Citations in Indiana
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Indiana.
Statistics for Indiana (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in Indiana
Dining staff did not consistently follow meal tickets, resulting in several residents not receiving menu items such as broccoli salad and garlic bread, with no substitutions provided. Grievances and interviews confirmed that staff failed to reference meal tickets as required by facility policy.
Dietary staff did not consistently temperature-test pureed meals for four residents on pureed diets. Observations and interviews revealed that food was sometimes served below the required temperature, and food temperature logs showed multiple days with missing records for pureed meals, contrary to the facility's safe food handling policy.
A multiple dose liquid medication bottle was found on a medication cart without an open date, despite being marked 'NOT OPEN' and having been used, with a punctured seal and residue present. The medication had been discontinued and was not on the active MAR. An LPN was observed handling the bottle, and the DON confirmed there was no current improvement plan for medication storage, despite a history of similar citations and ongoing audits reported in QAPI meetings.
A resident with a history of heart disease and other conditions was transferred to the ER for chest pain, but the facility did not notify the resident's emergency contact. Documentation did not show that the resident declined such notification, and the care plan indicated family involvement. Staff interviews provided conflicting explanations, and facility policy on notification was not followed.
A resident was subjected to inappropriate verbal comments by the Rehabilitation Director during a discussion about room conditions, including a reference to prison and a remark about being 'outnumbered' in the presence of staff and the resident, all of whom were black except the RD. The resident, who was cognitively intact, became visibly upset by the comments, which were corroborated by other staff present. The facility's policy on verbal abuse was not followed in this incident.
A resident with chronic pain conditions received oxycodone-acetaminophen for pain levels below the physician-ordered threshold, and there was no documentation that nonpharmacological pain interventions were provided as outlined in the care plan. The DON confirmed the medication was administered outside of the prescribed parameters without justification.
A resident with end stage renal disease requiring dialysis did not consistently have pre-dialysis vital signs and communication forms completed by facility staff before appointments. The dialysis center RN reported that the communication sheets were often blank and no separate facility assessment was provided, despite facility policy requiring this documentation. The DON could not verify that the necessary paperwork was sent with the resident.
A bottle of Guaifenesin liquid was found in a medication cart with 'NOT OPEN' written on the label, but the inner seal was punctured and some medication had been used. The bottle lacked an open date, and a resident did not have an active order for this medication. The DON confirmed the absence of a current order, and facility policies did not clearly address required labeling practices.
A resident who was on antiplatelet therapy and had a history of falls sustained a head injury during a transfer with a mechanical lift, resulting in significant bruising and a large hematoma. Although a physician ordered a CAT scan of the head and face due to the trauma, facility records and staff interviews confirmed that the scan was never completed as ordered.
A resident with metastatic breast cancer, who was cognitively intact, was approached by an LPN about selling her vehicle after the LPN noticed it had not been moved for some time. The resident felt the inquiry was inappropriate and was upset that staff were discussing her personal matters. Facility leadership confirmed that staff soliciting to purchase items from residents is not acceptable and violates resident rights policies.
Failure to Follow Resident Meal Tickets and Menu Postings
Penalty
Summary
The facility failed to ensure that dining staff followed resident meal tickets for four residents, resulting in residents not receiving items listed on their menus. During dining observations, two residents were not served broccoli salad as indicated on their meal tickets, and one resident reported not receiving garlic bread, with no substitutions provided. Review of posted menus confirmed that these items were scheduled to be served, and the postings were not updated to reflect any changes or substitutions. Additionally, grievances from two residents documented ongoing issues with meal trays, specifically that dining staff were not referencing meal tickets and were omitting food items. Interviews with facility leadership confirmed that staff are expected to review meal tickets to ensure residents receive appropriate items and avoid serving restricted foods. The facility's policy requires menus to be followed and to accommodate resident preferences, but observations and records indicated this was not consistently practiced.
Failure to Consistently Temperature-Test Pureed Meals
Penalty
Summary
The facility failed to ensure that pureed meals were consistently temperature-tested for four residents who required pureed diets. During an observation, dietary staff was seen checking the temperature of pureed broccoli, which registered at 130°F. A staff member acknowledged that the food was below the required temperature and indicated that she would reheat it. Interviews confirmed that on multiple occasions, food was not at the appropriate temperature before being served. A review of food temperature logs for December revealed that there were numerous days when no temperature records were documented for breakfast, lunch, or dinner pureed meals, despite four residents being on pureed diets during those times. The facility's policy on safe food handling, which aims to reduce the risk of foodborne illness, was not followed as evidenced by the lack of temperature documentation and inconsistent temperature checks for pureed meals.
Recurring Medication Storage Deficiency Due to Inadequate Labeling and Oversight
Penalty
Summary
The facility failed to maintain an effective process to prevent recurring medication storage issues, as evidenced by the observation of a multiple dose liquid medication bottle on a medication cart that was not properly labeled with an open date. The bottle, marked 'NOT OPEN' in black marker, was found to have been opened and used, with a punctured inner seal and visible red liquid residue. Review of the resident's record revealed that the medication had been discontinued and did not have an active order. This incident was cited under F0761 for improper labeling and storage of drugs and biologicals. Additionally, the facility had a history of similar citations for the same deficiency on multiple previous survey dates. During an interview, the DON confirmed that there was no current improvement plan specifically addressing medication storage, although routine audits were being conducted and results reported in QAPI meetings.
Failure to Notify Emergency Contact of Resident Transfer
Penalty
Summary
The facility failed to notify the emergency contact of a resident who was transferred to the emergency room for chest pain that was not relieved by Nitroglycerin and at the resident's request. Record review showed no documentation that the resident's emergency contact, his brother, was notified of the transfer. There was also no documentation indicating that the resident did not want his emergency contact notified. The resident's care plan indicated family involvement in the last 14 days and did not specify any wishes to exclude the brother from notification in emergencies. Interviews with facility staff revealed conflicting information. The DON stated that the resident did not wish for his brother to be notified and that this was reflected in the care plan, but review of the care plan did not support this claim. The Regional Nurse Consultant indicated that the brother was not notified because the resident was his own responsible party. Facility policy allows for disclosure of information to individuals involved in the resident's care or for notification purposes, but there was no evidence that this policy was followed in this instance.
Verbal Abuse Involving Inappropriate and Racially Charged Comments by Staff
Penalty
Summary
A deficiency occurred when a resident was subjected to inappropriate and potentially racially charged verbal comments by the Rehabilitation Director (RD) in the presence of other staff members. The incident took place during a discussion about the condition of the resident's room, specifically the walls being only half painted. The RD responded to the resident's complaint by making a comment referencing prison, which the resident found offensive, especially as he stated he had never been to prison and that prison was no place for an educated black man. The RD then remarked that she was 'outnumbered' and left the room, a statement interpreted by those present as referring to the racial makeup of the group. The resident was visibly upset during subsequent interviews, raising his voice and appearing emotional when recounting the incident. Multiple staff members, including an LPN and a QMA who were present, corroborated the resident's account of the RD's comments. The facility's investigation included statements from those involved, confirming the sequence of events and the nature of the remarks made. The resident was found to be cognitively intact, with a BIMS score of 15, and was able to clearly articulate his experience. The facility's policy defines verbal abuse as the use of disparaging or derogatory language toward residents, which was not adhered to in this instance.
Failure to Follow Pain Management Orders and Document Nonpharmacological Interventions
Penalty
Summary
A resident with multiple pain-related diagnoses, including arthritis, lupus, and sciatica, had physician orders for oxycodone-acetaminophen to be administered every 8 hours as needed for severe pain greater than 7 on the pain scale. However, the medication was administered on several occasions when the resident reported pain levels below the threshold specified in the order, with documented pain scores of 4 and 6. There was no documented justification for administering the medication outside the prescribed parameters. Additionally, the resident's care plan included interventions for nonpharmacological pain management, such as position changes, relaxation, a quiet environment, back rubs, and diversional activities. Despite this, there was no documentation in the progress notes that these nonpharmacological interventions were provided on the dates when the medication was administered for pain levels below 7. The DON confirmed that the medication should not have been given for pain less than 7 and could not provide a reason for the deviation from the physician's order.
Failure to Ensure Proper Dialysis Communication and Collaboration
Penalty
Summary
The facility failed to ensure proper collaboration with an off-site dialysis center for a resident diagnosed with end stage renal disease and dependent on renal dialysis. Review of the resident's dialysis communication records revealed that the pre-dialysis section, which should include vital signs, was incomplete or missing on multiple dates. The resident reported that the facility did not always complete the required communication form that he took to dialysis appointments, which contained his medications and the dialysis communication sheet. Interviews with facility staff and the dialysis center RN confirmed that the facility often sent the dialysis communication sheet blank and did not provide a separate facility assessment with the resident. The DON stated that the facility conducted its own assessments and sent them in a packet with the resident, but could not provide evidence that these assessments were actually sent, as no folder was maintained and the information was not tracked. The facility's policy required continued assessment and appropriate paperwork to be sent with the resident to the off-site dialysis center, which was not consistently followed.
Failure to Properly Label and Store Medications in Medication Cart
Penalty
Summary
The facility failed to ensure that only current medications with appropriate labeling were present in medication carts, as observed during a review of one out of three carts. A bottle of Guaifenesin liquid labeled for a specific resident was found with the words 'NOT OPEN' written on it, but the inner seal was punctured and some medication had been used, indicating it had been opened. There was no open date on the bottle, and the resident did not have an active order for this medication at the time of the review. The Director of Nursing confirmed that the resident should have had an order but did not currently have one. The facility's medication storage policy did not specify labeling practices, while the labeling policy required multidose vials to be labeled with the date opened or accessed.
Failure to Complete Physician-Ordered CAT Scan After Resident Injury
Penalty
Summary
A physician order for a CAT scan was not completed for a resident who had sustained direct trauma to the forehead during a transfer with a mechanical lift. The resident, who had a history of falls and a fractured right femur, was on antiplatelet therapy and was observed with faded bruising around her right eye and a dark red/purple bruise on her right cheekbone. Documentation indicated that the resident was struck on the forehead by the lift's weight mechanism, resulting in a large hematoma and periorbital ecchymosis. A physician subsequently ordered a CAT scan of the head and face due to these injuries. Record review did not show any results for the ordered CAT scan, and interviews with facility staff confirmed that the scan had not been completed as ordered. The facility's policy required timely submission and scheduling of physician-ordered diagnostic tests, but this process was not followed in this instance, resulting in the failure to provide the ordered diagnostic service.
Staff Inappropriately Solicits Resident's Personal Property
Penalty
Summary
A facility failed to honor a resident's rights when a staff member, specifically an LPN, approached a resident to inquire about purchasing the resident's personal vehicle. The LPN had noticed a car in the facility parking lot that had not been moved for some time and, after learning it belonged to the resident, directly asked if the vehicle was for sale, stating it was for her daughter to use for college. The resident, who was cognitively intact and had a diagnosis of metastatic breast cancer, expressed concern about staff discussing her personal matters and felt the inquiry was inappropriate, especially given her medical condition. The resident reported feeling upset by the interaction and questioned the appropriateness of staff discussing her situation among themselves. The Executive Director and Director of Nursing confirmed that the action of a staff member attempting to purchase an item from a resident was inappropriate and not in line with resident rights policies. The facility's policy requires that residents be treated with respect and dignity, including the right to retain and use personal possessions. The LPN acknowledged in a written statement that she had inquired about the car and stated she meant no harm. The incident was identified through interviews and record review, and it was determined that the resident's rights to dignity and self-determination were not upheld in this situation.
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