Briarcliff Health & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in South Bend, Indiana.
- Location
- 5024 Western Avenue, South Bend, Indiana 46619
- CMS Provider Number
- 155831
- Inspections on file
- 32
- Latest survey
- March 20, 2026
- Citations (last 12 mo.)
- 33
Citation history
Health deficiencies cited at Briarcliff Health & Rehabilitation Center during CMS and state inspections, most recent first.
A resident with cervical spine hardware, spinal cord dysfunction, and non-ambulatory status, who required two-person assistance and an EZ stand mechanical lift for transfers, was being moved from bed to wheelchair when the sit-to-stand sling strap snapped, causing the resident to fall to the knees and graze the neck on the bed frame. The CNA reported checking the sling before use and seeing no issues, but later observation showed the strap had torn off at its attachment point, the rings were stiff, and the label was torn and faded with no visible manufacturer directions. Manufacturer guidance required pre-use condition checks, non-use of slings with illegible tags, and replacement of reusable slings every six months, and further guidance noted that faded/missing tags and stiff, brittle straps indicate deterioration and loss of tensile strength, meaning such slings should not be used for lifting.
A resident experienced severe pain during a wound dressing change because the facility failed to administer pain medication beforehand. Despite the resident's cries of pain, the ADON continued the procedure without ensuring pain relief, contrary to the care plan and physician's orders. The resident's pain management regimen included Morphine, Norco, and a Fentanyl patch, but a PRN dose of Morphine was not given prior to the dressing change.
The facility failed to ensure proper covering of residents' clothing during transport by laundry staff, leading to a deficiency in infection prevention and control. Observations showed that clothing was only partially covered, contrary to facility policy. Interviews revealed a lack of adequate cart covers, and staff acknowledged the need for better coverage.
A facility failed to include a resident with stage 5 chronic kidney disease, osteoarthritis, and type 2 diabetes in care plan meetings. Despite an intact cognition and participation in goal setting, the resident reported not attending any care plan meetings since admission. The Social Services Director admitted to not documenting a meeting with the resident, and the facility's policy mandates the inclusion of family or representatives in care planning.
A facility failed to implement fall prevention interventions for a resident with severe cognitive impairment and a history of falls. Despite being at high risk, the resident's room lacked the required 'Call don't Fall' signage and adaptive call light system. The facility did not adhere to its policy on accidents and supervision, resulting in a deficiency.
The facility failed to reconcile controlled substances on the 800 Hall medication cart, as required by policy. Missing signatures on the Shift Change Accountability Record indicated that controlled substances were not counted and reconciled by two staff members on multiple shifts. A QMA confirmed the expectation for dual staff verification, and the facility's policy mandates this practice.
The facility failed to ensure timely physician review and action on pharmacy recommendations for two residents, resulting in significant delays in medication changes. The DON acknowledged issues with the previous Medical Director's responsiveness, leading to the termination of his position.
The facility's kitchen had several sanitation deficiencies, including undated food items in the freezer, wet food processor bowls stored as clean, dusty ductwork and ceiling, a dusty electrical outlet, and pans with flaking Teflon coating. These issues were acknowledged by the Dietary Manager and had the potential to affect 88 residents.
The facility failed to maintain a sanitary environment in the 500 Hall, where a food cart was placed under a dusty air vent with condensation, causing mud-like droplets to fall onto the cart. All vents and surrounding ceiling tiles in the hall were covered in dust. The Director of Maintenance was initially unsure of the cleaning responsibilities, but later confirmed it was the maintenance department's duty. The facility's policy requires maintenance to ensure a sanitary environment.
Failure to Ensure Safe Condition of Mechanical Lift Sling Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a mechanical sit-to-stand lift sling was in good working order before use, resulting in a fall during transfer. A resident with surgically repaired cervical stenosis stabilized with rods and screws, spinal cord dysfunction, weakness of extremities, and non-ambulatory status required staff assistance and use of an EZ stand mechanical lift with two staff for transfers. The resident’s care plan and interventions identified the need for staff to inspect slings for visible signs of wear or decreased integrity and for therapy to confirm safety with sit-to-stand transfers and weight-bearing ability. On the day of the incident, two CNAs were transferring the resident from bed to wheelchair using the mechanical sit-to-stand lift. One CNA reported that she checked the sling and saw no issues before placing it around the resident’s back and under his arms, attaching the loops to the lift, and elevating him to a standing position. While the resident was standing, slightly bent forward, the sling strap snapped off where it attached to the body of the sling, causing the resident to fall to his knees, partially on the lift and partially on the floor, and graze the back of his head/neck on the bed frame. Initially, there were no visible injuries and no immediate complaints of pain, but later the resident reported dull, aching right knee pain and subsequently requested ER evaluation. Record review showed that the resident was diagnosed in the ER with a neck strain and a sprain to the right knee following the fall. Observation of the involved sling revealed that the strap had torn off at the attachment point to the sling body, the rings on the strap were intact but stiff, and the sling label was torn and faded with no visible manufacturer directions, with the resident’s name written over the torn label. Manufacturer guidelines provided by the DON stated that sling condition should be checked prior to use, that slings with illegible wash tags should not be used, and that reusable slings should be replaced every six months. Additional guidance from the manufacturer’s website indicated that completely faded or missing tags and strap brittleness or stiffness are indicators of deterioration and loss of tensile strength, even when the sling appears otherwise intact, and such slings should not be used for lifting a resident.
Failure to Administer Pain Medication Before Wound Care
Penalty
Summary
The facility failed to administer pain medication to a resident prior to a wound dressing change, resulting in severe pain during the procedure. During an observation, the resident expressed significant discomfort, repeatedly yelling in pain as the Assistant Director of Nursing (ADON) performed the wound care. The ADON acknowledged that the resident had not been given pain medication before the dressing change and was unsure if anyone else had administered it. The Unit Manager confirmed that the resident had been given Norco earlier in the day and could have received Morphine prior to the dressing change, but this was not done. The resident, who had a diagnosis of pressure ulcer, mild cognitive impairment, and dementia, was on a pain management regimen that included Morphine, Norco, and a Fentanyl patch. The Medication Administration Record indicated that the resident could have received a PRN dose of Morphine before the dressing change. The facility's policy on pain management emphasized recognizing and managing pain in accordance with the resident's care plan, which included administering pain medication as needed. Despite this, the dressing change proceeded without addressing the resident's pain, contrary to the care plan and physician's orders.
Inadequate Covering of Residents' Clothing During Transport
Penalty
Summary
The facility failed to ensure proper transportation of residents' clothing by laundry staff, leading to a deficiency in infection prevention and control. During observations, two laundry aides were seen transporting residents' personal clothing on carts that were only partially covered with a draw sheet, leaving the lower portion of the clothing exposed and uncovered. This was contrary to the facility's policy, which requires clean linens to be transported in a manner that ensures cleanliness and protection from dust and soil, such as using a properly cleaned cart with a secure cover. Interviews with the laundry aides and the Housekeeping/Laundry Director revealed that the facility did not have adequate covers for the carts, and the aides acknowledged that the clothing should have been covered more completely.
Failure to Include Resident in Care Plan Meetings
Penalty
Summary
The facility failed to include Resident 17, or her representative, in meetings to review her care plan. Resident 17, who has diagnoses including stage 5 chronic kidney disease, unspecified osteoarthritis, and type 2 diabetes mellitus, was admitted on 5/29/2024. An Admission Minimum Data Set (MDS) assessment dated 6/5/2024 indicated that her cognition was intact and she participated in goal setting. However, during an interview on 8/6/2024, the resident stated she had not attended a care plan meeting since her admission. A Social Service Progress Note from 5/30/2024 mentioned her goal of returning to the community after therapy, but there were no records of a care plan meeting being planned or conducted. The Social Services Director acknowledged meeting with the resident but failed to document the discussion. The facility's policy requires the comprehensive care plan to be prepared by an interdisciplinary team, including family members or others desired by the resident.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement fall prevention interventions for a resident with a history of repetitive falls. Resident 10, who has severe cognitive impairment and requires extensive assistance for transfers, reported a fall that occurred the previous day, resulting in soreness. The resident's clinical record indicated multiple falls over the past year, with the most recent fall being unwitnessed and resulting in an equivocal fracture. Despite being at high risk for falls, as indicated by a recent Fall Risk Evaluation, the facility did not adhere to the interventions outlined in the resident's Care Plan. During an observation, it was noted that the resident's room lacked the 'Call don't Fall' signage and the adaptive touch pad call light system specified in the Care Plan. Interviews with the Unit Manager and Regional Nurse confirmed the absence of these interventions and highlighted a failure to update or remove outdated interventions from the Care Plan. The facility's policy on accidents and supervision, which emphasizes the implementation and communication of specific interventions to reduce risks, was not followed in this case.
Failure to Reconcile Controlled Substances
Penalty
Summary
The facility failed to maintain a system for the reconciliation of controlled substances on one of the medication carts reviewed, specifically the 800 Hall medication cart. During an observation, it was noted that the Shift Change Accountability Record for Controlled Substances was missing signatures on several dates and shifts. These missing signatures indicated that the controlled substances had not been counted and reconciled by two staff members, as required by the facility's policy. The specific dates and shifts with missing signatures included the first shift on 8/1/2024, the first and third shifts on 8/4/2024, the third shift on 8/5/2024, the third shift on 8/6/2024, and the first shift on 8/7/2024. During an interview, a Qualified Medication Aide (QMA) confirmed that there should not be any missing signatures and that staff members are expected to count the controlled substances with another staff member, with both signing off on the count. The facility's policy, provided by the Unit Manager, stated that all scheduled II controlled substances should be counted each shift or whenever there is an exchange of keys between off-going and on-coming licensed nurses, with both nurses signing the Shift/Shift Controlled Substance Count Sheet to acknowledge the count. This deficiency highlights a failure in adhering to the facility's policy for controlled substance reconciliation.
Delayed Physician Response to Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure timely review and action on pharmacy recommendations by a physician for two residents. For Resident 55, the pharmacist recommended discontinuing Cyanocobalamin and Biofreeze Gel, and initiating weekly blood glucose monitoring. However, there were significant delays in the physician's response and implementation of these recommendations, with the discontinuation of Cyanocobalamin and Biofreeze Gel taking several months, and the blood glucose monitoring order being delayed by over a month. The facility was unable to provide documentation of the physician's response dates for these recommendations. Similarly, for Resident 10, the pharmacist recommended discontinuing Pantoprazole and Atorvastatin. The physician agreed to these recommendations, but there were delays in discontinuing the medications, with Pantoprazole being discontinued nearly two months after the recommendation and Atorvastatin about two months later. The facility's Director of Nursing acknowledged issues with the previous Medical Director's responsiveness and had attempted to contact him multiple times without documented success. The facility eventually terminated the Medical Director's position due to these timeliness issues.
Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to store and prepare food in a sanitary manner in its kitchen, potentially affecting 88 out of 89 residents who consumed food prepared there. During an observation, it was noted that vegetable burgers, strawberries, and three tubs of ice cream in the reach-in freezer were not dated. Additionally, food processor bowls were stacked together while still wet, and the ductwork and ceiling in the food preparation area had a thick layer of dust. The electrical outlet above the spices was also dusty. Furthermore, two large and one small pans had missing and/or flaking Teflon coating on their cooking surfaces. The Dietary Manager acknowledged these issues, indicating that the food should have been dated, the bowls should have been dry before stacking, the ceiling, ductwork, and outlet should have been clean, and the Teflon pans should have been replaced.
Sanitation Deficiency in 500 Hall
Penalty
Summary
The facility failed to maintain a sanitary environment in the 500 Hall, as observed during a survey. A food cart was positioned under an air vent that had accumulated a thick layer of dust mixed with condensation, forming mud-like droplets that dripped onto the cart. Further inspection revealed that all five vents in the 500 Hall, along with the surrounding ceiling tiles and light covers, were covered in dust. One vent was particularly problematic, with condensation mixing with the dust and causing mud-colored droplets to fall to the floor. Interviews with the Director of Maintenance (DM) revealed uncertainty about whether the maintenance or housekeeping department was responsible for cleaning the vents and ceiling tiles. Initially, the DM attributed the condensation issue to residents opening their windows, which increased humidity levels. However, it was later clarified that the maintenance department was responsible for cleaning these areas. The facility's policy, titled 'Safe and Homelike Environment,' indicated that housekeeping and maintenance services should maintain a sanitary, orderly, and comfortable environment.
Latest citations in Indiana
Surveyors observed that dietary staff repeatedly worked in kitchen and meal service areas with uncovered facial hair, despite facility policy and state sanitation requirements mandating effective hair restraints. Two dietary aides with short beards or mustaches were seen walking through food preparation areas, taking food temperatures, handling food, and plating meals at steamtables in dining rooms without any facial hair coverings, while the current policy required all hair, including facial hair, to be restrained to prevent contamination.
The facility failed to consistently provide and document required bed-hold policy notices when several residents were transferred to the hospital. In multiple cases, residents with dementia, psychotic disorders, COPD, chronic respiratory failure, altered mental status, and cerebral infarction were sent out for acute changes in condition, and while transfer notes reflected physician and family notifications, they lacked documentation that the bed-hold policy was discussed with the resident or responsible party. Notices of Transfer or Discharge often indicated a copy of the bed-hold policy was sent with the resident, but the records did not show signed and dated acknowledgment by the resident or appropriate representative, including in situations where a resident had moderate cognitive impairment, short-term memory issues, or a documented need for a proxy and a financial POA authorizing an agent for health care decisions.
Surveyors found that the facility failed to provide trauma‑informed and culturally competent care by not incorporating two residents’ extensive trauma histories and specific behavioral triggers into their care plans. One resident with documented homelessness, polysubstance abuse, severe accidents with multiple fractures, viral encephalitis with coma, physical and sexual abuse, loss of family contact, and a past suicide attempt had multiple behavior‑focused care plans that referenced identifying triggers but listed none and did not mention their physical, sexual, medical, or psychosocial trauma. Another resident with TBI from being struck by a truck, an 11‑month coma, long‑term state hospital residence, alleged shooting of a parent, and diagnoses including intermittent explosive disorder and borderline personality disorder had a PASRR identifying a specific trigger and notes of inappropriate sexual behavior, yet their care plans omitted these traumatic events, the identified trigger, and the sexual behavior. Staff interviews confirmed that residents were screened for trauma, but the trauma histories and triggers were not reflected in the individualized plans of care.
A resident with schizophrenia, post‑stroke hemiparesis, and mild cognitive impairment expressed feeling down and wanting to kill himself, but staff did not document asking about a specific plan, did not notify the physician or psychiatric NP as expected, and did not develop or update a care plan addressing depression or suicidal ideation. The SSD documented offering support and initiating 15‑minute checks once, but there was no further follow‑up or documentation of interventions after subsequent suicidal statements made in a care plan meeting with the resident’s father. The DON and Administrator reported that facility policy requires immediate notification of key staff, assessment for a plan and means of self‑harm, and thorough documentation, which were not carried out or reflected in the medical record for this resident.
A resident with schizophrenia, post-stroke hemiparesis, and mild cognitive impairment verbalized suicidal ideation, but the care plan did not address depression or suicidal thoughts, and required assessments and services were not accurately or timely documented. An SSD note recorded the resident saying he wanted to kill himself and referenced 15‑minute checks and a care plan update, yet the active care plan lacked depression/suicidal ideation interventions. Multiple late-entry Social Services notes were later added, describing follow-up visits and the resident denying suicidal ideation, but the SSD later reported she did not typically ask about a suicide plan and did not personally provide individual follow-up visits as described. These practices conflicted with the facility’s policy requiring factual, first-hand, and timely documentation of assessments and services.
A resident was observed with an Albuterol inhaler on an overbed table and later reported keeping the inhaler in a nightstand drawer, with no staff present during these observations. Record review showed the resident had no cognitive impairment on the admission MDS but lacked any documented self-medication administration assessment. The DON acknowledged that the required assessment had not been completed, despite facility policy requiring staff and the practitioner to evaluate each resident’s mental and physical abilities before allowing self-administration of medications.
Surveyors found that the facility submitted inaccurate direct care staffing data to CMS through the PBJ system over multiple days in a quarter. CASPER reports showed apparent gaps in 24-hour licensed nurse coverage, low weekend staffing, and a 1-star staffing rating, while internal staffing sheets documented that licensed nurses were present and the facility was fully staffed on those days. The Administrator reported that the discrepancies were due to PBJ data entry errors, despite a facility policy requiring all PBJ entries to be accurate, auditable, and verifiable against payroll, invoices, or contracts.
Surveyors found that the facility did not provide or document required written transfer/discharge notices and bed-hold policy information for four residents who were sent to the hospital, including individuals with conditions such as dementia, CHF, chronic respiratory failure, and CKD. In each case, progress notes showed that the resident was transferred for acute issues, but the clinical records lacked evidence that written notices were given to the residents or their representatives, and in one case lacked documentation that required information was sent to the receiving provider. Facility leadership, including the ADON, DON, and Administrator, acknowledged that the records did not contain the required documentation, despite a written policy requiring such notices and information exchange.
A resident with Alzheimer’s disease and depression, previously on an antidepressant, exhibited intermittent refusals of medications and care, occasional yelling at staff, and reports of unusual perceptions, such as believing men were in or near her room. Nursing notes over several months documented these refusals and complaints but did not show that the behaviors were evaluated or recorded as dangerous, non-redirectable, or causing significant distress, nor did they document specific non-pharmacological interventions attempted or their outcomes. Despite this, a psychiatric NP later added new diagnoses of schizoaffective disorder, borderline personality disorder, and delusional disorder and ordered an antipsychotic (Seroquel) without a comprehensive evaluation in the record to support these diagnoses. The facility’s psychotropic medication policy, which requires identification and documentation of target behaviors, use of nonpharmacological interventions, and ongoing behavior monitoring, was not followed for this resident.
The facility failed to keep PASARR Level I screenings accurate and current for three residents when new mental health diagnoses and psychoactive medications were initiated. One resident’s PASARR omitted a PTSD diagnosis and an added antidepressant, despite documentation of PTSD on the MDS and care plan and a physician order for Pristiq. Another resident’s PASARR listed only depression and dementia, even after additional diagnoses such as borderline personality disorder, delusional disorder, and schizoaffective disorder were added and an antipsychotic (quetiapine) was ordered, with the MDS later reflecting psychotic disorder, schizophrenia, and depression with antipsychotic and antidepressant use. A third resident’s PASARR did not include a depression diagnosis or newly ordered escitalopram and lorazepam, although the admission MDS documented depression with antianxiety and antidepressant use. These omissions occurred despite facility policy requiring a new Level I review after significant mental status changes, including new mental health diagnoses or new psychotropic medications.
Uncovered Facial Hair During Food Preparation and Meal Service
Penalty
Summary
The deficiency involves the facility’s failure to ensure that food was served in a sanitary and safe manner in accordance with professional standards and facility policy during multiple kitchen and meal service observations. During an initial kitchen observation, two dietary aides were seen walking through the kitchen food preparation area with uncovered facial hair. One aide had facial hair above and below the lip and along the jaw line, approximately one-fourth inch in length, and the other had a mustache of similar length; neither used any facial hair covering. These observations occurred while staff were present in the kitchen area where food was stored and prepared. During subsequent observations on the same day, the same two dietary aides were again observed with uncovered facial hair while directly involved in meal preparation and service. One aide walked through the kitchen while the noon meal was being prepared and placed into a transport cart for service in the south dining room, and later was observed plating the noon meal at the steamtable in that dining room, still without a facial hair covering. The other aide walked through the kitchen while the noon meal was being prepared and placed into the steamtable for the north dining room, took food temperatures, assisted with plating meals at the steamtable, and retrieved food items and supplies from the kitchen, all while having an uncovered mustache approximately one-fourth inch in length. The Dietary Manager stated that staff hair was to be covered when in the kitchen and during meal service, and the facility’s written policy and the cited Indiana Food Establishment Sanitation Requirements both required effective hair restraints, including for facial hair, to prevent contamination of food, equipment, and utensils.
Failure to Provide and Document Bed-Hold Policy at Time of Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure that required bed-hold policy information was provided and documented for four residents transferred to the hospital. For a resident with dementia, psychotic disorder, and autistic disorder who had a BIMS score of 0 indicating severe cognitive impairment, progress notes documented physician notification and guardian notification when the resident was sent to the hospital, but there was no documentation that the bed-hold policy was provided to the responsible party. A Notice of Transfer or Discharge later indicated a copy of the bed-hold policy was sent with the resident. Another resident with COPD and chronic respiratory failure, cognitively intact with a BIMS score of 13, experienced a decline in condition and was transferred to the hospital by ambulance; progress notes documented family notification but did not document any discussion of the bed-hold policy, although a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident. A third resident with altered mental status and cerebral infarction, with a BIMS score of 10 indicating moderate cognitive impairment and documented short-term memory impairment, experienced changes in condition and was transferred to the hospital. Progress notes stated the resident was their own responsible party and that no other notification was completed, and transfer documentation did not include the bed-hold policy, although an untimed Notice of Transfer or Discharge indicated a copy of the bed-hold policy was signed by the resident. A financial power of attorney document in the record showed the resident had designated an agent to act in consent or refusal of health care. For a fourth resident with dementia and osteomyelitis, transfer documentation and a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident, and the transfer form noted the resident required a proxy for decision making. The facility’s policy required that at the time of transfer to a hospital, written notice specifying the duration of the bed-hold policy and information on return to the next available bed be provided, and that a signed and dated copy of the bed-hold notice given to the resident or representative be kept in the resident file, which was not consistently documented for these residents.
Failure to Integrate Trauma Histories and Behavioral Triggers Into Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to identify and incorporate residents’ trauma histories and specific behavioral triggers into their care plans, despite documented histories of significant trauma and behavioral health issues. For one resident, extensive social service and progress notes documented homelessness, polysubstance abuse, major depressive and anxiety disorders, chronic pain, a history of severe car accidents with multiple fractures, viral encephalitis resulting in a three‑month coma, loss of child custody, multiple divorces, physical abuse by a spouse, the death of a fiancé who was struck by a car while in a wheelchair, lack of family contact, and a past suicide attempt by Valium overdose. Additional documentation noted a history of rape by a brother at age eight and prior placement under direct supervision and 15‑minute checks related to suicidal ideation. Despite these documented traumatic events and behavioral health concerns, the resident’s care plans did not identify a history of physical trauma, sexual trauma, homelessness, substance abuse, medical trauma, or attempted suicide. For this same resident, the MDS showed no cognitive deficit and identified behaviors such as verbal aggression and rejection of care, along with diagnoses including seizure disorder, depression, chronic pain syndrome, homelessness, and anxiety disorder. Multiple care plans addressed behaviors such as drug‑seeking, pretending to have seizures for attention or medication, making false allegations, verbal aggression when unable to smoke, and a desire for intimate relationships with consenting male residents. These care plans referenced goals such as effective coping skills, seeking staff support, and compliance with the smoking policy, and they called for identification and reduction of behavioral triggers. However, none of these care plans actually listed any specific triggers. The care plan addressing the resident’s right to consensual intimate relationships focused on assessment and education regarding consent but did not integrate the resident’s extensive trauma history. Staff interviews indicated the resident had displayed sexual behaviors since admission, including an incident where the resident expressed anger at another resident for not buying a soda after engaging in sexual acts. A second resident with a documented history of traumatic brain injury (TBI), dementia, seizure disorder, borderline personality disorder, anxiety, intermittent explosive disorder, tobacco use, and other behavioral/emotional disorders was also affected by the same deficiency. Social history and progress notes documented that this resident sustained a TBI after being hit by a semi‑truck while riding a bicycle at age 18, resulting in an 11‑month coma, followed by 13 years in a state hospital and subsequent residence in a group home. Additional documentation indicated the resident allegedly shot their father at age 26 after being sworn at and had a PASRR identifying TBI, intermittent explosive disorder, and borderline personality disorder, with a specific trigger of hearing the name of the current U.S. President. Progress notes also described inappropriate sexual behavior toward staff, including touching themselves intimately during personal care and refusing to stop when redirected. Despite this, the resident’s care plans, which addressed explosive disorder and history of altercations, risk for decreased psychosocial well‑being, and refusal to bathe or shower, did not list any specific behavioral triggers, did not reference the traumatic events such as being hit by a truck or shooting their father, and did not document the inappropriate sexual behavior. The Administrator and Social Service Director acknowledged that residents were to be screened for trauma and that trauma responses and PTSD should be added to care plans, but the specific trauma histories and triggers for these two residents were not incorporated into their plans of care.
Failure to Assess and Care Plan for Resident Suicidal Ideation
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess, investigate, and care plan for a resident’s suicidal ideation in accordance with its own policy and staff expectations. The resident had diagnoses including schizophrenia, cerebral edema, and hemiparesis/hemiplegia following a cerebral infarction, and a current MDS showed mild cognitive impairment (BIMS score 12). A progress note documented that the resident told the Social Services Director (SSD) he was feeling down and wanted to kill himself; the SSD offered assistance, activities, and initiated 15‑minute checks, and the note stated the care plan was updated. However, the note did not indicate that the SSD asked whether the resident had a plan to kill himself, and there were no additional notes regarding suicidal ideation or follow‑up. Review of the current care plan showed no problem, goal, or interventions addressing depression or suicidal ideation, and progress notes over the following month contained no documentation of physician notification related to the suicidal statement. Further record and interview evidence showed that the care plan conference summary did not document interventions for suicidal ideation, and the SSD acknowledged she did not normally ask residents expressing suicidal ideation if they had a plan. The SSD reported that the resident had admission paperwork mentioning suicidal ideation related to depression after a stroke and that the resident again vocalized suicidal ideation during a care plan meeting with his father, after which emotional support was offered and the father took the resident out on a leave of absence; no further visits or follow‑up were done. The DON stated that, upon notification of suicidal verbalization, staff should assess the resident, ask if there is a plan, remove potential means of self‑harm, immediately notify the psychiatric NP, and document the occurrence, and that a detailed progress note and updated care plan were expected but not present for this resident. The Administrator similarly stated that staff should ask about a plan, document interventions, notify the physician and family, and update the care plan, and indicated the resident should have had a care plan addressing depression with suicidal ideation. The facility’s written policy required immediate notification of the DON, SSD, and physician, an interview including asking about a plan and assessing mood and means for self‑harm, and thorough documentation of mood, behavior, and all actions taken, which were not reflected in the resident’s record.
Incomplete and Inaccurate Documentation of Suicidal Ideation and Follow-Up
Penalty
Summary
The facility failed to ensure accurate, complete, and timely documentation of assessments and services for a resident who verbalized suicidal ideation. Resident 6, who had schizophrenia, cerebral edema, and right-sided hemiparesis/hemiplegia following a cerebral infarction, had a BIMS score of 12 indicating mild cognitive impairment. The resident’s admission paperwork mentioned suicidal ideation related to depression after a stroke, and a Social Services note on 3/11/2026 documented that the resident was feeling down and said he wanted to kill himself. The Social Services Director (SSD) documented that she talked with the resident, coordinated with Activities, advised the resident to contact SSD or nursing if he wanted to talk, and that the resident was scheduled for 15-minute checks and the care plan was updated. However, the current care plan initiated on 2/26/2026 did not address depression or suicidal ideation. Multiple Social Services progress notes were later entered as late entries in April, with effective dates in March, stating that the resident had no plan and no longer had suicidal ideation, that he felt much better after 1:1 time, and that he continued his daily routine and therapy. These late entries described follow-up visits and reassessments of suicidal ideation on several consecutive days, but in interviews the SSD stated she did not normally ask residents about having a plan when they verbalized suicidal ideation and did not recall any other occurrences beyond the initial event. She further indicated she did not personally provide individual follow-up visits with this resident regarding suicidal ideation, despite the late-entry notes describing such visits. The DON acknowledged that late entries had been added to address concern about suicidal verbalization, and the Administrator stated that upon suicidal statements staff should ask about a plan, notify the physician and family, and update the care plan, and that this resident should have had a care plan addressing depression with suicidal ideation. The facility’s documentation policy required factual, first-hand, timely documentation, which was not followed in this case.
Failure to Complete Required Self-Administration Assessment for Inhaler Kept at Bedside
Penalty
Summary
Surveyors identified that a resident was allowed to keep and access an Albuterol inhaler without the facility completing the required self-administration medication assessment. During an initial tour, the resident was observed sitting in a wheelchair with a handheld Albuterol inhaler on the overbed table and no staff present in the room or hallway. On a subsequent observation, the resident again was in a wheelchair and reported that the Albuterol inhaler was stored in the top drawer of the nightstand, where it was found. Review of the clinical record showed an admission MDS indicating no cognitive impairment, but there was no documentation of a self-medication administration assessment. In an interview, the DON confirmed that the resident did not have the required self-medication assessment, despite the facility’s policy stating that staff and the practitioner must assess each resident’s mental and physical abilities to determine whether self-administering medications is clinically appropriate. This failure to complete and document a self-administration medication assessment for a resident who had an Albuterol inhaler kept at bedside constituted noncompliance with the facility’s own policy and with 410 IAC 16.2-3.1-11(a).
Inaccurate PBJ Staffing Data Submission to CMS
Penalty
Summary
The deficiency involves the facility’s failure to electronically submit complete and accurate direct care staffing information to CMS through the Payroll-Based Journal (PBJ) system for 22 days in a fiscal quarter. A CASPER report review on 4/6/26 showed that, according to PBJ data, the facility did not have licensed nursing coverage 24 hours per day on multiple specific dates across three months, had low weekend staffing, and held a 1-star staffing rating. However, review of the facility’s internal staffing sheets for that quarter indicated the facility was fully staffed and had licensed nurse coverage on all of the dates in question. During an interview, the Administrator stated that the PBJ information must have contained data entry errors, as she had verified licensed staff coverage on the timesheets. The facility’s PBJ policy in effect stated that all staffing data entered into the PBJ system would be auditable and verifiable through payroll, invoices, or contracts, but the submitted PBJ data did not accurately reflect the facility’s actual licensed nurse staffing as documented on internal records. No specific residents or clinical conditions were mentioned in the report, and the deficiency centers solely on inaccurate staffing data submission rather than direct resident care events.
Failure to Provide and Document Required Transfer/Discharge and Bed-Hold Notices
Penalty
Summary
The deficiency involves the facility’s failure to provide and document required written notices of transfer/discharge and bed-hold policies, as well as required information to receiving providers, for four residents who were transferred or discharged to the hospital. For a resident with generalized anxiety disorder, major depressive disorder, and dementia, progress notes showed that the resident was sent to the hospital via 911 for chest pain, lower back pain, and shortness of breath and later returned to the facility, but the clinical record lacked documentation that a written Notice of Transfer/Discharge and the bed-hold policy were provided to the resident or representative, and lacked documentation that required information was conveyed to the receiving facility. The ADON and the Administrator both confirmed there was no documentation that these written notices were provided. For a resident with congestive heart failure and muscle weakness who was sent to the emergency room for painful urination and bloody urine, the clinical record lacked documentation that a Notice of Transfer/Discharge or bed-hold policy was given to the resident or representative, which the DON confirmed. Another resident with chronic respiratory failure and diabetes was discharged to the hospital for respiratory failure, and a resident with chronic kidney disease and dementia was discharged to the hospital, but in both cases there was no documentation that a written notice of transfer/discharge or bed-hold policy was provided to the residents or their representatives. Review of the facility’s Transfer and Discharge policy, dated 1/15/26, showed that the policy required the facility to provide written transfer/discharge notices and bed-hold information to residents and representatives and to provide specified information to receiving providers, but the records for these four residents did not contain the required documentation.
Failure to Document Target Behaviors and Non-Pharmacological Interventions Before Initiating Antipsychotic
Penalty
Summary
The deficiency involves the facility’s failure to document how a resident’s behaviors presented danger or distress to self or others, and failure to document non-pharmacological interventions attempted prior to initiating an antipsychotic medication. Resident 6 had documented diagnoses of Alzheimer’s disease, depression, and severe cognitive impairment, and was receiving sertraline for depression. A PASSAR identified only depression and dementia, and the admission MDS listed Alzheimer’s disease and depression as active diagnoses. Over several months, nursing progress notes documented that the resident intermittently reported unusual perceptions, such as believing there were men causing trouble, a man in her room, or a man wanting to marry her and yelling through the walls, but there was no documentation that these episodes caused danger to the resident or others or that they resulted in unmanageable distress. From late April through mid-July, nursing notes primarily described the resident’s frequent refusals of evening and morning medications, blood sugar checks, blood pressure checks, insulin administration, hygiene care, and showers. Staff documented that the resident sometimes yelled at staff, said “Get out!”, was visibly upset by a room move, was leery of staff and asked to see name badges, and became upset about a pillow under her head until it was removed, after which she calmed down. The notes also recorded instances where the resident believed housekeeping had not cleaned her room or that she had not received medications when she had. However, there were no progress notes or assessments indicating that these behaviors were evaluated as dangerous, non-redirectable, or causing significant distress or functional impairment, and no detailed behavior monitoring logs were present as required by facility policy. On a psychiatric NP visit for initial psychotropic medication management, new mental health diagnoses of schizoaffective disorder, borderline personality disorder, and delusional disorder were added, and Seroquel 25 mg, an antipsychotic, was ordered. The clinical record did not contain a comprehensive evaluation to support these new diagnoses, and there was no documentation of target behaviors meeting the facility’s policy criteria for psychotropic use, such as behaviors representing danger to self or others, causing distress and impairment in functional abilities, or clearly attributable to psychosis or mania. The resident’s representative reported that the resident had no prior history of mental health disorders or psychiatric hospitalization and was unaware of the new diagnoses. The facility’s own psychotropic medication policy required identification and documentation of specific target behaviors, use and documentation of nonpharmacological interventions, and ongoing monitoring of behaviors and interventions, which were not reflected in the record for this resident.
Failure to Update PASARR Screens for New Mental Health Diagnoses and Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that Preadmission Screening and Resident Review (PASARR) Level I screenings were accurate and updated when new mental health diagnoses and psychoactive medications were initiated for multiple residents. For one resident with dementia, anxiety, depression, and post-traumatic stress disorder (PTSD), the PASARR completed on admission listed anxiety, depression, and dementia with sertraline and quetiapine, but did not include the PTSD diagnosis or the antidepressant Pristiq, despite the admission MDS and care plan documenting PTSD and a subsequent physician’s order for Pristiq. For another resident with Alzheimer’s disease, borderline personality disorder, delusional disorder, schizoaffective disorder, and depression, the PASARR only reflected depression and dementia with sertraline, even though additional mental health diagnoses were added later and an antipsychotic (quetiapine) was ordered for borderline personality disorder, and the quarterly MDS documented psychotic disorder, schizophrenia, and depression with antipsychotic and antidepressant use. A third resident had diagnoses including Alzheimer’s disease, depression, anxiety disorder, irritability and anger, and nonrheumatic aortic valve stenosis. The PASARR for this resident listed dementia and anxiety with Risperdal but omitted the diagnosis of depression and the medications escitalopram and lorazepam, although physician’s orders were in place for escitalopram for depression and lorazepam for anxiety, and the admission MDS documented depression with antianxiety and antidepressant use. Interviews with the Assistant Director of Nursing confirmed that new Level I PASARR screens should have been completed when new mental health diagnoses and psychoactive medications were added, and that the PASARR for one resident, completed prior to arrival, should have included all mental health diagnoses and medications. The facility’s own policy required notification of the state mental health authority within 14 days after a significant change in mental condition and specified that a new Level I screen is required for new mental health diagnoses or newly prescribed psychotropic medications, which was not followed in these cases.
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