Great Lakes Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Dyer, Indiana.
- Location
- 2300 Great Lakes Dr, Dyer, Indiana 46311
- CMS Provider Number
- 155218
- Inspections on file
- 48
- Latest survey
- March 24, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Great Lakes Healthcare Center during CMS and state inspections, most recent first.
Surveyors found widespread failures in following treatment orders and monitoring residents’ conditions, including several residents with very dry, scaly skin and documented NP recommendations for daily emollients who had no corresponding moisturizer orders and persistent dry, flaky skin. A resident with a buttock abscess did not receive ordered daily wound care on multiple days, and another with a biliary drain lacked early orders for drain care and had missing documentation of drain output after orders were written. One resident’s abrasions and scabbed areas were not assessed or monitored despite a care plan for impaired skin integrity. Multiple residents experienced inappropriate medication management: blood pressure medications were held without ordered parameters or given outside ordered BP ranges, a diabetic resident with frequent diarrhea and an order for PRN Loperamide had no doses documented despite notes stating it was given, and the same resident had numerous missed doses of long-acting, mixed, and sliding-scale insulins even when blood glucose readings met criteria for administration. Another resident with an arterial foot/heel ulcer had daily wound care ordered, but documentation of wound care was absent on several dates.
Surveyors found that three residents with pressure ulcers did not consistently receive wound care as ordered by physicians and a wound NP. One resident with a sacral ulcer present on admission had orders for cleansing and Zinc Oxide every shift, but TARs showed treatment only on day shift, and observation revealed an open, bloody coccyx wound without visible cream or dressing. Another resident with a new Stage 2 buttock ulcer had multiple missed or undocumented Zinc Oxide treatments across shifts, and later developed an additional open area on the opposite buttock. A third resident with a right hip pressure injury and contractures had evolving wound orders, including collagen and later Dakin’s with collagen-silver, yet TARs showed several dates where daily treatments were left blank. The wound nurse acknowledged treatments were to be done as ordered, and the DON provided no further explanation.
A resident with a history of stroke, severe protein malnutrition, seizures, pressure ulcer, and a documented right lower extremity contracture was admitted with limited ROM in both legs and was dependent for ADLs. PT was ordered to address decreased strength, impaired balance, and functional mobility, including a goal for use of a knee orthotic to inhibit abnormal positioning. However, the initial PT evaluation did not document lower extremity strength, degree of contracture, or specific functional limitations, and subsequent PT notes showed only assisted ROM and gentle stretching, with the resident unable to perform ROM independently. The right knee orthotic was briefly trialed but removed after short periods due to pain, and there was no further documented use or clinical rationale for discontinuation, despite recertified plans that continued to reference possible orthotic management. Staff interviews confirmed lack of clear documentation regarding the orthotic’s ordering, fitting, and discontinuation, and the restorative nurse reported the right knee contracture remained unchanged at the time of review.
A resident with Parkinson’s disease, diabetes, and morbid obesity experienced significant, ongoing weight loss that was not identified or addressed because ordered weekly weights were not consistently documented and weight data were not entered into the record. Although the care plan called for monitoring nutritional status and weights, and the RD documented stable intakes and goals to maintain weight, multiple weights obtained by staff were never recorded, so the RD, physician, NP, and responsible party were not informed of the resident’s substantial weight decline. The resident’s expressed desire to lose weight was also not incorporated into the care plan or communicated to the care team, contrary to the facility’s own weight policy requiring timely documentation and reporting of weight changes.
A resident with chronic kidney disease, a history of UTIs, and a nephrostomy catheter did not receive timely and valid UA and urine culture testing as ordered. Multiple urine specimens were collected, but one set of results was reported after an extended delay and marked invalid, another specimen was rejected due to urine stability lapsing, and results for a later ordered UA were not found in the record. The Corporate RN Consultant acknowledged the delays and missing results and confirmed there was no policy addressing timeliness of lab results, while the lab company reported having no results for the most recent ordered test.
A resident with hemiplegia, stroke, and Parkinson's who required maximal assistance with ADLs and was frequently incontinent did not have incontinence care documented on multiple shifts as required by their care plan. The resident reported staff did not consistently check or respond to requests for incontinence care, and the DON confirmed care should have been performed and documented each shift.
The facility's kitchen was found to be in poor condition, with issues such as a dark substance on the oven door, dirt on ceiling fixtures and vents, a sticky substance on a sugar bin handle, and dust under storage shelves. The Kitchen Manager acknowledged the need for deep cleaning and possible maintenance intervention.
The facility failed to accurately complete MDS assessments for four residents, leading to discrepancies in documenting pressure ulcers and medication use. A resident was incorrectly documented as having pressure ulcers on admission, while another was inaccurately recorded as not receiving antiplatelet medication. Additionally, a resident was wrongly noted as not receiving scheduled antipsychotics, and another was incorrectly marked as receiving insulin instead of Trulicity.
The facility failed to provide adequate personal hygiene care for several residents, resulting in long, dirty fingernails, greasy hair, and unshaven faces. Despite being dependent on staff for assistance, residents expressed dissatisfaction with the lack of regular showers and grooming. The facility's records lacked documentation of nail care or any indication of residents refusing such care, indicating a systemic issue in the provision and documentation of personal hygiene assistance.
The facility failed to administer medications per prescribed parameters and inadequately monitored residents' conditions, leading to potential health risks. A resident with hypertension received Midodrine despite high blood pressure, while another with heart failure did not receive Midodrine when needed. A resident with COPD was not properly assessed before and after nebulizer treatments, leading to hospitalization. Additionally, two residents with edema and skin conditions were not monitored or treated appropriately.
The facility failed to properly store and label medications, including insulin pens and multi-dose vials, which were found without opening or expiration dates. Observations on two units revealed loose pills in medication carts and expired insulin vials and pens. Staff interviews indicated a lack of awareness and adherence to protocols for medication storage and labeling, despite existing policies requiring such measures.
The facility failed to implement proper infection control practices, including handling medications with bare hands, improper disposal of sharps, and not adhering to Enhanced Barrier Precautions (EBP) for residents with indwelling medical devices. Staff were observed not wearing appropriate PPE and improperly storing medical supplies, contrary to facility policies.
The facility was found deficient in maintaining a clean and well-repaired environment. Observations included dirty equipment, stained curtains, overflowing garbage, and non-functional clocks across two units. The Administrator acknowledged the need for cleaning and repair. This relates to Complaint IN00443889.
A resident with severe cognitive impairment was observed wearing a hospital gown during the day, compromising his dignity. Despite requiring substantial assistance with dressing, there was no care plan addressing this issue. The DON acknowledged the situation and the resident's limited clothing.
Two residents were observed self-administering medications without proper assessments or physician's orders. One resident took antacids for stomach upset, while another applied Lidocaine cream before dialysis. Both residents were cognitively intact but lacked documented authorization for self-administration, contrary to facility policy.
A facility failed to provide a bed long enough for a resident, resulting in his feet touching the footboard. The resident, with a height of 73 inches and multiple health conditions, was observed in this position multiple times, indicating the bed was too short. Despite his need for assistance with movement, the facility did not accommodate his height, leading to discomfort. An LPN and the Assistant Director of Nursing acknowledged the issue.
A facility failed to provide a resident's medical records to the family in a timely manner. Despite a request logged in early September, the records were not released until late October and were only sent to the family in December. Interviews indicated that the records should have been provided more promptly, highlighting a failure to adhere to the facility's policy for handling medical record requests.
A facility failed to maintain professional standards when an LPN borrowed Tylenol from another resident's medication card during a medication pass for a resident who requested it for pain. The LPN admitted to the practice, which was against the facility's policy, and the Director of Nursing confirmed the breach. The facility's policy prohibits sharing or borrowing medications and touching them directly.
A resident with multiple medical conditions, including COPD and hypertension, reported that staff did not consistently perform treatments for her Stage 3 pressure ulcers. The care plan required daily treatments, but the Treatment Administration Records showed several instances where treatments were not documented as completed. The DON confirmed that treatments should have been completed as ordered.
A resident with limited range of motion did not receive the prescribed intervention of placing a washcloth in his right hand to prevent further decline. Despite observations showing the resident's wrist in a hyperextended position and contracted fingers, there was no documentation of the intervention being carried out. The resident had severe cognitive impairment and required significant assistance with daily activities.
A facility failed to secure smoking materials for a resident with a history of respiratory issues and nicotine dependence. The resident admitted to keeping cigarettes and a lighter in his coat pocket instead of locking them in a designated mailbox, as required by the facility's smoking guidelines. The guidelines stated that staff should store smoking materials securely when not in use, but this was not followed, leading to a deficiency.
A facility failed to maintain proper catheter care and documentation for a resident with an indwelling Foley catheter. The catheter collection bag was found on the floor, contrary to policy, and urinary output was not consistently documented as required. The resident had a history of prostate cancer, end-stage renal disease, and obstructive uropathy. The DON confirmed the lack of documentation and the need for proper catheter care.
The facility failed to document meal consumption for two residents with a history of weight loss. One resident, with conditions including COPD and anxiety, lost significant weight despite a care plan to monitor meal intake. Another resident, with a history of stroke and depression, also experienced weight loss, and meal logs were incomplete. The DON confirmed the lack of documentation.
The facility failed to properly administer medications and water flushes via a gastrostomy tube for two residents. An LPN was observed plunging medications and water instead of using gravity for Resident 147, contrary to facility policy. Additionally, Resident 58's enteral feeding was not started on time due to a shift change oversight, despite the resident's dependence on staff for nutrition and a specified feeding schedule.
A resident with COPD and other conditions was observed receiving oxygen at three liters per minute, contrary to the physician's order for two liters. This discrepancy was noted over several days, with both portable oxygen tanks and concentrators set incorrectly. The issue was confirmed by facility staff, highlighting a failure to follow prescribed oxygen therapy.
A resident with chronic pain conditions, including multiple sclerosis and quadriplegia, was inadequately managed for pain, receiving only over-the-counter Tylenol despite reporting significant pain levels. The facility failed to provide alternative pain relief options or conduct detailed pain assessments, leading to a delay in prescribing stronger medication. Staff interviews revealed a lack of awareness of the resident's pain needs until the issue was escalated to the NP, who then prescribed Tramadol.
A facility failed to monitor a resident's perma cath for infection signs, despite care plan and physician's orders. The resident, with multiple diagnoses including end stage renal disease, had no documented checks of the dialysis site for three months. The DON had no additional information.
A facility failed to maintain a medication error rate below 5%, resulting in a 7.14% error rate. An LPN administered insulin incorrectly by not priming the needle for a resident with diabetes, and another LPN improperly administered medications via a gastrostomy tube, including giving Lansoprazole at the wrong time. Both errors were acknowledged by the staff involved.
A resident with type 2 diabetes did not receive sliding scale insulin as prescribed due to a computer entry error marking it as PRN, leading to missed doses when blood sugar levels were high. An LPN administered insulin incorrectly during a medication pass, and the error was confirmed by the DON.
A resident who had undergone open heart surgery was observed during a physical therapy session where the therapist instructed him to pull his upper body using his arms, despite having sternal precautions in place that prohibited such movements. The therapy care plan included these precautions, but there was no documentation or physician's orders indicating they were not to be followed. The physical therapist's actions were questioned, and the Therapy Manager and Administrator were informed, but no further information was provided.
The facility failed to maintain accurate clinical records for two residents, leading to deficiencies in medication and tube feeding documentation. One resident's MAR showed discrepancies in medication administration without proper documentation, while another resident's eMAR contained inconsistent entries for tube feeding intake. The DON acknowledged the need for staff education on documentation practices.
A facility failed to accurately report a resident-to-resident altercation to the IDOH. Two residents were involved in an incident where one fell and sustained injuries after attempting to hit the other. The initial report contained inaccuracies regarding the location, circumstances, and diagnoses of the residents. The follow-up report omitted investigation findings, which clarified that no physical contact occurred and that one resident was intoxicated. The facility's abuse policy required detailed reporting, which was not met.
A facility failed to maintain a current smoking assessment for a resident with alcohol dependency who smoked independently. The last assessment was conducted over a year ago, and no updated assessment was available. A social service staff member confirmed the lack of a current assessment, despite the facility's policy requiring regular evaluations.
A resident with a history of alcohol dependency was inadequately monitored by the facility, leading to intoxication and an altercation with another resident. Despite signing a Behavioral Contract, the resident frequently left the facility without proper monitoring, resulting in further incidents. Interviews revealed a lack of behavior monitoring records and care plans, contributing to the deficiency.
A resident with paraplegia experienced an intrafacility room transfer that was not properly documented. The Notification of Room Change form lacked the resident's signature and was not uploaded into the electronic health record as required. Interviews revealed discrepancies between the resident's reported satisfaction and the documentation, with the Administrator acknowledging the lack of proper documentation.
A facility failed to protect a resident's privacy when an employee recorded a video of a cognitively impaired resident without the Court Appointed Guardian's approval. The video, taken on a private cell phone, was shared via Snapchat. The resident, diagnosed with dementia and depressive disorder, had a court-appointed guardian due to incapacity. The facility's policy prohibits such unauthorized recordings.
A resident with dementia and depressive disorder expressed suicidal ideation, but the facility failed to act promptly. The statement was recorded on video by a receptionist and sent to a housekeeping supervisor, who did not view it until days later. The delay resulted in a failure to notify Social Services and the Administrator until much later, contrary to the facility's policy requiring immediate action and notification of relevant personnel.
A facility failed to notify a resident's POA and physician of significant condition changes, including new skin issues and a hospital transfer. The resident, with multiple medical conditions, developed non-pressure skin areas and had abnormal lab results that were not promptly communicated. The DON confirmed the lack of documentation for notifying the family and physician, contrary to the facility's policy.
A resident with a history of stroke and other medical conditions experienced an unwitnessed fall, and the facility failed to initiate neurological checks as required by their policy. Despite being sent to the emergency room and returning, no checks were conducted, which was confirmed by the DON. This oversight represents a deficiency in the care provided.
A resident with a history of falls was observed wearing plain black ankle socks instead of the required non-skid footwear, as per their care plan. Despite being at risk for falls and having a history of falls, the facility did not ensure adherence to the care plan. The resident's medical history included stroke and hemiplegia, and they were not cognitively intact for daily decision-making. The DON confirmed the resident should have had appropriate footwear at all times.
The facility failed to ensure proper infection control guidelines were in place and implemented, particularly regarding the use of PPE and hand hygiene. Staff members provided care without the required enhanced barrier precautions and failed to perform hand hygiene after handling soiled items. Some staff had not attended recent training on these protocols.
The facility failed to ensure call lights were within reach for two residents, despite multiple observations and staff interactions. Resident G and Resident K were both found with call lights placed out of reach, contrary to their care plans and needs.
The facility failed to provide written notification to residents and/or their Responsible Parties of room changes due to a COVID-19 outbreak. Three residents were moved to quarantine units without receiving the required intrafacility transfer forms or documentation of room change notifications.
The facility failed to ensure a clean and homelike environment for its residents, as evidenced by observations of stained, dirty, and tattered bed linens for three residents. Despite the Administrator's acknowledgment that soiled linens should have been changed, the facility did not maintain the required standards.
The facility failed to document a recapitulation of the resident's stay on the discharge summary for three residents. The discharge summaries either had 'N/A' documented or were left blank in the course of illness/progress section, contrary to the facility's policy.
The facility failed to assist two residents with their meals. One resident's lunch tray was left untouched as no staff returned to help her eat, despite her needing partial to moderate assistance. Another resident was unable to cut her food and required assistance, which was not promptly provided.
A resident with multiple sclerosis and stage four pressure ulcers did not receive the necessary wound care as ordered by the Physician. Observations revealed missing dressings and a wound vacuum, and staff failed to report the issue to the Wound Nurse and Wound Nurse Practitioner.
Widespread Failures in Skin, Wound, Diarrhea, and Medication Management
Penalty
Summary
The deficiency involves multiple failures to provide treatment and care according to physician orders and residents’ needs, particularly for skin conditions, wound care, diarrhea management, and medication administration. One resident with stroke, PEG tube, Alzheimer’s disease, and peripheral vascular disease was repeatedly observed with very dry, scaly skin on the arms and legs and without a pressure-relieving cushion in the wheelchair, despite a care plan identifying risk for impaired skin integrity and physician orders for zinc oxide to the buttocks and ammonium lactate lotion to the feet every shift. Treatment records showed missed applications on several dates, and a wound NP had recommended Triad cream to the sacrum/buttocks, arm protectors, and daily emollient to the lower extremities, yet the resident’s creams were not available on the treatment cart and the dry, flaky skin persisted. Another resident with an abscess on the right inner buttock had a dressing dated several days earlier and the wound nurse acknowledged not performing the ordered daily treatment since the initial dressing change, with the TAR showing missed treatments on two dates. Additional failures were identified in the management of other residents’ skin and wound conditions. One resident with multiple cancers and a left biliary drain had no initial orders to empty and record drain output or clean the site until mid-March, and once ordered, drain output documentation was missing for specific shifts. Another resident with stroke and PEG tube was repeatedly observed with extremely dry, flaky, scaly skin on the lower extremities and feet, with large flakes on the floor, despite a wound NP recommendation for daily emollient to legs and feet and no corresponding physician orders for moisturizing cream. A further resident with diabetes, severe protein malnutrition, stroke, and pressure ulcer risk had extremely dry, scaly skin on both legs and feet, and although a wound NP had recommended routine moisturizer, there were no orders for any skin moisturizer and the wound nurse confirmed the absence of such orders. A resident with Parkinson’s disease and functional decline had reddened, scabbed areas on both hands and abrasions on the right elbow and upper arm that were not reflected in weekly skin checks, shower documentation, or any assessment or monitoring notes, despite a care plan for risk of impaired skin integrity. The survey also identified multiple medication-related deficiencies, including holding or administering medications without appropriate parameters and failing to administer ordered medications. One resident with diabetes and chronic kidney disease had Lisinopril held on numerous occasions when blood pressures were documented, with nursing notes citing lack of high blood pressure or low blood pressure per physician orders, yet there were no physician-ordered parameters to hold the medication. Another resident with atrial fibrillation, hypertension, and hypotension received metoprolol and midodrine outside of ordered blood pressure parameters on multiple dates, with no documentation explaining why medications were given when blood pressures were out of range. A resident with acute cor pulmonale and hypertension had metoprolol held repeatedly without any ordered parameters, and an LPN stated she would hold blood pressure medications if systolic blood pressure was less than 120 even when no parameters were ordered. A diabetic resident who reported frequent diarrhea and believed she received anti-diarrheal medication had multiple episodes of watery stools documented and an alert note stating Loperamide was given, but the MAR showed no doses administered. The same resident had multiple instances where long-acting, mixed, and fast-acting insulins, including sliding-scale Humalog for significantly elevated blood sugars, were not administered despite standing orders and no hold parameters, with no documentation of administration on numerous dates when blood glucose readings met criteria for dosing. Another resident with quadriplegia, diabetes, and peripheral vascular disease had an arterial ulcer on the right foot/heel with daily wound care ordered, yet documentation of wound care was missing on several specified dates, with no record of completion or refusal.
Failure to Provide Ordered Pressure Ulcer Treatments for Three Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care as ordered by physicians for three residents with existing pressure injuries. For one resident with severe protein malnutrition, adult failure to thrive, dysphagia, and a sacral pressure ulcer present on admission, the care plan and wound NP notes specified cleansing the sacrum/buttocks with soap and water, patting dry, and applying Zinc Oxide and collagen particles every shift, leaving the area open to air. Although the wound initially improved in size and remained 100% epithelial tissue, the Treatment Administration Records (TARs) for two consecutive months showed the treatment was documented only on the day shift instead of every shift as ordered. During observation, the resident was found on his side with an open, bloody coccyx wound and no visible cream or bandage. A later wound NP note documented that the Stage 2 ulcer had worsened significantly in size and was described as a Kennedy terminal ulcer, with treatment changed to a collagen silicone bordered foam dressing three times weekly. A second resident, cognitively intact with a history of stroke, dysphagia, and PEG tube, developed a new Stage 2 pressure ulcer to the right buttock. The wound NP ordered cleansing with soap and water and application of Zinc Oxide every shift, to be left open to air, and a physician’s order mirrored this. The TAR for the month showed blanks where the treatment was not signed out as completed on specific day and evening shifts. A subsequent NP note showed the ulcer had increased in size, and a later physician’s order changed the regimen to cleansing both buttocks with soap and water and applying Zinc Oxide every day shift. The TAR for the following month again contained multiple blank entries on day, evening, and midnight shifts where the buttock treatment was not documented as completed. Later NP documentation noted the right buttock ulcer measurements and identified a new open area, described as an abrasion, on the left inner buttock, with treatment changed to a collagen with silver dressing and silicone bordered gauze. A third resident with type 2 diabetes, severe protein malnutrition, stroke, contracture of the right lower leg, and an existing right hip wound was care planned as being at risk for pressure ulcers, with approaches including administering treatments as ordered. The wound began as an abrasion to the right hip and progressed to a full-thickness wound with slough, then to an unstageable pressure injury with increased depth and slough. The wound NP repeatedly adjusted the treatment orders, including cleansing with wound cleanser, then Honey Hydrogel Sheet Dressing, and later collagen with daily and PRN changes. The TAR for one month showed missed documentation of the daily collagen and bordered gauze treatment on two dates. After the wound was noted with undermining and malodor, the NP changed the treatment to cleansing with 0.25% Dakin’s solution, applying collagen with silver, and covering with bordered gauze daily and PRN, and a physician’s order reflected daily shift care. The TAR for the end of that month and into the next again showed blank entries on specific dates where the Dakin’s and collagen with silver treatment was not documented as completed. Throughout interviews, the wound nurse stated that treatments were supposed to be completed as ordered, and the DON had no additional information.
Failure to Provide Consistent ROM Treatment and Orthotic Management for Contracted Right Leg
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary treatment and services to maintain or improve range of motion (ROM) for a resident admitted with limited ROM and a right leg contracture. The resident had diagnoses including severe protein malnutrition, stroke, pressure ulcer, contracture of the right lower leg, and seizures, and MDS assessments documented limited ROM in both lower extremities and dependence on staff for ADLs. On observation, the resident’s right leg was found to be severely contracted and completely bent, with inability to fully extend. The care plan identified an alteration in musculoskeletal status related to the right leg contracture, and physician orders and PT documentation showed that the resident was to receive PT services, including evaluation for and use of an orthotic device to inhibit abnormal positions. PT documentation showed that the initial PT evaluation did not include objective measurements of lower extremity strength, degree of contracture, or specific functional limitations of the lower extremities. PT notes over time documented active assist ROM and gentle manual stretching to the bilateral lower extremities and specifically to the right lower extremity, but consistently indicated the resident could not return ROM demonstrations independently. A goal was established for the resident to safely wear the least restrictive splinting/orthotic device one hour on and one hour off without skin irritation. The orthotic device for the right knee was introduced and applied on several documented dates, but the resident was only able to tolerate about 15 minutes of wear due to pain, and there was no further documentation of the device being used after a short trial period. Subsequent PT recertifications continued to reference therapeutic exercises, gentle manual stretching, and that treatment to prevent further decline "may include" orthotic management and training, but there was no documentation explaining why the orthotic device was not continued or re-trialed after its initial brief use. Interviews with PT staff and the Director of Rehabilitation revealed that the therapist who performed the initial evaluation worked PRN and was unavailable, that staff were unaware when the orthotic was ordered or why it was discontinued, and that there was no documentation of initial lower extremity strength or functional ROM. The restorative nurse reported that the right knee contracture appeared the same at the time of interview as at PT discharge, and that the resident sometimes refused interventions due to pain. Overall, the record lacked adequate assessment data and documentation of consistent orthotic use or clinical rationale for discontinuing the orthotic device, despite the resident’s known right leg contracture and limited ROM.
Failure to Identify and Address Significant Weight Loss
Penalty
Summary
The deficiency involves the facility’s failure to identify and address significant weight loss for a resident with multiple comorbidities, including Parkinson’s disease, diabetes mellitus, and morbid obesity. A Significant Change MDS dated 12/14/25 documented the resident’s weight at 294 pounds with no significant weight loss or gain and noted that she was on a therapeutic diet and hypoglycemic medication. The care plan, revised on 12/23/25, identified a nutritional problem related to a BMI over 40, therapeutic diet, and prior weight gain, with a goal to maintain adequate nutritional status and stable weight. Interventions included monitoring meal intake, obtaining a nutritional consult on admission, quarterly and as needed, obtaining weekly weights if unplanned weight loss was identified, and providing meals per physician orders. Weight records showed the resident’s weight fluctuated from 296.6 pounds in early July 2025 to 293.5 pounds in November 2025. The resident was hospitalized for shortness of breath on 11/29/25 and readmitted on 12/3/25. A physician’s order dated 12/6/25 required weekly weights for four weeks, but the MAR for 12/2025 showed only one documented weight on 12/12/25 at 293.5 pounds, with no further weekly weights recorded until 2/3/26. An RD assessment on 12/15/25 referenced a weight of 293.5 pounds, noted dietary intakes of 75–100%, and estimated calorie needs of 1850–2200, with goals to maintain adequate nutritional status and stable weight. The resident expressed a desire to lose weight, but there were no care plan interventions or documentation that staff, the physician, or the responsible party were notified of this request. Subsequent information revealed undocumented weights and unrecognized significant weight loss. A weight on 2/3/26 was 259.3 pounds, representing an 11.6% loss from the 12/12/25 documented weight and a 14.5% loss over six months, while intake records for 12/2025 through 2/2026 showed average meal intakes of 76–100%. The RD’s 2/5/26 note identified a 10% loss in 180 days and questioned weight accuracy, requesting a re-weight. During interview, the Corporate RN Consultant reported that weights of 272.1 pounds on 12/8/25 and 264.6 pounds on 1/5/26 had been obtained but not documented in the record, resulting in staff and the RD being unaware of the ongoing weight loss, and the physician, NP, RD, and responsible party not being notified. The Restorative Aide stated she weighed residents, wrote weights on paper, and gave them to the Unit Manager for entry, and she was unaware the resident required weekly weights. The facility’s weight policy required admission weights, weekly weights for four weeks, and documentation of weights and any concerns in the record, but these requirements were not followed for this resident, leading to the failure to identify and address her significant weight loss.
Failure to Ensure Timely and Valid Urine Laboratory Testing
Penalty
Summary
The facility failed to ensure timely and valid laboratory services for urinalysis (UA) and urine culture and sensitivity testing for a resident with significant urinary and renal conditions. The resident had diagnoses including stage 3 chronic kidney disease, a history of UTIs, and a left nephrostomy catheter, with a care plan directing monitoring for UTI signs and symptoms. A nurse’s note documented that a urine sample was collected for testing, and lab records showed a UA with culture and sensitivity was collected on 12/10/25. However, the results were not reported until 11 days later and were marked invalid. A subsequent nurse practitioner note documented the nephrostomy tube status and included an order for another UA with culture and sensitivity. A nurse’s note later indicated another urine sample was collected on 12/26/25, and lab records showed the UA with culture and sensitivity was reported five days after collection, with the specimen rejected due to urine stability lapsing, rendering the results invalid. A physician’s order dated 1/9/26 directed that another UA be completed, but no results for this test were found in the resident’s record. During interview, the Corporate RN Consultant stated that the delay in results from the 12/10/25 UA had only come to their attention on 1/13/26, acknowledged that the 12/26/25 UA had not been completed, and confirmed there was no facility policy addressing timeliness of lab results. The lab company reported having no results yet for the UA ordered on 1/9/26.
Failure to Document and Provide Incontinence Care for Dependent Resident
Penalty
Summary
A deficiency was identified when the facility failed to document incontinence care for a resident who was dependent on staff for activities of daily living (ADLs). The resident, who had diagnoses including hemiplegia, stroke, and Parkinson's disease, was cognitively intact but required maximal assistance with ADLs and was frequently incontinent of bowel and bladder. The resident's care plan required staff to check for incontinence every two hours and as needed. However, a review of the Point of Service documentation for the month showed multiple shifts across several days where incontinence care was not documented as provided. During interviews, the resident reported that staff did not check on him at least once per shift for incontinence care and that, when he used the call light to request assistance, staff sometimes failed to return, resulting in him being left in a soiled brief for hours. The DON confirmed that incontinence care should be performed and documented each shift and was unable to explain the missing documentation for the identified dates and shifts.
Kitchen Cleanliness and Maintenance Deficiency
Penalty
Summary
The facility failed to maintain cleanliness and proper repair in the kitchen, as observed during an Initial Kitchen Sanitation Tour. Specific issues included a dark, dripping substance on the bottom of the oven door, dirt accumulation on the edges of ceiling light fixtures and vents above the food preparation area, a tan, sticky substance on the handle of the sugar storage bin, and dust and debris under the shelves in the dry storage room. During an interview, the Kitchen Manager acknowledged the need for deep cleaning and indicated that maintenance might be required to clean the light fixtures and vents. The facility's policy, as provided by the Administrator, mandates that all food preparation, service, and dining areas be maintained in a clean and sanitary condition.
Inaccurate MDS Assessments for Pressure Ulcers and Medications
Penalty
Summary
The facility failed to ensure accurate completion of the Minimum Data Set (MDS) assessments for four residents, leading to discrepancies in the documentation of pressure ulcers and medication use. Resident 59, who was cognitively intact, was documented as having two Stage 3 pressure ulcers present on admission, but a Skin and Wound Note indicated these ulcers developed in the facility. Resident 86, with moderate cognitive impairment, was documented as not receiving antiplatelet medication, despite physician orders and medication administration records showing daily administration of Plavix. Resident D, with moderate cognitive impairment, was incorrectly documented as not receiving scheduled antipsychotic medication, despite physician orders for daily Risperidone. Resident F, who was cognitively intact, was incorrectly documented as receiving insulin, although the medication administered was Trulicity, a GLP-1 agonist for diabetes, which should have been marked under hypoglycemic medication. These inaccuracies in MDS assessments highlight the facility's failure to ensure accurate resident assessments, impacting the documentation of care provided.
Deficiency in Personal Hygiene Care for Residents
Penalty
Summary
The facility failed to ensure that activities of daily living (ADLs) were completed for dependent residents, specifically in relation to personal hygiene tasks such as shaving, washing hair, providing showers, and nail care. This deficiency was observed in six residents, who were found with long, dirty fingernails, greasy hair, and unshaven faces. The residents expressed their dissatisfaction with the lack of personal care, indicating that they did not always receive the necessary assistance with bathing and grooming. Resident E, who was cognitively intact but physically dependent due to multiple sclerosis and quadriplegia, was observed multiple times with long, dirty fingernails and greasy hair. Despite being scheduled for showers twice a week, there was a lack of documentation indicating that these were consistently provided. Similarly, Resident D, who required assistance due to Parkinson's disease and other health issues, was found with long, dirty fingernails and unshaven, despite expressing a desire for regular showers and grooming. Other residents, such as Resident C, who had contracted fingers, and Resident F, who required maximal assistance due to Parkinson's disease, were also observed with inadequate nail care. Resident L, who had severe cognitive impairment, was found with long, dirty fingernails that were indenting into his face, and an unshaven appearance. The facility's records lacked documentation of nail care or any indication that residents refused such care, highlighting a systemic issue in the provision and documentation of personal hygiene assistance.
Medication Administration and Monitoring Deficiencies
Penalty
Summary
The facility failed to administer medications according to prescribed parameters for several residents, leading to potential health risks. Resident 59, who had a history of hypertension and other cardiovascular issues, was prescribed Midodrine HCl to be held if systolic blood pressure exceeded 100. However, the medication was not held on multiple occasions despite blood pressure readings above the specified threshold. Similarly, Resident M, with conditions including end-stage renal disease and heart failure, did not receive Midodrine when systolic blood pressure was below 100, and Metoprolol was administered when it should have been held due to low blood pressure readings. In another case, Resident 65, who had COPD and other respiratory issues, was not adequately monitored before and after receiving nebulizer treatments. The resident's oxygen saturation levels were critically low, yet there was a lack of documentation of pre and post-treatment assessments. This oversight contributed to the resident's eventual hospitalization for acute hypoxic respiratory failure. Additionally, Resident 87 had a large discoloration on his hand that was not assessed or monitored, despite being at risk for abnormal bleeding due to aspirin use. The facility also failed to address and monitor edema and skin conditions in other residents. Resident 75 exhibited swelling in the right arm and hand, and scaly skin on the feet, but there was no care plan or treatment in place. Similarly, Resident 24 had swollen legs with socks indenting into the skin, yet there was no care plan to monitor or treat the edema. These deficiencies highlight a pattern of inadequate assessment and monitoring of residents' conditions, leading to potential health risks.
Improper Medication Storage and Labeling
Penalty
Summary
The facility failed to ensure proper medication storage, specifically concerning insulin pens and multi-dose vials, which were not labeled with opening or expiration dates. During an observation on the [NAME] unit, eight loose pills were found in the medication drawers, and an opened multi-dose vial of Aplisol was discovered in the refrigerator without a date indicating when it was opened. The Assistant Director of Nursing (ADON) mentioned that the pharmacy was responsible for cleaning the carts and checking the medication rooms weekly. On the East unit, similar issues were observed. A medication cart contained 22 loose pills, and insulin vials and pens were found without proper discard dates. LPN 2 was unaware of the frequency of cart cleaning by the pharmacy. Another observation on the East unit revealed four loose pills and insulin vials and pens with expired discard dates. RN 1 admitted to checking the dates but failed to notice expired items. The Director of Nursing (DON) confirmed that protocols existed for cleaning medication carts and dating opened insulin pens and vials, but these were not followed. The facility's Storage of Medications policy required medications to be dated when opened and checked for expiration before administration, which was not adhered to in these instances.
Infection Control Deficiencies in Medication Handling and Resident Care
Penalty
Summary
The facility failed to implement proper infection control practices during medication administration and resident care. During a medication pass, an LPN was observed handling medications with bare hands and failing to disinfect a glucometer immediately after use. The LPN also improperly disposed of a used lancet by placing it in her shirt pocket instead of a sharps container. The Director of Nursing confirmed that these actions were against the facility's policies, which require immediate disinfection of glucometers and proper disposal of sharps. Another LPN was observed improperly disposing of a used lancet by placing it inside rolled-up gloves and then into a regular trash can instead of a sharps container. The LPN admitted to setting the gloves aside temporarily but failed to follow through with proper disposal. The Director of Nursing reiterated that used lancets should be disposed of in a sharps container, as per the facility's policy. Additionally, staff failed to adhere to Enhanced Barrier Precautions (EBP) for residents with indwelling medical devices. An LPN stored gloves and alcohol wipes in her shirt pocket, which is not allowed under EBP. Furthermore, two CNAs did not wear gowns while providing direct care to a resident on EBP, despite the presence of a sign indicating the requirement. The CNAs admitted to not wearing gowns, with one citing a lack of availability. The Director of Nursing confirmed that gowns and gloves should have been worn during the care of residents under EBP.
Environmental Cleanliness and Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain a clean and well-repaired environment for residents, as observed during an Environmental Tour. In the East Unit, a resident's bed handrails were found with a buildup of a dark brown substance. In the [NAME] Unit, multiple deficiencies were noted: a tube feeding pole had spillage on the floor and the pole itself, a Broda chair had dried brown substance, and clothing was piled on boxes and a wheelchair. Additionally, window curtains were stained, and emesis basins containing personal hygiene items were not properly contained. Further observations in the [NAME] Unit revealed overflowing garbage bins, crumbs and food spills on the floor, and uncontained briefs in the bathroom. Washcloths and hygiene items were improperly placed on the toilet seat. In another room, two clocks were not functioning, and a resident was unsure about the ownership of items in a bag on the floor. These findings were confirmed by the Administrator, who acknowledged the need for cleaning and repair in these areas. This citation is related to Complaint IN00443889.
Resident Dignity Compromised by Inappropriate Attire
Penalty
Summary
The facility failed to maintain the dignity of a resident, identified as Resident L, by allowing him to wear a hospital gown during the day instead of regular clothing. Observations on multiple occasions revealed that Resident L was seen in the dining room and in his room wearing a hospital gown. The resident's medical record indicated severe cognitive impairment and a need for substantial assistance with dressing. However, there was no care plan addressing the use of a hospital gown during the day. The Director of Nursing acknowledged awareness of the situation and noted the resident's limited clothing, but confirmed that this should have been included in a care plan.
Failure to Assess and Authorize Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that residents were properly assessed and had physician's orders to self-administer medications. Resident 83 was observed with a medicine cup containing chewable antacids on his bedside table, which he took as needed for stomach upset. Although the resident was cognitively intact and required set-up assistance for activities of daily living, there was no documented self-administration assessment or physician's order allowing him to self-administer the medication. The Director of Nursing (DON) had no additional information regarding this oversight. Similarly, Resident G was observed holding a tube of Lidocaine cream, which he applied himself to his AV fistula site before dialysis sessions. Despite being cognitively intact and requiring assistance with activities of daily living, there was no self-administration assessment or physician's order for this practice. The DON acknowledged awareness of the resident's self-administration but admitted that an order should have been in place. The facility's policy requires a skill assessment for residents who self-administer medications, which was not conducted in these cases.
Facility Fails to Provide Adequate Bed for Resident
Penalty
Summary
The facility failed to provide reasonable accommodations for a resident's needs, specifically regarding the length of the bed. Resident D, who has a height of 73 inches, was observed multiple times with his feet touching the footboard of his bed, indicating that the bed was too short for him. This was noted during several observations over a period of days, where the resident was consistently positioned high up in the bed with his feet touching the footboard. The resident, who has a history of Parkinson's disease, falls, depressive disorder, anxiety disorder, epilepsy, heart disease, kidney disorder, and stroke, indicated that he stayed in bed most of the time and required assistance to reposition himself. The resident's condition was further complicated by his moderate impairment in daily decision-making and his need for partial to moderate assistance with movement, as indicated in his Quarterly Minimum Data Set assessment. Despite these needs, the facility did not provide a bed that accommodated his height, leading to discomfort and potential risk. The issue was acknowledged by LPN 5, who observed the resident's feet touching the footboard and stated that the bed was too short. The Assistant Director of Nursing also confirmed that the resident's feet should not be touching the footboard, highlighting the facility's failure to meet the resident's needs for appropriate bed accommodations.
Delayed Release of Medical Records to Resident's Family
Penalty
Summary
The facility failed to ensure that a resident's family received the resident's medical records in a timely manner. Resident H, who had diagnoses including multiple sclerosis, respiratory failure, type 2 diabetes, pressure ulcers, and anxiety, was admitted to the facility and later discharged home. The resident's family requested the medical records, but there was a significant delay in providing them. The request for the medical records was initially logged on 9/6/24, but the records were not released by corporate until 10/30/24 and were only sent electronically to the family on 12/2/24. Interviews with the Medical Records Supervisor and the Administrator revealed that the records should have been provided more promptly. The facility's Medical Record Request Guide policy outlines a process for handling such requests, including ensuring HIPAA compliance and determining the necessary documentation. However, the delay in releasing the records indicates a failure to adhere to this policy, resulting in the deficiency noted in the report.
Medication Borrowing Breach During Medication Pass
Penalty
Summary
The facility failed to maintain professional standards of quality during a medication pass involving Resident C and LPN 1. During the medication pass, LPN 1 was observed removing medications from Resident C's punch cards and administering them. When Resident C requested Tylenol for pain, LPN 1 returned to the medication cart and took two Tylenol tablets from another resident's medication card, placing them into a medication cup with her bare hands. Upon questioning, LPN 1 admitted to borrowing the Tylenol from another resident because Resident C did not have any available, despite being aware that this practice was against policy. The review of Resident C's records confirmed a physician's order for Acetaminophen 325 mg, to be given as needed. During an interview, the Director of Nursing acknowledged that the nurse should not have taken medication from another resident's punch card. The facility's current Medication Administration policy explicitly states that medications should not be shared or borrowed from others, and that medications should not be touched directly. This incident highlights a breach in the facility's medication administration protocol.
Failure to Complete Ordered Pressure Ulcer Treatments
Penalty
Summary
The facility failed to ensure that treatments for pressure ulcers were completed as ordered for a resident with multiple medical conditions, including chronic obstructive pulmonary disease, chronic kidney disease, and hypertension. The resident, who was cognitively intact, reported that staff did not always perform the necessary treatments for her pressure ulcers. The resident had two Stage 3 pressure ulcers on her left buttock and sacrum, which were identified as having developed in the facility. The care plan required treatments to be administered as ordered by the medical provider. The treatment administration records indicated multiple instances where the prescribed treatments were not documented as completed. Specifically, the January 2025 Treatment Administration Record (TAR) showed that treatments were not signed out on four occasions, and the February 2025 TAR indicated missed treatments on two occasions. During an interview, the Director of Nursing acknowledged that the treatments should have been completed as ordered, highlighting a failure in adhering to the prescribed care plan for the resident's pressure ulcers.
Failure to Implement Range of Motion Intervention for a Resident
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident with limited range of motion, identified as Resident L, to increase or prevent further decrease in range of motion. Observations over several days revealed that Resident L consistently had his right wrist fixed in a hyperextended position, supporting his head, with contracted fingers and nothing in his right hand. The resident's care plan, revised on 10/18/23, specified that a washcloth should be placed in his right hand for 4-6 hours a day, up to 7 days a week, to address his condition. However, there was no documentation in the treatment record indicating that this intervention was being implemented. Resident L's diagnoses included dementia, type 2 diabetes, and adult failure to thrive, and he required substantial to maximum assistance with activities of daily living. During an interview, the Director of Nursing acknowledged the findings but did not provide further information.
Failure to Secure Smoking Materials for Resident
Penalty
Summary
The facility failed to ensure that smoking materials were secured for a resident who was reviewed for smoking. The resident, who was cognitively intact and had a history of respiratory failure, tracheostomy status, sleep apnea, and nicotine dependence, indicated during interviews that he was supposed to lock up his cigarettes and lighter in a mailbox located across from the smoking area after smoking. However, he admitted to rarely locking them up because he had previously lost the key, which made him nervous. Instead, he kept his cigarettes and lighter in his coat pocket, although he was aware that he should not smoke in his room. The facility's Resident Smoking Guidelines, which were identified as current, stated that facility staff would store smoking materials in a secure area when not in use by the resident, regardless of whether the resident was an independent or supervised smoker. Smoking materials were to be returned to the facility staff upon completion of smoking. The Administrator confirmed that smoking materials were to be left in the locked mailboxes outside of the smoking area, and residents were not to keep their smoking materials. This failure to adhere to the guidelines resulted in a deficiency related to accident hazards and supervision.
Deficiency in Catheter Care and Documentation
Penalty
Summary
The facility failed to ensure proper care and documentation for a resident with an indwelling Foley catheter. On two separate occasions, the resident's catheter collection bag was observed lying on the floor next to the bed, which is against the facility's policy. During an interview, a registered nurse acknowledged that the catheter bag should not have been on the floor and took corrective action by hanging it properly. The resident, who was moderately cognitively impaired, had a history of prostate cancer, end-stage renal disease, and obstructive uropathy, necessitating the use of an indwelling urinary catheter. Additionally, the facility did not consistently document the resident's urinary output as required by the physician's orders. The Treatment Administration Records for January and February 2025 showed missing documentation of urinary output on several dates and shifts. The Director of Nursing confirmed that staff should have documented the urinary output every shift but could not provide evidence that this was done on the specified dates. The facility's policy on catheter care emphasizes the importance of ensuring the collection bag is not on the floor and that any adverse findings are documented and reported.
Failure to Document Meal Consumption for Residents with Weight Loss
Penalty
Summary
The facility failed to ensure proper documentation of food consumption logs for two residents with a history of weight loss. Resident 65, who was admitted with diagnoses including COPD, high blood pressure, anxiety, dehydration, and alcohol abuse, experienced a significant weight loss from 91 pounds to 85 pounds within a month. Despite a care plan that included monitoring meal intake and a physician's order for a specific diet to promote weight gain, the meal consumption logs lacked documentation for several meals over a period of days. The Director of Nursing confirmed that meal consumptions were supposed to be documented after each meal. Similarly, Resident 67, who had a history of stroke, heart failure, hypertension, seizure disorder, and depression, also experienced weight loss, dropping from 136.8 pounds to 127.6 pounds over six months. The resident required supervision for eating, and the care plan included monitoring meal intake. However, the Task Nutrition-Amount Eaten Logs were missing documentation for numerous meals over the last 30 days. The Director of Nursing was unable to provide any documentation related to the resident's meal consumption for the specified dates.
Improper Administration of Gastrostomy Tube Medications and Delayed Enteral Feeding
Penalty
Summary
The facility failed to ensure proper administration of medications and water flushes via a gastrostomy tube for two residents. For Resident 147, an LPN was observed administering medications and water flushes by plunging them through the gastrostomy tube instead of using gravity, as required by the facility's policy. The LPN acknowledged awareness of the correct procedure but did not follow it. The Director of Nursing confirmed that the medications and water should be administered via gravity, aligning with the facility's Enteral Tube Medication Administration policy. For Resident 58, the facility did not start the enteral feeding at the scheduled time. The resident, who had a history of stroke, diabetes mellitus, and adult failure to thrive, was observed in bed with the feeding pump machine not connected and turned off. An RN admitted to being unaware that the resident's tube feeding had not been started after a shift change. The resident's care plan indicated total dependence on staff for eating, and the physician's order specified the feeding schedule, which was not adhered to, resulting in a delay in the resident's nutritional intake.
Oxygen Flow Rate Discrepancy for Resident
Penalty
Summary
The facility failed to ensure that a resident's oxygen was administered at the correct flow rate as prescribed by the physician. Resident 59, who has diagnoses including chronic obstructive pulmonary disease (COPD), chronic kidney disease, and hypertension, was observed multiple times over several days with her oxygen set at three liters per minute, despite a physician's order indicating it should be set at two liters per minute. This discrepancy was noted during observations on various dates, both when the resident was using a portable oxygen tank and an oxygen concentrator. The resident's care plan, which was intended to address her ineffective gas exchange, specified the need for oxygen therapy. However, the facility staff, including an LPN and the Director of Nursing, confirmed that the oxygen was consistently set higher than the prescribed two liters. This oversight was identified during a review of the resident's records and through direct observation, indicating a failure to adhere to the physician's orders for oxygen administration.
Inadequate Pain Management for Resident
Penalty
Summary
The facility failed to adequately manage the pain of a resident, identified as Resident E, who was observed crying out in pain and reported a consistent pain level of five to six out of ten. Despite her complaints, the resident was only provided with over-the-counter Tylenol and had previously stopped using Lidoderm patches due to skin irritation. The resident expressed a desire for stronger pain relief, but no alternative topical creams or stronger medications were offered until later. The resident's care plan included monitoring for pain and providing medication as ordered, but these measures were insufficient to address her chronic pain effectively. The resident's medical history included multiple sclerosis, quadriplegia, chronic pain, anxiety disorder, and low back pain. Despite being cognitively intact and able to communicate her pain levels, the facility's records showed a lack of detailed pain assessments, with the last comprehensive pain observation assessment dated nearly a year prior. Interviews with staff revealed a lack of awareness regarding the resident's pain levels and needs, leading to a delay in adjusting her pain management plan. It was only after the resident's continued complaints that the facility's Nurse Practitioner was informed, resulting in the prescription of Tramadol to better manage her pain.
Failure to Monitor Dialysis Site for Infection
Penalty
Summary
The facility failed to monitor for signs and symptoms of infection in a resident's perma cath used for dialysis. Resident M, who has diagnoses including end stage renal disease, type 2 diabetes, stroke, and high blood pressure, was observed with a clear bandage over the perma cath on the right upper chest. The care plan required evaluation for infection signs such as redness, tenderness, swelling, pain, and drainage, with visual inspection each shift. A physician's order also mandated checking the dialysis site for infection signs every shift. However, there was no documentation of these checks in the Medication or Treatment Administration Records for December 2024, January 2025, and February 2025. The Director of Nursing had no additional information to provide during an interview.
Medication Administration Errors Result in 7.14% Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in a 7.14% error rate during medication administration for two residents. The first incident involved a Licensed Practical Nurse (LPN) administering insulin to a resident with type 2 diabetes. The LPN failed to prime the second needle before administering the remaining 3 units of insulin after initially administering 30 units. This was contrary to the physician's order, which required 33 units of insulin to be administered subcutaneously before meals. The LPN acknowledged the mistake during an interview, and the Director of Nursing confirmed the need for priming the insulin pen before administration. The second incident involved another LPN administering medications via a gastrostomy tube to a resident with a history of stroke and dysphagia. The LPN administered Lansoprazole, Atorvastatin, and Metoprolol by pushing the medications with a plunger rather than allowing them to flow by gravity, as is standard practice. Additionally, the Lansoprazole was administered at 4:30 p.m., which was not in accordance with the physician's order for bedtime administration. The LPN admitted to the error, and the Director of Nursing confirmed that the administration time was incorrect.
Failure to Administer Sliding Scale Insulin Correctly
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors related to the administration of sliding scale insulin. During a medication pass, an LPN was observed administering insulin to a resident with a blood sugar level of 335. The LPN attempted to administer 33 units of Lispro Insulin as per the physician's order but was only able to administer 30 units initially due to the insulin pen's limitation. The LPN then administered the remaining 3 units separately. However, the resident did not receive any additional insulin as per the sliding scale order. The resident's medical record indicated a diagnosis of type 2 diabetes, with a physician's order for Humalog insulin to be administered according to a sliding scale. The sliding scale insulin was incorrectly entered into the computer system as a PRN order, which prevented it from appearing on the MAR for routine administration. Consequently, the resident did not receive the prescribed sliding scale insulin on numerous occasions when their blood sugar was above 200. Interviews with the LPN and the Director of Nursing confirmed the error in the computer system entry, which led to the oversight in administering the sliding scale insulin.
Failure to Follow Sternal Precautions in Physical Therapy
Penalty
Summary
The facility failed to provide specialized rehabilitative services as required for a resident, identified as Resident G, who was observed during a physical therapy session. Resident G, who had undergone open heart surgery and had an aortic valve replacement, pulmonic valve replacement, and tricuspid valve annuloplasty, was observed in bed with a dressing on his left upper arm AV fistula and a large gauze wrap on his left forearm with visible bleeding. Despite having sternal precautions in place, which included no pushing or pulling with the arms for 6 to 8 weeks, the physical therapist instructed Resident G to pull his upper body using his arms, which was contrary to the hospital's physical therapy notes that emphasized the importance of following these precautions. The therapy care plan included various precautions, but there was no documentation or physician's orders indicating that sternal precautions were not to be followed during physical therapy. The physical therapist's actions were questioned, and the Therapy Manager and Administrator were informed of the findings. However, there was no further information provided, and the Administrator suggested that the physical therapist might not have considered the need for sternal precautions. This lack of adherence to the prescribed precautions and absence of communication with the physician regarding safety measures for the resident led to the deficiency.
Deficiencies in Medication and Tube Feeding Documentation
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for two residents, leading to deficiencies in medication documentation and tube feeding records. For one resident, identified as Resident F, the Medication Administration Record (MAR) for February 2025 showed discrepancies in the administration of Metoprolol Succinate ER and Glimepiride. Specifically, there were missing entries and unexplained codes indicating the need to refer to nurse's notes, which were not available. The Director of Nursing (DON) was unable to provide documentation confirming whether the medications were administered on the specified dates, suggesting a lack of proper record-keeping. For another resident, identified as Resident 75, the facility failed to accurately document the percentage of tube feeding intake. The electronic Medication Administration Record (eMAR) contained inconsistent and nonsensical entries for the resident's enteral feeding intake, which did not reflect the actual percentage of intake as required. The DON acknowledged the discrepancies and indicated that the staff required further education on proper documentation practices. These failures highlight significant lapses in maintaining accurate and complete medical records for residents receiving critical medications and nutritional support.
Failure to Accurately Report Resident Altercation
Penalty
Summary
The facility failed to accurately and thoroughly report an allegation of resident-to-resident abuse to the Indiana Department of Health (IDOH). The incident involved two residents, C and D, who had a physical altercation resulting in Resident C falling to the ground and Resident D receiving a scratch to his left eye. The initial report to IDOH did not accurately describe the location of the altercation, the circumstances, or the correct diagnoses of the residents involved. Specifically, Resident C was incorrectly reported to have a diagnosis of bipolar disorder, whereas the record indicated alcohol dependency. Additionally, the injury was misreported as a hematoma to the back of the head instead of bruising to the left eye/brow. The follow-up report failed to include the investigation's findings, which clarified that there was no physical contact between the residents and that Resident C was intoxicated at the time of the incident. The investigation revealed that the altercation occurred outside the building in the smoking area at 3:30 a.m., and Resident C was intoxicated, having consumed alcohol obtained from a liquor store. Witness statements indicated that Resident C attempted to hit Resident D, who stepped aside, causing Resident C to fall and hit his face on the concrete. The facility's follow-up report to IDOH did not include these details or the conclusion that no physical contact had occurred. The facility's abuse policy required that the initial incident report provide sufficient information to describe the alleged violation and that the results of the investigation be reported within five working days, which was not adequately done in this case.
Failure to Maintain Current Smoking Assessment for Resident
Penalty
Summary
The facility failed to maintain a current smoking assessment for a resident who smoked independently. The resident, identified as having a diagnosis of alcohol dependency, had their last smoking assessment completed on September 20, 2023, which indicated they were capable of smoking independently. However, as of September 17, 2024, no updated assessment had been conducted. During an interview, a social service staff member confirmed the absence of a current smoking assessment. The facility's smoking policy, provided by the Director of Nursing, stated that residents should be assessed for smoking assistance upon admission, quarterly, and with any significant change in condition.
Failure to Monitor Resident with Alcohol Dependency
Penalty
Summary
The facility failed to adequately monitor a resident with a history of alcohol dependency, leading to an incident where the resident became intoxicated and had an altercation with another resident. The resident, identified as having alcohol dependency, was allowed to leave the facility on a pass and was later found intoxicated by a store employee. Despite being treated at a hospital for intoxication and a thumb fracture, the facility did not implement a comprehensive behavioral management plan to monitor the resident's alcohol use. Following the initial incident, the resident signed a Behavioral Contract agreeing to refrain from excessive alcohol consumption. However, the facility did not establish a care plan or behavior management plan to monitor the resident's alcohol use or behaviors related to alcohol consumption. The resident continued to sign out of the facility frequently without adequate monitoring for alcohol use, leading to another incident where the resident was involved in an altercation while intoxicated, resulting in physical injuries. Interviews with facility staff, including the Administrator and Director of Nursing, revealed that there were no behavior monitoring records or care plans in place for the resident's alcohol use. The facility's behavioral management policy required a resident-centered behavior management plan, but this was not implemented for the resident in question. The lack of monitoring and documentation of the resident's alcohol use and behaviors contributed to the deficiency identified in the report.
Incomplete Documentation of Resident's Room Transfer
Penalty
Summary
The facility failed to ensure the completeness and accuracy of a resident's medical record concerning an intrafacility transfer. Resident J, who has a diagnosis of paraplegia, was involved in a room transfer that was not properly documented. The Notification of Room Change form, dated 8/8/24, indicated the transfer and noted that the resident was satisfied with the change, but it lacked the resident's signature. The form's instructions required signatures and uploading into the electronic health record, which was not done. During interviews, it was revealed that the resident was not happy about the transfer, contradicting the form's indication. The Administrator claimed the resident was given notice and agreed to the transfer, but admitted that the conversation was not documented in the resident's record.
Violation of Resident Privacy Due to Unauthorized Video Recording
Penalty
Summary
The facility failed to ensure the privacy of a resident, identified as Resident B, who was cognitively impaired. An employee, Receptionist 1, used her private cell phone to take a video of Resident B without the approval of the resident's Court Appointed Guardian. The video was taken after Receptionist 1 asked Resident B about her weekend plans, to which the resident responded with a concerning statement about self-harm. The video was then sent to a Housekeeping Supervisor via Snapchat, an instant messaging application. Resident B had a diagnosis of dementia and depressive disorder, and a court document indicated that the resident was incapacitated due to dementia and poor judgment. A Court Ordered Guardian had been assigned to the resident. Despite this, a Photo Release Form was signed by the resident, not the Guardian, allowing the facility to use recordings or photographs for various purposes. The facility's policy prohibits employees from taking and distributing photos outside of medical or safety use, which was violated in this incident.
Delayed Response to Suicidal Ideation in Dementia Resident
Penalty
Summary
The facility failed to respond promptly to a suicidal ideation expressed by a cognitively impaired resident diagnosed with dementia and depressive disorder. On 7/10/24, the resident made a statement about wanting to kill herself during a conversation with a receptionist, who recorded the interaction on video. The receptionist sent the video to a housekeeping supervisor via Snapchat, but the supervisor did not view it until several days later. The delay in viewing and reporting the video resulted in a significant lapse in notifying the appropriate personnel, including Social Services and the Administrator, who were not informed until 7/23/24. The resident's medical records indicated a history of dementia and depressive disorder, with a recent psychiatric progress note on 7/11/24 showing no suicidal ideation. However, the psychiatric consultant was not informed of the resident's statement from 7/10/24. The facility's policy required immediate action upon any expression of suicidal ideation, including notifying the Director of Nursing, the Administrator, the Guardian, the Physician, and Psychiatric Services, as well as implementing one-on-one monitoring. These steps were not taken in a timely manner, leading to a deficiency in the facility's response to the resident's mental health needs.
Failure to Notify POA and Physician of Resident's Condition Changes
Penalty
Summary
The facility failed to promptly notify the resident's Power of Attorney (POA) and physician of significant changes in the resident's condition. Resident E, who was not cognitively intact and had multiple medical conditions including stroke, hemiplegia, and vascular dementia, developed new non-pressure skin areas and was transferred to the hospital without timely notification to the POA. The resident had moisture-associated skin damage, a skin tear, and a fluid-filled blister, but there was no documentation that the POA was informed of these conditions. Additionally, the resident was transferred to the hospital for a PICC line insertion, yet the POA was not notified of this transfer. Furthermore, the facility did not promptly notify the resident's physician of abnormal laboratory results. The resident had abnormal blood cell counts and neutrophil levels, but the Nurse Practitioner (NP) did not review these results until over 24 hours later. The Director of Nursing (DON) confirmed the lack of documentation regarding the notification of the resident's family about the non-pressure areas, the lump on the forehead, and the hospital transfer. The facility's policy required notification of changes in condition, but this was not adhered to in the case of Resident E.
Failure to Conduct Neurological Checks After Unwitnessed Fall
Penalty
Summary
The facility failed to initiate neurological checks after an unwitnessed fall involving a resident, identified as Resident D, who was at risk for falls. Resident D had a medical history that included stroke, dysphagia, hemiplegia, type 2 diabetes, and high blood pressure, and was not cognitively intact for daily decision-making. The resident was dependent on staff for toilet hygiene and had an indwelling foley catheter. Despite being at risk for falls, as noted in the care plan, the facility did not perform neurological checks after the resident was found on the floor on 5/28/24, following an unwitnessed fall. The resident was sent to the emergency room and returned the next day, yet no neurological checks were conducted upon their return. The Director of Nursing confirmed during an interview that no neurological checks were completed after the fall on 5/28/24. The facility's policy indicated that neurological checks should be performed for falls with unknown head injury, but this was not adhered to in this case. Additionally, another fall occurred on 6/10/24, which was reportedly witnessed, but the report does not indicate whether neurological checks were performed in this instance. The failure to conduct neurological checks after the unwitnessed fall on 5/28/24 constitutes a deficiency in the care provided to Resident D.
Failure to Ensure Proper Footwear for Fall-Risk Resident
Penalty
Summary
The facility failed to ensure that a resident with a history of falls was wearing the proper footwear to prevent further falls and/or injury. Resident D, who was observed multiple times wearing plain black ankle socks, was identified as being at risk for falls. The resident's care plan specifically indicated the need for appropriate non-skid footwear, yet this was not adhered to during observations. The resident had a history of falls, including incidents on 5/28/24 and 6/10/24, where he was found on the floor in his room. These falls were documented in the resident's records, and the care plan noted the resident's behavior of intentionally throwing his legs on the side of the bed, increasing his fall risk. The resident's medical history included stroke, dysphagia, hemiplegia, type 2 diabetes, and high blood pressure, and he was not cognitively intact for daily decision-making. Despite these conditions and the documented risk for falls, the facility did not ensure the resident was wearing the appropriate footwear as per the care plan. The Director of Nursing confirmed that the resident was supposed to have appropriate footwear on at all times, indicating a lapse in adherence to the care plan and supervision protocols designed to prevent accidents.
Infection Control Deficiencies
Penalty
Summary
The facility failed to ensure proper infection control guidelines were in place and implemented, particularly regarding the use of personal protective equipment (PPE) and hand hygiene. In one instance, a CNA entered a resident's room without the required enhanced barrier precautions (EBP) sign on the door and only donned gloves before providing care. The CNA admitted to not receiving education on EBP. Additionally, the CNA did not perform hand hygiene after removing gloves and left the room with soiled items. Another observation noted that the Wound Nurse Practitioner and Wound Nurse began wound care treatment without donning gowns, only doing so after being reminded. The resident involved had multiple sclerosis, an indwelling urinary catheter, and several pressure ulcers, with a care plan indicating the need for EBP due to a history of vancomycin-resistant enterococcus (VRE) infections and a physician's order for EBP related to the indwelling catheter and colonized multi-drug resistant organism. In another instance, two CNAs provided care to a resident without donning gloves and failed to perform hand hygiene after handling soiled items. One CNA exited the room with a soiled blanket without placing it in a plastic bag and without performing hand hygiene. The Director of Nursing indicated that staff had been educated on EBP, hand hygiene, and glove usage, but some staff members, including the involved CNAs and Wound Nurse, had not attended the training. The facility's failure to ensure proper infection control practices had the potential to affect residents on two of the three units and those requiring treatment for pressure wounds.
Failure to Ensure Call Lights Within Reach
Penalty
Summary
The facility failed to meet the needs of residents by not ensuring that call lights were placed within reach for two residents. Resident G was observed multiple times with the call light draped over the bedside dresser, out of reach. Despite staff entering the room and removing the meal tray, the call light remained inaccessible until CNA 4 repositioned it within reach. Resident G's medical history includes cerebrovascular insufficiency, dementia, and a history of falls, with a care plan intervention indicating that the call light should be within reach since 8/14/23. Similarly, Resident K was observed with the call light tied to the side rail and hanging down toward the floor, making it inaccessible. This condition persisted through multiple observations until CNA 5 provided incontinent care and placed the call light within reach. Resident K was lying in bed with her eyes closed during the initial observation, and the call light remained out of reach even after the meal tray was removed. These deficiencies were related to complaints IN00429320 and IN00429834.
Failure to Notify Residents of Room Changes Due to COVID-19
Penalty
Summary
The facility failed to notify residents and/or their Responsible Parties in writing of intrafacility transfers related to room changes due to a COVID-19 outbreak. Resident D, who was cognitively intact, was moved to a different room after testing positive for COVID-19 and remained there for 20 days without receiving written notification of the room change. The Director of Nursing confirmed the absence of an intrafacility transfer form for this move. Similarly, Resident M, who had severely impaired cognitive decision-making skills, was moved to a quarantine unit after testing positive for COVID-19 without any documentation of a room change notification. The Social Service Director admitted to not completing the required notification form for Resident M's room change. Resident N, who was cognitively intact, was also moved to a quarantine unit after testing positive for COVID-19 without any documentation of a room change notification. The Social Service Director confirmed that no notification form was completed for Resident N's room change. These deficiencies were identified during a complaint investigation and were related to the facility's failure to honor residents' rights to receive written notice before a room change.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to ensure a clean and homelike environment for its residents, as evidenced by observations of stained, dirty, and tattered bed linens. Resident D was observed with a hole in the bottom sheet of his bed, which remained unchanged the following day. Resident J was found lying in bed with a brownish/tan dried stain on the pillowcase of the bottom pillow. Resident C was observed with an orange stain on the pillowcase under her head and large dried beige stains on the bottom sheet under her. Despite the resident's indication that no one had been in her room all night, the Unit Manager confirmed that the morning care had not yet been provided, and the linens had not been changed during the night when the resident was repositioned and checked. During interviews, the Administrator acknowledged that soiled linens should have been changed and mentioned that the facility had ordered new sheets to replace tattered and stained ones. However, the observations indicated that the facility did not maintain a clean and homelike environment for the residents, as required. This deficiency was related to complaints IN00429320 and IN00429834.
Failure to Document Recapitulation of Resident's Stay on Discharge Summary
Penalty
Summary
The facility failed to ensure a recapitulation of the resident's stay was documented on the discharge summary provided to the resident at the time of discharge for three residents. Resident B's discharge summary had 'N/A' documented under the course of illness/progress section, and there was no documentation of a recapitulation of the resident's stay. Resident E's discharge summary also had 'N/A' documented under the course of illness/progress section, and there was no documentation in the nursing progress notes at the time of discharge. Resident F's discharge summary had the course of illness/progress section left blank and not completed. During interviews, the Director of Nursing indicated she was unaware that the nursing staff were documenting 'N/A' under the course of stay and confirmed that the discharge summaries were supposed to be completed and given to the residents at the time of discharge. The facility's Transfer and Discharge policy stated that a discharge summary should include a summary of the resident's stay, including diagnosis, course of illness/treatment or therapy, pertinent labs, radiology, and consultation results. This policy was not followed for the three residents reviewed.
Failure to Assist Residents with Meals
Penalty
Summary
The facility failed to ensure that residents who were dependent and/or required assistance with activities of daily living (ADLs) received the necessary help with their meals. During a random observation, a CNA delivered a lunch tray to Resident L, who was asleep at the time. The tray was left on the over bed table, and no staff returned to assist the resident with eating. The resident's record indicated that she needed partial to moderate assistance with eating. The Director of Nursing confirmed that no staff had gone back to help the resident eat after the tray was delivered. The resident later confirmed that she needed assistance with eating at times. In another instance, Resident C's lunch meal was delivered and placed on a shelf while care was being completed. After her treatments were finished, the meal tray was placed in front of her, but she was unable to cut the sausage on her plate. The resident indicated she wanted to eat the sausage but needed assistance to cut it. The Director of Nursing was informed and indicated that a staff member would assist. Resident C's record showed she had multiple sclerosis and required supervision/set-up for eating. The care plan also indicated that staff should provide assistance with meals as needed.
Failure to Provide Necessary Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure a resident with pressure ulcers received the necessary treatment and services to promote healing. During an observation, it was noted that Resident C, who had multiple pressure ulcers, did not have the required dressings in place as ordered by the Physician. Specifically, the wound vacuum was not in place on the sacrum/coccyx area, and there were no dressings on the pressure ulcers on the left and right ischium. The CNAs indicated that the dressings were not present during their shift, and the Wound Nurse and Wound Nurse Practitioner were not informed about the missing dressings. Resident C's medical record indicated a diagnosis of multiple sclerosis and detailed the presence of stage four and unstageable pressure ulcers. The Physician's Orders required specific treatments, including a wound vacuum and hydrocolloid dressings, which were not adhered to. The Director of Nursing confirmed that the night shift CNA had forgotten to inform the nurse about the dressings coming off during the night. The facility's Skin Care & Wound Management policy required daily monitoring and application of treatments, which was not followed in this instance.
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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