Dyer Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Dyer, Indiana.
- Location
- 601 Sheffield Ave, Dyer, Indiana 46311
- CMS Provider Number
- 155220
- Inspections on file
- 43
- Latest survey
- March 3, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Dyer Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with end stage renal disease, heart failure, diabetes, and bilateral lower extremity impairment, who was cognitively intact and dependent on dialysis, did not receive fully documented dialysis monitoring as ordered and care planned. Although the care plan and physician orders required pre- and post-dialysis vital signs and assessment of the dialysis access site for redness, swelling, pain, or drainage, the MARs for two months lacked documentation of access site assessments, and several post-dialysis vital signs and related progress notes were missing. Facility policy required observation and documentation of dialysis access site findings, and during interview, a nurse consultant acknowledged the missing post-dialysis vitals and documentation.
Surveyors found that the facility failed to provide required ADL assistance, including timely incontinence care and at least twice-weekly bathing, for three dependent residents. One resident with chronic kidney disease, diabetes, and a history of UTIs was observed with a saturated brief and waited over 30 minutes for incontinence care after activating the call light, and records showed multiple missed scheduled baths despite a care plan requiring regular bathing and bed baths. Another resident, cognitively intact and always incontinent, had a care plan for hygiene assistance and was noted as resistive to care, yet bathing records showed very few baths over several months, with many scheduled bath days left blank or marked non-applicable and no documentation of refusals. A third resident with diabetes and schizophrenia, dependent for bathing and toileting, reported only being bathed when she asked, and her bathing records also showed numerous missed scheduled baths. These practices were inconsistent with facility policies requiring staff to maintain personal hygiene and provide routine incontinence care for residents unable to perform ADLs.
A resident with dementia and diabetes did not consistently receive care according to physician orders and professional standards. Ordered blood glucose checks and sliding-scale insulin doses were missed and not documented on multiple occasions, with no blood sugar results recorded elsewhere in the record. The same resident, who was also ordered olanzapine three times daily for psychosis, repeatedly refused the morning dose over an extended period, yet there was no documentation of physician notification, no evidence that the care plan intervention to crush medications was used, and no recorded reasons for the refusals. The DON later reported that the nurse indicated the resident was agitated in the mornings, and no additional interventions were attempted.
A resident with chronic kidney disease, diabetes mellitus, a history of UTIs, and a multi-drug resistant organism UTI, who was incontinent and dependent on staff for care, reported ongoing burning with urination. Nursing staff notified the NP, who ordered a UA with C&S, but the test was never completed, and there was no documentation of results in the record. The DON later confirmed that the ordered UA with C&S had not been carried out.
A resident with significant neurological and physical impairments developed new right lower extremity edema and pain, prompting a Doppler ultrasound that revealed a partial clot. The abnormal results were not promptly communicated to the ordering practitioner, resulting in a delay of several days before anticoagulant therapy was initiated.
A resident dependent on staff for ADLs and with significant physical and cognitive impairments was repeatedly observed with a soiled, raised shirt that exposed his body and incontinence brief, as well as food stains on his clothing and body. Staff were aware of the situation but did not address the resident's dignity needs throughout the day.
A dependent resident with significant cognitive and physical impairments did not receive timely incontinence care, resulting in prolonged exposure to soiled clothing and incontinence brief. Staff observed the resident with visible soiling and food debris on his clothing and body, and confirmed that incontinence care had not been provided for several hours despite awareness of the need. The care plan and facility policy required routine assistance, which was not followed in this instance.
The facility failed to provide adequate assistance with ADLs, including meal assistance, oral care, and personal hygiene, for several residents. Observations showed delays in meal assistance and neglect in providing regular showers and nail care. Residents with cognitive impairments and those dependent on staff were particularly affected, with staff interviews confirming these deficiencies.
The facility failed to document and administer insulin properly for two residents, neglected to monitor and treat skin conditions and edema for two residents, and inadequately addressed a change in condition for another resident, leading to hospitalization. The Director of Nursing acknowledged the documentation lapses, and the Assistant Director of Nursing was unaware of a resident's deteriorating condition until the following day.
The facility failed to supervise residents in the memory care unit during meals, as observed on multiple occasions. Residents were left unsupervised while eating, with one resident consuming another's milk and another eating a jelly packet without staff present. The Director of Nursing confirmed that residents should be supervised during meals, indicating a lapse in oversight.
The facility failed to implement proper infection control practices, including inadequate disinfection of multi-use equipment, improper hand hygiene, and incorrect handling of medications. Staff were observed not following protocols for using personal protective equipment and managing soiled linens. Additionally, personal care equipment was improperly stored, violating the facility's infection prevention and control program.
A resident with cognitive impairment and dependency on staff for dressing was repeatedly observed wearing a hospital gown in bed during the day, compromising her dignity. Despite her condition, there was no care plan addressing her attire preferences, as confirmed by the DON.
The facility failed to assess and authorize three residents for self-administration of medications and oxygen. A resident used an Albuterol inhaler without a care plan or physician's order, another had unsupervised potassium medication left by an LPN, and a third used an oxygen concentrator independently without assessment. The facility did not follow its policies requiring evaluations for self-administration.
A facility failed to complete a PASARR level 2 when a new mental health diagnosis was added for a resident. The resident's record included diagnoses such as metabolic encephalopathy, dementia, and unspecified psychosis. A PASARR level I indicated no further screening was needed unless a serious mental illness was present. However, after the diagnosis of unspecified psychosis was added, no level 2 was performed. The Social Services Director acknowledged the oversight and indicated plans to redo the level 1 and arrange for a level 2 assessment.
A facility failed to create an individualized care plan for a resident with bilateral below-the-knee amputations. The resident, who was cognitively intact and required maximum assistance with ADLs, had a care plan that included inappropriate foot care interventions. The DON acknowledged the need to update the care plan to reflect the resident's current condition, given their medical history of ESRD, congestive heart failure, diabetes, and stroke.
The facility failed to involve two residents in decisions about their care, specifically regarding new medications and lab results. One resident was not informed about changes in medication, while another did not receive lab results directly, as they were communicated to a family member with POA. Both residents were cognitively intact, and the lack of communication was confirmed by facility staff.
A facility failed to apply a physician-ordered splint for a resident with limited range of motion due to a stroke and hemiplegia. The resident was observed multiple times without the required anti-contracture device, despite a care plan and physician's order for a daily resting hand splint. Staff interviews revealed confusion over responsibility for the splint application, and records showed no documentation of the splint being applied for several months.
Two residents with a history of weight loss were not adequately assisted with meals or had their nutritional supplement consumption documented. One resident was left unattended with her meal and consumed another's milk, while another played with her food without staff intervention. Both residents had significant weight loss and required assistance with eating, as confirmed by the DON.
The facility failed to follow proper procedures for gastrostomy tube care for two residents. An RN administered medication to a resident without checking for residuals and used a syringe plunger instead of gravity. Another resident's peg tube site care was not documented, and water was pushed through the tube with a syringe plunger. The facility's policies were not followed, leading to deficiencies in care.
The facility failed to administer oxygen at the correct flow rate for three residents. A resident with COPD was observed using oxygen at four liters per minute instead of the prescribed two liters. Another resident received oxygen at 1.5 and one liter per minute, contrary to the order of two liters. A third resident used oxygen at three liters per minute, despite an order for two liters as needed. The DON confirmed the discrepancies.
The facility exceeded the acceptable medication error rate with errors involving three residents. A resident received incorrect insulin and antibiotic dilution, another was given a discontinued medication, and a third received an incorrect dosage of Lexapro. The errors were confirmed by the DON.
The facility failed to ensure a controlled substance was double locked in one of the medication rooms. An unlocked refrigerator contained an unlocked hospice box with Morphine Sulfate Roxanol 20 mg, a Schedule II controlled substance. The ADON confirmed the box should have been locked, as per facility policy requiring double lock storage for Schedule II medications.
A resident did not receive routine dental services due to a failure in the facility's process. The resident, who was cognitively intact and had a diagnosis of dysphasia, expressed a desire for dental treatment. Despite having a signed consent form for dental services, no appointments were documented. The facility switched dental providers, and the resident was accidentally skipped because they did not sign a new consent form.
The facility failed to administer medications as ordered for two residents. A resident did not receive Vitamin D due to a pharmacy delay, and another resident's senna was documented as given despite being unavailable. The facility lacked a re-ordering policy.
A resident with significant cognitive impairment and a left femoral fracture experienced inadequate pain management due to the facility's failure to monitor and assess pain, evaluate medication effectiveness, and attempt non-pharmacological interventions as required by physician's orders. Despite frequent complaints of knee pain, the facility did not consistently document pain assessments or manage the resident's pain effectively, leading to the need for surgical repair.
A facility failed to implement a behavior plan for a resident with dementia who exhibited aggressive behaviors. During a combative episode, an LPN intervened without being asked and allegedly became rough, resulting in the resident's ears being reddened. The behavior care plan, which included interventions to deescalate agitation, was not effectively followed, leading to the escalation of the resident's aggressive behavior.
A facility failed to accurately document the administration of Norco for a cognitively impaired resident with a history of falls. Discrepancies were found between the Controlled Drug Form and the MAR, with missing or inconsistent records of medication administration and pain assessments. The DON confirmed the need for accurate documentation on both records.
A facility failed to provide effective pressure ulcer prevention and treatment for a dependent resident, resulting in a facility-acquired sacral pressure injury that deteriorated and required hospitalization for septic shock and surgical debridement. The facility's staff did not consistently assist with repositioning, and there were gaps in communication and documentation regarding the resident's skin condition and necessary interventions.
The facility failed to provide adequate supervision during a mechanical lift transfer for a resident with right-side paralysis, resulting in a fracture. Additionally, the facility did not ensure fall prevention interventions, such as keeping call lights within reach, for another resident with a history of falls.
A facility failed to timely document a resident's change in condition, with late entries made 9 days after the event. The resident, with a complex medical history, experienced abnormal vital signs and loss of consciousness, necessitating an emergency room transfer. The delay in documentation was attributed to a busy shift change and miscommunication between nursing staff.
Failure to Document Post-Dialysis Vitals and Access Site Assessments
Penalty
Summary
The facility failed to provide complete and documented dialysis-related monitoring for a resident receiving renal dialysis. The resident had diagnoses including heart failure, end stage renal disease, diabetes, bilateral lower extremity impairment, and was dependent on dialysis. An MDS assessment indicated the resident was cognitively intact for daily decision making. The care plan, initiated in June and revised in February, identified the need for dialysis related to renal failure and included interventions to assess the dialysis access site for redness, swelling, pain, or drainage, and to encourage attendance at scheduled dialysis appointments. A physician’s order dated December 19 directed staff to record vital signs pre- and post-dialysis, and another order dated March 2 directed staff to assess the dialysis access site for redness, swelling, pain, and drainage. Record review showed that there was no physician’s order to assess the dialysis access site until March 2, despite the care plan intervention to do so. The MARs for January and February lacked documentation of dialysis access site assessments. The January MAR showed post-dialysis vital signs coded with a “9” (indicating to see progress notes), but there were no corresponding progress notes for multiple dialysis dates in January. Additionally, the February MAR lacked any documented post-dialysis vital signs on one dialysis date. The facility’s Dialysis Monitoring and Communication Policy required observation of the dialysis access site for increased redness, swelling, bleeding, pain, and drainage, and documentation of abnormal findings in the medical record. During interview, the Nurse Consultant acknowledged the absence of post-dialysis vital signs on the identified February date and understood the concern regarding missing January post-dialysis progress notes and lack of access site assessments.
Failure to Provide Required Bathing and Timely Incontinence Care for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide required ADL assistance, including timely incontinence care and bathing at least twice weekly, for residents dependent on staff. One resident was observed lying in bed with an uncovered, visibly saturated incontinence brief and reported waiting to be cleaned. Her call light was not activated until prompted, and although an RN responded and stated the CNA would be notified, incontinence care was not provided until over 30 minutes later. The resident, who had chronic kidney disease, a history of UTIs, diabetes mellitus, and was always incontinent of bowel and bladder per MDS, reported that she sometimes went one to two weeks without a bath and had previously gone six weeks without being bathed. Review of her care plan and shower schedule showed she was to receive bathing twice weekly with bed baths on non-shower days, but bathing records documented multiple missed scheduled baths over several months. A second resident’s closed record showed she was cognitively intact, always incontinent of bowel and bladder, and dependent on staff for toileting, bathing, and hygiene. Her care plan required assistance with ADLs and hygiene, and a later care plan noted she was resistive to care, with interventions to allow her to make decisions and be educated on outcomes of non-compliance. The shower schedule indicated twice-weekly bathing, but bathing input forms showed she received only three of eight scheduled baths in one month, a single bed bath in the following month, and no showers or baths in the subsequent month before discharge. Several scheduled bathing dates were left blank or marked non-applicable, and there was no documentation that she refused or resisted bathing. The DON confirmed she could not locate documentation of refusals and acknowledged a lack of twice-weekly bathing. A third resident, who had diabetes mellitus and schizophrenia and was dependent for toileting and bathing per MDS, stated she only received bathing when she asked staff. Her care plan required assistance with ADLs and hygiene, and the bathing schedule called for twice-weekly evening baths. Bathing input forms showed she received only four of eight scheduled baths in one month and five of nine in the next, with multiple dates marked non-applicable. The DON was unable to provide additional information or documentation explaining the missed baths. Facility policies on ADLs and bowel and bladder incontinence required that residents unable to perform ADLs receive necessary services to maintain personal hygiene and that staff routinely provide incontinence care, including brief changes, pericare, and clothing and linen changes, which were not consistently carried out for these residents.
Failure to Administer and Document Insulin and Antipsychotic Medications as Ordered
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice for a resident with dementia and diabetes mellitus when ordered blood glucose testing and insulin administration were not consistently completed or documented. The resident had a care plan for diabetes indicating medications would be administered as ordered and an MDS showing she received insulin and an antipsychotic. A physician’s order required Humalog insulin to be given twice daily at specific times based on sliding-scale dosing after blood glucose testing. The MAR for one month showed that blood glucose testing was not completed at several ordered times, and there was no documentation of blood sugar results or whether insulin was or was not administered. No corresponding glucose results were found in progress notes or blood glucose listings. The facility also failed to follow physician orders and care plan interventions related to an antipsychotic medication, olanzapine, ordered three times daily for psychosis. The MAR documented repeated refusals of the 6:00 a.m. dose on numerous days over two consecutive months. There was no documentation that the physician had been notified of these missed doses, no evidence that the care plan intervention to crush medications as needed had been implemented, and no documentation of the reasons for the refusals. During interview, the DON reported that the nurse assigned on the refusal days stated the resident was agitated in the morning, and no other interventions had been attempted, despite a facility policy stating medications were to be administered in a safe, accurate, and effective manner.
Failure to Complete Ordered UA with C&S for Resident with Recurrent UTI
Penalty
Summary
The deficiency involves the facility’s failure to complete a urinalysis (UA) with culture and sensitivity (C&S) as ordered for a resident with a history of urinary tract infections. The resident, who had diagnoses including chronic kidney disease, history of UTIs, and diabetes mellitus, reported having burning with urination for a while and indicated that different medications had been tried without resolving the infection. A quarterly MDS assessment documented that the resident was cognitively intact, dependent on staff for bathing and toileting, required maximum assistance with bed mobility, and was always incontinent of bowel and bladder. The care plan, last reviewed in mid-December, indicated the resident required enhanced barrier precautions due to a multi-drug resistant organism UTI. On a late-December date, a nurse’s progress note documented the resident’s complaint of burning with urination, and the NP was notified, resulting in an order for a UA with C&S. The NP’s order, dated the following day, specified that a UA with C&S was to be collected. However, there was no documentation in the medical record that the laboratory test was ever completed. During an interview, the DON confirmed that the ordered UA with C&S had not been completed, demonstrating that the facility did not ensure the ordered laboratory test was obtained and results communicated as required.
Delay in Reporting Doppler Results Leads to Delayed Treatment
Penalty
Summary
A resident with a history of stroke, aphasia, hemiparesis, dysphagia, and weakness experienced new onset edema and pain in the right lower extremity. In response, a physician ordered a Doppler ultrasound to assess for possible vascular issues. The Doppler was completed and interpreted, revealing partial clotting in the superficial femoral vein. However, there was no documentation that the abnormal results were communicated to the physician or nurse practitioner upon receipt. From the time the Doppler results were available, there was no follow-up or notification to the ordering practitioner for several days. The lack of timely communication resulted in a delay in treatment, as the resident did not receive an order for anticoagulant therapy until several days after the results were available. The Director of Nursing confirmed that the results were reported by the interpreting company but could not determine when or if the results were relayed to the physician, acknowledging the delay in treatment.
Failure to Maintain Resident Dignity Related to Soiled and Exposed Clothing
Penalty
Summary
A resident with a history of stroke, left side hemiplegia, Parkinson's disease, major depressive disorder, hypertension, and anxiety disorder, who was dependent on staff for activities of daily living (ADLs) including toileting, bathing, dressing, and required substantial to maximum assistance with eating, was observed multiple times throughout the day with dignity concerns. The resident was seen sitting in a wheelchair with his shirt raised, exposing his abdomen, back, and sides, as well as his incontinent brief. There was a wet red stain and scrambled eggs on his clothing and body, which remained unaddressed for several hours. A white towel was later placed over the front of his shirt, but the shirt remained raised and soiled, and the resident continued to be exposed in public areas. Staff interviews confirmed awareness of the resident's soiled and exposed state, with a CNA acknowledging the presence of dried stains and food on the resident's clothing and body. The resident's care plan indicated the need for assistance with personal hygiene, dressing, and eating, but these needs were not met in a manner that maintained the resident's dignity. The Director of Nursing also acknowledged that the resident's shirt should have been pulled down and changed.
Failure to Provide Timely Incontinence Care for Dependent Resident
Penalty
Summary
A deficiency was identified when a dependent resident, who required assistance with activities of daily living (ADLs) including toileting, bathing, and dressing, did not receive timely incontinence care. During a morning observation, the resident was found sitting in a wheelchair with his shirt raised, exposing his abdomen, incontinence brief, and back. There was a wet red stain on the shirt, and scrambled eggs were present on his shorts and lower abdomen. Later that day, when the resident was returned to his room for incontinence care, staff discovered the brief was heavily soiled with urine and bowel movement, and dried scrambled eggs were still present near the pubic area. The CNA confirmed that although the resident had been showered and changed before breakfast, he had not been changed again until the afternoon, despite being aware of the soiling. The resident's medical record indicated multiple diagnoses, including stroke with left side hemiplegia, Parkinson's disease, and cognitive impairment, necessitating substantial to maximum assistance with ADLs. The care plan required staff to check and change the resident as needed for incontinence. Documentation showed inconsistent recording of incontinence care, and the facility's policy required routine assistance with incontinence care, including brief and clothing changes. The DON acknowledged that incontinence care should have been provided more promptly.
Deficiencies in ADL Assistance and Personal Hygiene
Penalty
Summary
The facility failed to ensure that activities of daily living (ADLs) were adequately completed for dependent residents, affecting 12 out of 14 residents reviewed. Observations revealed that residents were not assisted with meals in a timely manner, with some residents left without assistance for extended periods. For instance, Resident E, who was cognitively impaired and required setup assistance with eating, was observed not receiving timely help during meal times. Similarly, Resident M, who needed substantial assistance with eating, was left without her meal tray set up and was not assisted promptly. Additionally, the facility did not provide adequate oral care, shaving, and nail care for several residents. Resident K, who was dependent on staff for oral hygiene, was observed with dry, cracked lips over multiple days, indicating a lack of daily oral care. Resident O had long fingernails digging into his skin, and Resident B had long, dirty fingernails and was not assisted with shaving, despite expressing a preference for being clean-shaven. These observations highlight a pattern of neglect in personal hygiene and grooming needs. The facility also failed to provide regular showers or bed baths as scheduled. Multiple residents, including Residents G, H, and P, reported not receiving showers twice a week as per their care plans. Documentation in the electronic records often lacked evidence of showers being given or resident refusals being recorded, indicating a systemic issue in maintaining personal hygiene schedules. Interviews with staff confirmed these deficiencies, with the Director of Nursing acknowledging the lapses in care.
Deficiencies in Insulin Administration and Resident Monitoring
Penalty
Summary
The facility failed to ensure proper documentation and administration of insulin for two residents with diabetes. Resident S had multiple instances where blood sugar levels and insulin administration were not documented in the Medication Administration Record (MAR) across several months. Similarly, Resident R's MAR showed numerous occasions where insulin was not signed out as administered, despite having specific physician orders for insulin administration based on a sliding scale. The Director of Nursing acknowledged that the insulin and blood sugar results should have been documented. The facility also failed to provide appropriate treatment and monitoring for non-pressure related skin conditions and edema. Resident T, who was at risk due to antiplatelet therapy, had multiple discolored areas and a skin tear that were not properly assessed or treated. The facility did not have orders to monitor these conditions, and the Director of Nursing confirmed that such areas should have been monitored every shift. Additionally, Resident F had a swollen hand and excoriated skin patches that were not assessed or treated, and the hospice aide was unaware of any treatment for these conditions. Furthermore, the facility did not adequately address a change in condition for Resident Q, who exhibited signs of respiratory distress and dehydration. Despite observations of a congested cough and gurgling, there was no documented assessment of lung sounds or timely follow-up on the resident's condition. The resident was eventually sent to the hospital with influenza A, healthcare-associated bacterial pneumonia, and acute kidney injury. The Assistant Director of Nursing was unaware of the resident's condition until the following day, highlighting a lack of communication and timely intervention.
Lack of Supervision During Meals in Memory Care Unit
Penalty
Summary
The facility failed to ensure adequate supervision for residents in the memory care unit during meal times, as observed on multiple occasions. On one occasion, four residents were left unsupervised in the memory care unit lounge while eating their lunch. Resident R was served a meal that included whole pork, which was not cut into smaller pieces, and Resident 81 was served a pureed meal. Resident R drank Resident 81's lactose-free milk without any staff present to assist or supervise. Similarly, Residents 6 and L were eating their meals without staff supervision. A CNA entered the room later but did not supervise these residents, indicating a lack of oversight during meal times. On another occasion, Resident 81 was observed eating a jelly packet unsupervised in the dining room. Later, when lunch trays were delivered, the Assistant Director of Nursing began distributing them, but once the CNA left to deliver trays to other residents, there was no staff present to supervise the residents in the dining room. This lack of supervision was confirmed during an interview with the Director of Nursing, who stated that residents were supposed to be supervised while eating. These observations highlight a consistent failure to provide necessary supervision during meals, potentially compromising resident safety.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement proper infection control practices, as observed in several instances involving staff and residents. In one case, CNAs did not disinfect a Hoyer lift after use and failed to perform hand hygiene after glove removal. The lift was used in multiple resident rooms without being disinfected until much later. Additionally, a CNA was observed handling soiled linens improperly, dragging them through the hallway and wearing gloves outside the resident's room, which is against the facility's infection control policy. In another instance, an RN was observed preparing medications for residents by dispensing them into her bare hand, which is contrary to the facility's policy that requires avoiding direct contact with medications unless gloves are worn. Furthermore, the RN did not perform hand hygiene before or after administering medications. Another RN failed to sanitize hands before and after checking a resident's blood pressure and blood sugar, and did not disinfect the glucometer after use, which was meant for multiple residents. Environmental observations revealed improper storage of personal care equipment, such as wash basins and bed pans, which were found uncontained and in inappropriate locations like the floor or on the back of toilets. These practices were not in line with the facility's infection prevention and control program, which mandates proper containment and storage of such items to prevent cross-contamination and maintain hygiene standards.
Resident Dignity Compromised by Inappropriate Attire
Penalty
Summary
The facility failed to maintain the dignity of a resident by allowing her to wear a hospital gown while in bed during the day. This was observed multiple times over several days, with the resident consistently found in her room wearing a hospital gown. The resident, who has diagnoses including dementia without behavior disturbance, dysphagia, and gastrostomy status, was noted to be cognitively impaired and dependent on staff for dressing. Despite these observations, there was no care plan in place addressing the resident's preference or need to wear a gown during the day, as confirmed by a review of the resident's care plan and an interview with the Director of Nursing.
Failure to Assess and Authorize Self-Administration of Medications and Oxygen
Penalty
Summary
The facility failed to ensure that residents were properly assessed and had physician's orders to self-administer medications and oxygen therapy. Three residents were involved in this deficiency. Resident 91 was observed with an Albuterol inhaler on her over bed table, which she brought from home and used daily without a care plan or physician's order for self-administration. The resident was cognitively intact, but there was no assessment completed to determine her ability to self-administer the medication. The facility's policy required an interdisciplinary team to evaluate the resident's capacity to self-administer medications, which was not done in this case. Resident 105 was found with a cup containing potassium medication on her over bed table, which was left unsupervised by an LPN who was called away for an emergency. The resident had no care plan or assessment indicating she could consume medication without supervision. Additionally, Resident 30 was using an oxygen concentrator independently without an assessment or order for self-administration. The resident was cognitively intact and had a physician's order for oxygen as needed, but the facility failed to assess his ability to use the oxygen correctly. The facility's policies required staff to remain with residents while administering medication and to assess residents' ability to self-administer oxygen, which were not followed in these instances.
Failure to Complete PASARR Level 2 for New Mental Health Diagnosis
Penalty
Summary
The facility failed to ensure a PASARR (preadmission screening and resident review) was completed when a new mental health diagnosis was added for a resident. The resident's record, reviewed on February 7, 2025, included diagnoses such as metabolic encephalopathy, dementia, and unspecified psychosis not due to a substance or known physiological condition. A PASARR level I, dated January 10, 2025, indicated no further screening was needed unless the resident had a serious mental illness or intellectual development disability. However, the diagnosis of unspecified psychosis was added to the resident's record on January 13, 2025, and no PASARR level 2 was performed. During an interview on February 4, 2025, the Social Services Director acknowledged that a level 2 PASARR was not conducted and mentioned plans to redo the level 1. She was uncertain if the psychosis diagnosis was present since a prior hospitalization. A subsequent PASARR level I, completed on February 5, 2025, indicated the need for a face-to-face level 2 assessment. The Social Services Director later confirmed arrangements were being made for the level 2 assessment.
Inadequate Individualized Care Plan for Amputee Resident
Penalty
Summary
The facility failed to develop an individualized care plan for a resident with bilateral below-the-knee amputations. During a random observation, it was noted that the resident, who was cognitively intact and required maximum assistance with activities of daily living (ADLs), had a care plan that included foot inspection and podiatry services, which were inappropriate given the resident's amputations. The resident's medical history included end-stage renal disease (ESRD), congestive heart failure, diabetes, and stroke. The Director of Nursing (DON) acknowledged that the care plan should have been updated to reflect the resident's current condition, specifically removing the foot care interventions that were no longer applicable.
Failure to Involve Residents in Care Decisions
Penalty
Summary
The facility failed to ensure that residents were involved in decisions about their care, specifically regarding the communication of new medications and lab results. Resident 4, who was cognitively intact, reported not being informed about new medications prescribed by her doctor. The resident's records showed changes in medication orders, including the discontinuation of Xarelto and the initiation of Aspirin and Plavix, as well as the start of Bactrim and other medications for urinary tract infections. However, there was no documentation indicating that Resident 4 was informed of these changes, although her daughter was notified. Additionally, there was a missing care plan conference for Resident 4, as confirmed by the Social Service Director. Resident 30, also cognitively intact, expressed concerns about not receiving his lab results directly, as they were communicated to his sister, who was the power of attorney. The resident had undergone lab testing on multiple occasions, but there was no documentation that he was informed of the results. The Assistant Director of Nursing acknowledged that the family member was updated due to their POA status but stated that the resident would be informed of his results. These deficiencies highlight a lack of communication and involvement of residents in their care planning and decision-making processes.
Failure to Apply Physician-Ordered Splint for Resident with Limited ROM
Penalty
Summary
The facility failed to ensure that a resident with a limited range of motion had a physician-ordered splint in place. The resident, who had a history of stroke and hemiplegia affecting the left side, was observed multiple times without the required anti-contracture device in his left hand. The resident's left hand was noted to be flaccid and closed, and he was unable to open it without assistance. Despite a care plan indicating the need for a splint due to a contracture in the left hand, and a physician's order specifying the application of a resting hand splint daily for a minimum of four hours, the splint was not documented as being applied in the treatment and medication administration records for several months. Interviews with staff revealed a lack of clarity regarding responsibility for applying the splint. A CNA indicated that the restorative team was responsible for the splint, and the Director of Nursing had no additional information to provide. There was no documentation in the care plan that the resident refused the splint, indicating a lapse in the facility's adherence to the prescribed care plan and physician's orders, leading to the deficiency.
Failure to Assist Residents with Meals and Document Nutritional Intake
Penalty
Summary
The facility failed to ensure adequate assistance with meals and documentation of nutritional supplement consumption for two residents with a history of weight loss. Resident R was observed on multiple occasions sitting with her meal in front of her without any staff assistance. On one occasion, she drank a carton of milk belonging to another resident, and on another, she consumed a health shake without encouragement to eat her meal. Her care plan indicated she required supervision or assistance with eating due to cognitive impairments and a significant weight loss of over 10% in six months. Similarly, Resident 81 was observed playing with her food and using her fingers to eat without staff intervention. She was seen pouring her beverage over her food and attempting to place her plate on the floor, mistaking it for a dog's dish. Despite her care plan indicating a need for supervision or assistance with eating, staff were not present to assist or encourage her to eat properly. Her weight records showed a significant weight loss of 11.2% in three months, necessitating staff assistance with meals. Interviews with the Director of Nursing confirmed that both residents required more assistance with eating, and there was a lack of documentation regarding the consumption of health shakes for Resident R. The facility's failure to provide necessary assistance and documentation contributed to the residents' nutritional deficiencies.
Deficiencies in Gastrostomy Tube Care for Two Residents
Penalty
Summary
The facility failed to ensure proper procedures were followed for residents with gastrostomy tubes, leading to deficiencies in care for two residents. For Resident 72, an RN administered medication through a gastrostomy tube without checking for residuals beforehand and used a syringe plunger to push water and medication through the tube instead of allowing them to instill by gravity. This was contrary to the facility's policy, which requires checking the tube's placement and residuals before administering medication and using gravity for flushing and medication administration. For Resident K, the facility did not document proper care of the peg tube site, and an RN used a syringe plunger to push water through the tube to check for patency, rather than using gravity. The resident, who had multiple diagnoses including cerebral palsy and dysphagia, was observed not connected to enteral feeding as per physician orders. Additionally, there were no documented orders for daily cleaning of the peg tube site, and the care plan did not include necessary instructions for site care, which is required to decrease the risk of infection.
Oxygen Flow Rate Discrepancies for Residents
Penalty
Summary
The facility failed to ensure that oxygen was administered at the correct flow rate for three residents who required oxygen therapy. Resident T, diagnosed with chronic respiratory failure and COPD, was observed using oxygen at a flow rate of four liters per minute, despite a physician's order for two liters per minute. This discrepancy was noted over several days, and the Director of Nursing confirmed that the oxygen concentrator should have been set to the prescribed flow rate. Similarly, Resident G, who has COPD, was observed receiving oxygen at a flow rate of 1.5 liters per minute and later at one liter per minute, contrary to the physician's order of two liters per minute. Resident 30, with diagnoses including COPD and sleep apnea, was using oxygen at three liters per minute, although the physician's order specified two liters per minute as needed. The LPN acknowledged the incorrect setting and intended to adjust it, but the Director of Nursing later confirmed the flow rate remained incorrect.
Medication Error Rate Exceeds 5% Due to Multiple Administration Errors
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, as evidenced by four errors observed during 34 opportunities, resulting in an error rate of 11.7%. For Resident 72, a registered nurse (RN) administered 8 units of Lispro insulin instead of the prescribed 10 units for a blood sugar level between 351 and 400. Additionally, the RN improperly diluted Entrapenem with 10 cc's of normal saline, contrary to the physician's order to dilute it only with 3.2 mls of Lidocaine. The Director of Nursing confirmed these errors during an interview. Resident 9 received a 5 mg tablet of Buspirone, which had been discontinued two days prior, indicating a failure to remove the medication from the cart. For Resident 114, a licensed practical nurse (LPN) dispensed only one 5 mg tablet of Lexapro instead of the prescribed three tablets. The Director of Nursing acknowledged that the resident should have received the correct dosage. These errors highlight the facility's failure to adhere to physician orders and ensure proper medication administration.
Controlled Substance Not Double Locked
Penalty
Summary
The facility failed to ensure that a controlled substance was double locked at all times in one of the two medication rooms observed. During an observation of the West Unit Medication Room, it was found that an unlocked refrigerator contained an unlocked white hospice box with Morphine Sulfate Roxanol 20 mg, a Schedule II controlled substance. The Assistant Director of Nursing (ADON) confirmed that the hospice box should have been locked due to the presence of narcotics. The facility's policy on receiving controlled substances requires medications listed in Schedules II, III, IV, and V to be stored under double lock, which was not adhered to in this instance.
Failure to Provide Routine Dental Services
Penalty
Summary
The facility failed to provide routine dental services to a resident, identified as Resident J, who was reviewed for dental services. During an interview, Resident J expressed a desire to see a dentist for routine treatment. The resident's record, reviewed on February 5, 2025, showed a diagnosis of dysphasia and indicated that the resident was cognitively intact according to the Quarterly Minimum Data Set (MDS) assessment dated December 9, 2024. A signed dental consent form from March 28, 2024, confirmed the resident's wish to receive dental services offered by the facility. However, there was no documentation of any dental appointments being completed for the resident. The Social Service Director provided documentation indicating that the facility switched to a different dental company in July 2024, and during an interview, it was revealed that the resident did not sign a consent form for the new dental company, resulting in the resident being accidentally skipped for dental services.
Medication Administration Deficiencies for Two Residents
Penalty
Summary
The facility failed to ensure that two residents received necessary care and services related to medication administration as ordered by their physicians. For Resident F, during a random observation, it was noted that Vitamin D was missing from the medication cart, despite being ordered from the pharmacy days earlier. The resident's records showed that Vitamin D2 was to be administered daily, but there was a gap in administration on one day in September. The pharmacy audit revealed a delay in the delivery of the medication, and the Director of Nursing confirmed that the medication was on back order. For Resident G, during a medication administration observation, it was found that the morning dose of senna was not available in the medication cart. The medication had last been ordered in July and delivered in early August. The records indicated that the senna was administered daily, but the Nurse Consultant acknowledged that the medication would have been depleted by early September, suggesting that the medication was documented as given when it was not available. The facility's medication administration policy required medications to be administered according to physician's orders, but a policy for re-ordering medications was not provided.
Inadequate Pain Management for Resident with Fracture
Penalty
Summary
The facility failed to provide adequate pain management for a resident with a comminuted, displaced left femoral fracture. The resident, who had significant cognitive impairment and was dependent on assistance for toileting and transfers, was noted to have pain in the left knee, with swelling observed. Despite receiving scheduled and PRN pain medication, the facility did not consistently monitor and assess the resident's pain or evaluate the effectiveness of the medication. Non-pharmacological interventions were not attempted prior to administering pain medication, as required by the physician's orders. The resident's pain was not adequately documented, with missing pain assessments and ineffective pain management noted in the records. The resident frequently complained of knee pain, and staff were aware of her discomfort, yet there was a lack of appropriate response and documentation. The facility's failure to adhere to the care plan and physician's orders resulted in inadequate pain management for the resident, who ultimately required surgical repair for the fracture.
Failure to Implement Behavior Plan for Resident with Dementia
Penalty
Summary
The facility failed to implement a behavior plan of care for a resident with dementia who exhibited challenging and aggressive behaviors. The incident involved a resident diagnosed with Alzheimer's dementia, depression, and peripheral vascular disease, residing in a locked memory care unit. During a combative episode while being changed by two CNAs, a nurse intervened without being asked for assistance. The nurse allegedly became rough with the resident, resulting in the resident's ears being reddened. Witness statements from the CNAs indicated that the nurse tapped the resident's ears in an attempt to calm him, but this did not deescalate the situation. The nurse was terminated for failing to deescalate the situation. The resident's behavior care plan, revised prior to the incident, included interventions such as providing physical and verbal cues to alleviate anxiety and giving positive feedback. Staff were instructed to intervene before agitation escalated and to walk away calmly if the response was aggressive, reapproaching later. However, during the incident, these interventions were not effectively implemented, leading to the escalation of the resident's aggressive behavior. The facility's failure to adhere to the behavior care plan contributed to the deficiency identified in the report.
Inaccurate Documentation of Pain Medication Administration
Penalty
Summary
The facility failed to ensure thorough and accurate documentation of medical records related to the administration of pain medication for a resident with significant cognitive impairment and a history of repeated falls. The resident, who was dependent on assistance for toileting and transfers, was prescribed Norco for pain management. However, discrepancies were found between the Controlled Drug Receipt/Record/Disposition Form and the electronic Medication Administration Record (MAR) regarding the administration of Norco. The records showed inconsistencies in the dates and times the medication was administered, and there were instances where the MAR did not reflect the administration of the medication as recorded on the Controlled Drug Form. Additionally, the documentation of the resident's pain levels was incomplete, with some shifts lacking pain assessments and others showing discrepancies in pain evaluation. Nurses' notes indicated the resident experienced pain and received medication, but follow-up notes often lacked details about the effectiveness of the medication or the specific location of the pain. The Director of Nursing confirmed that prn Norco should be documented on both the Controlled Drug Form and the MAR for each administration, highlighting a failure in maintaining accurate and complete medical records.
Failure to Prevent and Treat Pressure Ulcer Leads to Resident Hospitalization
Penalty
Summary
The facility failed to provide effective services to a dependent resident at risk of developing pressure injuries, resulting in the resident developing a facility-acquired pressure injury on the sacrum. This injury deteriorated and exhibited signs of infection, ultimately leading to the resident experiencing a significant change in condition that required hospitalization for wound-related septic shock and surgical debridement. The resident's medical history included stroke, subarachnoid hemorrhage, respiratory failure, bipolar disorder, aphasia, vascular implants and grafts, spina bifida with shunts, and a history of breast cancer. Upon admission, the resident was incontinent, bedfast, and required maximum assistance with mobility, with no pressure ulcers present at that time. However, the facility did not implement effective interventions for pressure relief as indicated in the care plan and physician's orders dated 3/4/24. The facility's records indicated that staff failed to consistently remind or assist the resident with repositioning every two hours, as required. Documentation showed that staff did not assist with repositioning on 26 of 39 shifts between 3/5/24 and 3/17/24. Additionally, a discolored area was found on the resident's skin on 3/6/24, but it was not thoroughly assessed or documented, and the nurse on duty did not recall being notified. The facility's wound nurse did not assess the area until 3/15/24, by which time the injury had deteriorated to an unstageable pressure ulcer with significant necrotic tissue. The facility's documentation and care plans did not include sufficient interventions to provide complete pressure relief to the sacral area. The resident's condition continued to decline, and on 3/18/24, the resident was transferred to the emergency room with symptoms of septic shock. The hospital diagnosed the resident with a sacral wound infection and septic shock, and surgical debridement of the wound was performed. Interviews with facility staff revealed gaps in communication and documentation regarding the resident's skin condition and the implementation of appropriate interventions. The facility's policies for skin condition assessment and pressure ulcer prevention were not adequately followed, leading to the resident's significant decline in health and subsequent hospitalization.
Removal Plan
- The facility determined a deficiency in their wound prevention, assessment, and treatment program and immediately implemented a plan of improvement.
- Interventions were initiated for Resident C.
- All nurses were educated on skin assessments at the time of admission and any newly identified skin concerns.
- Nurses were educated on the policy if a new skin concern was found, a Risk Management Form was to be initiated, the Physician and family were to be notified, a treatment was to be obtained and initiated, and the DON and Wound Nurse was to be notified.
- Braden scales were to be completed and accurate with appropriate interventions, orders and care plans to be initiated for anyone with a low Braden score.
- The Clinical team were to audit and follow through with the treatments and plan of care.
- CNAs were educated to ensure the nurses were notified of all new skin concerns found during care, interventions to be implemented and where to find those interventions.
- For any concerns, the DON, Wound Nurse, and Administrator may be notified.
- All residents have had updated Braden Scales and those with changes had interventions initiated for prevention.
- Nursing staff and CNAs from different shifts were interviewed and all were knowledgeable of the policies and procedures they were educated on.
- The Administrator indicated staff who had not been educated would receive the education prior to working.
- Audits had been completed and were still ongoing to ensure Braden assessments, care plans, and interventions were in place.
- All information would be reviewed and submitted to the facility's Quality Assurance Program.
Inadequate Supervision and Fall Prevention
Penalty
Summary
The facility failed to ensure adequate supervision for Resident B during a sit-to-stand mechanical lift transfer. Resident B, who required two staff members for assistance due to a stroke with right-side paralysis and obesity, was transferred by only one CNA. This improper transfer resulted in Resident B sliding out of the sling, causing her right arm to get caught and leading to a fracture of the right humeral neck. The incident was witnessed, and the resident was found lying on the floor with a hematoma on the back of her head. Despite recommendations from therapy staff to use a full mechanical lift (Hoyer), the resident refused, preferring the sit-to-stand lift, which ultimately led to the fall and injury. Additionally, the facility failed to ensure that fall prevention interventions were in place for Resident F. During observations, Resident F was found lying in bed with the call light out of reach on multiple occasions. The resident, who had a history of falls and required assistance with bed mobility and transfers, was unsure how to call for staff assistance. Despite a fall occurring on a previous date, there were no updates or new interventions added to the care plan to address the risk of falls. The facility's policies on mechanical lift transfers and fall prevention were not adequately followed. The mechanical lifting device policy required two caregivers for residents needing two-person assistance, which was not adhered to in Resident B's case. Similarly, the fall prevention policy mandated that call lights be within residents' reach at all times, which was not ensured for Resident F. These failures contributed to the incidents and injuries sustained by the residents.
Failure to Timely Document Change in Resident's Condition
Penalty
Summary
The facility failed to ensure a Resident's record was completed in a timely manner, specifically related to a change in condition assessment that was not charted at the time of the change. Late entries were made 9 days after the event for one of the ten residents reviewed for medical records. Resident C, who had a history of stroke, subarachnoid hemorrhage, respiratory failure, bipolar disorder, aphasia, vascular implants and grafts, spina-bifida with shunts, and breast cancer, experienced a significant change in condition on 3/18/24. The resident had abnormal vital signs and a loss of consciousness, necessitating a transfer to the emergency room. However, the documentation of this change was not completed until 3/27/24, well after the event occurred. During an interview, the LPN responsible for the documentation indicated that the delay was due to a busy shift change and the assumption that the evening shift nurse would chart the change of condition. This lapse in timely documentation was identified during a record review and interview, highlighting the facility's failure to maintain accurate and timely medical records in accordance with accepted professional standards. This deficiency was related to a specific complaint investigation (IN00430826).
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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