:20 PM, indicated Resident 64 was sitting in the recliner in the lounge with her feet up and scooted down to the foot of the recliner. The CNA on duty attempted to scoot the resident back in the chair but was alone on the hall with no one to assist her so she had to lower the resident to the floor.
Resident 64's current care plan titled Fall Risk indicated the resident had a problem of being at risk of falls, with a goal date of 10/29/24. No new fall interventions were added after the 8/27/24 fall from the wheelchair. On 9/27/24 an intervention of raising the footrest while the resident was in the recliner was added. No additional interventions were added on 9/27/24.
During an observation, on 9/26/24 at 7:01 PM, the recliners were observed located in a lounge located at the end of a short hallway across from the nurses' station. The recliners were not visible from the hallways where the residents on the southwest unit resided.
An as worked schedule for 9/17/24, confirmed by payroll records, indicated one CNA was assigned to the Southwest unit at the 9:20 PM when Resident 64 slid down to the end of the recliner in the lounge.
In an interview on 10/1/24 at 10:22 AM, the Director of Nursing indicated she was aware that Resident 64 fell from the recliner twice in the same day. She indicated short staffing was a factor in the falls.
A current policy titled Guidelines for Incidents/Accidents/Falls, dated 6/30/23, provided by Regional Nurse Consultant on 9/30/24 at 2:25 PM, indicated each fall should have a new care plan intervention added.
3.1-45(a)
2. Resident 19's record was reviewed on 9/27/24 at 10:00 AM. Diagnoses included bipolar disorder, anxiety disorder, delusional disorders, complete traumatic amputation of right lower leg, idiopathic peripheral autonomic neuropathy, muscle weakness, and lack of coordination.
Resident 19's current quarterly Minimum Data Set (MDS), dated [DATE], indicated her Basic Interview for Mental Status (BIMS) score was 8, moderate cognitive impairment. The MDS indicated for 7 to 11 days in a period of 14 days, she felt tired or had little energy, had trouble concentrating, poor appetite and was on an antidepressant. The MDS indicated the resident was impaired on 1 side of her lower extremity and used a wheelchair. The MDS indicated she required substantial/maximal assist with rolling left to right, transfers, and toileting.
Resident 19's current care plan, initiated 2/12/24, indicated her care plan focus was high risk for elopement/wandering related to her bi-polar disorder. The goal of her focus area was the resident would not wander out of the facility or off the floor with a target date of 11/7/24. Interventions included Wanderguard placed initiated 6/10/24, assess/record/report to Medical Doctor (MD) risk factors for potential elopement initiated 2/12/24, and supervise closely and make regular compliance rounds whenever the resident was in her room initiated 2/12/24.
Resident 19's quarterly MDS, dated [DATE], indicated their Basic Interview for Mental Status (BIMS) score was 15 (cognitive intactness).
Care Plan Meeting progress note, dated 5/2/24 at 8:54 AM, indicated when Resident 19 went outside she was to be monitored. The note indicated the resident was not able to physically sign for herself anymore. The note indicated the facility was requesting the MD to evaluate Resident 19 to see if guardianship (a legal process that gives a person or entity the authority to make decisions for another person, called a ward, who is considered incompetent) was appropriate.
Resident 19's Elopement Risk Review, dated 5/7/24, indicated there were questions to complete; only one question was completed. The Elopement Risk total score was not determined due to the other questions being left blank; the Elopement Risk total score indicated not applicable (NA).
Resident 19's MDS, dated [DATE], indicated her BIMS score was 9 (moderate cognitive impairment).
A progress note, dated 6/9/24 at 1:11 PM, indicated Resident 19 was found by activity personnel outside on the pavement of the parking lot lying on her right side. The resident indicated a non-employee let her out of the building. The resident fell from the sidewalk curb and reported hitting her head. Abrasions were found on the resident's left knee, redness found on her right elbow/shoulder, and swelling/discoloration on the right side of her forehead/temple. Resident 19 reported slight pain to her head and right hip immediately after the incident; ice was applied to the area.
A Fall Risk Assessment, dated 6/9/24 at 12:54 PM, indicated Resident 19's incident occurred in the morning. The assessment indicated the resident was wheelchair bound, had predisposing factors of mental status changes, impaired memory, depression, decreased safety awareness, and was non-compliant with safety instructions. The assessment indicated the resident was using an electric wheelchair outside without supervision. The resident did not inform nurses she was going outside, the resident did not sign out to go outside, and per the resident a visitor let the resident out of the facility to the outside.
An Interdisciplinary Team (IDT) note, dated 6/10/24 at 9:42 AM, indicated the fall incident on 6/9/24 at 12:54 PM, root cause was due to the resident leaving the building without assistance. A Wanderguard was applied to resident.
Resident 19's Elopement Risk Review, dated 8/19/24, indicated there were questions to complete, but only one question was completed. The Elopement Risk total score was not determined due to questions not completed. The Elopement Risk total score indicated NA.
During an observation, on 9/25/24 at 9:05 AM, the facility was noted to have 3 sets of doors to get to the outside from the resident rooms where Resident 19 lived to the location Resident 19 was found on 6/9/24 on the ground outside. The first set of doors led from the Resident 19's home location in the facility, required a code to be entered into a security numerical code pad or an alarm would sound, had wooden double swing doors, and led to a lounge area. The second set of doors led from the lounge area, had a security numerical code pad (not on during day hours), metal double swing doors, and led to the anteroom ( small room, that led into a larger more important room). The third set of doors allowed exit from the anteroom of the facility, required no code for entrance/exit, had metal double swing door, and led to the outside of the building to sidewalks and the front parking lot.
In an interview, on 10/2/24 at 1:42 PM, the Director of Nursing (DON) indicated Former Employee 45, working on the Assisted Living unit, was looking out the large main window in the Facility's Assisted living (located midway down the unit) and observed Resident 19 exit the building. The DON indicated Employee 45 went to find Resident 19 (down half the corridor of the Assisted living, through the facility's lobby, through one set of doors, through the anteroom, through the second set of doors, and to the outside of the building). The DON indicated Former Employee 45 indicated before she could reach Resident 19 she fell out of her wheelchair outside the facility. The DON indicated the incident was reviewed and was decided it was not an elopement (a resident who leaves a healthcare facility without authorization or supervision) and was not investigated as an elopement.
A current policy titled, Elopement and Missing Resident Prevention, reviewed 4/20/23, provided by the Registered Nurse (RN) 27 on 9/30/24 at 2:18 PM, indicated all residents would be provided adequate supervision to meet personal and nursing needs and be assessed for behaviors/conditions that put them at risk for elopement. The policy indicated all resident would be assessed for risk of elopement annually, quarterly, and with any significant change which included any attempt or actual elopement.
Resident 19's record was reviewed on 9/27/24 at 10:00 AM. Diagnoses included bipolar disorder, anxiety disorder, delusional disorders, complete traumatic amputation of right lower leg, idiopathic peripheral autonomic neuropathy, muscle weakness, and lack of coordination.
Based on observation, interview and record review the facility failed to ensure adequate supervision to prevent resident elopement, falls and ensure safe smoking for 4 of 6 residents reviewed (Residents 32, Resident 19, Resident 64 and Resident 76).
Findings include:
1. On 9/26/24 at 11:12 AM, a voice was heard calling for help. A staff member was observed entering the shower room. A voice was heard asking who the nurse was. The Director of Nursing (DON) entered the shower room. A voice was heard saying they were unable to stand the resident up. An overhead page was heard summoning the maintenance staff to the unit STAT (immediately).
On 9/26/24 at 11:55 AM, Resident 32 was observed leaving the unit on a gurney escorted by 2 paramedics. Resident 32 was covered with a blanket.
In an interview, on 9/26/24 at 11:57 AM, Certified Nurse Aide (CNA) 30 indicated they had started working at the facility on 9/12/24 and they were being trained by CNA 35. CNA 30 indicated they entered the shower room after hearing the resident call for help. CNA 30 observed Resident 32 sitting on the floor in the shower room with their right arm stuck in the handrail. CNA 30 indicated they were unable to remove Resident 32's arm from the handrail. CNA 30 indicated Resident 32 had been in the shower room alone since 10:55 AM. CNA 30 indicated they were directed by CNA 35 to place Resident 32 in the shower unsupervised. CNA 30 indicated they were not permitted to provide direct care to the residents until their training was complete but had been providing direct care due to a staffing shortage. CNA 30 indicated they were directed by CNA 35 to provide direct care due to low staffing.
In an interview, on 9/26/24 at 12:05 PM, CNA 35 indicated Resident 32 was unsupervised in the shower room due to low staffing. CNA 35 indicated the unit had been short staffed for a few months. CNA 35 indicated the unit was often staffed with 1 CNA and 1 Qualified Medication Aide (QMA) (a CNA with medication training). CNA 35 indicated the unit QMA was on a break due to having stayed over from night shift. CNA 35 indicated the facility management was aware of the short staffing issues. CNA 35 indicated the corporate office would not allow the facility to use a staffing agency due to the cost. CNA 35 indicated CNAs in training were not supposed to provide resident care. CNA 35 indicated the Unit Manager had directed the CNA in training to provide direct care to residents due low staffing. CNA 35 indicated the Unit Manager had directed the unsupervised shower of Resident 32.
In an interview, on 9/26/24 at 1:50 PM, the Maintenance Director (40) indicated they had been summoned to the shower room to remove a handrail. The Maintenance Director indicated they observed Resident 32 sitting on the floor with their right arm lodged in the handrail. The Maintenance Director indicated they left the unit to get a drill and upon their return, Resident 32's arm was no longer stuck in the handrail.
Resident 32's record was reviewed on 9/26/24 at 2:10 PM. Diagnoses included dementia, osteoarthritis and seizure disorder.
Resident 32's Annual Minimum Data Set (MDS), dated [DATE], indicated their Brief Interview for Mental Status (BIMS) score was 13 (no cognitive impairment). The MDS indicated the resident required partial to moderate assistance with showering or bathing. The MDS indicated the resident had 2 or more recent falls. The MDS indicated Resident 32 had diagnoses of arthritis, osteoporosis, dementia and seizure disorder.
Resident 32's Care Plan, dated 12/28/23, indicated the resident had a self-care deficit. The target goal was for the resident to participate in self-care with supervision through 9/17/24. Interventions included assisting the resident according to the resident's level of need and offering frequent rest breaks.
Resident 32's Care Plan, dated 8/22/24, indicated the resident was at risk for falls. The target goal was to reduce risks to avoid significant injury from falls through 9/17/24. Interventions included increasing supervision and referring the resident to therapy.
Resident 32's Care Plan, dated 9/7/24, indicated the resident required therapy due to decreased leg strength, impaired balance, decreased walking ability and a recent fall. The target goal was for the resident to receive therapy services through 9/17/24. Interventions included gait training, therapeutic exercise and neuromuscular re-education.
An Incident Description, dated 1/8/24 AT 7:00 am, indicated Resident 32 had impaired memory, decreased strength and endurance and had not been using their walker.
A Fall Risk Review, dated 1/8/24 at 8:14 AM, indicated Resident 32 had a fall risk score of 12 (a fall risk score 10 or above is high risk). The review indicated Resident 32 required an assistive device to walk.
An Interdisciplinary Team (IDT) note, dated 1/8/24 at 9:30 AM, indicated Resident 32 lost their balance and did not have their walker within reach. A new intervention was to place a reminder sign on the resident's walker.
A Fall Risk Review dated 8/16/24 at 12:25 AM, indicated Resident 32 had a fall risk score of 9. The review indicated Resident 32 required the use of an assistive device to walk
An Incident Description, dated 8/22/24 at 5:50 AM, indicated Resident 32 fell while getting clothes from their closet and had swelling above their right eye.
A Fall Risk Review dated 8/22/24 at 7:10 AM, indicated Resident 32 had a fall risk score of 9. The review indicated Resident 32 had a balance problem while standing and walking.
An IDT note, 8/22/24 at 9:54 AM, indicated Resident 32 had lost their balance and fell while getting clothes from their closet. A new intervention was to remain with the resident while choosing their clothes.
An Incident Description, dated 9/5/24 at 7:30 PM, indicated Resident 32 fell while getting their pajamas.
A Fall Risk Review, dated 9/5/24 at 8:00 PM, indicated Resident 32 had a fall risk score of 9. The review indicated Resident 32 had a normal gait, normal balance, required the use of an assistive device to walk.
An IDT note, dated 9/6/24 at 9:42 AM, indicated Resident 32 fell while getting night clothes from their closet. A new intervention was for staff to lay out night clothes after supper each night.
Resident 32's current [NAME], (care plan summary for CNAs), dated 9/26/24, indicated the resident's preference for bathing was to have a shower. The [NAME] indicated Resident 32 required assistance with the application and removal of stockings and to lay out the resident's clothes after supper. The [NAME] did not indicate the resident was at risk for falls. The [NAME] did not indicate Resident 32 required assistance with walking. The [NAME] did not indicate the resident had a seizure disorder.
On 9/27/24 at 9:45 AM, purple and blue bruises were observed on Resident 32's right lower forearm. An arm sling was above the resident's elbow. Resident 32 indicated they had moved the sling out of the way. Resident 32 indicated they must have bumped their arm on the table.
In an interview, on 9/30/24 at 2:50 PM, the DON indicated Resident 32 should not have been unsupervised in the shower room. The DON indicated Resident 32's Care Plan should have included interventions for fall precautions. The DON indicated fall risk precautions should have been included on the resident's [NAME].
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected most or all residents
Based on interviews and record review, the facility failed to ensure sufficient nursing staff to meet the anticipated and unanticipated needs for 82 of 82 residents residening in the facility receivin...
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Based on interviews and record review, the facility failed to ensure sufficient nursing staff to meet the anticipated and unanticipated needs for 82 of 82 residents residening in the facility receiving nursing services.
Findings include:
An Indiana Department of Health complaint intake, dated 9/10/24 at 8:14 PM, indicated on 9/10/24 one nurse, one QMA, and one CNA were scheduled in the building for the evening shift. The complaint indicated CNAs frequently work on a hall by themselves with over 30 residents to assist to bed.
An as worked schedule form, verified by payroll records, dated 9/10/24, indicated one certified nurse aide worked between 6:30PM and 10:00 PM for a total of 89 residents. One QMA worked on the Southwest Unit with 38 residents, one LPN worked on the Northwest Unit with 22 residents, and one LPN worked on the dementia unit with 18 residents.
An Indiana Department of Health complaint intake, dated 9/18/24 at 7:32 AM, indicated one CNA was present in the building to assist residents to get up and dressed for breakfast. She indicated 80 residents were in the building.
An as worked schedule form, verified by payroll records, dated 9/18/24, indicated one CNA worked from 6:02 AM to 6:30 PM. No additional CNAs were on the schedule until 1:22 PM.
An Indiana Department of Health complaint intake, dated 9/20/24 at 7:28 AM, indicated the dementia unit had been staffed with one staff member for 18 residents to provide all nursing and aide care. The complainant indicated they were unable to complete all needed services for the residents and feared risking injury to themselves or residents.
An as worked schedule form, verified by payroll records, dated 9/20/24 indicated three certified nurse aide worked between 7:00 PM and 10:00 PM. The schedule indicated the CNA from the dementia unit had been pulled from the unit to help on the other units.
An Indiana Department of Health complaint intake, dated 9/24/24 at 2:34 PM, indicated on 9/21/24 there were no aides during the first and second shifts for one hall, and on 9/22/24 there was one aide for 36 residents on one hall. On 9/22/24 evening shift there was one aide on one hall for the second and third shift and no aides on the other hall.
An as worked schedule form, verified by payroll records, dated 9/21/24 indicated two CNAs were scheduled between 6:00 PM and 10:00 PM. One CNA was scheduled for the night shift.
An as worked schedule form, verified by payroll records, dated 9/22/24 indicated two CNAs were present from 6:00 AM to 6:00 PM, with an additional aide working 6:00 AM to 2:00 PM for the Southwest and Northwest units. No CNAs were scheduled on the dementia unit for the day, evening, or night shift. The dementia unit was staffed with an LPN for 15.53 hours and a QMA for 10.25 hours in the 24-hour period.
The Center for Medicare and Medicaid Services (CMS) Payroll Based Journal (PBJ) Staffing Data Report for the facility's fiscal year third quarter of 2024 from April 1 - June 30 was reviewed. The PBJ triggered a one-star staff rating (the star rating system was 1-5 with nursing homes with 5 stars considered much above average quality and nursing homes with 1 star considered much below average quality).
During an observation and interview, on 9/26/24 at 6:36 PM, the dementia unit halls and lounge were dimly lit. Qualified Medicine Aide (QMA) 21 indicated some of the residents who had been up for days without sleep had finally gone to sleep, so the staff tried to keep the unit darker and quiet to provide a good sleeping environment. 5 residents were seated in recliners in the resident lounge that was also dimly lit. QMA 21 indicated she and a nurse were working on the dementia unit that evening. She indicated the building had better staffing than usual that evening. She indicated most evenings she had to put her residents to bed quickly and then go out to the outer units and assist other halls with putting people to bed, leaving the unit unattended. She indicated staff started getting residents up between 6 and 6:30 in the morning, but since so many residents go to bed so early, they get up around 2:00 AM. She indicated the night shift has one staff member on the unit most of the time.
See F689 for additional information on an accident occurring on the dementia unit involving an unattended resident falling in the shower while only one certified nurses' aide was present on the unit.
In an interview, on 9/26/24 at 12:05 PM, CNA 35 indicated Resident 32 was unsupervised in the shower room due to low staffing. CNA 35 indicated the unit had been short staffed for a few months. CNA 35 indicated the unit was often staffed with 1 CNA and 1 Qualified Medication Aide (QMA) (a CNA with medication training). CNA 35 indicated the unit QMA was on a break due to having stayed over from night shift. CNA 35 indicated the facility management was aware of the short staffing issues. CNA 35 indicated the corporate office would not allow the facility to use a staffing agency due to the cost. CNA 35 indicated CNAs in training were not supposed to provide resident care. CNA 35 indicated the Unit Manager had directed the CNA in training to provide direct care to residents due low staffing. CNA 35 indicated the Unit Manager had directed the unsupervised shower of Resident 32.
In an interview, on 9/26/24 at 1:50 PM, the Maintenance Director (40) indicated The Maintenance Director indicated many staff members had left the facility recently. The Maintenance Director indicated the staff members who remained were overworked and the new staff members didn't know what they were doing yet.
During an observation and interview on 9/26/24 at 6:43 PM, Licensed Practical Nurse (LPN) 25 and Registered Nurse (RN) 46 were each at separate medication carts placing pills in medication cups. LPN 22 was observed talking with a resident near the southwest lounge area across from the nurse's station. LPN 22 indicated she came on duty at 6:00 pm and had not been able to attend to shift report because the unit had been so busy. She indicated one CNA was on duty and 2 Basic Nurse Aides (BNA)s were on duty for the evening shift. She indicated this evening was better staffed than usual. She indicated she had come in on several shifts where no second shift CNAs were present, and she was responsible for all the needs of the 38 residents on the unit. She indicated she had called the scheduler for assistance, but did not receive a response.
During an interview, on 9/26/24 at 6:49 PM, LPN 23 indicated she was working on the northwest unit with 2 CNAs. She indicated she normally worked with 1 CNA. She indicated nine residents on the unit required a full body sling lift, requiring two staff to perform the lift. She indicated when she assisted the CNA with the lift, there were no staff on the unit available to watch the residents on the unit who were at high risk for falls. She indicated one CNA on the unit was not enough to meet the anticipated and unanticipated needs of the resident on the unit.
During an interview, on 9/26/24 at 6:58 PM, CNA 24 indicated he came in to work early at 4:00 PM to assist on an understaffed shift. He indicated staffing at the facility on second shift had been very bad in the last few months. He indicated staff had not called and not come to work and continue to work for the facility. He indicated he had not heard of any disciplinary action being taken on habitual offenders who violate the attendance policy. He indicated employees who had terminated employment continued to be placed on the schedule for weeks after they no longer work for the facility. He indicated people were added to the schedule on their days off without their knowledge.
See F689 for additional information on a resident residing on the northwest unit eloping from the facility and falling in the parking lot.
During a confidential interview, on 9/26/24 at 10:10 AM, a staff member indicated they did not have sufficient staff to monitor residents when they were wandering.
During an interview, on 9/26/24 at 7:04 PM, LPN 25 indicated she had worked the day shift and was supposed to leave at 6:30 PM. She indicated there were two nurses and one CNA on the unit on the day shift, so much of her day was consumed with answering call lights, toileting residents and other immediate care needs. She indicated she was finishing passing medications that were overdue because she had fallen so far behind.
During an interview, on 9/26/24 at 7:06 PM, LPN 23 indicated she was on the hall with 38 residents and no aide on 9/23/24. She indicated a resident had fallen behind the doors and she had no one on the unit to monitor the residents on the unit while she enlisted help from another hall to help her get the resident up off the floor. She indicated names were placed on the schedule for people who no longer work in the facility. She indicated 7 residents on the unit required the use of a mechanical lift and two assist to transfer. She indicated when she reports to work and does not have an aide to work with, the facility management would only give her suggestions of people to call and ask if they are willing to pick up a shift. She said the responsibility to call people in lies on the employees in the building who are already struggling to provide care for the residents.
See F677 for more information on a resident not receiving showers as scheduled due to low staffing.
In an interview, on 9/26/24 at 7:06 PM, Licensed Practical Nurse (LPN) 22 indicated evening shift showers were not being done consistently for the prior few months due to lack of staff to complete them.
See F689 for more information on a resident requiring two staff to assist to transfer being lowered to the floor due to only one staff member being present on the unit.
A fall investigation, dated 9/17/24 at 9:20 PM, indicated Resident 64 was sitting in the recliner in the lounge with her feet up and scooted down to the foot of the recliner. The CNA on duty attempted to scoot the resident back in the chair but was alone on the hall with no one to assist her so she had to lower the resident to the floor.
During an interview on 10/1/24 at 10:22 AM, the Director of Nursing indicated she indicated staffing was her biggest concern in the building. She indicated some CNA staff had returned to school and were unable to work, many nurse aides in training had quit during their training and others had not completed their certification as anticipated. She indicated the facility had been using agencies in the past, but their corporate office had not allowed any staffing use since June 2024.
The Facility Assessment Tool, last updated 6/26/24-6/28/24, was reviewed during Quality Assessment and Assurance (QAA) and Quality Assurance and Performance Improvement (QAPI) committee. The Facility Assessment Tool indicated an average daily census of 77-85; the facility consisted of 100 licensed beds with 16 beds in memory care. Current census was 82. Staffing included: Projected needed hours per day:
CNA Day Shift
60-75 hours
CNA Eve Shift
45-67.5 hours
CNA Night Shift
22.5-30 hours 3-4
Hours worked as verified per as worked schedule and payroll records indicated the following:
9/1/24
Day shift: 38 hours
Evening shift: 20.25 hours
Night shift: 0 hours
9/2/24
Day shift: 31.5 hours
Evening shift: 39.25 hours
Night shift: 7.5 hours
9/3/24
Day shift: 30.75 hours
Evening shift: 25 hours
Night shift: 7.5 hours
9/4/24
Day shift: 15.5 hours
Evening shift: 18 hours
Night shift: 7.5 hours
9/5/24
Day shift: 32 hours
Evening shift: 30.5 hours
Night shift:0 hours
9/6/24
Day shift: 37.75 hours
Evening shift: 28 hours
Night shift: 22.5 hours
9/7/24
Day shift: 36.25 hours
Evening shift: 22 hours
Night Shift: 7.75 hours
9/8/24
Day shift: 30.25 hours
Evening shift: 25.75 hours
Night shift: 15 hours
9/9/24
Day shift: 38 hours
Evening shift: 27.5 hours
Night shift: 5 hours
9/10/24
Day shift: 30 hours
Evening shift: 23 hours
Night shift: 15.75 hours
9/11/24
Day shift: 38 hours
Evening shift: 38.5 hours
Night shift: 18.5 hours
9/12/24
Day shift: 38.5 hours
Evening shift: 27.75 hours
Night shift: 7.5 hours
9/13/24
Day shift: 39 hours
Evening shift: 15.5 hours
Night shift: 7.5 hours
9/14/24
Day shift: 45.25 hours
Evening shift: 29.75 hours
Night shift: 7.5 hours
9/15/24
Day shift: 30.25 hours
Evening shift: 44.75 hours
Night shift: 15 hours
9/16/24
Day shift: 26 hours
Evening shift: 27.75 hours
Night shift: 7.5 hours
9/17/24
Day shift: 28.75 hours
Evening shift: 12.75 hours
Night shift: 0 hours
9/18/24
Day shift: 15 hours
Evening shift: 22.25 hours
Night shift: 15.5 hours
9/19/24
Day shift: 30 hours
Evening shift: 42.75 hours
Night shift: 15 hours
9/20 /24
Day shift: 53 hours
Evening shift: 31.25 hours
Night shift: 15 hours
9/21/24
Day shift: 37.5 hours
Evening shift: 27.25 hours
Night shift: 7.5 hours
9/22/24
Day shift: 31 hours
Evening shift: 18.25 hours
Night shift: 0 hours
9/23/24
Day shift: 47.25 hours
Evening shift: 36.5 hours
Night shift: 0 hours
9/24/24
Day shift: 37.5 hours
Evening shift: 24 hours
Night shift: 8 hours
9/25/24
Day shift: 30 hours
Evening shift: 33 hours
Night shift: 15 hours
9/26/24
Day shift: 45 hours
Evening shift: 38.25 hours
Night shift: 14.5 hours
9/27/24
Day shift: 38 hours
Evening shift: 37.25 hours
Night shift: 15.25 hours
The Facility Assessment Tool, last updated 6/26/24-6/28/24, reviewed during Quality Assessment and Assurance (QAA) and Quality Assurance and Performance Improvement (QAPI) committee, was provided by the Executive Director on 9/25/24 at 9:30 AM. The tool indicated resources necessary to care for residents competently during day-to-day operation and emergencies. The tool is used to make decisions concerning the direct care of staffing needs to ensure residents are provided care, so residents maintain and or attain their highest practicable physical, mental and psychosocial well-being. The tool included a staffing plan based on a resident daily census between 77-85 and included a budgeted and staffing plan.
This citation is related to complaints IN 00443025, IN00443527, IN00443716 and IN00443976.
3.1-17(a)
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
QAPI Program
(Tag F0867)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure a process was in place to identify and correct...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure a process was in place to identify and correct deficiencies from re-occurring for 82 of 82 residents residing in the facility
Findings include:
The facility annual survey completed on 12/1/2023 identified noncompliance regarding failure to report, failure to investigate incidents, failure to follow care planned interventions to prevent accidents, failure to maintaining minimum staffing levels to ensure safety, and failure to investigate and identify underlying causes of resident specific behaviors. The facility indicated the noncompliance would be corrected by 1/8/2024.
In an interview, on 9/30/24 at 11:40 AM, the Administrator indicated Resident 19's elopement had not been reported to the proper agencies.
See F609 for additional information about failure to report incidents requiring reporting.
In an interview, on 10/2/24 at 1:42 PM, the Director of Nursing (DON) indicated Former Employee 45, working on the Assisted Living unit, was looking out the large main window in the Facility's Assisted living (located midway down the unit) and observed Resident 19 exit the building. The DON indicated Employee 45 went to find the Resident 19 (through half the corridor of the Assisted living, through the facility's lobby, through one set of doors, through anti-room, through second set of doors, and to the outside of the building). The DON indicated Former Employee 45 indicated before she could reach Resident 19 she fell out of her wheelchair outside the facility. The DON indicated the incident was reviewed and was decided it was not an elopement (a resident who leaves a healthcare facility without authorization or supervision) and was not investigated as an elopement.
See F610 for additional information about failure to investigate incidents.
In an interview, on 9/30/24 at 2:50 PM, the DON indicated Resident 32 should not have been unsupervised in the shower room. The DON indicated Resident 32's Care Plan should have included interventions for fall precautions. The DON indicated fall risk precautions should have been included on the resident's [NAME].
During an interview, on 9/30/24 at 1:34 PM, the Social Services Director (SSD) indicated upon admission, when a resident had a history of smoking, a smoking evaluation should be performed by therapy. The resident's ability to open and close the facility door and handle smoking materials appropriately would be assessed. The SSD indicated staff was aware of who smoked by common knowledge and by reading the [NAME]. Residents must follow smoking assessment recommendations to be allowed to continue to smoke. She indicated a care plan should be in place to inform the staff of a resident's smoking status and any special instructions, such as signing out of the building to smoke, care of smoking materials and any devices needed to smoke safely
See F689 for additional information about failure to follow care planned interventions to prevent accidents.
In an interview on 10/1/24 at 10:22 AM, the Director of Nursing indicated she was aware that Resident 64 fell from the recliner twice in the same day. She indicated short staffing was a factor in the falls.
During an interview on 10/1/24 at 10:22 AM, the Director of Nursing indicated she indicated staffing was her biggest concern in the building. She indicated some CNA staff had returned to school and were unable to work, many nurse aides in training had quit during their training and others had not completed their certification as anticipated. She indicated the facility had been using agencies in the past, but their corporate office had not allowed any staffing use since June 2024.
See F725 for additional information on failure to maintain minimum staffing levels to ensure safety.
In an interview on, 10/1/24 at 1:36 PM, The Social Service Director (SSD) indicated the kiss between another resident and Resident 49 on 9/18/24 was a brief peck on the lips. The SSD indicated the incident was not reportable as both the residents had a diagnosis of dementia. The SSD indicated the kiss was not sexual. The SSD indicated the other resident was a willing participant. The SSD indicated although Resident 49 has displayed sexual behaviors the kiss was friendly. The SSD indicated Resident 49's sexual behaviors had improved with medication and the resident was now easily redirected.
See F744 for additional information about failure to investigate and identify underlying causes of resident specific behaviors.
A QAPI (Quality Assurance Performance Improvement) committee list was provided by the Executive Director (ED) on 9/25/24 at 9:15 AM. The member list included the Administrator, Director of Nursing, Medical Director, MDS coordinator, Housekeeping Supervisor, Business Office Manager, Social Service Director, Unit Managers, Dietary Manager, and Therapy Lead.
The QAPI Plan, dated 8/2024, was reviewed. The QAPI Plan indicated concerns including falls, pressure ulcers, and other matrix related tops were recommended for review by the electronic medical record reporting system.
In an interview on, 10/1/24 at 2:05 PM, the Administrator indicated he began work in the building in mid-August, identified staffing as the most critical problem in the facility and directed his team to direct their energies toward ensuring enough staff was always in the building to care for the residents. He initiated a program to meet each morning and check for staffing needs as a management team prior to any manager beginning their workday. He indicated he was beginning attendance accountability for the staff. He indicated use of agency to fill staffing needs began on 9/29/24. Additional QAPI focus areas were not available for review due to the critical nature of the staffing concerns.
The facility failed to ensure identification of trends, and implement interventions to prevent repeat concerns related to Reporting abuse allegations (F609), investigating Abuse allegations and accidents (F610), Preventing accidents (F689), Maintaining staffing to esure the anticipated and unanticipated needs of the resident scould be met (F725) and implement dementia care interventions (F744).
A current policy titled Clinical Policy and Procedure Quality Assurance/Performance Improvement Program (QAPI), last revised 3/9/22, indicated the QAPI program should provide a process that will enhance the care and experience for all residents, improve the work environment for stakeholders, and quality of all services provided by the facility.
3.1-52
MINOR
(C)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Minor Issue - procedural, no safety impact
Staffing Information
(Tag F0732)
Minor procedural issue · This affected most or all residents
Based on observation, interview, and record review, the facility failed to ensure nursing staffing numbers including the facility name, date, facility census, total number and actual hours worked per ...
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Based on observation, interview, and record review, the facility failed to ensure nursing staffing numbers including the facility name, date, facility census, total number and actual hours worked per shift by licensed and unlicensed direct care staff were posted in an area accessible to residents and visitors. for 82 of 82 residents resided in the building.
Findings include:
During an observation, on 9/25/24 at 1:00 PM, a plastic document holder was observed in the front lobby area next to postings of Resident Rights and names, addresses and phone numbers of state agencies. A set of doors at the end of the lobby were locked with a push- button activator to open the doors leading to the area of the building where residents resided. The doors required a keypad code to be entered to reach the lobby area from the area where the residents resided. An additional door was observed, with a keypad entry and exit code required, which lead to the locked dementia unit.
During an interview, on 9/25/24 at 3:29 AM, the Administrator indicated the signs had been recently moved to their current location. He was unsure of the location of the posting of nursing hours, but indicated he would find out.
During an observation and interview, on 9/25/24 at 3:53 PM, the Administrator pointed to the empty plastic document holder near the resident rights posting and indicated the nursing hours should be posted in that location, and he would provide a copy.
During a record review, on 9/25/24 at 3:57 PM, a document titled daily staffing 9/26/24 was reviewed. The document indicated the census was 80, but no nursing hours were indicated on the form.
During an interview on 9/25/24 at 4:20 PM, the Director of Nursing indicated the Daily Staffing form posted in the lobby was dated 9/26/24, indicated the next day's date and a census of 80, which should have reflected a census of 82.
During an observation, on 9/30/24 at 11:51 AM, a staffing notice, dated 9/27/24, was posted in the lobby.
A current undated policy titled BIPA Staffing Posting Requirement indicated the facility specific shift schedule for the 24-hour period should be posted. The policy indicated the post should include the number and category of nursing staff employed or contracted by the facility for each 24-hour period, as well as the number of hours worked by licensed staff and staff who are directly responsible for resident care. The policy indicated the data must be in a conspicuous, prominent location, accessible to residents and visitors.
Sept 2024
2 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Pressure Ulcer Prevention
(Tag F0686)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure staff effectively identified skin impairment o...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure staff effectively identified skin impairment on the left inner calf from friction and shear was correctly identified as a pressure injury, failed to ensure a physician's order was received prior to the use of a medical device, and failed to ensure a resident with a history of pressure injuries received effective treatment and services to prevent the wound from deteriorating, from developing infection, or to prevent the development of a second wound for 1 of 1 resident reviewed for wound care. (Resident J) This deficient practice resulted in Wound 1 deteriorating to a stage three pressure injury with infection and required sharp debridement.
Findings include:
In an interview on 9/3/24 at 12:07 P.M., the Resident Council President (RCP) indicated Resident J, who sat at her table in the dining room, had been taken back to her room, without eating lunch, due to her crying out in pain. The RCP was very concerned for the resident because she had been crying about pain in her left lower leg, foot and toes.
In an interview on 9/3/24 at 12:15 P.M., the facility Activity Assistant indicated the resident had been having a bad day and liked to be babied at times. The Activity Assistant indicated she had just come from the resident's room and she had been doing fine.
An annual MDS (Minimum Data Set) with Care Area Assessments, dated 6/25/24, indicated Resident J had a BIMS (Brief Interview Mental Status) score of 12 (mildly impaired cognition). Her speech was clear, she was able to make her needs known and was able to understand others. She required substantial assistance with bed mobility, transfers, and toileting. She was frequently incontinent of bowel and bladder and had no identified wounds. Staff would continue to anticipate her needs, provide assistance, and keep her physicians informed of any changes.
A skin risk assessment dated [DATE] indicated she was at risk for pressure injuries. There were no other assessments or care plans documented related to the identified risk.
A current care plan regarding potential for pain, dated 9/3/23, indicated the resident had the potential for pain and would be free from pain with interventions as needed. Interventions included: medications as ordered; notify doctor of uncontrolled pain; and observe for signs and symptoms of pain.
A current care plan regarding at risk for skin breakdown due to edema from heart disease, dated 2/1/24, indicated goals were to provide the resident with preventative measures to avoid skin breakdown and resolution of her edema without complications. Interventions included: float heels while in bed; monitor skin daily during care; mild compression stockings daily-on in the morning and off at night; weekly skin assessment; and observe for any increase in edema.
An Incident Report dated 8/8/24 at 9:00 a.m., indicated the resident had a skin tear to her left inner calf with slight bleeding. The skin tear was cleansed and covered with a dry dressing. No other characteristics of the wound had been documented, the physician or family notified. The incident report did not include documentation to determine the root cause of the skin impairment.
An Interdisciplinary (IDT) note, dated 8/9/24, indicated the root cause of the left inner calf wound was from the resident rubbing the left leg against an air cast that was applied to the right lower leg. There was no measurement of the area, other characteristics, physician or family notification documented about the skin tear. There was no care plan to address friction and shear related to the air cast.
Current physician orders, dated September 2024, did not include an order for the air cast.
According to Advances in Skin and Wound Care pg. 222 June 2004 article, friction and shear are mechanical forces contributing to pressure ulcer formation. The tissue injury resulting from these forces may look like a superficial area, yet they often work together to create tissue ischemia (low oxygen) and ulcer development.
A nurse progress note, dated 8/11/24 at 4:31 p.m., indicated the resident had a skin tear (stage two pressure ulcer) to her right (sic) (left) lower leg. Her leg was swollen and leaking fluid. The wound was cleaned and her leg wrapped. There was no documentation of how the wound was cleansed, the characteristics of the wound or how the wound had been dressed.
A care plan for a skin tear on the right (sic) (left) lower leg, dated 8/12/24, indicated the stage two pressure ulcer on the left lower leg was a skin tear. The goal was to heal without complications. Interventions included: investigate cause of the skin tear; observe for signs/symptoms of infection; take necessary precautions to prevent new areas; and treatments as ordered.
There was no assessment or plan of care for pressure risk related to the use of a medical device.
A Treatment Administration Record (TAR), dated August 2024, indicated a treatment was ordered on 8/12/24 for a skin tear (ulcer) to the right (sic) (left) lower leg. The skin tear (ulcer) was to be cleansed with soap and water, rinsed, patted dry and dressing applied as needed one time per day.
A Daily Skilled Nursing Note, dated 8/13/24 at 11:13 a.m., indicated the stage two pressure ulcer (a partial thickness loss of skin with exposed dermis, presenting as a shallow, open ulcer) identified as a skin tear (ulcer) on her left lower leg continued to drain. There was no documentation of how the wound was cleansed, the specific characteristics of the wound, any drainage associate with the wound or if the wound had been dressed.
A Nurse Practitioner note, dated 8/14/24 at 10:29 a.m., indicated the resident reported she was having drainage from her left lower leg. The area was dressed with bandages. She had no excessive warmth, redness, or surrounding swelling, but no other characteristics of the wound had been documented.
There was no documentation in the progress notes or wound documentation between 8/14 and 8/26-24 to indicate the facility effectively assessed, monitored, or evaluated the skin impairment.
The record contained no documentation, in the progress notes, wound reports, or treatment records, between 8/14/2024 and 8/26/2024, to indicate the facility effectively assessed, monitored, or evaluated the skin impairment including 8/15/24, 8/22/24 and 8/29/24.
Care plans, dated August and September 2024, did not contain interventions to remove the air cast, or interventions to provide relief to the wounds on the left lower leg.
A Change in Condition form, dated 8/26/24 at 11:17 p.m., indicated the resident had 2 newly identified skin tears (ulcers) on her left lower calf. The form indicated the Left lower leg areas caused her significant pain. New orders were obtained to cover the skin tears on the left lower inner leg and left lower outer leg with Mepitel (a wound dressing to allow drainage to pass on to a secondary dressing, reducing pain) followed by Mepilex (a wound dressing to absorb drainage and protect from damage due to the drainage) until healed every night shift, every 7 days. Resident J was administered pain medication-Tramadol 50 mg 1 tablet by mouth every 8 hours as needed-at 8:18 p.m. for a pain level of 9 out of 10 with 10 being the worst pain. The form did not include sufficient documentation to determine the specific characteristics of the wounds, assessments of the wound, possible root cause.
According to Molnlycke.us, Mepitel is a dressing designed to minimize pain and trauma at the dressing site. Mepitel does not adhere to a moist wound so it can be easily removed without damaging the skin. Mepitel is designed to remain in place for 14 days, it protects the skin to support faster healing, and seals the wound to prevent the skin from softening and breaking down related to moisture.
According to Molnlycke.us, Mepilex is a dressing designed to designed to minimize pain and trauma at the wound site. It seals the wound and absorbs drainage to protect the wound from breakdown.
A Change in Condition follow up note, dated 8/27/24 at 9:39 a.m., indicated skin tears (ulcers) to the residents left lower leg were cleansed and redressed. Her left lower leg was swollen, reddened, tender to touch, and had a moderate amount of bloody drainage. There were no measurements or characteristics of the wound documented. The note did not include documentation to indicate the pain/ tenderness in the left lower leg was effectivly assessed.
A new onset pain assessment was not completed to address Resident J's pain/tenderness to the left lower leg.
The pain assessments, dated from 8/8/24 to 8/31/24 did not include documentation to indicate a pain assessment was completed on 8/27/24.
A Medication Administration Record (MAR) dated August 2024 indicated the resident was not provided any pain medication on 8/27/24.
An untimed physician's order, dated 8/27/24, indicated to cover the skin tears (ulcers) on the left lower inner leg (Wound 1) and left lower outer leg (Wound 2) with Mepitel followed by Mepilex until healed every night shift, for 14 days to be discontinued on 9/3.
A Wound Nurse Practitioner (NP) note, dated 9/3/24 indicated Wound 1 measured 3.5 cm Length (l) X 2 cm Width (w) with moderate bloody drainage. No further assessment of the area had been documented. Wound 2 measured 1 cm (l) X 1 (w) cm in a V shape with moderate bloody drainage, but no further assessment of the area was documented.
An Incident Note, dated 8/28/24 at 8:05 p.m., indicated the residents dressings had been changed per wound orders and she was to be seen by the wound NP the following day (8/29/24). There was no measurement or description of the wound areas or characteristics in the note.
An Incident Note, dated 8/29/24 at 2:19 a.m., indicated the dressings to the residents skin tears (ulcers) were intact and there were no signs/symptoms of infection observed. There was no measurement or description of the wound areas or characteristics in the note.
The Wound NP progress notes and the Physician progress notes, dated between 8/27/24 and 8/31/24, did not include documentation to indicate Wound 1 or Wound 2 was evaluated on 8/29/24.
A Daily Skilled Nursing Note, dated 8/31/24 at 5:47 a.m., indicated the resident complained of pain in her left foot. There was no documentation completed of the wound site, the measurements of the wounds, swelling in the leg or condition of dressings. There was no pain assessment completed nor pain medication administered. The note did not include documentation to indicate Wound 1 or Wound 2 was evaluated on 8/31/24.
There was no documentation of wound evaluations, treatments, monitoring, or pressure relief between 8/31 and 9/3/24.
During an observation from the hallway outside Resident J's room, on 9/3/2024 at 2:20 P.M., Resident J was heard crying out in pain. She was observed lying in her bed with her legs flat on the mattress, covered with a sheet and blanket. She was anxious, grimacing, moaning, and calling out. She was crying and indicated her left leg hurt terribly. Licensed Practical Nurse (LPN) 3 was observed to enter the room and indicated the resident had her left leg wound debrided (physical removal of necrotic tissue with use of scalpel and forceps) before lunch. LPN 3 indicated Resident J had been administered Tylenol after the procedure but needed something stronger for the pain. LPN 3 was observed to administer Tramadol (pain medication used for moderate to severe pain) 50 mg (milligrams) 1 tablet by mouth for the leg pain. After she took the medication, she began to yell for her leg to be elevated. LPN 3 placed pillows below her legs to elevate them. After the medication administration, Resident J was observed to yell for the left leg to be elevated and LPN 3 was observed to place pillows under the resident's legs.
A care plan for skin impairment, dated 9/3/24, indicated Resident J had a wound to her left posterior calf and skin tear (ulcer) to her left lower leg. Goals were for the wound to show signs of improvement, be free from infection, and her skin tear to heal. Interventions included: encourage the resident to elevate her legs; provide wound care as ordered; evaluate and change treatment as needed; monitor for signs/symptoms of pain, administer medications, and re-assess as needed; measure wounds at regular intervals; and monitor signs of healing or wound declining.
On 9/4/24 at 9:44 A.M., Resident J was observed in her room, seated in her wheelchair, with both leg pedals slightly elevated, but low to the floor. Her left leg was wrapped from mid foot to top of her calf with an ace wrap bandage. The toes of her left foot were uncovered. The toes were red in color. She was feeling better on this day but indicated the day prior (9/3/24), had been a rough day. The Wound Nurse Practitioner (NP) had been in to visit to treat the wound on her left calf. The wound was painful during the treatment and worsened as the day wore on. She indicated she had been given stronger pain medication. The medication had provided relief from the pain.
A Wound NP progress note, dated 9/3/24, indicated the resident was being seen to evaluate skin tears (ulcers) to her left lower extremity. She was observed to have a 1 cm x 1 cm x 0.1 cm V shaped laceration-type skin tear (ulcer) to the left anterior calf (Wound 2) with a non-viable flap and a 3.5 cm x 3.5 cm x 0.4 cm full thickness ulceration to the left medial part of her posterior lower left calf (Wound 1) which appeared consistent with a venous ulcer. There was slough observed to wound (Wound 1) which required sharp debridement to clearly assess the wound. The resident had no documented history of venous stasis disease but had chronic edema to her lower legs due to extensive history of CHF. The resident indicated she had pain at rest in her left lower leg. The tissue around the wound to the left anterior calf (Wound 2) was intact but fragile and there was a scant amount of serosanguineous (blood and clear fluid) drainage. The resident indicated no pain at rest with this wound. The wound to her left posterior lower calf (Wound 1) was 80% covered with slough (dead skin cells) (Stage 3 pressure area presents as a full-thickness loss of skin. Slough may be visible, but does not obscire the depoth of tissue loss) . Tissue around the wound was fragile and there was a heavy amount of serous (clear/cloudy) drainage. The resident complained of severe pain during removal of the bandages and indicated she had severe pain at rest with this wound. Both wounds were numbed and debrided which the resident tolerated without pain. New treatment orders were given to cleanse both wounds, apply calcium alginate (a dressing to promote fliud and enzyme stasis with a wound) to base of wounds, secure with a dressing and rolled gauze, every other day and as needed, followed by compression with Ace wrap to the left lower extremity. Recommendation was made to obtain venous reflux imaging to confirm the diagnosis of venous stasis ulcer to the left medial posterior calf. Intermittent leg elevation, at or above the heart level, was to be completed as tolerated. There was no documentation related the the air cast on the right lower leg.
The results of the venous imaging were not available related to the test not having been completed at the time of the survey.
Care plans did not reflect they had been updated to include the addition of the Calcium alginate.
A Daily Skilled Nursing Note, dated 9/3/24 at 7:40 p.m., indicated the resident's wound showed signs and symptoms of infection and new orders were received to start Keflex (antibiotic) 500 mg by mouth, 3 times per day for 10 days. The note did not include sufficient documentation to determine the signs/symptoms exhibited.
On 9/3/24 at 2:36 P.M., LPN 3 was interviewed. She indicated she'd asked the wound NP to check on Resident J's skin tears (ulcers) while she was in the facility on 9/3/24, seeing other residents. She indicated the resident's wounds looked bad and she was complaining of pain to the area. She indicated the resident had skin tears (ulcers) since the beginning of August but didn't have treatments or follow up documentation completed. Resident J was to wear compression stockings daily but hadn't been wearing them due to her wounds leaking fluids. LPN 3 did not indicate how long the wounds had been leaking, what was the facility's response was, or any interventions implemented. On 8/31 and 9/1/24, LPN 3 had wrapped the residents 's legs with ace wraps because her legs were too swollen for the compression stockings. When asked, she was unsure how the resident got the skin tears (ulcers) but thought the resident may have hit her calves on the wheelchair pedals or sides of the chair.
In an interview on 9/4/24 at 10:19 AM, the Regional Nurse Consultant indicated she was unable to find any further documentation of the skin tear (ulcer) on the left lower leg, identified on 8/8/24 nor was there further documentation of the skin tear (ulcer) on the right lower leg which had been identified on 8/12/24. There were no observations for signs/symptoms of infection, no investigation for cause of the skin tears (ulcers), no documentation of interventions put into place to prevent further skin tears (ulcers) and no documentation of the wound being healed. The Regional Nurse Consultant indicated she was unable to find any further documentation of the skin tear (ulcer) on the right lower leg, and there was no documentation of the skin tear (ulcer) on the right lower leg being healed.
On 9/4/24 at 11:10 A.M., the Wound NP was interviewed. She indicated she visited the facility on Tuesdays for wound rounds. She would see residents with different types of wounds, upon notification from staff. She indicated, there was no designated nurse to complete wound rounds with and would speak with the nurse caring for the resident on the day of her visits. On 9/3/24, she was notified by LPN 3, of the skin tears (ulcers) Resident J had. She had last seen the resident on 8/6/24 for follow up to a pressure wound she'd acquired while hospitalized in July 2024. The pressure wound was healed and required no further treatment. She indicated she hadn't been made aware of the resident's skin tears/wounds to her right or left lower extremities prior to 9/3/24. She indicated the resident complained of much pain when her left calf was lifted up and old dressings removed because of the swelling to her calf. She had proceeded with the debridement of both wounds following numbing the area and resident's comfort determined. The resident had tolerated the procedure without complaints of pain but had pain when the calf was re-dressed. The nurse gave the resident Tylenol after the procedure was completed. When questioned, she indicated residents with painful wounds should be pre-medicated with pain medication prior to her visits and treatments. She had not been told the resident had severe pain following the debridement procedure. When questioned regarding a visit to have been done on 8/29/24, she indicated her partner completed wound rounds on that day and their progress notes had not indicated Resident J was to be visited so she was not.
On 9/4/24 at 10:19 A.M., the Regional Nurse Consultant indicated there was no facility policy specific to skin tears but provided a current copy of their policy monitoring skin and weights (S.W.A.T.) program. The policy indicated: Skin alterations such as the following will appear on the weekly skin assessments and will be followed by the clinical management staff for progress. These conditions/alterations will be care planned and managed and treated as per physician order. any concerns with progress and/or healing will be reported to the physician for guidance, recommendations, and/or orders .These areas are non-Pressure Ulcers or Pressure injuries and are therefore not routinely reviewed/discussed at the S-W-A-T meetings. a. skin tears .f. lacerations .m. other
On 9/4/2024 at 12:09 P.M., Resident J was observed in the dining room, seated in her wheelchair with her legs slightly elevated but low to the floor. She wore a frown on her face and her eyes were partially closed. When questioned, she indicated she was fine but was observed to be intermittently grimacing.
This Citation refers to Complaint IN00440946.
3.1-40
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0697
(Tag F0697)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to provide effective pain management for 1 of 1 residents experiencing pain (Resident L).
Findings include:
On 9/3/24 at 2:01 P.M...
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Based on observation, interview and record review, the facility failed to provide effective pain management for 1 of 1 residents experiencing pain (Resident L).
Findings include:
On 9/3/24 at 2:01 P.M., Resident L's record was reviewed. Diagnoses included unstageable pressure ulcer to the right heel, diabetes, intellectual disabilities, and neuropathy. The resident had been hospitalized for a hip fracture due to a fall.
A quarterly Minimum Data Set (MDS ) assessment, dated 8/17/24, indicated her cognition could not be assessed due to intellectual disabilities. She had verbal behaviors and behaviors not affecting others 1-3 days of the assessment and when asked, indicated she had pain but was unable to give further details. She required maximal assistance with all Activities of Daily Living (ADL's ).
Care plans with effective dates, indicated:
-8/13/24: Resident had potential for pain related to neuropathy and recent hip fracture. The goal was her pain to be controlled at an acceptable level. Interventions included: assess pain using the 0-10 scale; administer pain medication and monitor effectiveness; offer non-pharmacological interventions for pain relief such as dim lights, repositioning, back rub, heat or cold; document and report complaints and non-verbal signs of pain; and reposition as needed for comfort.
-9/4/24: Resident was admitted with a pressure injury to her right heel. The goal was to heal. Interventions were: administer treatments as ordered; nurse to measure/assess weekly and notify family and physician as needed; provide heel protectors in bed; and refer to nutritional plan of care.
On 9/3/24 at 10:30 A.M., Resident L was observed seated in a wheelchair across from the nurses desk. She was speaking animatedly with other residents around her. She repeated herself often, was restless and fidgeting in her chair. Both feet were resting on the carpeted floor with a sock on her left foot and ace wrap around her right ankle/foot. She verbalized twice, she was having pain in her right foot and indicated she had a sore on the foot.
-At 2:15 P.M., the resident remained seated in her wheelchair with her feet down in front of the nurses desk. A bedside table sat in front of her and she was playing with a peg board with colored pegs. She indicated her foot hurt twice during the observation.
On 9/4/24 at 9:42 A.M., the resident was observed seated in her wheelchair with her feet on the floor, across from the the nurse desk. She had the table in front of her and was playing with her peg board. She was heard telling staff present, several times, her foot hurt. One staff member, told her the doctor and staff were aware and the pain was due to swelling in her foot.
A physician order, dated 8/10/24, was for Gabapentin (used to treat nerve pain) 100 mg (milligrams)-give 1 capsule by mouth 2 times per day and give 2 capsules at bedtime for neuropathic pain.
A physician order, dated 7/25/24, was for Tylenol 325 mg-give 2 tablets by mouth every 4 hours as needed for pain.
A Medication Administration Record (MAR), dated September 2024, indicated the resident had been administered Tylenol 325 mg-2 tablets by mouth on 9/1/24 at 11:33 a.m. for pain and again, on 9/2/24 at 4: 00 p.m. Both doses were noted to have been ineffective in relieving the residents pain. Tylenol was not administered on 9/3/24 or 9/4/24 when the resident complained of pain in her right foot.
A nurse progress note, dated 9/2/24 at 5:20 p.m., indicated the resident had swelling to her right foot and complained of pain. The nurse assessed the wound and indicated there was pitting edema in her right foot. Tylenol was given as ordered without pain relief. The unit manager was notified and staff would continue to monitor.
A Wound Nurse Practitioner (NP) progress note, dated 9/3/24 at an unknown time, indicated the resident had been seen for continued care to the unstageable pressure ulcer on her right heel. Resident L refused to have the pressure ulcer debrided due to pain. She had pitting edema to the right foot and it was tender to touch. The wound was healing and there was no redness/warmth, foul odor or abnormal drainage from the wound.
On 9/4/24 at 2:30 P.M., the Administrator and Regional Nurse Consultant were interviewed. They indicated it was expected, residents verbalizing pain would be assessed, pharmacological and non-pharmacological interventions put into place.
A current policy, titled Guidelines for Pain Management was provided by the Regional Nurse Consultant, on 9/4/24 at 2:45 P.M., which stated the following: Methods to achieve goals of pain management: 1. Promptly and accurately recognizing and assessing pain. 2. Encouraging residents to self-report to staff when they experience pain. 3. Being cognizant of the non-verbal signs/symptoms of pain in residents not able to verbally express their pain .7. Preventing and minimizing anticipated pain when possible. 8. Using non-pharmacological means for pain relief when appropriate
This Citation relates to Complaint IN00440946.
3.1-37(a)
Jul 2024
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0744
(Tag F0744)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to ensure dementia care and services was provided to 1 of 3 residents reviewed for dementia care (Resident E).
Findings include:
...
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Based on observation, interview and record review, the facility failed to ensure dementia care and services was provided to 1 of 3 residents reviewed for dementia care (Resident E).
Findings include:
A complaint reported to the Indiana Department of Health, alleged residents who resided on the memory care unit at the facility were unsafe due to lack of nursing staff, medications not being provided timely, and lack of activities.
On 7/17/24 at 11:27 A.M., Resident E's record was reviewed. Diagnoses included dementia with behavioral disturbance, delusional disorder, insomnia, major depressive disorder, and diabetes. He had been hospitalized for 2 weeks in May 2024 for increased delusions and physical behaviors. Hospital notes indicated the plan of care was to minimize polypharmacy and provide a structured, secured environment. The resident returned to the facility on 5/20/24 with orders for 2 antidepressant medications and an antipsychotic medication which hadn't been prescribed prior to his hospitalization.
A quarterly MDS (Minimum Data Set) assessment, dated 4/9/24, indicated Resident E had severely impaired cognition. He had little interest or pleasure doing things 2-6 days but had no behaviors, rejection of care or wandering. He required partial assistance with eating, dressing and ambulation. The resident was always incontinent of bladder and required maximal assistance with toileting. He'd had no falls since his previous assessment, dated 1/24/24.
Care plans included:
-Dated 10/6/23: The resident resided on the memory care unit due to dementia and would benefit from programming on the unit. The goal was he would participate in programming on the unit. Interventions included: Secured unit and provide specialized programming. there was no indication what the specialized programming consisted of.
-Revised 3/26/24: The resident was interested in activities such as movies, bingo and trivia. The goal was for him to attend at least 3 activities per week. Interventions included: Invite, encourage, and assist resident to activities of his interest.
-Revised 5/23/24: The resident had mood issues exhibited by screaming, yelling, swearing and delusions of believing others were out to get him. The goal was he would have no side effects from his medications. Interventions were: Administer psychotropic medications as ordered and monitor side effects; notify physician as needed; monitor use of psychotropic medication quarterly; Listen to his concerns, provide support and encouragement; Social Services Director (SSD) to visit as needed.
On 7/16/24 between 9:00 Am and 10:55 A.M., Resident E was observed at the dining room table being assisted to eat by his spouse. She indicated the purple-yellow bruise around his right eye had been due to a fall. There was music playing, but no activities or programming was observed on the unit.
On 7/17/24 between 9:45 A.M. and 10:00 AM, Residents who resided on the unit were observed seated in recliner chairs in the lounge area; most appeared asleep with eyes closed. 1 female resident was wandering around the lounge. Resident E was observed in his room, lying in bed with his eyes closed. There were no activities or programmng on the unit.
-At 1:45 P.M., he was observed lying in bed in his room, sleeping. His spouse was present and she indicated he slept a lot now. She was asked about activities on the unit and she indicated the activities and programming were very sporadic and not routine.
Progress notes and Psychiatric NP ((Nurse Practitioner) notes were:
-6/18/24 at 9:01 a.m., the IDT (Interdisciplinary Team) met to discuss the residents recent behaviors. Staff would complete a dipstick to rule out UTI (urinary tract infection) and have the psychiatric NP visit their next time in the facility.
-6/20/24 at 4:30 p.m., the resident was tearful, confused and asking why his wife hadn't visited yet. Staff offered reassure which was effective for a short period of time.
-At 5:31 p.m., he was sitting in the nurse station when he asked staff if he could go out and get his gun. Staff tried to distract him which was initially effective however the resident told staff they needed to call the police because he had killed someone. His wife later visited which calmed him and he had no further behaviors. There was no activites or programming offered for Resident E.
-6/30/24 at 8:45 a.m., the resident swatted a staff member on the side of their face with the back of his hand. He'd been restless, agitated and tried to walk without his walker. Staff reported he had been awake all night. Staff spent 1:1 time with him, read a book and was give and accepted hot chocolate. Interventions were ineffective however, his wife called and after speaking with her, he was calm.
-At 12:32 p.m., the SSD called and spoke with the psychiatric NP regarding increase in residents behaviors. New order was given to restart Trazodone (used for sleep) as he'd previously been on the medication and had slept better with a decrease in his behaviors during the day.
-At 8:44 p.m., the resident was restless, agitated and had attempted to stand and walk around his room with an unsteady gait. He had refused his evening medications, knocked a cup of water over the staff member and his wife and hit out. Wife and staff tried to talk to him, offered snacks and activities. He eventually agreed to take his medication, was assisted into bed, calmed down and fell asleep with his wife at his bedside. There was no activites or programming offered for Resident E.
-7/3/24, a psychiatric NP progress note indicated the resident had been seen for medication management and symptoms of severe dementia with aggression, insomnia, and depression. The resident was currently prescribed Lexapro (anti-depressant) and Nortriptyline (anti-depressant) daily and Risperdal (antipsychotic) 0.5 mg 2 times per day for delusions. Trazodone, initially prescribed for insomnia had been discontinued by the primary care team due to belief insomnia was related to pain however, the medication was restarted last weekend due to persistence of insomnia despite pain management. Since restarting the medication, the resident had been sleeping well at night, was more pleasant, had no signs of agitation or aggression and was actively participating in mealtimes and activities. His overall condition was reported by staff as being good. All medications were to be continued as ordered and staff were to monitor for changes in his behaviors.
-7/4/24 at 5:44 a.m., the resident was awake and restless throughout the night. He attempted to get out of bed and walk but his gait was unsteady and he came close to falling several times. Staff attempted to sit and talk, and walk with him but he was too unsteady. He was taken down to the nurse station where he was offered an activity and snack. He indicated he had wanted to go to bed but continued to be up and down the rest of the night.
-7/11/24 at 12:54 p.m., the resident was agitated at breakfast and refused to eat and take his pills. He threw the pills and water at staff. He calmed down once his wife visited. There was no other activites or programming offered for Resident E.
On 7/16/24 at 1:42 PM, the activity documetnation indicated Resident E was engaged in self directed activity, however, Resident was observed to be sleeping at that time.
Confidential interviews with residents, staff, and families were conducted during the course of the survey. They alleged 2nd and 3rd shift staff was not consistent and staff never knew who would relieve them at the end of their shifts. It was alleged the unit was staffed in the evening and night shifts with a CNA (Certified Nurse Aid) instead of a nurse or QMA (Qualified Medication Aid). This was a concern as several residents were up and wandered at night. There had been, but no longer was an activity person on the unit and activities were sporadic. There was no specific dementia care programming for the unit nor planned activities. A staff member had come up with some activities for morning and evening which was handwritten on a paper hanging in the nurses station. Staff had routinely provided music at meals to enhance resident's dining experience but had no other routine activities or schedule that were person centered and meaningful to residents residing on the unit. The memory care coordinator was a unit manager who worked another unit and was only allotted 8 hours per week to update care plans and complete required documentation. It was alleged the unit ran out of popular items such as hot chocolate which residents enjoyed and drank daily so staff were purchasing and bringing it in.
Documentation of sensory stimulation and activities in June 2024 indicated between 6/1/24 through 6/6/24, the resident had participated in activities 5 of the 6 days and sensory stimulation 1 day. There was no sensory stimulation or activities documented between 6/7/24 through 6/19/24 and 6/20/24 through 6/30/24, Resident E participated in an activity 5 days, refused 2 days and no activities were offered 4 days. Sensory stimulation of hearing music occurred 1 time per day for 6 days during a mealtime. There no other activities or programming scheduled for Resident E.
Documentation of sensory stimulation and activities in July 2024, indicated between 7/1/24 through 7/16/24, sensory stimulation of hearing music occurred 6 days and activities 6 days with 2 refusals. There no other activities or programming scheduled for Resident E.
Resident E's care plan indicated a decline in his functional abilities and increase in behaviors without new interventions put into place to prevent further decline in his condition. The care plan indicated he should be encouraged to exercise during the day and naps discouraged but no other non-pharmacological interventions were put in place.
A current facility policy, provided by the Regional Nurse Consultant on 7/17/24 at 11:47 A.M. and titled A Dedicated Dementia Care Unit Philosophy, stated: We believe that the quality of life for our residents is enriched when their days are filled with meaningful and enjoyable structured activity. We believe that this activity serves as a powerful coping mechanism in times of fear and stress .We believe that behaviors displayed during this [dementia] journey are caused by a progressive degeneration of the brain .We choose to modify the environment, change our expectation and focus on intervention/redirection to ensure our residents have opportunities to be content and socially successful .Pre-admission Assessment: Memory Springs is a secured neighborhood and a program specifically designed to provide a safe and home-like environment that promotes independence and socialization .Guidelines for Initial admission .Individual will benefit from a specialized dementia program
This tag relates to Complaint IN00438589.
3.1-37
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0740
(Tag F0740)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review, the facility failed to develop and implement an effective behavior management plan for a resident with a history of alcohol abuse. This resulted in p...
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Based on observation, interview and record review, the facility failed to develop and implement an effective behavior management plan for a resident with a history of alcohol abuse. This resulted in public resident to staff altercations (Resident G) and 5 residents fearing for their safety (Resident P, Resident Q, Resident S, Resident T, and Resident U).
Findings include:
On 7/16/24 at 11:06 A.M., during an initial tour of the southwest hallway, a middle aged appearing male resident (Resident G) was observed seated in a wheelchair at the nurses station, speaking with a staff member. His speech was slightly slurred and rapid. Seated behind the resident, approximately 5 feet away, sat a female resident in a wheelchair with her feet resting on foot pedals. She was observed to have a grimace on her face, furrowed eyebrows, and nervous expression as she stared at the back of Resident G's wheelchair. She shifted her weight several times as if trying to move her wheelchair herself. Residents seated in the adjacent lounge area, indicated there had been issues with Resident G and they were frightened of him.
On 7/17/24 at 10:16 A.M., Resident G's record was reviewed. Diagnoses included alcohol dependence with withdrawal, generalized anxiety disorder, major depressive disorder, mild cognitive impairment and muscle weakness.
An admission MDS (Minimum Data Set) assessment, dated 6/11/24, indicated he had a BIMS (Brief Interview Mental Status) score of 14-no cognitive impairment but had inattention and disorganized thinking daily. He had mood indicators of feeling down, depressed, and hopeless but had no behaviors, hallucinations, delusions, rejection of care or wandering.
Care plans and dates initiated included:
--6/10/24: The resident had a history of alcohol abuse with a goal of reducing or eliminating the consumption of alcohol. Interventions were to inform his visitors not to bring in alcohol; notify physician as needed; and praise resident for demonstrating consistent acceptable behavior.
-6/10/24: The resident wandered due to cognitive impairments and feeling lost. Interventions included: provide assistance in locating his room; provide directional cues such as pictures or name on his door; and wander guard to prevent elopement.
-7/11/24: Level II recommendations-the resident had mental illness due to major depressive disorder with a goal of his psychosocial needs being met. Interventions included: case management to explore community living; training in community living skills; training in self healthcare management; behaviorally based treatment plan, dementia workup; and individual therapy from mental health services.
A hospital note, dated 6/7/24, indicated the resident had been hospitalized for disorientation, electrolyte imbalances, and alcohol withdrawal following lifelong alcoholism. He was a chronic cigarette smoker and used a marijuana vape pen. He had physical debility of uncertain reason and was wheelchair bound. He was recommended to have inpatient physical therapy at an extended care facility. While hospitalized , he had been prescribed Librium (sedative to treat alcohol withdrawal symptoms) which was discontinued following hospital discharge.
Progress notes, Behavior charting, and Psychiatric Nurse Practitioner notes indicated the following:
-6/13/24 at 7:00 a.m., the resident made homophobic slurs toward staff and harassed them for matches. He was observed trying to elope and wandered off to other units looking for exits. Staff tried to redirect him, offered snacks and activities but the resident refused. All interventions were ineffective.
-6/14/24 at 8:50 a.m., the resident was observed at the central doors watching persons entering through the door. He indicated he wanted to get through the doors and get to his people. He was re-directed towards the south hall which was effective.
-6/16/24 at 2:54 a.m., the resident was brought to the south nurses station several times by staff as he was looking for ways to leave the building to go smoke. He had cigarettes and a lighter in his pocket. He was asked to surrender them for safe keeping in the medication cart which he had done but was angry about. He was redirected to watch TV in the southwest lounge and eventually went to bed.
-6/20/24 at 12:46 a.m., Resident G was looking on the floor and picking up things not there. He had the entire back off of his wheelchair, wanted to go home, and refused to go to bed.
A psychiatric NP progress note, dated 6/20/24 indicated the resident was seen for medication management. The resident had a long-standing history of alcohol abuse. He'd experienced withdrawal symptoms and given Librium at the hospital but was no longer prescribed. Since being admitted to the facility, his anxiety levels fluctuated and he exhibited intermittent irritability, anger and at times, had become verbally and physically aggressive with staff. Assessment and Plan were:
-Alcohol dependence:continue on thiamine supplement (B vitamin), monitor for signs of withdrawal and manage symptoms. Encourage the resident to engage in alcohol cessation programs and provide resources for support.
-Major depressive disorder: resident with history of depression and had been off his antidepressants for an unspecified period; Initiate Lexapro (antidepressant) 5 mg by mouth daily for depression.
-Generalized anxiety disorder: Continue to monitor anxiety symptoms closely and if symptoms persist, will consider antianxiety medication. Encourage him to engage in stress management techniques and provide resources for support.
Progress notes continued:
-6/23/24 at 6:50 p.m., the resident repeatedly asked to leave the facility. He was looking for his children, was grabbing, yelling out to and asking every person seen to help find his kids. He yelled at staff for lying and trying to keep him from them. He went into other resident's rooms and moved their furniture in attempts to find them. His behaviors started in the morning and increased in frequency throughout the day. Staff had tried to redirect, reassure him, and attempted to call his family to have them reassure him but there had been no answer. Other residents were upset he was going into their rooms, yelling and grabbing at them and their visitors. All interventions were ineffective.
-6/24/24 at 2:05 p.m., the resident asked for help. He was tearful and said he had to get to the bank for money because his wife took his and he owed someone money and was in trouble. Staff tried to reassure him, redirected the conversation, and offered him a snack; all interventions were ineffective.
A psychiatric NP progress note, dated 7/3/24 indicated the resident was seen for follow up and medication management. He was initiated on Lexapro during the last visit due to history of depression. Despite the treatment, he continued to have increased anxiety, exit-seeking behavior, and intermittent cognitive impairment. His anxiety was difficult to redirect, prompting the initiation of Librium 10 mg by mouth 3 x/day. Following initiation of Librium, the resident had shown overall improvement and was less anxious and calm. Staff report he was less impulsive and was able to participate in mealtimes and activities. His sleep had improved and he was sleeping through the night. Assessment and Plan were:
-Alcohol dependence: The resident had a history of alcohol abuse. There were no acute concerns or negative symptoms reported during the visit which suggested his alcohol abuse was uncomplicated. He would be monitored for alcohol consumption and potential impact on overall health. He was encouraged to continue to abstain from alcohol and to participate in support groups or counseling if needed.
-Major depressive disorder: His depression was being managed with Lexapro 5 mg per day. He reported feeling better overall and would continue the current regimen.
-Generalized anxiety disorder: His anxiety had been a concern with symptoms of increased anxiety, exit seeking, and difficulty with redirection. Librium 10 mg 3 x/day was initiated on 6/24/24 which resulted in significant improvement in his anxiety symptoms. Would continue with current regimen of Librium 10 mg 3 x/day.
-Mild cognitive impairment: He had been experiencing intermittent cognitive impairment however since initiation of Librium, he reported feeling like his brain was slowing down which suggested an improvement in his cognitive function.
Progess notes contiued:
-7/10/24 at 5:30 p.m., the CNA (Certified Nurse Aid) reported to the SSD (Social Service Director), that the resident had rolled up to them and stated If you go anywhere near that golf team of children again, I am going to shoot you in the face. You have no business coaching them again. The resident was redirected but was ineffective. He continued to wheel himself down the hallway.
-At 5:55 p.m., the resident became very upset after his mother left. He went between sobbing and yelling/swearing at staff for trying to take his things and fun times away. He believed his family was harming his rehomed pets. He believed his roommate was talking poorly about his father and tried to hit the roommate. These behaviors occurred from 3:30 p.m. - 6:00 p.m. Staff tried to reassure and distract him with conversation which was not effective. He went to bed and started to relax until his roommate entered the room. Staff intervened when he tried to hit his roommate and the roommate began screaming which escalated his behaviors. The behavior caused behaviors in his roommate. Staff were afraid he would be violent with them. The resident cries or screams almost every time staff talk to him. All interventions were ineffective.
-7/11/24 at 3:40 p.m., the resident was observed, by the Admissions Director, standing at the central nurses station shaking. She attempted to help him sit down when he pointed a finger in her face and yelled accusations of her killing everyone. She backed up and gave him space and tried to calm him. Another staff member walked by and he started screaming at them for killing everyone too. The SSD came up and tried to calm the resident but he began to shout at her to give him her gun because the Admissions Director had killed all the babies. He was assisted to sit down but then began to swing his arms at staff and continued to yell at each staff member as they approached and tried to calm him. He jumped from topic to topic and continued talking about guns, people trying to kill each other, shackles and being in jail. All non-pharmacological interventions were ineffective. The psychiatric NP was contacted and orders given for 1 time dose of Haldol (antipsychotic) 5 milligrams (mg) intramuscularly (IM) for agitation and start Risperdal (antipsychotic) 0.5 mg by mouth twice daily.
-At 3:55 p.m., the resident was extremely agitated, stood up from his wheelchair and tried to open the furnace room door while yelling they are coming to kill me. He pointed at female staff and said he was going to hit them. His mother was contacted by phone and indicated she would come right away to the facility. All interventions were ineffective.
-4:05 p.m., the resident continued with agitation. He was assisted into the lounge area and away from other residents who witnessed the outburst. He begged staff to shoot him in the head and was inconsolable. His family arrived to the facility and he continued to cry excessively. He was administered the injection of Haldol which eventually helped to calm him.
-7/14/24 at 3:15 p.m., the resident was observed walking down the hallway without his walker or wheelchair with a very unsteady gait. Staff attempted to help him sit in his wheelchair. He refused and threatened to hit staff while kicking staff and the wheelchair. He began yelling You all are going to blow this place up and kill me and kill them all! After 40 minutes, staff were able to calm him down. He had been physically and verbally aggressive towards staff and visually agitated. Other residents became anxious while the resident was yelling and agitated. All interventions were ineffective
-7/15/24 at 1:02 p.m., a Change in Condition form indicated the resident had increased confusion, delusions, hallucinations, physical and verbal aggression and was a danger to himself and others. The resident was unable to differentiate between what was real and what was in his mind. The primary care provider responded back to monitor the resident. All interventiosn were ineffective
-At 2:51 p.m., a Change in Condition form indicated the resident had other behavioral symptoms which were not identified. There was no response from the primary care provider. All interventions were ineffective.
-At 4:52 p.m., the resident was yelling down the hallway, they're killing them, they're killing them as 5 visitors exited another resident's room. He attempted to go into another resident's room. He was redirected to come to the nurses station where he continued to yell out and tried to hit staff. He was able to grab a staff members arm and punched another staff member in the head as his behaviors escalated and more staff called to the area for assistance. All residents in the immediate area were moved. He eventually calmed after being assisted to walk and talk with staff.
-7/16/24 at 2:05 p.m., the psychiatric NP gave orders to send the resident to the psychiatric hospital for increased behaviors. He was to be picked up the following day and transported to the hospital.
-At 10:00 p.m., the resident was seated in the recliner chair in the TV lounge after refusing to go to bed. Staff heard a noise and observed the resident crawling on his hands and knees on the floor. He was asked if he needed assistance and he replied with name calling and threw his wheelchair at the staff member. He then kept repeating kill me, kill me, kill me. All interventions were ineffective.
-At 11:30 p.m., the physician was notified of the resident's behaviors and new order given for Haldol 5 mg IM 1 time for agitation.
-7/17/24 at 12:15 a.m., the SSD indicated she had been notified of the resident's behaviors and interventions tried. The resident had gotten back into the recliner chair and lights turned down low which calmed the resident and he wasn't administered the Haldol injection.
-At 10:52 a.m., the resident was transported to the psychiatric hospital.
Confidential interviews were conducted during the course of the survey. Resident P, Resident Q, Resident S, Resident T, and Resident U each indicated they were afraid of Resident G. They had witnessed his verbal behaviors toward other residents and staff and physical behaviors with staff. The resident had wandered into their rooms and became angry when asked to leave. He had yelled at them and their visitors and in some rooms, had moved other resident's personal items and furniture. They indicated everything the staff tried was ineffective.
Confidential employee interviews indicated there had not been enough staff to manage Resident G's behavior, no education provided on caring for a resident with substance use disorder (SUD), unanswered calls for help when the resident was acting out, slow staff response during physical altercations, and concerns regarding other residents who witnessed the behaviors, their distress and need for protection, intrusion in their personal space and change in other residents preferences and movements in the facility (i.e., having to close their door to keep the resident out and having to be moved away from common areas when his behaviors occurred). They indicated they had no direction to provide interventions for the behaviors.
On 7/17/24 at 1:56 P.M., the SSD was interviewed. She indicated prior to admission and while hospitalized , the resident had no behaviors. During his admission MDS assessment time frame, he had no behaviors and a care plan was not developed for behavior management nor had one been developed and implemented since his behaviors started. She was aware he had a history of alcohol abuse but had not received training for residents with substance abuse disorders nor had staff. When questioned about the facility behavior management program, documentation of behaviors and how interventions were communicated to staff, she indicated behaviors and interventions were documented in the nurse progress notes and in the resident's MAR. CNA's had no access to the residents MAR and she wasn't sure how behavior interventions were communicated to them.
A care plan was not developed and interventions put into place when Resident G began to exhibit behaviors which affected other residents and staff safety. He was not offered services to assist him with alcoholism or stress management as recommended by the psychiatric NP. There was no follow up for behaviors not able to be altered by staff including actions taken when the resident was a threat to other residents safety.
A current facility policy, titled Guidelines for Behavior Management Meetings and Psychotropic Medications was provided on 7/17/24 at 2:35 P.M. by the Regional Nurse Consultant who indicated this was the policy followed for behavior management which stated: Standards: The facility will investigate behaviors in an effort to determine the root cause of the behavior. In so doing, it may become evident that a non-pharmacological intervention would be effective in managing or even eliminating the behavior without the use of psychoactive medications .Psychiatrist/Mental Health Provider may assist the facility in establishing appropriate guidelines for use, dosage and monitoring of psychoactive medications .be available for consultation and helps develop behavior management plans as needed .Nursing .Monitors for presence of target behaviors on a daily basis and documenting same .Assist in developing behavior care plans .Social Services .assists in compiling quantitative data (number of behaviors/side effects of med's) .Guidelines for Psychotropic Medication: Policy .Residents will not receive psychotropic medications unless other types of interventions have been attempted to meet the resident's targeted behavioral goals and have failed. These include Behavioral Programming by a trained Behavioral Therapist, environmental changes and/or other non-pharmacological interventions
This tag relates to Complaint IN00436738.
3.1-37
Apr 2024
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure a resident's right to be free from abuse for 1 of 3 residents reviewed (Resident Q).
Findings include:
A report, submitted to the In...
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Based on interview and record review, the facility failed to ensure a resident's right to be free from abuse for 1 of 3 residents reviewed (Resident Q).
Findings include:
A report, submitted to the Indiana Department of Health (IDOH), dated 3/26/24, indicated on 3/19/24 at 6:30 a.m., a CNA (Certified Nurse Aid) had used their cell phone to create a video of Resident Q without her permission. The video was shared with several staff members.
On 4/2/24 at 2:16 P.M., Resident Q's record was reviewed. Diagnoses included dementia with behavioral disturbance, delusional disorder, and generalized anxiety disorder.
A quarterly MDS (Minimum Data Set) assessment, dated 12/19/23, indicated Resident Q had severely impaired cognition and verbal behaviors of yelling out.
A care plan, revised on 1/15/24, indicated Resident Q displayed mood issues such as yelling out at staff and calling them derogatory names, delusions, hitting, kicking, and barricading herself. An intervention, dated 3/27/24, was for care to be provided in pairs (2 staff members).
In an interview on 4/2/24 at 9:55 A.M., the Director of Nursing (DON) indicated, on 3/19/24 at an unknown time, CNA (Certified Nurse Aide) 5 sent her a video recording of CNA 7 providing care for Resident Q. CNA 5 alleged CNA 7 mistreated the resident while providing care. The DON indicated she passed the video on to the Administrator and CNA 5 was instructed to delete the video from her phone. CNA 7 was suspended pending investigation. The video was viewed by the Administrator, DON, and other nurse managers. The actions of CNA 7 were determined to be appropriate, without any signs of mistreatment, and CNA 7 was allowed to come back to work the following day. The DON indicated, there had been no further action regarding CNA 5's use of her cell phone to record a resident without permission, until 3/25/24 when CNA 5 was suspended and then terminated on 3/26/24.
In an interview on 4/2/24 at 10:58 A.M., CNA 7 indicated on 3/19/24, she was sent home after being told there had been an allegation made against her for mistreatment of Resident Q. She indicated, the morning of 3/19/24, she had been providing care to the resident while she lay in bed. The resident hadn't felt well and was resistant to being changed and yelling at her. She indicated she kept trying to encourage the resident as she quickly tried to change her soiled brief. CNA 5 came into the room and asked if she could finish the resident's care as the resident was upset and perhaps a different caregiver would calm her down. CNA 7 left the room and continued caring for other residents until she was sent home. She indicated she was told after she returned the following day, CNA 5 had opened the door to the room while she was providing peri-care to the resident and began recording her and Resident Q. She had no idea she or the resident were being recorded.
In an interview on 4/2/24 at 1:07 P.M., CNA 5 indicated she had worked 3rd shift and the morning of 3/19/24, she was doing rounds before her shift ended when she heard a resident yelling. She indicated she knew it was Resident Q because she always yelled out when care was given. She went to the room to help and walked into what she alleged was mistreatment. She indicated CNA 7 wasn't verbally mistreating the resident but believed her actions indicated mistreatment. She hadn't provided what actions the CNA 7 had taken to indicate mistreatment. She began recording the care provided by CNA 7 and how the resident had responded. After recording, she went into the room, took over for CNA 7 and finished care of the resident. After caring for the resident, she showed the recording to the 1st shift nurse who reported to the DON. When questioned, CNA 5 indicated staff were not allowed to record residents on any devices including cell phones. She provided no further information.
A current policy, titled Abuse Prevention Program, was provided by the Regional Director of Operations on 4/2/24 at 12:15 P.M. which stated: It is the policy of this facility to prevent resident abuse, neglect, mistreatment and misappropriation of resident property. Each resident receives care and services in a person-centered environment in which all individuals are treated as human beings .6. Mental Abuse: Each resident has the right to be free from all types of abuse, including mental abuse. Mental abuse includes, but not limited to, abuse that is facilitated or caused by nursing home staff taking or using photographs or recordings in any manner that would demean or humiliate residents .Neglect/Mistreatment: means the failure to provide, or willful withholding of adequate medical care, mental health treatment, psychiatric rehabilitation, personal care or assistance with activities of daily living that is necessary to avoid physical harm, mental anguish or mental illness of a resident
This tag relates to Complaint IN00431290.
3.1-27(a)(b)
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure a timely report of suspected abusefor 1 of 3 residents reviewed. (Resident Q).
Findings include:
A report, submitted to the Indiana ...
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Based on interview and record review, the facility failed to ensure a timely report of suspected abusefor 1 of 3 residents reviewed. (Resident Q).
Findings include:
A report, submitted to the Indiana Department of Health (IDOH), dated 3/26/24, indicated on 3/19/24 at 6:30 a.m., CNA 7 (Certified Nurse Aid) had used their cell phone to videotape Resident Q without her permission. The video was shared with several staff members.
Refer to F600.
In an interview on 4/2/24 at 12:28 P.M., the Director of Nursing (DON) indicated, on 3/19/24, CNA 5 (Certified Nurse Aid) reported mistreatment of Resident Q by CNA 7 and provided a cell phone recording of the alleged event. CNA 7 was suspended pending investigation and allowed to return to work the following day after the allegation of mistreatment was unsubstantiated. The unauthorized recording of Resident Q, obtained while the resident was being provided pericare, was not reported to IDOH until someone reported to corporate. CNA 5 still had the recording on her phone. CNA 5 had not been suspended pending investigation after sharing the video with staff members. The allegation of mistreatment regarding Resident Q by CNA 7 was not reported to IDOH as required. The DON indicated the event and CNA 5 should have been reported to IDOH within 24 hours per regulations.
On 4/2/24, confidential interviews were conducted with staff. The interviews indicated CNA 5 recorded Resident Q receiving pericare without knowledge of the resident or CNA being recordeded and the recording remained on her cell phone. CNA 5 was not suspended for filming the care and had continued to provide resident care for approximately one week after the event. Staff anonymously notified corporate staff on 3/25/26. CNA 5 was suspended and terminated.
A current policy, titled Abuse Prevention Program, was provided by the Regional Director of Operations on 4/2/24 at 12:15 P.M. which stated: Abuse reporting: This facility will not tolerate resident abuse or mistreatment by anyone, including staff members .6. Mental Abuse: Each resident has the right to be free from all types of abuse, including mental abuse. Mental abuse includes, but not limited to, abuse that is facilitated or caused by nursing home staff taking or using photographs or recordings in any manner that would demean or humiliate residents .Any alleged violations involving mistreatment, abuse, neglect .MUST be reported to the Administrator and Director of Nursing .After notification of alleged abuse or neglect, the Administrator or person in charge of the facility shall immediately commence an investigation of the incident reported .the Administrator or person in charge of the facility will notify .immediately .State Licensing and Certification Agency (IDOH)
This tag relates to Complaint IN00431290.
3.1-28(c)
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to ensure protection from abuse for residents while an investigation of abuse was conducted for 1 or 3 residents reviewed (Resident Q).
Finding...
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Based on interview and record review the facility failed to ensure protection from abuse for residents while an investigation of abuse was conducted for 1 or 3 residents reviewed (Resident Q).
Findings include:
A report, submitted to the Indiana Department of Health (IDOH), dated 3/26/24, indicated on 3/19/24 at 6:30 a.m., a CNA (Certified Nurse Aid) had used their cell phone to record Resident Q without her permission. The recording was shared with several staff members. The incident was not reported on 3/19/24 when it occurred. The involved CNA was not suspended until 6 days later. After 3/19/24, the CNA provided care to residents on 3/21/24, 3/23, and 3/24/24 from 6:30 p.m. until 7 a.m.
Refer to F600.
During an interivew on 4/2/24 at 12:28 P.M., the Director of Nursing (DON) indicated, on 3/19/24, CNA 5 (Certified Nurse Aid) reported mistreatment of Resident Q and provided a cell phone recording of the alleged event. The unauthorized recording of Resident Q, obtained while the resident was being provided pericare, was not reported nor was CNA 5 suspended for making the recording. The DON indicated after CNA 5 reported the allegation of mistreatment and the recording viewed, CNA 5 was told to delete the video. The DOn indicated she asked CNA 5 why she hadn't intervened if she believed the resident was being mistreated. CNA 5 indicated if she could do it over, she would have intervened to keep the resident safe.
Staff meetings were scheduled and began on 3/19/24. Staff were re-educated regarding the abuse policy, use of cell phones and unauthorized recording of residents.
In an interivew on 4/2/24 at 1:07 P.M., CNA 5 indicated she had worked 3rd shift and the morning of 3/19/24. She was doing rounds before her shift ended when she heard a resident yelling. She indicated she knew it was Resident Q because she always yelled out when care was given. She went to the room to help and walked into what she alleged was mistreatment. She indicated CNA 7 wasn't verbally mistreating the resident but believed her actions indicated mistreatment. She hadn't provided what actions CNA 7 had taken to indicate mistreatment. She began recording the care provided by CNA 7 and how the resident had responded. After recording, she went into the room, took over for CNA 7 and finished care of the resident but had not attempted to intervene during the recording. After caring for the resident, she showed the recording to the 1st shift nurse who reported to the DON. When questioned, CNA 5 indicated staff were not allowed to record residents on any devices including cell phones.
Confidential interviews were conducted with staff on 4/2/24. The staff indicated CNA 5 recorded the resident receiving pericare without knowledge of the resident or staff member being recorded and alleged the recording remained on her cell phone. She was not suspended for recording the care and had continued to provide resident care for approximately one week after the event. Staff anonymously notified corporate staff on 3/25/26, CNA 5 was suspended and terminated.
A current policy, titled Abuse Prevention Program, was provided by the Regional Director of Operations on 4/2/24 at 12:15 P.M. which stated: If you suspect abuse: Separate the alleged perpetrator and assure all residents safety .Any incident or allegation involving abuse or mistreatment will result in an abuse investigation .Protection of Residents: The facility will take steps to prevent mistreatment while the investigation is underway .Staff members who are suspected of abuse or misconduct shall immediately be barred from any further contact with residents of the facility and be suspended from duty, pending the outcome of the investigation
This tag relates to Complaint IN00431290.
3.1-28(d)
Dec 2023
8 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report an episode of attempted self-harm for 1 of 1 resident review...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report an episode of attempted self-harm for 1 of 1 resident reviewed (Resident 34).
Findings include:
On 11/27/23 at 12:12 PM Resident 34 was observed sitting on their bed holding stuffed toys. Resident 34 did not respond to a verbal greeting and avoided eye contact. There was no call light in Resident 34's room.
Resident 34's record was reviewed on 11/28/23 at 2:27 PM. Diagnoses included dementia with psychotic disturbance, major depressive disorder, delusional disorder, anxiety, stroke with right side paralysis and aphasia (inability to speak).
Resident 34's most recent quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident had severe cognitive impairment. The MDS indicated Resident 34 was unable to respond.
A progress note dated 5/31/23at 10:39 PM indicated Resident 34 had removed the bed sheets and had wrapped the alarm cord around her head and arm.
Resident 34's current care plan entry dated 6/1/23 and revised on 11/21/23 indicated the resident had acted out a suicide attempt. Interventions included removal of the call light, the utilization of a cordless bed, removal of items that could be used to inflict injury, physician notification and the provision of psychiatric services.
A progress note dated 6/1/23 at 11:09 AM indicated Social Services had removed Resident 34's call light after the resident had displayed suicidal behaviors. Social Services educated Resident 34 on the use of a bell. Social Services removed all belts and other items that could be used to inflict self-harm. Social Services requested permission from Resident 34's daughter to enroll the resident into psychiatric services.
In an interview on 11/30/23 at 12:30 PM the Director of Nursing (DON) indicated Resident 34 did not have a call light in their room due the resident had been found with the call light cord wrapped around their head or neck.
In an interview on 12/1/23 at 10:24 AM, the DON indicated Resident 34's suicidal action had not been investigated or reported to the proper agencies.
A current undated copy of the facility policy titled Suicide Precautions provided by the DON on 12/1/23 at 10:30 AM indicated suicide attempts would be reported to the appropriate State agencies per policy and regulation.
3.1-28(c)
3.1-28(e)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to investigate an episode of attempted self-harm for 1 of...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to investigate an episode of attempted self-harm for 1 of 1 resident reviewed (Resident 34).
Findings include:
On 11/27/23 at 12:12 PM Resident 34 was observed sitting on their bed holding stuffed toys. Resident 34 did not respond to a verbal greeting and avoided eye contact. There was no call light in Resident 34's room.
Resident 34's record was reviewed on 11/28/23 at 2:27 PM. Diagnoses included dementia with psychotic disturbance, major depressive disorder, delusional disorder, anxiety, stroke with right side paralysis and aphasia (inability to speak).
Resident 34's most recent quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident had severe cognitive impairment. The MDS indicated Resident 34 was unable to respond.
A progress note dated 5/31/23 at 10:39 PM indicated Resident 34 had removed the bed sheets and had wrapped the alarm cord around her head and arm.
A progress note dated 6/1/23 at 11:09 AM indicated Social Services had removed Resident 34's call light after the resident had displayed suicidal behaviors. Social Services educated Resident 34 on the use of a bell. Social Services removed all belts and other items that could be used to inflict self-harm. Social Services requested permission from Resident 34's daughter to enroll the resident into psychiatric services.
Resident 34's current care plan entry dated 6/1/23 and revised on 11/21/23 indicated the resident had acted out a suicide attempt. Interventions included removal of the call light, the utilization of a cordless bed, removal of items that could be used to inflict injury, physician notification and the provision of psychiatric services.
In an interview on 11/30/23 at 12:30 PM the Director of Nursing (DON) indicated Resident 34 did not have a call light in their room due the resident had been found with the call light cord wrapped around their head or neck.
In an interview on 12/1/23 at 10:30 AM the DON indicated Resident 34's suicidal action had not been investigated or reported to the proper agencies.
A current undated copy of the facility policy titled Suicide Precautions provided by the DON on 12/1/23 at 10:30 AM indicated suicide attempts would be investigated.
A current copy of the facility policy dated 10/22/22 titled Abuse Prevention Program provided by the DON on 21/1/23 at 10:30AM indicated all incidents whether abuse occurred or not would be documented and investigated. The policy indicated bruises, lacerations or any other abnormalities would be documented in the Risk Management section of the resident's medical record. The policy indicated the Incident Report form should be forwarded to the Indiana State Department of Health by the Administrator or designee.
3.1-28(d)
3.1-28(e)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0676
(Tag F0676)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 16's record was reviewed on 11/30/23 at 1:06 PM. Diagnoses included chronic obstructive pulmonary disease, myocardia...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 16's record was reviewed on 11/30/23 at 1:06 PM. Diagnoses included chronic obstructive pulmonary disease, myocardial infarction, atherosclerotic heart disease of native coronary artery without angina pectoris, heart failure, displaced fracture of lateral malleolus of unspecified fibula, age-related osteoporosis with pathological fracture of the right ankle and foot, chronic pain, weakness, lack of coordination, muscle wasting and atrophy, reduced mobility, difficulty in walking, and other idiopathic peripheral autonomic neuropathy.
Resident 16's current quarterly Minimum Data Set (MDS) assessment, dated 10/26/23, indicated her Basic Interview for Mental Status (BIMS) score was 13 (cognitively intact). The MDS indicated she used a wheelchair for mobility and required supervision to touch assistance to transfer from lying to sitting on the side of her bed, from sitting to standing, and to walk a least 10 feet in a room, corridor, or similar space.
Resident 16's current care plan, dated 8/25/23, titled Self Care deficit indicated the resident had a problem of impaired mobility and ambulation and would benefit from participation in the Ambulation Restorative Nursing Program. The resident's goal was to ambulate 10 feet with her walker, gait belt and assistance of 1 staff 6-7 days a week thru 11/24/2023 with the same intervention.
Resident 16 had no physician orders for Ambulation Restorative Nursing Program.
In an interview on 12/01/23 at 10:26 AM, the Director of Nursing (DON) indicated the Restorative Nursing Program assistance did not appear in physician orders.
In an interview on 11/30/23 at 2:25 PM, the DON indicated therapy had indicated Resident 16 no longer received Physical Therapy (PT) since meeting her maximum potential on 9/27/23.
There was no record in Resident 16's medical record she received Ambulatory Restorative Nursing Program assistance of 1 staff to ambulate 10 feet using her walker and a gait belt 6-7 days a week from 8/25/23 through 11/24/23.
In an interview on 12/01/23 at 10:26 AM, the DON indicated the Ambulation Restorative Nursing Program assistance in the care plan was not added to the Certified Nurse Aide (CNA) tasks program. Since the task was not add, the CNAs on the unit were unaware one of their tasks should had been to assist Resident 16 to ambulate 10 feet 6-7 days a week using her walker and a gait belt, and it was not done from 8/25/23 through 11/24/23.
A current policy titled Policy and Procedure for facility Restorative Nursing Programming, undated , provided by the DON on 12/1/23 at 10:26 AM indicated the restorative staff would create/activate the Nursing Rehab Task in the facility nursing software for point of care documentation by the facility nursing staff. The qualified nursing staff documentation would show the resident's progam was ongoing and administered as plannned.
3.1-38(a)(1)
3.1-38 (a)(2)(A)-(E)
Based on observation, record review and interview, the facility failed to ensure services were provided for communication deficits and activities of daily living for 2 of 2 residents reviewed. (Resident 34, Resident 16).
Findings include:
1. On 11/27/23 at 12:12 AM Resident 34 was observed sitting on their bed holding stuffed toys. Resident 34 did not respond to a verbal greeting and avoided eye contact. There was no call light in Resident 34's room.
Resident 34's record was reviewed on 11/28/23 at 2:27 PM. Diagnoses included dementia with psychotic disturbance, major depressive disorder, delusional disorder, anxiety, stroke with right side paralysis and aphasia (inability to speak).
Resident 34's most recent quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident had severe cognitive impairment. The MDS indicated Resident 34 did not speak, was rarely or never understood.
Resident 34's current care plan entry dated 7/30/23 and revised on 9/22/23 indicated the resident would communicate by yelling due to the inability to speak English. The target goal was for Resident 34 to make basic needs known by sounds or gestures on a daily basis by 12/24/23. The interventions included the anticipation and meeting of needs, call light in reach, adequate low glare lighting and avoidance of isolation.
On 11/28/23 at 3:20 PM Resident 34 was observed sitting on their bed holding stuffed toys. There was no visible hand bell on the resident's bedside table or on the resident's bed.
On 11/29/23 at 8:40 AM Resident 34 was observed lying in bed with their eyes closed. There was no visible hand bell on the resident's bedside table or on the resident's bed.
In an interview on 11/29/23 at 11:45 AM Registered Nurse (RN) 20 indicated Resident 34 was nonverbal. RN 20 indicated Resident 34 yelled incoherently when they needed something. RN 20 indicated it was unclear if Resident 34 spoke English. RN 20 indicated they had never observed a hand bell in the resident's room.
In an interview on 11/29/23 at 12:08 PM Resident 34's daughter indicated she was aware of the resident not having a call light. Resident 34's daughter indicated the resident yelled out and the staff then guessed what the resident needed.
In an interview on 11/30/23 at 12:30 PM the Director of Nursing (DON) indicated Resident 34 did not have a call light in their room due the resident had been found with the call light cord wrapped around their head or neck. The DON was unaware of the resident not having a hand bell in their room. The DON indicated the facility did not have a hand bell policy.
In an interview on 12/1/23 at 1:19 PM the Social Service Director (SSD) indicated they were unaware of a hand bell as a care plan intervention for Resident 34. The SSD indicated they had resumed the SSD role 1 month ago. The SSD indicated Resident 34 communicated by yelling out. The SSD indicated Resident 34 had refused a communication board in the past. The SSD indicated they were unaware of translator services. The SSD indicated they had not attempted to communicate with the resident using any translation applications.
A current copy of a facility policy dated 1/1/20 titled Use of Call Lights provided by the DON on 12/1/23 at 10:30 AM indicated all residents were to have a functioning call light. The policy indicated all residents were to be instructed on the use of call lights. The policy did not address the use of hand bells in place of call lights.
A current copy of an undated facility policy titled Communication in the Predominant Language provided by the DON on 12/1/23 at 10:30 AM indicated residents had a right to a dignified exsistence, self-determination and communication to staff . The policy indicated the facility staff was encouraged to speak the predominant language of any non English speaking residents if the staff was capable.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to follow care planned interventions for 1 of 3 residents reviewed with pressure ulcers (Resident 35).
Findings include:
On 11/27...
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Based on observation, interview and record review, the facility failed to follow care planned interventions for 1 of 3 residents reviewed with pressure ulcers (Resident 35).
Findings include:
On 11/27/23 at 9:53 A.M., Resident 35 was observed lying in bed, covered up with blankets. 2 heel protectors sat on top of her covers at the bottom of the bed. A heel up cushion device sat in a chair next to her bed.
On 11/29/23 1:10 P.M., the resident was observed sitting in her wheelchair in her room. She wore no heel protectors on her feet and her heels were lying on the the footrest of the chair.
On 11/29/23 at 12:56 P.M., Resident 35's record was reviewed. Diagnoses included dementia. She had been receiving hospice services since 8/20/21 for Alzheimer's disease.
A care plan, revised 9/10/22, indicated the resident was at risk for skin breakdown related to end of life, incontinence, and decreased mobility. The goal was for the resident to be be provided preventative measures in an attempt to avoid skin breakdown. Interventions included: Heels up cushion while in bed.
A care plan, dated 7/6/23, indicated the resident had a wound to her right heel. The goal was for the wound to decrease in size. Interventions included: Heels up cushion.
A hospice plan of care, dated 8/26/23, was to manage/maintain the resident's right heel wound for comfort and prevent complications with no expectation for complete healing.
A CNA (Certified Nurse Aide) care sheet, provided by the Unit Manager (UM), on 11/30/23 at 10:20 A.M., indicated Resident 35 was to have her heels floated on a heel up cushion and heel boot protectors on when in bed and when up in the wheelchair.
In an interview on 11/30/23 at 10:05 AM, the UM indicated heel boot protectors were a nursing measure and had not required a physicians order.
A Weekly Wound Evaluation, dated 11/23/23 at 12:25 p.m., indicated Resident 35 had a wound to her right heel. The wound measured 2.5 cm (centimeters) by 2.5 cm by 0.3 cm. The wound was covered with 100% slough, black in color with a foul odor, and tender to touch. Current preventative interventions were: heel boot protectors.
On 11/30/23 at 11:30 A.M., the wound nurse was observed to remove the old dressing from the resident's right ankle wound. The wound was cleansed and new dressing put into place. The wound nurse indicated the wound was not expected to heal but to prevent it getting worse, the resident was to wear foam heel boots at all times and heel up cushion while in bed to decrease pressure on the wound.
A Weekly Wound Evaluation, dated 11/30/23 at 2:59 p.m., indicated Resident 35's wound to her right heel measured 3.0 cm by 0.3 cm. The wound remained black in color and had a foul odor. Current preventative interventions were: heel boot protectors.
A current facility policy, titled Guidelines for Prevention/Treatment of Pressure Injuries, provided by the Director of Nursing on 12/1/23, stated: A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice to promote healing, prevent infection and prevent new ulcers from developing .Not all risk factors are fully modifiable or can be completely addressed .Others such as pressure can be modified promptly
3.1-40
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to follow care planned interventions to prevent accidents for 2 of 5 residents reviewed (Resident 3 and Resident 74).
Findings in...
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Based on observation, interview and record review, the facility failed to follow care planned interventions to prevent accidents for 2 of 5 residents reviewed (Resident 3 and Resident 74).
Findings include:
1. On 11/27/23 at 10:10 A.M., Resident 3 was observed lying on her back in bed. The bed was low to the ground but there was no mat on the floor beside her.
On 11/27/23 at 2:03 P.M., Resident 3's record was reviewed. Diagnoses included hemiplegia and hemiparesis following a stroke, dementia, and contracture of the left wrist. The resident had resided at the facility for several years and did not walk.
An annual MDS (Minimum Data Set) assessment, dated 11/17/23, indicated the resident had severely impaired cognition. She was dependent on staff for bed mobility and transfers.
A care plan, revised on 4/10/23, indicated the resident was at risk for falls due to confusion, and poor positioning and trunk control when seated. The goal was her risk factors would be reduced to avoid significant injury related to falls. Interventions included: 11/21/23-low bed and mat on floor next to bed; resident to be in lowest position when in bed; 4/10/23-mechanical lift for transfers; 11/21/23-re-educate staff on bed positioning; and 4/10/23-re-educate staff on how to safely use the mechanical lift.
On 11/29/23 at 1:19 P.M., Resident 3 was observed being transferred into bed with the mechanical lift and 1 CNA (Certified Nurse Aide).
In an interview on 11/30/23 at 10:45 AM, CNA 10 indicated the resident was able to be transferred with the mechanical lift and assistance of 1.
-At 1:25 P.M., the resident was observed lying in bed with the mat on the floor however, the bed was elevated and not placed low to the ground.
During a confidential interview, a staff member indicated they had several residents who required mechanical lifts for transfers. Staff were to use 2 staff members for safety when using the lifts however, they were not always 2 staff members available due to staffing challenges. They indicated staff tried to do their best however, weekends and some weekdays were very challenging as there weren't always even 2 CNA's working the halls.
On 11/29/23 at 1:55 P.M., the Administrator was interviewed. He indicated it was the company's policy to use the mechanical lift with 2 staff members for all transfers. A current policy and procedure for Mechanical Lift Transfer Usage was provided by the Administrator which stated the mechanical lift should always be used with two people. One person should be helping control the movement of the resident while the other operates the lifting mechanism and opens the legs of the lift for optimal stability.
2. On 11/27/23 at 9:57 A.M., Resident 74 was observed lying in an elevated bed with his legs hanging off. There was a brown mat partially under his bed lying horizontally.
On 11/28/23 at 11:27 A.M., the resident was observed lying in an elevated bed on his back. There was no mat next to his bed and the brown mat was lying on the floor next to his roommates bed.
On 11/29/23 at 9:50 A.M., the resident was observed lying in bed. The bed was elevated and had no mat beside it on the floor. His head was resting on the marble window sill.
On 11/29/23 at 9:39 A.M., Resident 74's record was reviewed. Diagnoses included fracture of the left femur, chronic kidney disease, pain in left hip, and muscle wasting and atrophy. He had been admitted to the facility following a fall at home which resulted in a hip fracture.
An admission MDS assessment, dated 8/25/23, indicated the resident had moderately impaired cognition. He was dependent on staff for transfers and bed mobility.
A care plan, dated 8/22/23, indicated the resident was at risk for falls and had a history of falls in the past 30 days. The goal was to reduce his risk factors to prevent significant injury if falls occurred. Interventions included: 11/13/23-bed mat on floor beside bed when resident in bed and 11/13/23-low bed, keep in lowest position when resident in bed except during care.
A physician order, dated 11/13/23 at 6:00 p.m., was for Assistive device: Low bed with mat on floor for safety (bed in low position when resident in bed) every shift for safety for falls.
A CNA (Certified Nurse Aide) care sheet, provided by the Unit Manager (UM), on 11/30/23 at 10:20 A.M., indicated Resident 74 had a fall on 11/11/23 from bed. He was to have a low bed with mat on the floor and bed in the lowest position.
A current facility policy, titled Guidelines for Incidents/Accidents/Falls was provided on 11/28/23 at 12:00 P.M. by the Director of Nursing which stated the following: .The facility will ensure that incidents and accidents that occur involving residents are identified, reported, investigated, and resolved .Based on the results of the incident/accident/fall, the resident's care plan will be addressed to ensure that any needed points of focus have measurable goals with appropriate interventions in place. The CNA information sheet will be updated as indicated to reflect the plan of care.
3.1-45(a)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0744
(Tag F0744)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to investigate and identify underlying causes of resident specific beh...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to investigate and identify underlying causes of resident specific behaviors for 1 of 1 resident reviewed (Resident 34).
Findings include:
On 11/27/23 at 12:12 AM Resident 34 was observed sitting on their bed holding stuffed toys. Resident 34 did not respond to a verbal greeting and avoided eye contact. There was no call light in Resident 34's room.
Resident 34's record was reviewed on 11/28/23 at 2:27 PM. Diagnoses included dementia with psychotic disturbance, major depressive disorder, delusional disorder, anxiety, stroke with right side paralysis and aphasia (inability to speak).
Resident 34 was admitted to the facility on [DATE].
Resident 34's most recent quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident had severe cognitive impairment. The MDS indicated Resident 34 did not speak and was rarely or never understood. The MDS indicated the resident did not display behaviors of yelling, resistance of care, disrobing, wandering or smearing of food and/or fecal material.
Resident 34's quarterly MDS assessment dated [DATE] indicated the resident had severe cognitive impairment. The MDS indicated Resident 34 did not speak and was rarely or never understood. The MDS indicated the resident did not display behaviors of yelling, resistance of care, disrobing, wandering or smearing of food and/or fecal material.
Resident 34's quarterly MDS assessment dated [DATE] indicated the resident had severe cognitive impairment. The MDS indicated Resident 34 did not speak and was rarely or never understood. The MDS indicated the resident did not display behaviors of yelling, resistance of care, disrobing, wandering or smearing of food and/or fecal material.
A physician order dated 4/7/23 indicated Resident 34 could utilize psychiatric and counseling services as needed.
A progress note dated 4/13/23 at 3:30 PM indicated Resident 34 was attempting to get into the beds of other residents.
A progress note dated 4/27/23 at 8:47 AM indicated Resident 34 had been eating a soiled brief.
A progress note dated 4/29/23 at 9:11 AM indicated Resident 34 had fecal material in her mouth.
A progress note dated 5/1/23 at 2:04 PM indicated Resident 34 had been combative with care. Interventions were ineffective.
A progress note dated 5/2/23 at 9:49 AM indicated Resident 34 had been combative with care and had been entering the rooms of other residents. Interventions were ineffective.
A progress note dated 5/3/23 at 2:22 PM indicated Resident 34 had shredded their brief into small pieces.
A progress note dated 5/4/23 at 12:48 PM indicated Resident 34 had been continuously removing their brief and had been resistant to care. Interventions were ineffective.
A progress note dated 5/4/23 at 4:16 PM indicated Resident 34 had removed their brief and had been eating fecal material.
A progress note dated 5/7/23 at 2:24 PM indicated Resident 34 had removed their brief, placed their fingers into rectum and licked their fingers.
A progress note dated 5/8/23 at 2:09 PM indicated Resident 34 had attempted to enter the rooms of other residents and had smeared fecal material on their self and their belongings. Interventions were ineffective.
A progress note dated 5/11/23 at 7:48 AM indicated Resident 34 had been attempting to enter the rooms of other residents and had been combative with care.
A progress note dated 5/11/23 at 5:29 PM indicated Resident 34 had repeatedly removed their brief and threw the brief onto the floor. Interventions were not effective.
A progress note dated 5/13/23 at 1:47 AM indicated Resident 34 had repeatedly removed their brief and repeatedly set off the bed alarm. Interventions were not effective.
A progress note dated 5/13/23 at 9:40 AM indicated Resident 34 had repeatedly removed their brief, had been combative with care when attempts were made to apply a new brief and refused their medication. Interventions were not effective. The physician was notified.
A progress note dated 5/17/23 at 8:33 AM indicated Resident 34 had removed their brief and placed their fingers into their private areas.
A progress note dated 5/19/23 at 1:55 AM indicated Resident 34 had removed their bedding and all clothing. The resident was combative with the staff upon attempts to dress the resident. The resident refused a blanket and remained lying fully nude in their bed. Resident 34 had been administered morphine as an intervention and went to sleep while being fully nude.
A progress note dated 5/22/23 at 12:15 AM indicated Resident 34 had refused their medication. Interventions were not effective.
A progress note dated 5/22/23 at 9:46 AM indicated Resident 34 had refused their medication. The staff member utilized their cell phone to Russian translation and requested the resident to please take their medication. Resident 34 then took their medication.
A progress note dated 5/24/23 at 10:18 AM indicated Resident 34 had removed their brief and had been playing with their private areas.
A progress note dated 5/25/23 at 2:20 AM indicated Resident 34 had removed all their clothing and had rubbed flower petals and dirt all over their body.
A progress note dated 5/25/23 at 10:35 AM indicated Resident 34 had eaten fecal material and smeared it all over their body, body, face and hair.
A progress note dated 5/26/23 at 9:47 AM indicated Resident 34 had refused their medications and was combative with care. Interventions were not effective.
A progress note dated 5/26/23 at 4:23 AM indicated Resident 34 had removed their brief and had been eating the brief.
A progress note dated 5/30/23 at 9:00 AM indicated Resident 34 had smeared fecal material all over their body, hair, mouth and their personal belongings. Interventions were ineffective.
A progress note dated 5/30/23 at 1:00 PM indicated Resident 34 had removed fecal material from their brief and smeared it all over their body and in their mouth. Interventions were ineffective.
A progress note dated 5/31/23at 10:39 AM indicated Resident 34 had removed the bed sheets and had wrapped the alarm cord around her head and arm. The note indicated the resident had been touching their genitalia. Interventions were ineffective.
A progress note dated 6/1/23 at 11:09 AM indicated Social Services had removed Resident 34's call light after the resident had displayed suicidal behaviors. Social Services educated Resident 34 on the use of a bell. Social Services removed all belts and other items that could be used to inflict self-harm. Social Services requested permission from
Resident 34's daughter to enroll the resident into psychiatric services.
Resident 34's current care plan entry dated 6/1/23 and revised on 11/21/23 indicated the resident had acted out a suicide attempt. The target goal was for the resident to remain safe by 12/24/23. Interventions dated 10/9/23 included removal of the call light and replacing the call light with a hand bell, room searched for harmful items, treatment by psychiatric services and use of a cordless bed.
Resident 34's current care plan entry dated 7/30/23 and revised on 9/22/23 indicated the resident would communicate by yelling due to the inability to speak English. The target goal was for Resident 34 to make basic needs known by sounds or gestures on a daily basis by 12/24/23. The interventions included the anticipation and meeting of needs, call light in reach, adequate low glare lighting and avoidance of isolation.
Resident 34's current care plan entry dated 9/13/23 indicated the resident had behaviors of yelling out for an unknown cause, restlessness, excessive worrying, excessive crying, smearing fecal material and eating fecal material. The target goal was for the resident to have decreased behaviors by 12/24/23. Interventions included listening to concerns, provide stuffed toys, provide music, provide cartoons, administer medications and monitor medications.
Resident 34's current care plan entry dated 11/21/23 indicated the resident had cognitive impairment and delusions related to dementia that did not interfere with care or cause distress. The target goal was to have needs anticipated and met and confused thoughts would not interfere with care by 12/24/23. Interventions included orientation to reality, providing 2 choices for decisions and giving 1 instruction at a time.
In a phone interview on 11/29/23 at 12:08 PM Resident 34's daughter indicated the resident had been admitted for respite care several times in the past. The daughter indicated Resident 34 was now a long-term resident with no plans to go home due the daughter's inability to provide the resident's care. The daughter indicated Resident 34 had never acted out suicidal behavior while at home or during previous admissions to the facility. The daughter indicated Resident 34 had never smeared or eaten fecal material at home or during previous facility admissions. The daughter indicated Resident 34 had become nonverbal after their most recent stroke. The daughter indicated Resident 34 understood the Russian language and communicated with their eyes and facial expressions. The daughter indicated Resident 24 had become extremely distraught when they realized there was not a plan for the resident to return home. The daughter indicated Resident 34 had been having a difficult time processing the loss of function after the most recent stroke. The daughter indicated loud noises and the glare of artificial light were stressors for the resident. The daughter indicated she hoped Resident 34's TV was turned off at night. The daughter indicated Resident 34 was very receptive to negative speaking tones, negative facial expressions and body language. The daughter indicated Resident 34 became anxious when people were tense even if the unhappy facial expressions and tone of voice were not directed towards the resident. The daughter indicated she had made the facility staff had been made aware of possible stressors. The daughter indicated the resident would tightly squeeze their stuffed animals when they were starting to become anxious.
In an interview on 11/30/23 at 12:30 PM the Director of Nursing (DON) indicated the facility did not investigate Resident 34's suicidal action or smearing and eating fecal material. The DON indicated the resident had not displayed suicidal actions or smearing and eating fecal material in the past.
In an interview on 12/1/23 at 11:19 AM the Social Service Director (SSD) indicated they were unaware of any events that could have caused Resident 34 to display new behaviors of smearing fecal material and suicidal action. The SSD indicated there was no investigation related to possible underlying causes or events prior to the resident's behaviors. The SSD indicated they were unaware of loud noises and artificial light glare being possible stressors to the resident's behaviors. The SSD indicated Resident 34 became more agitated after their daughter left the facility after visitation. The SSD indicated resident specific behaviors were monitored on behavior flow sheets and the progress notes. The SSD indicated direct care staff were made aware of specific resident behavior on the Certified Nurse Aide (CNA) assignment sheets. The SSD indicated they had resumed the SSD role 1 month ago.
A review of Resident 34's CNA assignment sheet provided by Registered Nurse 21 on 12/1/23 at 11:31 AM indicated the resident had a behavior of being nonverbal.
A current copy of a facility policy dated 8/18/23 titled Behavior Management Meetings provided by the DON on 12/1/23 at 10:30 AM indicated the facility would investigate behaviors in an effort to determine the root cause of the behaviors. The policy indicated the facility would monitor and document target behaviors daily.
A current copy of an undated facility policy titled Suicide Precautions provided by the DON on 12/1/23 at 10:30 AM indicated any resident who displays suicidal ideation or suicide attempt will be immediately placed on suicide precautions and the physician, Administrator, DON and family representative would be notified. The policy indicated suicide precautions would be in place until the resident can be sent out for a psychological evaluation or a physician order is obtained to discontinue the precautions. The policy indicated suicide precaution interventions would include 1 on 1 observance by a staff member within 6 feet of the resident. The policy indicated the 1 on 1 staff member would document the resident's mood and behavior every 15 minutes throughout the duration of the precautions.
3.1-37
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0745
(Tag F0745)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide Social Services to identify and track abnormal behaviors fo...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide Social Services to identify and track abnormal behaviors for 1 of 1 resident reviewed (Resident 34).
Findings include:
On 11/27/23 at 12:12 AM Resident 34 was observed sitting on their bed holding stuffed toys. Resident 34 did not respond to a verbal greeting and avoided eye contact. There was no call light in Resident 34's room.
Resident 34's record was reviewed on 11/28/23 at 2:27 PM. Diagnoses included dementia with psychotic disturbance, major depressive disorder, delusional disorder, anxiety, stroke with right side paralysis and aphasia (inability to speak).
Resident 34 was admitted to the facility on [DATE].
Resident 34's most recent quarterly MDS assessment dated [DATE] indicated the resident had severe cognitive impairment. The MDS indicated Resident 34 did not speak and was rarely or never understood. The MDS indicated the resident did not display behaviors of yelling, resistance of care, disrobing, wandering or smearing of food and/or fecal material.
Resident 34's current care plan entry dated 6/1/23 and revised on 11/21/23 indicated the resident had acted out a suicide attempt. An intervention dated 10/9/23 included removal of the call light and replacing the call light with a hand bell.
Resident 34's current care plan entry dated 7/30/23 and revised on 9/22/23 indicated the resident would communicate by yelling due to the inability to speak English. The target goal was for Resident 34 to make basic needs known by sounds or gestures on a daily basis by 12/24/23. The interventions included the anticipation and meeting of needs, call light in reach, adequate low glare lighting and avoidance of isolation.
A physician order dated 4/7/23 indicated Resident 34 could utilize psychiatric and counseling services as needed.
A progress note dated 4/13/23 at 3:30 PM indicated Resident 34 was attempting to get into the beds of other residents.
A progress note dated 4/27/23 at 8:47 AM indicated Resident 34 had been eating a soiled brief.
A progress note dated 4/29/23 at 9:11 AM indicated Resident 34 had fecal material in her mouth.
A progress note dated 5/1/23 at 2:04 PM indicated Resident 34 had been combative with care. Interventions were ineffective.
A progress note dated 5/2/23 at 9:49 AM indicated Resident 34 had been combative with care and had been entering the rooms of other residents. Interventions were ineffective.
A progress note dated 5/3/23 at 2:22 PM indicated Resident 34 had shredded their brief into small pieces.
A progress note dated 5/4/23 at 12:48 PM indicated Resident 34 had been continuously removing their brief and had been resistant to care. Interventions were ineffective.
A progress note dated 5/4/23 at 4:16 PM indicated Resident 34 had removed their brief and had been eating fecal material.
A progress note dated 5/7/23 at 2:24 PM indicated Resident 34 had removed their brief, placed their fingers into rectum and licked their fingers.
A progress note dated 5/8/23 at 2:09 PM indicated Resident 34 had attempted to enter the rooms of other residents and had smeared fecal material on their self and their belongings. Interventions were ineffective.
A progress note dated 5/11/23 at 7:48 AM indicated Resident 34 had been attempting to enter the rooms of other residents and had been combative with care.
A progress note dated 5/11/23 at 5:29 PM indicated Resident 34 had repeatedly removed their brief and threw the brief onto the floor. Interventions were not effective.
A progress note dated 5/13/23 at 1:47 AM indicated Resident 34 had repeatedly removed their brief and repeatedly set off the bed alarm. Interventions were not effective.
A progress note dated 5/13/23 at 9:40 AM indicated Resident 34 had repeatedly removed their brief, had been combative with care when attempts were made to apply a new brief and refused their medication. Interventions were not effective. The physician was notified.
A progress note dated 5/17/23 at 8:33 AM indicated Resident 34 had removed their brief and placed their fingers into their private areas.
A progress note dated 5/19/23 at 1:55 AM indicated Resident 34 had removed their bedding and all clothing. The resident was combative with the staff upon attempts to dress the resident. The resident refused a blanket and remained lying fully nude in their bed. Resident 34 had been administered morphine as an intervention and went to sleep while being fully nude.
A progress note dated 5/22/23 at 12:15 AM indicated Resident 34 had refused their medication. Interventions were not effective.
A progress note dated 5/22/23 at 9:46 AM indicated Resident 34 had refused their medication. The staff member utilized their cell phone to Russian translation and requested the resident to please take their medication. Resident 34 then took their medication.
A progress note dated 5/24/23 at 10:18 AM indicated Resident 34 had removed their brief and had been playing with their private areas.
A progress note dated 5/25/23 at 2:20 AM indicated Resident 34 had removed all their clothing and had rubbed flower petals and dirt all over their body.
A progress note dated 5/25/23 at 10:35 AM indicated Resident 34 had eaten fecal material and smeared it all over their body, body, face and hair.
A progress note dated 5/26/23 at 9:47 AM indicated Resident 34 had refused their medications and was combative with care. Interventions were not effective.
A progress note dated 5/26/23 at 4:23 AM indicated Resident 34 had removed their brief and had been eating the brief.
A progress note dated 5/30/23 at 9:00 AM indicated Resident 34 had smeared fecal material all over their body, hair, mouth and their personal belongings. Interventions were ineffective.
A progress note dated 5/30/23 at 1:00 PM indicated Resident 34 had removed fecal material from their brief and smeared it all over their body and in their mouth. Interventions were ineffective.
A progress note dated 5/31/23at 10:39 AM indicated Resident 34 had removed the bed sheets and had wrapped the alarm cord around her head and arm. The note indicated the resident had been touching their genitalia. Interventions were ineffective. The progress note did not indicate suicide precautions had been implemented.
A progress note dated 6/1/23 at 11:09 AM indicated Social Services had removed Resident 34's call light after the resident had displayed suicidal behaviors. Social Services educated Resident 34 on the use of a bell. Social Services removed all belts and other items that could be used to inflict self-harm. Social Services requested permission from Resident 34's daughter to enroll the resident into psychiatric services. The progress note did not indicate suicide precautions had been implemented.
Resident 34's current care plan entry dated 6/1/23 and revised on 11/21/23 indicated the resident had acted out a suicide attempt. The target goal was for the resident to remain safe by 12/24/23. Interventions dated 10/9/23 included removal of the call light and replacing the call light with a hand bell, room searched for harmful items, treatment by psychiatric services and use of a cordless bed.
Resident 34's current care plan entry dated 7/30/23 and revised on 9/22/23 indicated the resident would communicate by yelling due to the inability to speak English. The target goal was for Resident 34 to make basic needs known by sounds or gestures on a daily basis by 12/24/23. The interventions included the anticipation and meeting of needs, call light in reach, adequate low glare lighting and avoidance of isolation.
Resident 34's current care plan entry dated 9/13/23 indicated the resident had behaviors of yelling out for an unknown cause, restlessness, excessive worrying, excessive crying, smearing fecal material and eating fecal material. The target goal was for the resident to have decreased behaviors by 12/24/23. Interventions included listening to concerns, provide stuffed toys, provide music, provide cartoons, administer medications and monitor medications.
Resident 34's current care plan entry dated 11/21/23 indicated the resident had cognitive impairment and delusions related to dementia that did not interfere with care or cause distress. The target goal was to have needs anticipated and met and confused thoughts would not interfere with care by 12/24/23. Interventions included orientation to reality, providing 2 choices for decisions and giving 1 instruction at a time.
In a phone interview on 11/29/23 at 12:08 PM Resident 34's daughter indicated the resident had been admitted for respite care several times in the past. The daughter indicated Resident 34 was now a long-term resident with no plans to go home due the daughter's inability to provide the resident's care. The daughter indicated Resident 34 had never acted out suicidal behavior while at home or during previous admissions to the facility. The daughter indicated Resident 34 had never smeared or eaten fecal material at home or during previous facility admissions. The daughter indicated Resident 34 had become nonverbal after their most recent stroke. The daughter indicated Resident 34 understood the Russian language and communicated with their eyes and facial expressions. The daughter indicated Resident 24 had become extremely distraught when they realized there was not a plan for the resident to return home. The daughter indicated Resident 34 had been having a difficult time processing the loss of function after the most recent stroke. The daughter indicated loud noises and the glare of artificial light were stressors for the resident. The daughter indicated she hoped Resident 34's TV was turned off at night. The daughter indicated Resident 34 was very receptive to negative speaking tones, negative facial expressions and body language. The daughter indicated Resident 34 became anxious when people were tense even if the unhappy facial expressions and tone of voice were not directed towards the resident. The daughter indicated she had made the facility staff had been made aware of possible stressors. The daughter indicated the resident would tightly squeeze their stuffed animals when they were starting to become anxious.
In an interview on 11/30/23 at 12:30 PM the Director of Nursing (DON) indicated Resident 34 did not have a call light in their room due the resident had been found with the call light cord wrapped around their head or neck. The DON indicated they were not aware of any possible stressors related to Resident 34's behaviors of suicidal action and smearing and eating of fecal material. The DON indicated the facility did not investigate Resident 34's suicidal action or smearing and eating fecal material. The DON indicated Resident 34 had been admitted to the facility numerous times in the past. The DON indicated the resident had not displayed suicidal actions or smearing and eating fecal material in the past.
In an interview on 12/1/23 at 11:19 AM the Social Service Director (SSD) indicated they were unaware of any events that could have caused Resident 34 to display new behaviors of smearing fecal material and suicidal action. The SSD indicated there was no investigation related to possible underlying causes or events prior to the resident's behaviors. The SSD indicated they were unaware of loud noises and artificial light glare being possible stressors to the resident's behaviors. The SSD indicated Resident 34 became more agitated after their daughter left the facility after visitation. The SSD indicated resident specific behaviors were monitored on behavior flow sheets and the progress notes. The SSD indicated direct care staff were made aware of specific resident behavior on the Certified Nurse Aide (CNA) assignment sheets. The SSD indicated they had resumed the SSD role 1 month ago.
A review of Resident 34's CNA assignment sheet provided by Registered Nurse 21 on 12/1/23 at 11:31 AM indicated the resident had a behavior of being nonverbal.
A current copy of a facility policy dated 8/18/23 titled Behavior Management Meetings provided by the DON on 12/1/23 at 10:30 AM indicated the facility would investigate behaviors in an effort to determine the root cause of the behaviors. The policy indicated the facility would monitor and document target behaviors daily.
3.1-34(a)
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review the facility failed to maintain minimum staffing levels to ensure safety with 2 staff members to transfer 22 residents who required use of a mechanica...
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Based on observation, interview and record review the facility failed to maintain minimum staffing levels to ensure safety with 2 staff members to transfer 22 residents who required use of a mechanical lift daily.
Findings include:
An Indiana Report Form, dated 10/25/23, alleged the facility hadn't enough staff to transfer residents who required a mechanical lift with assistance from 2 staff members. The complainant alleged there was only one staff working on a hall with 31 residents, some who required use of a mechanical lift for transfers.
On 11/27/23 at 1:18 P.M., a confidential interview with a resident identified as interviewable, indicated they had to wait to be transferred to and from bed because they needed a mechanical lift with 2 staff members. The facility didn't always have 2 staff on the hall and they would have to wait for a second person from another unit to come and help.
On 11/29/23 at 11:17 A.M., during a Resident Council meeting, residents indicated the facility was short staffed, especially on weekends. Several residents present, indicated they required a mechanical lift for transfers and had to wait up to an hour for 2 staff members to get them up from or down to bed.
On 11/29/23 at 1:19 P.M., Resident 3 was observed being transferred into bed via a mechanical lift. One CNA (Certified Nurse Aide) operated the lift during the transfer. there was not a second CNA available to assist with the transfer.
During a confidential interview, a staff member indicated they had several residents who required mechanical lifts for transfers. Staff were to use 2 staff members for safety when using the lifts however, they were not always 2 staff members available due to staffing challenges. They indicated staff tried to do their best however, weekends and some weekdays were very challenging as there weren't always 2 CNA's working the halls.
On 11/29/23 at 1:55 P.M., the Administrator was interviewed. He indicated it was the company's policy to use the mechanical lift with 2 staff members for all transfers.
On 12/1/23 at 1:00 P.M., the Facility Assessment Form was reviewed. The form, updated on 10/2/23, indicated the facility's average daily census was 75 - 80 residents. The form indicated the residents and their various diagnoses which the facility was prepared and able to care for in addition to the types of treatments the facility could provide (i.e., IV medications, oxygen therapy, behavioral health, etc). The facility assessment indicated the average number of residents who required assistance with ADL's (activities of daily living) and needed staffing to provide the assistance. The average number of residents who were dependent (need for mechanical lift) for transfers was 12. The assessment indicated to have sufficient staff to meet the needs of the resident, based on their resident population and census, the facility required 135 hours of CNA care per 24 hours.
A list of residents requiring mechanical lifts was provided by the Director of Nursing (DON) on 12/1/23 at 8:30 A.M. The list indicated there were currently 22 residents that required a mechanical lift and assistance of 2 staff members for all transfers.
Review of as-worked CNA hours, provided by the DON on 12/1/23 at 2:09 P.M., for 11/23 thru 11/30/23 indicated the following days without the minimum 135 CNA hours:
-11/24/23: 134.25 hours
-11/25/23: 124.75 hours
-11/26/23: 98.75 hours
-11/27/23: 107.5 hours
This citation is related to complaint IN00420496
3.1-17(a)
Aug 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure 1 of 3 residents was treated with respect and dignity during non-care related interactions (Resident L).
Findings include:
An Indian...
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Based on interview and record review, the facility failed to ensure 1 of 3 residents was treated with respect and dignity during non-care related interactions (Resident L).
Findings include:
An Indiana report, dated 8/14/23 at 12:13 p.m., indicated a resident reported an activity aide had shown her inappropriate photographs that were on the aides personal cell phone.
On 8/16/23 at 11:58 A.M., Resident L, identified as interviewable, was interviewed. She was observed seated in her wheelchair, wearing her dark purple colored dress and white cap-covering which was indicative of her Amish expression of faith. She was animated, with her voice rising when expressing disbelief, while telling her story. The activity aide had shown her nude photos of herself as well as men she was dating on a dating app. The resident indicated this had occurred while she had been in the activity room working on puzzles approximately 1-2 weeks ago. She reported it, on Monday, 8/14/23 to the Activity Director. Resident L indicated she told the activity aide she hadn't wanted to see that and she could get into trouble showing those photo's around. When asked, the resident indicated it hadn't happened again after she told the activity aide she didn't want to see it. The resident hadn't expressed any distress over the incident and was exuberant in her telling of the event.
On 8/16/23 at 11:44 A.M., Resident L's record was reviewed. Diagnoses included a neurological movement disorder. The resident had lived in the facility for several years. Her care plans indicated she was single and part of the Old Amish Order. Participation in religious services and practices was very important to her.
On 8/16/23 at 1:28 P.M., the Social Services Director (SSD) and Activity Director (AD) were interviewed. The AD indicated on Monday, 8/14/23, Resident L asked if she could speak with her and shared that the activity aide had shown her a picture of male genitalia on her cell phone. The resident indicated she hadn't wanted to see that and told that to the aide. The SSD indicated the activity aide was suspended and the resident monitored for psychosocial distress related to the incident. The AD indicated during investigation of the allegation, the activity aide admitted she had shown the picture to Resident L and hadn't understood why it was a problem she had done this.
On 8/16/23 at 3:37 P.M., the Director of Nursing (DON) was interviewed. She indicated she met with Resident L who indicated the activity aide had shown her a picture of male genitalia from a picture posted on the aides dating app. The DON and AD spoke with the activity aide who indicated she had shown the resident a picture of a male penis and hadn't understood the problem with this. The activity aide was suspended and indicated she was going to look for a different job.
A current facility policy, titled Resident Rights, was provided by the DON on 8/16/23 at 4:10 P.M., stated the following: As a resident of this facility, you have the right to a dignified existence and communicate with individuals and representatives of choice. The facility will protect and promote your rights as designated below .Quality of Life-The facility must care for you in a manner and environment enhances or promotes your quality of life. Dignity-The facility will treat you with dignity and respect in full recognition of your individuality
Old Amish Order, Beliefs and way of life, (Britannica 2023) was retrieved on 8/16/23 at 4:00 P.M. and indicated the following: Humility, family, community, modesty, and separation from the world were the mainstays of the Amish. Everyday life and custom were governed by an unwritten code of behavior.
This Federal tag relates to Complaint IN00415319.
3.1-3(t)
Dec 2022
2 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0740
(Tag F0740)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure resident specific care as evidenced by failure ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure resident specific care as evidenced by failure to identify behaviors for 3 of 3 residents reviewed for behavioral services. (Resident 11, Resident 18, Resident 22)
Findings include:
1. On 12/15/22 at 12:11 PM Resident 11 was observed trying to open the door of another resident's room.
A record review on 12/16/22 at 10:13 AM indicated Resident 11's diagnoses included unspecified dementia with behavioral disturbances, unspecified anxiety disorder, and other specified depressive disorders.
A Quarterly MDS assessment dated [DATE] indicated the resident had a BIMS score of 2 (severe cognitive impairment). The MDS assessment indicated the resident did not exhibit physical or verbal behaviors, delusions, wandering, exit seeking, or rejection of care.
A care plan revision dated 9/21/22 indicated the resident displayed agitation and restlessness.
A care plan revision dated 9/22/22 indicated on 9/21/22 the resident preferred to not have male nursing assistants.
A progress note dated 3/10/22 at 5:46 PM indicated the resident thought her son was her husband and wanted to leave with him. The resident threw her drinks on the floor after the staff tried to console her.
A progress noted dated 4/26/22 at 11:44 AM indicated the resident was increasingly agitated and stating her family was there to take her home. Attempts to console or distract the resident were unsuccessful. There were no other interventions documented.
A progress note by NP (Nurse Practitioner)1 dated 5/6/22 at 6:19 PM indicated the facility requested the resident be evaluated for disruptive behaviors including yelling, excessive talking, and irritability. The plan was to continue to monitor safety, moods, sleep, behaviors, response to medications and note any trends in moods or behaviors.
A progress note dated 6/4/22 at 6:43 PM indicated the resident continued to get angry. The resident propelled herself in her wheelchair up and down the hall to find her family. The resident yelled no one was nice to her and asked if she could leave through the back door. The progress note indicated the resident kept pulling the fire doors shut on herself. There were no interventions to indicate staff had tried to redirect the behavior
A progress note dated 6/22/22 at 6:32 PM by NP 1 indicated the resident currently had delusions. The resident reported her mood as lonely, and she missed talking to people. The resident indicated it was nice talking to NP 1.
A progress note dated 7/19/22 at 10:32 AM indicated the resident was agitated and yelling at the staff. The resident demanded she be given the staff narcotic and schedule books. The resident was offered other books and refused. The resident was intermittently yelling and laughing.
A progress note dated 7/27/22 at 2:28 PM by NP 1 indicated there were no concerns reported by the staff.
A progress note dated 8/5/22 at 4:03 AM indicated the resident was awake most of the night and agitated. The resident was offered a book but indicated she was too nervous to read. No other intervention attempts were documented.
A progress note dated 8/6/22 at 3:00 AM indicated the resident was agitated and had been awake since 8/4/22. The resident's anti-anxiety medication was to be resumed.
A progress note dated 8/8/22 at 12:55 AM indicated the resident was restless and unable to stay in bed. No ontervention attempts were documented.
A progress note dated 8/25/22 at 6:35 AM indicate the resident fell out of her bed and crawled to her doorway. The resident spent the rest of the night at the nurse station.
A progress note dated 8/29/22 at 6:47 AM indicated the resident attempted to crawl out of her bed and remained awake the entire night. No intervention attempts were documented.
A progress note dated 9/26/22 at 2:51 AM indicated the resident had been awake all night at the nurse station. Attempts by the staff to redirect the resident were unsuccessful. The resident thought she was at the bank or at the dentist. The resident kept repeating that she didn't do anything and asked why she couldn't go home. No intervention attempts were documented.
A progress note dated 9/26/22 at 1:24 PM indicated the resident continued to have increased agitation. The resident became more restless and upset after attempts to divert her attention. No other intervention attempts were documented.
A progress note dated 10/26/22 at 11:29 PM by NP 1 indicated the resident had extreme mood changes, increased agitation, increased aggression, and had been exit seeking.
A progress note dated 11/10/22 at 6:55 AM indicated the resident had been up throughout the night looking for her car so she could go home. No intervention attempts were documented.
A progress note dated 11/16/22 at 5:32 AM indicated the resident had been provided continuous 1 on 1 supervision throughout the night. The resident wanted to go outside and get her car. No intervention attempts were documnted.
A progress note dated 12/10/22 at 12:15 AM indicated the resident had kicked a nursing assistant in the chest during resident care. No intervention ateempts were documented.
During an interview on 12/19/22 at 11:05 the Director of Nursing (DON) indicated the resident did not have a history of exit seeking behavior or resistance to care. She indicated general assessments such as behaviors should be completed quarterly. She indicated social services was responsible for quarterly behavioral assessments.
During an interview on 12/19/22 at 2:29 PM the Social Service Director (SSD) indicated she was not aware of the resident's exit seeking behavior or resistance to care. She indicated she remembered revising the resident's care plan on 9/22/22 to indicate the resident's preference for female nursing assistants. She indicated she recalled an episode of the resident being agitated during a shower that prompted the care plan revision. She indicated she was aware of the lack of progress notes on 9/21/22. She indicated she believed the nursing staff had documented the episode. She indicated the nursing staff usually monitored exit seeking behavior and revised the resident's care plan as needed.
2. A record review on 12/18/22 at 10:56 AM indicated Resident 18 had diagnoses of unspecified psychosis, unspecified dementia with behavioral disturbance, anxiety disorder, auditory hallucinations, visual hallucinations, delusional disorders, and major depressive disorder.
A quarterly (MDS) assessment dated [DATE] indicated the resident had a (BIMS) score of 12 on a 0-15 scale (moderate cognitive deficit). The MDS indicated the resident had trouble concentrating. The MDS indicated the resident did not experience hallucinations or delusions. The MDS did not indicate the resident expressed suicidal ideation.
A care plan entry dated 10/28/21 and revised 7/13/22 indicated the resident experienced delusions of children being abused and believing everyone is talking about her. Interventions included psychotropic medications, one on one conversation, and prompt follow up of the resident's concerns.
A care plan entry dated 1/26/22 and revised 9/16/22 indicated the resident experienced delusions. Interventions include assessment of pain, hunger, thirst, energy level, room climate, positioning, and clothing comfort level. Other inventions included breaking activities into manageable subtasks, providing one instruction at a time, allowing the resident time to process explanations related to procedures, providing the resident with 2 choices when presenting decisions, providing activities for mental stimulation, and establishing a daily routine.
A care plan entry dated 5/3/21 and revised on 9/16/22 indicated the resident has made accusations against unidentified people. Interventions included investigating the accusations, gathering insight from the resident's family, gathering as much information as possible from the resident, providing reassurance, TLC, and initiating a family visit if the resident is distressed.
The resident's care plan did not address hallucinations or suicidal ideations
A progress noted dated 10/26/22 at 11:43 PM by NP 1 indicated the resident was a survivor of abuse and neglect. The progress noted indicated the resident was experiencing hallucinations of bugs in her room. The resident indicated her children were outside crying in the rain and the facility staff refused to let them in. The resident indicated the staff lying to her about her children being safe while her children were screaming for her was more distressing than the bugs in her room. The resident indicated she had a history of believing she would be better off dead and making suicidal threats. The resident denied suicidal ideation at that time. The resident indicated she had a bad childhood and everyone in her family has depression due to her father being a drunk. The progress note indicated the resident experienced increased delusions the previous week.
During an interview on 12/19/22 at 2:49 PM the Social Service Director (SSD) indicated she was not aware of the resident's history of suicidal ideation. She indicated the documentation for psychiatric service providers was delayed in getting to the facility. She indicated she was aware of the resident being a trauma survivor. She indicated she did not evaluate the resident for potential triggers. She indicated she should have evaluated the resident for possible triggers related to the resident's history of trauma. She indicated possible triggers and suicidal ideation should have been added to the resident's care plan and monitored on a behavior tracking form.
3. A record review on 12/19/22 at 6:30 AM indicated Resident 22 had diagnoses of drug induced subacute dyskinesia, bipolar disorder, unspecified psychosis, major depressive disorder, and schizoaffective disorder.
A comprehensive MDS assessment dated [DATE] indicated the resident had no cognitive impairment.
A progress note dated 10/26/22 at 11:59 PM by NP 1 indicated the resident had delusions and hallucinations. The resident had a history of suicidal ideation with a plan but no suicide attempts. The resident's past suicide plan involved saving up her pills to take all at once, but she never completed the plan. The resident's spouse had a history of sneaking medications not ordered by a physician into the facility (Benadryl and Imodium). The resident had a history of consuming alcohol when leaving the facility with her spouse.
The resident's care plan initiated 9/11/2017 revised 11/8/22 did not indicate the resident had a history of suicidal ideation, medications in her room, or alcohol use.
During an interview on 12/19/22 at 11:06 AM, the DON indicated the resident's history of suicidal ideation, possession of medications in her room, and alcohol consumption should be documented in the resident's care plan and monitored on a behavior tracking form.
In an interview on 12/19/22 at 4:07 PM the DON indicated she was unable to locate a specific policy related to behavioral services or trauma informed care assessments.
A current policy (no date) titled Policy and Procedure Regarding Missing Residents and Elopement provided by the DON on 12/19/22 at 4:05 PM indicated all residents are provided adequate supervision to meet their needs. The policy indicated all residents would be assessed for all behaviors and conditions that placed them at risk for elopement and would be addressed in each resident's care plan.
3.1-37
3.1-43
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Garbage Disposal
(Tag F0814)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain sanitation of the outside trash storage area ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain sanitation of the outside trash storage area in 1 of 1 observation.
Findings include:
During a tour with the Dietary Manager (DM) on 12/14/22 at 11:28 AM a lid on an outside storage container was observed to be open. The DM indicated the wind opened the lid at times. The DM unsuccessfully attempted to close the lid with a garden [NAME]. The DM indicated the lid had been problematic for awhile. She indicated she notified maintenance of past events when she was unable to close the lid. On the ground beside the dumpster, there was a puddle of an orange liquid containing carrots and potato chunks. The area surrounding the puddle was dry and rust colored. The DM indicated there should not be debris on the ground surrounding the dumpster. The DM indicated she was unaware of who was responsible for cleaning the dumpster area. She indicated the spillage on the ground should have been cleaned up immediately.
During an interview 12/15/22 at 9:47 AM the DM on indicated the spillage observed around the dumpster on 12/14/22 had been cleaned up. She indicated the spillage was most likely due to breakage of a trash bag. She indicated the spillage had not been cleaned immediately due to the inability to spray the area down. She indicated the hose had been disconnected by the maintenance department due to winter. She indicated the debris could have been swept up with a broom.
During an interview with the Maintenance Director on 12/15/22 at 1:50 PM he indicated he was aware of the dumpster lid being opened by high winds. He indicated the sanitation company was aware of the faulty dumpster lid. He indicated he had contacted the sanitation company a few times without success. He indicated the DM had requested his assistance in closing the dumpster lid a few times in the past year.
The Maintenance Director indicated he had disconnected the dumpster area hose 2 weeks ago. He indicated he disconnected the hose to avoid breakage of the spigot and spray nozzle in cold weather. He indicated he was not aware of debris in the dumpster area. He indicated the area around the dumpsters should be free from debris. He indicated the debris should have been removed despite the hose being disconnected. He indicated he was not aware which department was responsible for ensuring cleanliness of the dumpster area.
During an interview on 12/15/22 at 2:05 PM, the Administrator indicated she was unaware of the dumpster lid being blown open by the wind. She indicated she was aware dumpster lids were to always remain closed. She indicated there should be no debris on the ground in the dumpster area.
A review of dietary cleaning assignment sheets for 2022 provided by the Director of Nursing (DON) on 12/16/22 at 11:10 AM did not indicate the outside dumpster area was on the cleaning assignment list.
An undated current facility policy provided by the Administrator on 12/15/22 at 3:22 PM titled Waste Disposal Procedure indicated the dining services department would hold, transfer, and dispose of waste in a manner to not create a nuisance or breeding place for insects and rodents. The policy indicated dumpster lids were to always be closed and the dumpster area was to be free of debris.
3.1-21(i)(5)
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What safeguards are in place to prevent abuse and neglect?"
- "Why is there high staff turnover? How do you retain staff?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No fines on record. Clean compliance history, better than most Indiana facilities.
Concerns
- • Multiple safety concerns identified: Federal abuse finding, 1 harm violation(s), Payment denial on record. Review inspection reports carefully.
- • 34 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
- • Grade F (25/100). Below average facility with significant concerns.
- • 60% turnover. Above average. Higher turnover means staff may not know residents' routines.
Bottom line: This facility has a substantiated abuse finding. Extreme caution advised. Explore alternatives.
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About This Facility
What is Waters Of Lagrange Skilled Nursing Facility, The's CMS Rating?
CMS assigns WATERS OF LAGRANGE SKILLED NURSING FACILITY, THE an overall rating of 2 out of 5 stars, which is considered below average nationally. Within Indiana, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Waters Of Lagrange Skilled Nursing Facility, The Staffed?
CMS rates WATERS OF LAGRANGE SKILLED NURSING FACILITY, THE's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 60%, which is 14 percentage points above the Indiana average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs. RN turnover specifically is 67%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Waters Of Lagrange Skilled Nursing Facility, The?
State health inspectors documented 34 deficiencies at WATERS OF LAGRANGE SKILLED NURSING FACILITY, THE during 2022 to 2025. These included: 1 that caused actual resident harm, 32 with potential for harm, and 1 minor or isolated issues. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Waters Of Lagrange Skilled Nursing Facility, The?
WATERS OF LAGRANGE SKILLED NURSING FACILITY, THE is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by INFINITY HEALTHCARE CONSULTING, a chain that manages multiple nursing homes. With 100 certified beds and approximately 74 residents (about 74% occupancy), it is a mid-sized facility located in LAGRANGE, Indiana.
How Does Waters Of Lagrange Skilled Nursing Facility, The Compare to Other Indiana Nursing Homes?
Compared to the 100 nursing homes in Indiana, WATERS OF LAGRANGE SKILLED NURSING FACILITY, THE's overall rating (2 stars) is below the state average of 3.1, staff turnover (60%) is significantly higher than the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Waters Of Lagrange Skilled Nursing Facility, The?
Based on this facility's data, families visiting should ask: "What safeguards and monitoring systems are in place to protect residents from abuse or neglect?" "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" These questions are particularly relevant given the substantiated abuse finding on record, the facility's high staff turnover rate, and the below-average staffing rating.
Is Waters Of Lagrange Skilled Nursing Facility, The Safe?
Based on CMS inspection data, WATERS OF LAGRANGE SKILLED NURSING FACILITY, THE has documented safety concerns. The facility has 1 substantiated abuse finding (meaning confirmed case of resident harm by staff or other residents). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in Indiana. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Waters Of Lagrange Skilled Nursing Facility, The Stick Around?
Staff turnover at WATERS OF LAGRANGE SKILLED NURSING FACILITY, THE is high. At 60%, the facility is 14 percentage points above the Indiana average of 46%. Registered Nurse turnover is particularly concerning at 67%. RNs handle complex medical decisions and coordinate care — frequent RN changes can directly impact care quality. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?
Was Waters Of Lagrange Skilled Nursing Facility, The Ever Fined?
WATERS OF LAGRANGE SKILLED NURSING FACILITY, THE has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Waters Of Lagrange Skilled Nursing Facility, The on Any Federal Watch List?
WATERS OF LAGRANGE SKILLED NURSING FACILITY, THE is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.