Brickyard Healthcare - Merrillville Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Merrillville, Indiana.
- Location
- 8800 Virginia Place, Merrillville, Indiana 46410
- CMS Provider Number
- 155362
- Inspections on file
- 31
- Latest survey
- February 24, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Brickyard Healthcare - Merrillville Care Center during CMS and state inspections, most recent first.
Surveyors observed that a nurse prepared and administered Lantus and Novolog insulin to a resident with DM without priming the insulin pens as required by facility policy, despite having physician orders for a specific sliding-scale Lispro (Novolog) dose and a daily Glargine (Lantus) dose. The nurse acknowledged being unsure how to properly prime the pens. This incident occurred during a medication pass in which two errors were identified out of 25 opportunities, resulting in a medication error rate of 8%, exceeding the required threshold of less than 5%.
Surveyors found that multiple made beds on the Advanced Alzheimer’s Care Unit contained visibly soiled linens, including brown stains, food crumbs, and a brown substance on sheets and a pillowcase. An RN supervisor confirmed that four beds had been made without changing dirty linens, while the Administrator reported that staff denied making the beds and suggested residents may have done so, and there was no linen-change policy. The affected residents had severe cognitive impairment, dementia or Alzheimer’s disease, frequent incontinence, and required staff assistance for ADLs, with care plans for several residents not indicating that they made their own beds.
A cognitively impaired resident suffered significant injuries in an LTC facility, allegedly at the hands of a roommate. Despite the resident's limited communication abilities, he indicated his roommate as the assailant. The facility's staff discovered the injuries during morning rounds, and the police were notified. The roommate denied the allegations, although bruising was noted on his hands. The facility's policy on abuse prevention was reviewed, revealing a failure to protect the resident from harm.
A resident with a traumatic wound on the left knee was discharged without appropriate follow-up for an infection indicated by an abnormal wound culture. Despite signs of infection, no new physician orders were obtained before discharge. The issue was compounded by a language barrier with the nurse, leading to confusion about necessary follow-up actions.
The facility failed to manage medications appropriately for two residents. One resident did not receive prescribed Xanax due to a lack of communication with the NP or Physician, despite a family request for discontinuation. Another resident missed several doses of prescribed antibiotics, with notes indicating the medications were on order. The Interim Administrator could not provide further information on the missed administrations.
The facility's main kitchen was found to have several sanitation deficiencies, including improperly stored food, dusty equipment, and a malfunctioning dishwasher. A dietary employee failed to follow proper sanitary procedures, such as changing gloves and wearing a beard guard while preparing food. These issues had the potential to affect 137 residents.
The facility's main kitchen area was found to have sanitation deficiencies, including dust and debris accumulation on floors, piping, and fan blades, as well as loose baseboards. These issues were observed during a Kitchen Sanitation Tour, and the Dietary Food Manager acknowledged the need for cleaning and repair.
A resident with severe cognitive impairment and a history of cerebral infarction and chronic respiratory failure did not receive adequate oral care, despite being dependent on staff for personal hygiene. Observations showed the resident's mouth was dry and crusty, with discolored teeth and buildup, indicating a failure to follow the care plan and physician's orders for oral care every shift. Staff interviews revealed oral care was limited to using a foam swab with mouthwash, without brushing the resident's teeth.
A resident with impaired vision did not receive necessary services due to the facility's failure to reschedule a cataract evaluation. The resident initially canceled an appointment due to weather and required a stretcher for transportation, complicating access to care. Despite recommendations for further evaluation, the facility did not document efforts to arrange the needed services.
A resident with hemiplegia and hemiparesis was improperly transferred by CNAs without using the required Hoyer lift, as indicated on the Resident Care Sheet. The resident was unable to sit upright and was falling backward during the attempted transfer. Despite facility policy emphasizing the use of mechanical lifts, staff were unaware of the requirement, leading to non-compliance with safe handling protocols.
A facility failed to administer gastrostomy tube feedings as ordered for a resident with severe cognitive impairment and chronic health conditions. The resident's feeding pump was set to infuse at 70 ml/hour, contrary to the physician's order of 75 ml/hour. The care plan required specific feeding protocols, which were not followed, and the DON had no additional information on the issue.
A resident with acute respiratory failure and chronic bronchitis was observed receiving oxygen at a flow rate of 4.5 lpm, contrary to the physician's order of 3 lpm if oxygen saturation was 90% or below. The care plan required adherence to physician's orders for oxygen therapy, but this was not followed, resulting in a deficiency.
A resident with a history of spinal fusion surgery did not receive prescribed Tramadol for pain management due to the facility's failure to follow up on a pain specialist's order. The resident's daughter provided the medication to the facility, but it was not administered as there was no documented order. The facility's NP assessed the resident and determined Tylenol was sufficient, without further follow-up with the specialist.
A facility failed to update a physician's orders after a medication regimen review for a resident with end-stage renal disease. The review recommended changing hydroxyzine administration from nightly to as needed, but the orders were not updated accordingly. A Nurse Consultant confirmed the oversight.
The facility failed to manage medications for two residents, one attending dialysis and another with diabetes. A resident's Pepcid was not administered during dialysis times, and another resident's insulin was not documented despite recorded blood sugar levels. The facility's policies did not address these scheduling and documentation issues.
Failure to Prime Insulin Pens Resulting in Elevated Medication Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with surveyors identifying an 8% error rate during a medication pass observation. During a morning medication pass, RN 1 prepared insulin for Resident G after obtaining a glucometer reading of 285. Based on the resident’s physician orders, this blood sugar level required administration of 6 units of Lispro (Novolog) insulin per sliding scale, and the resident also had a separate order for 46 units of Glargine (Lantus) insulin to be given daily. RN 1 removed two insulin pens from the cart and dialed 46 units on the Lantus pen and 6 units on the Novolog pen. Before administering the insulin, RN 1 entered the resident’s room and was stopped. She then stated she was unsure about priming the insulin pens and did not know the correct way to prime them. The facility’s insulin pen administration policy required priming insulin pens with 2 units of insulin prior to administering the ordered dose. At the time of the survey, the DON reported that RN 1 was new to the facility and had been oriented to the medication pass policies and procedures. Resident G’s record documented a diagnosis of diabetes mellitus and contained the physician’s orders for both the sliding scale Lispro (Novolog) and daily Glargine (Lantus) insulin that were involved in the observed error.
Soiled Bed Linens Found on Multiple Made Beds in AACU
Penalty
Summary
The deficiency involves the facility’s failure to provide a clean, safe, and homelike environment by allowing multiple residents to have made beds with visibly soiled linens on the Advanced Alzheimer’s Care Unit (AACU). During observations conducted with the AACU Supervisor, four of seven resident beds were found with dirty linens despite appearing to be made. One resident’s bed had a moderate amount of a brown substance on the top sheet hanging over the side of the bed, which the AACU Supervisor acknowledged. Another resident’s bed, when the top sheet and cover were removed, revealed brown stains on the bottom sheet. A third resident’s bed was made with a bottom sheet, top sheet, and bed cover, but when the top layers were removed, food crumbs were observed on the bottom sheet and a brown substance was present on the pillowcase. A fourth resident’s bed, made with a bottom sheet and bath blanket, was found to have brown stains on the bottom sheet once the blanket was removed. The AACU Supervisor stated that these four beds had soiled linens that had been made without the linens being changed by the night shift. The Administrator later reported that both night and day shift staff denied making the beds and suggested that residents may have made them, and also indicated there was no facility policy for changing linens. The residents involved all had significant cognitive impairments and varying levels of dependence on staff for activities of daily living (ADLs). One resident with Alzheimer’s disease had a severely impaired cognitive status, required staff assistance for bed mobility, bathing, and transfers, and was occasionally incontinent; her care plan noted she would sometimes make her own bed but required one to two staff for ADLs and short, simple instructions. Another resident with vascular dementia had a severely impaired cognitive status, was dependent on staff for toileting, showers, dressing, bed mobility, transfers, and ambulation, and was frequently incontinent; there was no care plan indicating she made her own bed. A third resident with dementia and bipolar disorder required moderate to maximum assistance for ADLs, was frequently incontinent, and had impaired cognition with need for cueing and supervision, with no care plan indicating she made her own bed. The fourth resident, with Alzheimer’s disease and severely impaired cognition, required staff assistance for ADLs, was frequently incontinent, and also had no care plan indicating he made his own bed.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect a cognitively impaired resident, Resident B, from physical abuse, resulting in significant injuries. Resident B, who suffers from paranoid schizophrenia, hemiplegia following a stroke, and vascular dementia, was found with multiple injuries, including swelling and discoloration of the eyes, a swollen wrist, and lacerations on the right toe and ankle. The incident was reported to have occurred in the morning, and upon questioning, Resident B pointed to his roommate, Resident C, as the perpetrator. Resident C, who is cognitively intact but has mobility impairments, denied the allegations, although bruising was noted on his hands. The incident was discovered by a CNA during morning rounds, who observed blood on Resident B's bed and injuries on his body. Despite Resident B's limited verbal communication abilities, he indicated Resident C as the assailant. The facility's staff, including CNAs and nurses, were interviewed, and none reported witnessing the incident or any prior behavioral issues between the two residents. The police were notified, and an investigation was conducted, but no conclusive evidence was found to confirm the assault, although Resident C was found with a pocketknife and scissors in his possession. The facility's policy on abuse, neglect, and exploitation was reviewed, which mandates the protection of residents and the investigation of alleged abuse. However, the report indicates a failure to prevent the incident and protect Resident B from harm. The facility's response included notifying the police, conducting interviews, and separating the residents, but the deficiency highlights a lapse in ensuring the safety and well-being of residents, particularly those who are vulnerable due to cognitive impairments.
Failure in Discharge Planning for Resident with Wound Infection
Penalty
Summary
The facility failed to implement a complete discharge planning process for a resident with a traumatic wound on the left medial knee. The resident, who was cognitively intact and required substantial assistance for hygiene and transfers, had an abnormal wound culture indicating an infection. Despite the presence of signs of infection such as redness, warmth, and swelling, there was no follow-up or new orders from the physician prior to the resident's discharge. The resident was discharged home with family, and the abnormal wound culture results were not addressed until after the discharge. The deficiency was identified when the facility did not ensure ongoing physician follow-up for the abnormal wound culture results. The wound culture, which showed the presence of enterobacter cloacae and staphylococcus aureus, was not acted upon before the resident's discharge. The physician was informed of the results, but no new orders were given at the time, and the resident was discharged without appropriate treatment for the infection. The issue was further complicated by a language barrier with the nurse who documented the notes, leading to confusion about the orders and follow-up required.
Medication Management Deficiencies for Two Residents
Penalty
Summary
The facility failed to manage medications appropriately for two residents, leading to deficiencies in medication administration. Resident B, who had multiple fractures and insomnia, was prescribed Xanax but did not receive it from 7/3/24 to 7/9/24. The resident's son requested the discontinuation of Xanax, but there was no documentation of communication with the Nurse Practitioner or Physician to discontinue the medication until 7/15/24. The Interim Administrator confirmed that the medication was not available and acknowledged the family's request for discontinuation, but no action was taken to address the medication order until later. Resident G, diagnosed with a wound infection, high blood pressure, and type 2 diabetes, was prescribed a regimen of antibiotics, including Cefazolin, Ceftriaxone, and Vancomycin. However, these medications were not administered as ordered on several occasions in July 2024, with Nurses' Notes indicating that the medications were on order. The Interim Administrator could not provide further information regarding the missed antibiotic administrations. This deficiency was related to a specific complaint, IN00439994.
Sanitation Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to maintain sanitary conditions in the main kitchen, which had the potential to affect 137 residents. During a kitchen sanitation tour, several issues were observed, including a bag of noodles in the dry storage room that was not properly fastened, resulting in loose noodles on shelves and food boxes. Additionally, there was an accumulation of crumbs and dust on the upper shelf of the oven, and dust and dried food spillage on the front of the convection oven. A large fan in the dish room was covered in dust and was blowing towards clean dishes. Furthermore, the high-temperature dishwasher's final rinse temperature gauge was not functioning correctly, consistently registering 140 degrees Fahrenheit, which was below the required temperature for effective sanitation. In another observation, a dietary employee was seen handling food without following proper sanitary procedures. The employee donned clean gloves but did not change them after touching various items, including a bag of lettuce, a knife, and a boiled egg. Additionally, the employee was not wearing a beard guard while preparing the salad. These actions were acknowledged by the Dietary Food Manager, who indicated that the areas observed needed cleaning and that the employee should have adhered to proper sanitary protocols.
Sanitation Deficiencies in Kitchen Area
Penalty
Summary
The facility failed to maintain a sanitary environment in the main kitchen area, as observed during a Kitchen Sanitation Tour. The deficiencies included an accumulation of dust and debris on the floor and piping behind the convection oven, as well as dried food spillage on white pipes. Additionally, a ceiling vent between the steam table and the kitchen exit door was covered in dust. In the dish room, a fan mounted on the wall had dust on its blades and cover, although it was not in use at the time. Furthermore, the baseboard beneath the eye wash sink in the dish room was loose and detached in some sections. During an interview, the Dietary Food Manager acknowledged the need for cleaning and repair in these areas.
Inadequate Oral Care for Dependent Resident
Penalty
Summary
The facility failed to provide adequate assistance with Activities of Daily Living (ADLs) for a resident who was dependent on staff for oral hygiene. Observations on multiple occasions revealed that the resident's mouth was dry and crusty, and his teeth were discolored with buildup. Despite a care plan indicating the need for oral care assistance and a physician's order for oral care every shift, the resident did not receive proper oral hygiene care. The Medication Administration Record indicated that oral care was signed off as completed every shift, yet the resident's condition suggested otherwise. The resident, who was severely cognitively impaired and dependent on staff for personal hygiene, had a history of cerebral infarction and chronic respiratory failure. Interviews with staff revealed that oral care was limited to wiping the resident's mouth with a foam swab dipped in mouthwash, without using a toothbrush. The Nurse Consultant confirmed the resident's inability to follow commands for oral care but did not provide further information. This lack of comprehensive oral care led to the deficiency noted in the report.
Failure to Provide Necessary Vision Services for a Resident
Penalty
Summary
The facility failed to ensure that a resident with impaired vision received necessary services. The resident, who was cognitively intact and had a history of chronic obstructive pulmonary disease and hyperlipidemia, expressed the need to have his cataracts checked. An appointment for a cataract evaluation was initially scheduled but canceled by the resident due to cold weather, with the intention to reschedule when the weather improved. Despite a subsequent optometry note recommending a cataract evaluation and possible treatment, there was no documentation indicating that the facility made efforts to reschedule the appointment or arrange for the recommended eye care services. The resident's care plan meetings noted the last optometry visit, but no further actions were documented. Social Services staff acknowledged the challenge of finding a traveling eye doctor due to the resident's transportation needs, as he required a stretcher and assistance that ambulance staff would not provide. However, there was no documentation of follow-up actions taken to address the optometry recommendation, and the staff member admitted to needing better documentation practices.
Improper Transfer of Resident Without Required Mechanical Lift
Penalty
Summary
The facility failed to ensure a dependent resident was transferred using a Hoyer lift as indicated on the Resident Care Sheet. On the morning of June 11, a CNA attempted to transfer a resident from her bed to a wheelchair without using the required mechanical lift. The resident, who had hemiplegia and hemiparesis, was unable to sit upright and was falling backward during the attempted transfer. The CNA instructed the resident to hold onto her neck, but the resident was unable to comply due to her physical limitations. Another CNA intervened, indicating that the resident required a sit-to-stand lift, highlighting the improper transfer method being used. Further review of the resident's records confirmed that she was dependent on a Hoyer mechanical lift for transfers. Despite this, another CNA admitted to transferring the resident by standing and pivoting her to the wheelchair, unaware of the requirement for a mechanical lift. The facility's policy on Safe Resident Handling/Transfers emphasizes the use of mechanical lifts for safe handling, which was not adhered to in this instance. The deficiency was identified through observation, record review, and interviews with staff, revealing a lack of compliance with established transfer protocols.
Improper Gastrostomy Tube Feeding Administration
Penalty
Summary
The facility failed to ensure proper gastrostomy tube care for a resident, identified as Resident 54, who was dependent on tube feedings. Observations on two separate occasions revealed that the resident's tube feeding pump was set to infuse Jevity 1.5 cal at 70 ml/hour. However, the physician's order specified that the feeding should be administered at 75 ml/hour for 22 hours a day. The resident, who was severely cognitively impaired and dependent on staff for various hygiene needs, had diagnoses including cerebral infarction and chronic respiratory failure. The care plan required the head of the bed to be elevated during and after feedings, and for feedings to be administered as ordered, which was not adhered to in this instance. The Director of Nursing was unable to provide further information regarding the discrepancy.
Improper Oxygen Administration for a Resident
Penalty
Summary
The facility failed to provide proper care and treatment related to oxygen administration for a resident. Resident 13, who was diagnosed with acute respiratory failure, chronic bronchitis, and adult failure to thrive, was observed on two occasions with an oxygen concentrator set to a flow rate of 4.5 liters per minute (lpm) via nasal cannula. However, the physician's order specified that oxygen should be administered at 3 lpm if oxygen saturations were 90% or below, as needed for shortness of breath. The resident's care plan also indicated that oxygen therapy should be administered as needed per physician's orders. Despite these directives, the oxygen flow rate was not adjusted according to the physician's order, leading to a deficiency in the resident's care.
Failure to Administer Prescribed Pain Medication
Penalty
Summary
The facility failed to ensure a follow-up for a pain specialist's medication order for a resident with a history of spinal fusion surgery and other conditions, who was experiencing pain during activities of daily living and therapy. The resident's daughter had taken her to a pain specialist who prescribed Tramadol, an opioid pain medication, to be used as needed. The daughter filled the prescription at a pharmacy and brought it to the facility, but the medication was never administered to the resident. The facility staff claimed there was no order for the medication and that pain assessments indicated the resident was not in pain. The resident's medical records showed a diagnosis of wedge compression fracture, dementia with psychotic disturbance, and arthrodesis. The care plan included administering pain medication as ordered, but the Physician's Order Summary only listed Tylenol, with no mention of Tramadol. Progress notes indicated that the resident's daughter had requested the Tramadol be administered, but the facility's Nurse Practitioner denied the request, believing Tylenol was sufficient. There was no documentation of follow-up with the pain specialist or communication with the resident's daughter regarding the medication. Interviews with facility staff revealed that the resident's daughter had provided the Tramadol to the nurse without an accompanying order or script. The Director of Nursing and the D Wing Unit Manager both acknowledged the lack of follow-up with the pain specialist and the absence of a valid prescription. The facility's policy required verification of orders and prescriptions for controlled substances, but this process was not completed, resulting in the resident not receiving the prescribed pain medication.
Failure to Update Physician's Orders After Medication Review
Penalty
Summary
The facility failed to update a physician's orders following a medication regimen review for a resident with end-stage renal disease and dependence on renal dialysis. The resident's record was reviewed, revealing that a Pharmacy Medication Regimen Review recommended reducing polypharmacy. The review suggested changing the administration of hydroxyzine from a regular nightly dose to as needed. However, the June 2024 Physician's Order Summary still indicated hydroxyzine to be administered nightly, contrary to the recommendation. During an interview, a Nurse Consultant acknowledged that the orders should have been updated.
Medication Management Deficiencies for Dialysis and Insulin Administration
Penalty
Summary
The facility failed to manage and monitor the medication regimen of two residents, leading to deficiencies in their care. Resident 28, who attended dialysis three times a week, had a physician's order for Pepcid to be administered in the afternoon on dialysis days. However, the medication was not given on multiple occasions because the resident was not present at the facility during the scheduled administration times. The facility's administrator acknowledged that the medication was scheduled during dialysis times and later indicated that the medication had been discontinued. The facility's medication administration policy did not address medication scheduling, contributing to the oversight. For Resident 74, who had diagnoses including type 2 diabetes mellitus, there were significant lapses in documenting blood sugar levels and insulin administration. The resident's care plan required glucose monitoring and insulin administration per a sliding scale. However, the Medication Administration Record (MAR) showed blanks for blood sugar results and insulin administration on several dates and times. Although blood sugar levels were recorded in a daily log, there was no corresponding documentation of insulin administration. The Director of Nursing explained that when a Qualified Medication Aide (QMA) was on duty, blood sugars were logged on paper, and nurses administered insulin without documenting it in the MAR. This lack of documentation was identified during monthly audits, but the issue persisted.
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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