Brickyard Healthcare - Fountainview Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Mishawaka, Indiana.
- Location
- 609 W Tanglewood Ln, Mishawaka, Indiana 46545
- CMS Provider Number
- 155178
- Inspections on file
- 33
- Latest survey
- February 23, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Brickyard Healthcare - Fountainview Care Center during CMS and state inspections, most recent first.
A resident with dementia and multiple comorbidities remained on a full liquid diet carried over from a hospital stay, even though the liquid diet had been ordered for nutritional reasons rather than swallowing issues and the resident was observed eating without difficulty. The resident’s POA and family repeatedly requested a change to a soft/mechanical diet, reporting they had safely fed the resident soft foods such as mashed potatoes and cottage cheese, but facility staff stated they would not change the order and discussed requiring a legal waiver if the family fed foods outside the ordered diet. Therapy and nursing leadership indicated that, because the resident could not follow commands, they believed she did not meet criteria for a diet change and did not ensure a timely, thorough swallow evaluation, resulting in the facility not honoring the resident representative’s diet preferences despite a policy supporting resident self-determination.
A resident with dementia, acute kidney failure, and documented concerns about food and fluid intake was repeatedly observed in common areas and in her room without fluids available and without being offered fluids between meals. A CNA confirmed that no fluids were given between breakfast and lunch, and the resident’s family reported that staff did not "push fluids," which they associated with a recent hospitalization for severe dehydration and abnormal lab values requiring IV fluids. The resident’s care plan identified risk for dehydration, and the facility’s hydration policy required offering sufficient fluids to maintain hydration, but these measures were not implemented for this resident.
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.
The facility did not notify the LTC Ombudsman in a timely manner about the discharges of three residents, including one who was discharged home after therapy and two who were sent to the hospital and not readmitted. Record reviews and interviews confirmed that required notifications were not sent, despite facility policy requiring documentation of such notifications.
The facility did not maintain a safe and sanitary environment in several rooms, as evidenced by gouged walls, broken closet doors, and damaged or non-functional window blinds. The Area Maintenance Director confirmed that these issues should have been identified and addressed through regular room tours and the facility's maintenance reporting system.
A resident with a Foley catheter experienced new, significant pain and bleeding at the catheter site, but staff did not promptly notify the physician or hospice provider as required. Despite repeated complaints and visible symptoms, the pain was not assessed or addressed in a timely manner, and documentation of notification was lacking. The facility's pain management policy requiring practitioner notification for uncontrolled pain was not followed.
The facility did not provide two residents with timely SNF-ABN and NOMNC forms after the end of their Medicare skilled services. Required notifications were either undated or not given at least 48 hours before therapy ended, and staff interviews confirmed a lack of awareness of these requirements.
A resident with severe cognitive impairment and multiple medical conditions required substantial assistance with ADLs, including bathing. The care plan documented the need for staff assistance but did not include the resident's preferences for type and frequency of bathing, as required by facility policy. The DON confirmed this omission during interview.
A resident with severe cognitive impairment and multiple medical conditions experienced a fall resulting in a head injury. Although interventions such as a fall mat and low bed were implemented after the incident, the care plan was not promptly updated to reflect these changes, with the fall mat added much later and the low bed not documented at all.
A resident with multiple serious diagnoses, including dysphagia and malnutrition, did not receive a physician-ordered health shake with lunch on several observed occasions, even though documentation indicated it was provided. Staff interviews confirmed the supplement was not served and highlighted a breakdown in communication between dietary and nursing staff regarding responsibility for ensuring the supplement was delivered and documented.
A resident experienced significant pain related to a Foley catheter, with staff failing to promptly assess, document, and communicate the new pain to the physician or Hospice provider. Despite repeated complaints and visible signs of discomfort, no PRN pain medication was ordered or administered, and catheter care was continued without proper pain management or reassessment, contrary to facility policy.
A Unit Manager failed to wear a gown, as required by Enhanced Barrier Precautions, while providing Foley catheter care to a resident with an indwelling urinary catheter. Although gloves were used, the omission of a gown was inconsistent with the facility's policy and a physician's order for high-contact care activities involving medical devices.
The facility failed to respond promptly to grievances from four residents, who reported issues such as long wait times for care and missing personal items. Despite grievances being reviewed and resolved, residents did not receive any written or verbal responses, contrary to the facility's policy.
The facility failed to follow physician's orders and document wounds for several residents. A resident with a fluid restriction was given excess water due to staff unawareness. Another resident's wounds were not documented or assessed, and post-operative treatment orders for a third resident were delayed. Additionally, a new admission did not have treatment orders obtained, and dressings were not dated, indicating lapses in care and documentation.
The facility did not ensure the Medical Director or their designee attended quarterly QAPI meetings over the past year. The Administrator acknowledged the absence and mentioned reviewing meetings with the Medical Director or sending minutes via email. The Nurse Practitioner attended some meetings but was not recorded in the QAPI signature log. The facility's policy mandates an interdisciplinary QAA Committee, including the Medical Director, to meet quarterly.
The facility failed to inform two residents of the bed hold policy upon their transfer to a hospital. One resident, with type 2 diabetes and anxiety disorder, was hospitalized for a staph infection, while another, with leg amputations and diabetes, was transferred for congestive heart failure. In both cases, the families were notified of the transfers, but there was no documentation that the bed hold policy was communicated or provided. Interviews with staff confirmed the lack of documentation.
The facility failed to provide adequate nail care for three residents who were dependent on staff for activities of daily living. One resident, severely cognitively impaired, was observed with long, curled fingernails, and there was no documentation of nail care being offered after refusals of baths or showers. Another resident, with moderate cognitive impairment, had long fingernails with dark matter underneath, and the care plan lacked reference to nail care. A third resident, requiring substantial assistance, was observed with very long fingernails and dark matter, with no documentation of nail care provided.
A resident with a urinary catheter did not receive a catheter strap to prevent excessive tension, despite multiple requests. The resident, who had conditions such as paraplegia and pressure ulcers, was observed without a catheter strap on two occasions. The care plan included an intervention to anchor the catheter, but this was not followed. An LPN confirmed the need for securing the catheter, and the facility's policy also required it, yet it was not implemented.
A facility failed to follow physician orders for a resident's tube feeding, as observed when the resident had 350 mL of Jevity 1.5 remaining in the feeding bag, contrary to the order of 1050 mL daily. The resident, with severe cognitive impairment and multiple diagnoses, was dependent on tube feeding. Despite the Medication Administration Record indicating full compliance, the Unit Manager confirmed the resident did not receive the full prescribed amount, violating the facility's policy on feeding tube care.
A facility failed to follow physician orders for a resident's PICC line dressing changes, leading to a deficiency. The resident reported infrequent dressing changes, with discrepancies noted in the Medication Administration Records. The Infection Preventionist Nurse confirmed inaccuracies and lack of documentation for an initial dressing change upon admission, contrary to the facility's policy.
The facility failed to reconcile controlled drugs for three medication carts, resulting in missing signatures on narcotic reconciliation sheets over several weeks. An LPN and a QMA confirmed that narcotics should be counted and signed off by both the off-going and oncoming nurses every shift. The facility's policy requires all controlled substances to be accounted for to prevent loss or diversion.
The facility failed to store medications properly in the C-Wing Hall 1 medication cart. An unopened bottle of Lantus insulin for a resident was found unrefrigerated, contrary to its label instructions. Additionally, two opened bottles of eye drops for another resident were undated. The facility's policy requires refrigerated storage for certain medications.
The facility failed to dispose of leftovers in the kitchen's walk-in cooler in a timely manner, potentially affecting two residents with altered diets. During a kitchen tour, it was found that trays containing thickened drinks for residents were dated beyond the three-day limit for leftovers. The Regional Certified Dietary Manager confirmed that prepared food should have a made-on date and a discard date, and provided a policy indicating that refrigerated foods should be labeled and discarded within the allowed days.
An LPN failed to follow infection control protocols during a PICC line dressing change for a resident. The LPN placed the dressing kit on an uncleaned nightstand, did not change gloves or perform hand hygiene between steps, and did not offer the resident a mask or ask them to turn their head away from the insertion site. These actions were contrary to the facility's infection control policy.
The facility did not document declination forms for COVID-19 immunizations for three residents. A record review showed missing signed declination forms, and the Infection Prevention Nurse confirmed the absence of these forms, despite the facility's policy requiring such documentation for residents who refuse or have contraindications for the vaccine.
A facility failed to maintain a temperature log for a resident's personal refrigerator, as required by its policy. During a survey, it was observed that a resident's refrigerator lacked both a thermometer and a temperature log. The Unit Manager confirmed the absence of these items, which are necessary for compliance with the facility's policy. The policy requires weekly temperature recordings and the presence of a calibrated thermometer, along with regular cleaning and adherence to safe food handling practices.
The facility failed to report a resident's abnormal vital signs to the physician. The resident had a significant drop in blood pressure and an irregular pulse, which were not communicated to the Nurse Practitioner, contrary to the facility's policy. This oversight was identified during a review of the resident's clinical records and an interview with the Nurse Practitioner.
The facility failed to create a wound vac care plan for a resident admitted with multiple pressure ulcers and a wound vac to the right buttock. Despite the resident's extensive medical needs and the facility's policy on comprehensive care plans, no care plan was developed for the wound vac intervention.
The facility failed to reassess a resident after a significant drop in blood pressure and an elevated irregular pulse. Despite these abnormal vital signs, no further readings were documented, and the resident was later admitted to the ER for confusion and a possible infection. The LPN did not document follow-up vital signs, and the NP was not informed of the abnormalities.
Failure to Honor Resident Representative’s Diet Preferences and Fully Evaluate Diet Needs
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident representative’s request to change a resident’s diet from full liquid to a soft/mechanical consistency, despite evidence the resident could tolerate soft foods and that the liquid diet was not ordered for swallowing concerns. Surveyors observed the resident being fed full liquid meals, including broth, yogurt, supplements, pudding, and juice, which she took via spoon and straw without difficulty. A CNA who frequently assisted with meals reported the resident ate well and did not exhibit choking, coughing, or other eating concerns. The resident’s diagnoses included Alzheimer’s disease, dementia, COPD, acute kidney failure, and issues concerning food and fluid intake, and a prior hospital nutrition note documented that the full liquid diet was intended to promote nutritional intake due to hypernatremia and poor intake, not because of dysphagia. The resident’s POA reported that before a recent hospitalization for dehydration and malnutrition, the resident had been on soft foods and that the family had continued to feed her soft items such as mashed potatoes and cottage cheese without any swallowing difficulty. The POA stated the family had repeatedly requested a change from a liquid diet to a mechanical soft diet but were told by the facility that the diet order would not be changed. In a care plan meeting, the family reported being able to feed the resident cottage cheese, pudding, and yogurt in the hospital without problems, and were informed by the Administrator that a legal waiver would be needed if the family chose to feed foods outside the liquid diet ordered from the hospital. Interviews with facility staff showed that the facility continued the full liquid diet order from the hospital and did not ensure a timely, thorough evaluation of the resident’s swallowing capabilities upon readmission. The Therapy Department Manager and DON stated that because the resident could not follow commands, she did not meet criteria for a diet change and that a swallow study could not be performed, and it was unclear why physical therapy was involved in decisions about swallow testing. The DON also stated that the facility had to follow the physician’s full liquid diet order and referenced multiple meetings with the family about their desire for a soft diet and the family’s refusal to sign a waiver. A subsequent swallow study by Speech Therapy, observed by surveyors, confirmed the resident had previously been on a soft mechanical diet and that the hospital’s liquid diet was for nutritional reasons, after which Speech Therapy initiated a pureed diet; however, the deficiency centers on the period when the facility did not act on the family’s requests or fully evaluate the resident’s diet needs in accordance with her rights to self-determination as outlined in the facility’s Resident Rights policy.
Failure to Provide Adequate Fluids to Dependent Resident
Penalty
Summary
Surveyors identified that the facility failed to provide adequate fluids to maintain hydration for one dependent resident. Over multiple observations on consecutive days, the resident was repeatedly seen seated in a reclining wheelchair in the common area and in her room without any fluids available nearby. During the morning hours, no water or other fluids had been passed to the resident in her room or in the common area, and by late morning the resident remained without access to fluids. During a lunch dining observation, a CNA fed the resident a liquid diet meal that included broth, yogurt, a magic cup, a mighty shake, pudding, and juice, and the resident’s family took over feeding during the meal. The CNA reported that she had not given the resident any fluids between breakfast and lunch. The resident’s family member reported that staff had not “pushed fluids,” which they believed led to a recent hospitalization for dehydration and elevated sodium levels, and that family members came daily to feed the resident because staff did not feed or offer enough fluids. The family member stated that when they were unable to visit due to illness, the resident became dehydrated, and that the facility continued not to offer fluids even after the resident returned from the hospital. Record review showed the resident had multiple diagnoses including Alzheimer’s disease, dementia, acute kidney failure, and signs and symptoms concerning food and fluid intake. A recent ED note documented that the resident was admitted with severe dehydration, dry oral cavity, and significantly abnormal labs, including sodium of 170 and potassium of 3.0, and was treated with IV fluids. The resident’s care plan identified dehydration or potential for fluid deficit related to diuretic use, with an expectation that the resident would be free of dehydration symptoms, and the facility’s hydration policy required offering sufficient fluids to maintain proper hydration and health.
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.
Failure to Notify LTC Ombudsman of Resident Discharges
Penalty
Summary
The facility failed to notify the Long Term Care (LTC) Ombudsman in a timely manner regarding resident discharges for three out of five residents reviewed. Specifically, one resident was discharged to home after completing therapy, but the discharge notification for that month was not sent to the Ombudsman as required. The Executive Director (ED) confirmed that the discharge notifications for April had not been sent, despite being due at the beginning of the following month. Additionally, two other residents were sent to the hospital and subsequently discharged, but their names were not included on the Ombudsman notification lists for their respective months. Record reviews and interviews with the ED confirmed that these residents' discharges were omitted from the required notifications. The facility's policy states that evidence of notification to the Ombudsman should be maintained, but this was not followed in these cases.
Failure to Maintain Safe and Sanitary Resident Environment
Penalty
Summary
The facility failed to provide a safe and sanitary environment for residents, staff, and the public in 7 out of 19 rooms reviewed. Observations on the 100 Unit revealed multiple instances of environmental disrepair, including gouges in the walls near the baseboard behind a resident's bed, several basketball-sized gouges on a room's north wall, broken and partially missing window blind slats, and multiple rooms with broken closet doors and non-functional window blinds. During interviews, the Area Maintenance Director confirmed that 24 rooms are toured monthly to identify issues and that a technological system (TELS) is used for submitting maintenance work orders, with all staff expected to report problems. The Director acknowledged that the damaged and disrepaired items required repair. The DON provided the facility's maintenance policy, which states that maintenance should attempt to repair items as soon as possible.
Failure to Notify Physician of New Catheter-Related Pain
Penalty
Summary
A deficiency occurred when staff failed to notify the physician of a resident's new pain associated with a Foley catheter. The resident, who had diagnoses including neurogenic bladder, schizophrenia, anxiety disorder, dysphagia, and major depressive disorder, reported significant pain (rated 7-8 out of 10) and visible blood at the catheter site. Despite the resident's repeated complaints of pain and the presence of blood, there was no documentation that the physician or hospice provider was notified of the new pain on the day it was first reported. Observations and interviews revealed that the unit manager was aware of the resident's pain and had requested a PRN pain medication from hospice, but no order was received, and the pain was not addressed promptly. The resident continued to experience pain, and staff proceeded with catheter care without reassessing or addressing the pain. Communication lapses were evident, as the pain was reported to a nurse not assigned to the resident, and the assigned nurse did not assess the pain before continuing care. Further review showed that hospice staff were not informed of the new pain until days after the initial complaint, and there was no record of calls or notes from the facility to hospice regarding the pain on the day it began. The facility's pain management policy required staff to notify the practitioner if pain was not controlled, but this was not followed, resulting in the resident experiencing ongoing pain without timely intervention or notification to the appropriate medical providers.
Failure to Provide Timely Medicare Coverage Notices
Penalty
Summary
The facility failed to provide timely Skilled Nursing Facility-Advanced Beneficiary Notice (SNF-ABN) and Notice of Medicare Non-Coverage (NOMNC) forms to two residents following the end of their Medicare skilled services. For both residents, documentation showed that Medicare coverage had ended, but the NOMNC forms provided were undated, and there was no evidence indicating when the residents were informed. Additionally, the required SNF-ABN forms were not given to the residents at least 48 hours before the end of their therapy, as required by facility policy and federal regulations. Interviews with the Business Office Manager revealed a lack of awareness regarding the requirement to provide these notices in a timely manner. The Director of Nursing provided an undated policy that specified the need to give residents or their representatives at least two days' notice before the end of Medicare Part A coverage, but this policy was not followed in the cases reviewed. The deficiency was identified through record review and staff interviews, confirming that the necessary notifications were not provided as required.
Failure to Individualize ADL Care Plan for Resident with Self-Care Deficits
Penalty
Summary
The facility failed to develop and implement a comprehensive, individualized care plan for a resident with significant ADL self-care performance deficits. The resident, who had diagnoses including local skin infection, falls, anxiety, depression, hypertension, bipolar disorder, sepsis, and dysphagia, was assessed as severely cognitively impaired and requiring substantial assistance with multiple ADLs such as dressing, hygiene, toileting, and bathing. The care plan in place noted the need for assistance by one staff member but did not specify the resident's preferences regarding the type and frequency of bathing. During interviews, the DON confirmed that care plans were created using an interdisciplinary approach and acknowledged that the omission of the resident's bathing preferences was a deficiency. The facility's policy required comprehensive, person-centered care plans with measurable objectives and timeframes based on the resident's assessment, but this was not fully implemented for the resident in question.
Failure to Timely Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to update the care plan with new interventions following a fall incident involving a resident with severe cognitive impairment, acute and chronic respiratory failure with hypoxia, and depression. The resident, who was dependent for toileting, bed mobility, and transfers, experienced a fall from bed resulting in a head injury. Although a post-fall evaluation was conducted and interventions such as placing a fall mat and using a low bed were implemented, these changes were not promptly reflected in the resident's care plan. The fall mat was not added to the care plan until over a month later, and the low bed intervention was never documented in the care plan, contrary to facility policy requiring timely care plan updates after status changes.
Failure to Provide Ordered Nutritional Supplement
Penalty
Summary
The facility failed to follow a physician's order to provide a health shake as a nutritional supplement at lunch and dinner for a resident with diagnoses including dysphagia, rhabdomyolysis, protein-calorie malnutrition, starvation, and a sacral pressure ulcer. During meal observations on three consecutive days, the resident did not receive the prescribed health shake with lunch, despite the medication administration record indicating it had been given. Interviews with staff revealed that the kitchen was responsible for providing the health shake, while nursing staff were responsible for documenting intake, and that if the supplement was missing, the nurse should have contacted the kitchen. The facility's policy required providing nutritional supplements consistent with residents' assessed needs.
Failure to Timely Address and Manage Resident's Catheter-Related Pain
Penalty
Summary
A resident with a Foley catheter reported significant pain, rating it as 7 to 8 out of 10, and was observed to have a catheter leg strap stuck to the tip of his penis with a small amount of blood present. Despite the resident's repeated complaints of pain, the only pain medication available was a scheduled dose, with no PRN (as needed) pain medication ordered for breakthrough pain. The Unit Manager acknowledged that a request for PRN pain medication had been made to the Hospice provider, but no order had been received, and there was no documentation that the physician or Hospice had been contacted regarding the new pain on the day it was first reported. The resident's pain persisted over multiple days, and staff continued to provide catheter care without reassessing the resident's pain or obtaining appropriate pain management interventions. Communication lapses were evident, as the pain was reported to a nurse who was not assigned to the resident, and the nurse responsible did not assess the pain before proceeding with care. The Hospice nurse and Director of Operations confirmed that no calls or requests for PRN pain medication were received from the facility prior to the day the deficiency was identified, and the Hospice nurse only became aware of the pain after a subsequent visit. The facility's pain management policy required staff to evaluate and report new or uncontrolled pain to the practitioner, but this was not followed in the resident's case. Documentation was lacking regarding timely notification to the physician or Hospice, and staff failed to ensure the resident's pain was addressed before continuing with catheter care. The deficiency was substantiated by interviews, observations, and record reviews showing a delay in both assessment and intervention for the resident's pain.
Failure to Follow Enhanced Barrier Precautions During Catheter Care
Penalty
Summary
A deficiency occurred when the Unit Manager (UM) failed to follow Enhanced Barrier Precautions (EBP) while providing care to a resident with an indwelling urinary catheter. During an observed care activity, the UM wore gloves but did not don a gown as required by the facility's EBP policy, despite a visible EBP sign and available PPE supplies outside the resident's room. The resident had multiple diagnoses, including neurogenic bladder and an indwelling catheter, and a current physician's order specified the need for both gown and gloves during high-contact care. The UM later acknowledged not wearing a gown during the procedure, which was inconsistent with the facility's policy for residents with indwelling medical devices.
Failure to Respond to Resident Grievances
Penalty
Summary
The facility failed to ensure that resident grievances were responded to promptly and acted upon, affecting four out of 21 residents reviewed. Resident 52 reported waiting an hour on every shift for care, with staff turning off his call light without providing assistance. He filed a grievance on June 7, 2024, regarding a 40-minute wait for bathroom assistance, which was reviewed and resolved by the Executive Director on June 10, 2024, but he did not receive any response or outcome. Similarly, Resident 30 experienced a two-hour wait for care, with staff turning off his call light without returning. He filed a grievance on June 30, 2024, about the care received on June 29, 2024, which was resolved on July 13, 2024, but he was not informed of the outcome. Resident 70 reported a 20-minute wait for her call light to be answered, with staff turning it off and not returning. Her significant other filed a grievance on June 8, 2024, which was resolved on June 10, 2024, but she did not receive any response or outcome. Resident 128 reported missing $20 from his wallet, with a grievance filed on June 27, 2024. The Admissions Director was assigned to investigate but did not follow up or inform the resident of any outcome. The facility's policy required written responses to grievances, but the Administrator admitted that residents were not provided with written responses, indicating a failure to adhere to the grievance policy.
Failure to Follow Physician's Orders and Document Wounds
Penalty
Summary
The facility failed to adhere to physician's orders for several residents, leading to deficiencies in care. Resident 11, who had a fluid restriction order of 1800 mL per day due to conditions such as chronic kidney disease and hypertension, was observed with swollen legs and feet and was given more water than prescribed. The staff, including CNA 2, were unaware of the fluid restriction as it was not listed in the kitchenette, resulting in the resident receiving full cups of water exceeding the allowed amount. Resident 5, who had peripheral venous insufficiency and diabetes, was found to have wounds on his toes that were not documented or assessed during weekly skin inspections. The Unit Manager and LPN 4 were unaware of these wounds, indicating a failure in the facility's skin assessment process. The policy required weekly skin inspections, but the wounds were not noted, leading to a lack of appropriate wound care. Resident 63 returned from a post-operative appointment with treatment orders that were not initiated until two days later, delaying necessary wound care. Additionally, Resident 127, who had a surgical site on the hip and a skin tear on the wrist, did not have treatment orders obtained upon admission, and dressings were not dated as required. The Wound Nurse confirmed that treatment orders should have been obtained and dressings dated, but this was not done, indicating a lapse in following the facility's wound treatment management policy.
Failure to Ensure Medical Director Attendance at QAPI Meetings
Penalty
Summary
The facility failed to ensure the Medical Director or their designee attended the quarterly Quality Assurance and Performance Improvement (QAPI) meetings during the past year. During an interview, the Administrator admitted that the Medical Director had not attended these meetings, although she reviewed them with him or sent the meeting minutes via email. The Nurse Practitioner attended some facility meetings, but the QAPI signature log did not show her attendance at any QAPI meetings over the past year. The facility's policy on Quality Assurance and Performance Improvement, which was undated but indicated as current, requires the QAA Committee to be interdisciplinary. It must include, at a minimum, the Director of Nursing Services, the Medical Director or their designee, at least three other staff members (including the Administrator, Owner, a Board Member, or another individual in a leadership role), and the Infection Preventionist. The committee is required to meet at least quarterly to coordinate and evaluate activities under the QAPI program.
Failure to Inform Residents of Bed Hold Policy
Penalty
Summary
The facility failed to ensure that residents were informed of the bed hold policy upon transfer to a hospital, as evidenced by the cases of two residents. Resident 28, who had diagnoses including type 2 diabetes mellitus and anxiety disorder, was admitted to the hospital due to a methicillin-resistant staph aureus infection. Although the family was notified of the hospital transfer, there was no documentation indicating that the bed hold policy was explained or a copy provided to the resident or their family. Similarly, Resident 64, with diagnoses including acquired absence of both legs below the knee and type 2 diabetes mellitus, was transferred to the hospital for congestive heart failure. The family was informed of the transfer, but there was no record of the bed hold policy being communicated or a copy given to the resident or their family. Interviews with facility staff, including an LPN and the Executive Director, confirmed the absence of documentation regarding the provision of the bed hold policy to these residents. The facility's policy required that a notice of transfer and the bed hold policy be provided to the resident and their representative.
Failure to Provide Adequate Nail Care for Dependent Residents
Penalty
Summary
The facility failed to provide adequate nail care for three residents who were dependent on staff for activities of daily living. Resident 35, who was severely cognitively impaired and dependent on staff for personal hygiene, was observed multiple times with long, curled fingernails. Despite being given bed baths and showers, there was no documentation indicating that nail care was offered after the resident refused baths or showers. Additionally, there was no current care plan addressing the resident's rejection of care, and the Unit Manager could not provide documentation explaining the lack of nail care. Resident 5, with moderate cognitive impairment and dependent on staff for bathing and personal hygiene, was observed with long fingernails and dark matter underneath them. Although his toenails were trimmed, his fingernails remained unkempt. The care plan and facility documentation did not reference nail care, and a Qualified Medication Aide (QMA) confirmed that the resident's fingernails should have been clean and trimmed. Resident 28, who required substantial assistance for personal hygiene, was observed with very long fingernails and dark matter underneath them. The care plan and facility documentation lacked any reference to nail care. A Certified Nursing Assistant (CNA) indicated that nail care should be part of shower routines, especially for diabetic residents, but there was no documentation of such care being provided. The Unit Manager acknowledged that fingernails should be cleaned and trimmed, particularly for diabetic residents.
Failure to Provide Catheter Strap for Resident
Penalty
Summary
The facility failed to ensure proper care for a resident with a urinary catheter, specifically by not providing a catheter strap to prevent excessive tension on the catheter. Resident 128, who had diagnoses including paraplegia, osteomyelitis, and pressure ulcers, reported asking for a catheter strap multiple times over several days on all three shifts. Despite these requests, observations on two separate days confirmed that no catheter strap was in place. The resident expressed concern about blood in the catheter and the risk of it being pulled out. The resident's care plan, dated 7/3/2024, included an intervention to anchor the catheter to avoid excessive tugging during transfers and care. However, this intervention was not implemented. An LPN acknowledged that the catheter should be secured to prevent trauma, although the physician's orders did not specifically mention catheter straps. The facility's policy on indwelling catheter use also emphasized the importance of keeping the catheter anchored to prevent urethral tears or dislodgement, yet this was not adhered to in the case of Resident 128.
Failure to Follow Tube Feeding Orders
Penalty
Summary
The facility failed to adhere to physician orders regarding tube feeding for a resident identified as Resident 35. During an observation, it was noted that Resident 35 had a container of Jevity 1.5 with 350 mL of formula remaining, and the feeding tube pump was turned off. This observation was inconsistent with the physician's order, which specified that the resident should receive 1050 mL of Jevity 1.5 daily. Despite this, the Medication Administration Record for July 2024 inaccurately indicated that the resident had received the full prescribed amount of Jevity 1.5 on the day of the observation. Resident 35's medical history included severe cognitive impairment, conversion disorder with seizures, diabetes insipidus, bipolar disorder, dysphagia, anxiety, and dementia. The resident was dependent on tube feeding, with care plan goals to prevent undesirable weight changes, discomfort, and dehydration. The facility's policy on the care and treatment of feeding tubes required that enteral nutrition administration be consistent with practitioner orders. However, during an interview, the Unit Manager confirmed that Resident 35 did not receive the full prescribed tube feeding on the observed day, indicating a failure to follow the established care plan and physician orders.
Failure to Follow PICC Line Dressing Change Orders
Penalty
Summary
The facility failed to adhere to physician orders regarding the timely changing of a PICC line dressing for a resident. The resident, who had a diagnosis including paraplegia and osteomyelitis, reported that his PICC line dressing had only been changed once since admission, with the last recorded change on 6/29. The physician's order specified that the dressing should be changed upon admission, then weekly and as needed, specifically on the night shift every Sunday. However, the Medication Administration Records indicated discrepancies, showing changes on 6/23, 6/30, and 7/7, with the latter being inaccurately signed according to the Infection Preventionist Nurse. During interviews, it was revealed that the dressing had been reinforced with tape, which was not appropriate, and there was no documentation of a dressing change upon the resident's admission. The facility's policy required weekly dressing changes or when soiled, but the Infection Preventionist Nurse could not find documentation supporting the initial change upon admission. This oversight in following the physician's orders and facility policy led to a deficiency in the safe administration of IV fluids for the resident.
Failure to Reconcile Controlled Drugs
Penalty
Summary
The facility failed to ensure proper reconciliation of controlled drugs for three medication carts, leading to a deficiency in pharmaceutical services. During an observation of the B-Wing Hall 1 medication cart, it was found that the narcotic reconciliation sheets were missing signatures between June 17, 2024, and July 11, 2024. An LPN confirmed that narcotics should be counted by both the off-going and oncoming nurses, with both required to sign the reconciliation sheet every shift. Similarly, the C-Wing Hall 1 medication cart was observed to have missing signatures on the narcotic reconciliation sheets between June 13, 2024, and July 11, 2024. A QMA indicated that the reconciliation should occur every shift with signatures from both nurses. Additionally, the C-Wing Hall 2 medication cart had missing signatures from May 30, 2024, to June 12, 2024. The Infection Preventionist Nurse confirmed that both the off-going and oncoming nurses should sign the sheets after counting the narcotics. The facility's policy on controlled substance administration and accountability was provided, indicating that all controlled substances should be accounted for to prevent loss or diversion.
Improper Medication Storage in C-Wing Hall 1 Cart
Penalty
Summary
The facility failed to properly store medications in one of the three medication carts reviewed, specifically the C-Wing Hall 1 medication cart. During an observation, an unopened bottle of Lantus insulin for a resident was found in the cart, despite the label indicating it should be refrigerated until opened. The IP nurse confirmed that the insulin should have been stored in the refrigerator. Additionally, two bottles of eye drops, Timolol and Brimonidine, for another resident were found opened but undated. A QMA acknowledged that the eye drops should have been dated when opened. The facility's policy on medication storage, provided by the Regional Nurse Consultant, stated that all medications requiring refrigeration should be stored in designated refrigerators.
Failure to Timely Dispose of Leftovers in Kitchen
Penalty
Summary
The facility failed to dispose of leftovers in a timely manner in the walk-in cooler of the kitchen, which could potentially affect two residents with altered diets who received their meals from the kitchen. During a kitchen tour with the Registered Dietician (RD), it was observed that three trays dated 7/2/2024 were in the refrigerator, containing thickened drinks for residents with altered liquid diet orders. The drinks included 8 glasses of milk, 2 glasses of water, 3 glasses of cranberry juice, and 2 glasses of orange juice. The RD confirmed that the date on the tray was the preparation date of the drinks. In an interview, the Regional Certified Dietary Manager (RCDM) stated that leftovers were considered good for three days and that prepared food should have a made-on date and a discard date. The RCDM later provided an undated policy titled 'Storage of Refrigerated Foods,' which indicated that refrigerated foods should be labeled with a use-by date and discarded within the allowed days per manufacturer directions. Recipe-prepared items should be discarded three days from preparation if not used.
Infection Control Breach During Dressing Change
Penalty
Summary
The facility failed to maintain proper infection control practices during a dressing change procedure for a resident with a peripheral inserted central catheter (PICC) line. During the observation, the Licensed Practical Nurse (LPN) placed the dressing kit on the resident's nightstand without using a barrier or disinfecting the surface. The LPN then donned sterile gloves and removed the old dressing. Without changing gloves, she cleaned the area below the insertion site and around it with an antimicrobial sponge disk, applied skin prep, and patted it with gauze before applying a transparent dressing. The resident was not offered a mask, nor was he asked to turn his head away from the insertion site, and he continued talking to the nurse during the procedure. The LPN indicated in an interview that she believed a barrier was unnecessary since the items were inside the packet and did not think it was necessary to change gloves or perform hand hygiene before cleaning the site and applying a new dressing. The facility's policy, provided by the Infection Preventionist Nurse, outlined specific steps for hand hygiene, mask usage, and setting up a clean field, which were not followed during the procedure. The policy also specified the need for the resident to turn their head away from the insertion site or wear a mask, which was not adhered to in this instance.
Failure to Document COVID-19 Vaccine Declination Forms
Penalty
Summary
The facility failed to document declination forms for COVID-19 immunizations for three residents. During a record review, it was found that the medical records for these residents lacked signed declination forms for the COVID-19 vaccine. An interview with the Infection Prevention Nurse revealed that she did not have the signed declination forms for these residents, although she acknowledged that she should have obtained them. The facility's policy on COVID vaccination, as provided by the Regional Nurse, requires that the resident's medical record include documentation if the resident did not receive the COVID-19 vaccine due to medical contraindication or refusal.
Failure to Maintain Temperature Log for Resident's Refrigerator
Penalty
Summary
The facility failed to maintain a temperature log for a resident's personal refrigerator, as observed during a survey. Specifically, Resident 9's personal refrigerator lacked both a thermometer and a temperature log, which are required by the facility's policy. This deficiency was confirmed during an interview with the Unit Manager, who acknowledged that there should have been a thermometer and a temperature log in place. The facility's policy, provided by the Administrator, mandates that staff record refrigerator temperatures weekly and ensure a thermometer is present and calibrated. Additionally, the policy requires that nursing or housekeeping staff clean the refrigerator weekly and discard any non-compliant foods, while residents and staff must adhere to safe food handling and storage principles.
Failure to Report Abnormal Vital Signs to Physician
Penalty
Summary
The facility failed to ensure that a resident's abnormal vital signs were reported to the physician. Resident B, who was admitted with diagnoses including toxic encephalopathy, anemia, atrial fibrillation, heart failure, hypertension, orthostatic hypotension, and paraplegia, had abnormal vital signs recorded on 3/7/24. Specifically, the resident's blood pressure was 76/42 and the pulse was 108 and irregular at 9:17 A.M. These abnormal readings were not reported to the Nurse Practitioner, who was unaware of the irregular pulse and low blood pressure at that time. The Nurse Practitioner had ordered routine labs and started the resident on an antibiotic for a suspected urinary tract infection but was not informed of the abnormal vital signs that could have indicated a significant change in the resident's condition. The facility's policy titled 'Notification of Change' requires prompt consultation with the resident's physician when there is a significant change in the resident's physical status. Despite this policy, the abnormal vital signs were not communicated to the Nurse Practitioner, leading to a failure in addressing the resident's potentially critical condition. This deficiency was identified during a review of Resident B's clinical records and an interview with the Nurse Practitioner, who confirmed that the abnormal vital signs should have been reported immediately.
Failure to Create Wound Vac Care Plan
Penalty
Summary
The facility failed to ensure a wound vac care plan was created for Resident B, who was admitted with multiple pressure ulcers and a wound vac to the right buttock. The resident's clinical record indicated no care plan had been created for the wound vac intervention. The resident was admitted with diagnoses including toxic encephalopathy, anemia, atrial fibrillation, heart failure, hypertension, orthostatic hypotension, and paraplegia. An admission assessment noted the resident required extensive assistance with most activities of daily living, utilized an indwelling catheter, and required a wheelchair for locomotion. Despite these needs, the facility did not develop a care plan for the wound vac intervention, as confirmed by the MDS nurse during an interview. The facility's policy on comprehensive care plans, which mandates the development and implementation of a person-centered care plan for each resident, was not followed in this case.
Failure to Reassess Resident After Change in Condition
Penalty
Summary
The facility failed to reassess a resident after a change in condition. Resident B, who was admitted with multiple diagnoses including toxic encephalopathy, anemia, atrial fibrillation, heart failure, hypertension, orthostatic hypotension, and paraplegia, experienced a significant drop in blood pressure and an elevated irregular pulse on 3/7/24. Despite these abnormal vital signs, there were no further vital sign readings documented for the rest of the day. The resident was later admitted to the emergency room for confusion and a possible infection. The LPN responsible for Resident B on that day did not document any follow-up vital signs and did not return to work to complete a late entry in the resident's electronic medical record. The Director of Nursing confirmed that the vital signs should have been monitored throughout the day, but the facility lacked a policy to address the monitoring of abnormal vital signs. The Nurse Practitioner, who was present in the facility on the morning of 3/7/24, was unaware of the abnormal blood pressure and irregular pulse. She had ordered routine labs and started the resident on an antibiotic for a suspected urinary tract infection but was not informed of the abnormal vital signs. The NP indicated that she would have expected the nurse to repeat and monitor the abnormal vital signs. The facility's failure to reassess and monitor the resident's condition after the initial abnormal readings led to the deficiency cited in the report.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
