Harbor Health & Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in East Chicago, Indiana.
- Location
- 5025 Mccook Ave, East Chicago, Indiana 46312
- CMS Provider Number
- 155653
- Inspections on file
- 33
- Latest survey
- February 25, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Harbor Health & Rehab during CMS and state inspections, most recent first.
The facility failed to keep care plans current and comprehensive for several residents with dementia, schizophrenia, behavioral issues, fall risk, and abuse/neglect risk. One resident with Alzheimer’s and psychotic disorder had incidents involving other residents, including a verbal altercation that led to pain and hospital transfer, yet elopement, abuse/neglect, and fall care plan interventions had not been revised for many months. Another resident with schizophrenia and multiple comorbidities had repeated verbally aggressive behaviors, was placed on frequent safety checks, and was twice sent to the hospital, but behavior care plan interventions were not updated to reflect these events until much later. Additional residents with suicidal ideation, psychotic disorder, paranoid schizophrenia, and hemiplegia were involved in aggressive or maladaptive interactions, while their abuse/neglect and behavior-related care plan interventions remained outdated despite later revision dates on the care plans themselves.
A resident with Alzheimer’s disease, psychotic disorder, HTN, depression, anemia, and COPD, who was documented as cognitively impaired for daily decision making on the MDS, experienced a change in roommate. A nurse’s progress note indicated the resident was adjusting well to the new roommate, confirming the change occurred, but there was no documentation that the resident’s Responsible Party was notified. During interview, the DON acknowledged that the Responsible Party had not been informed of the roommate change, as she believed notification was only required for a room change.
A resident with Alzheimer's disease, psychotic disorder, HTN, depression, anemia, and COPD, identified on the MDS as cognitively impaired for daily decision making, did not have ongoing care plan meetings conducted and documented as required. A social services note showed that a care plan meeting was arranged with the resident's daughter and held on the same day, but records indicated this was the last documented care plan meeting, with no further meetings recorded. During interview, a nurse consultant confirmed there was no documentation of any subsequent scheduled or rescheduled care plan meetings, despite the expectation that any cancelled meetings be documented as rescheduled.
A resident with schizophrenia, dementia, depression, anxiety, HIV, alcohol abuse, and a history of verbal and physical aggression exhibited escalating behaviors, including unprovoked verbal abuse and striking staff and another resident, leading to multiple hospital and psychiatric evaluations. Despite physician orders for 15‑minute safety checks and a behavior care plan citing aggression toward staff and peers, the record lacked required safety check documentation over an extended period, and behavior interventions were not updated for many months despite repeated aggressive incidents. Staff interviews confirmed the resident’s unpredictable aggression, absence of effective de‑escalation techniques, and that ordered close monitoring was not consistently implemented after returns from behavioral health hospitalizations.
A resident with multiple psychiatric, cognitive, and medical diagnoses, including schizophrenia, dementia, depression, anxiety, HIV, and alcohol abuse, had a physician’s order for 15-minute safety checks every shift. Review of safety logs showed that the ordered 15-minute checks were not signed out for a one-hour period. An LPN reported that the checks had been done but not yet charted, and the DON stated that staff are expected to complete all ordered 15-minute checks and sign off each time, acknowledging that the documentation for that hour should have been completed.
A resident with COPD and other medical conditions was observed receiving oxygen therapy at a flow rate below the physician-ordered 2 liters per minute on multiple occasions. The nasal cannula was not always properly positioned, and an LPN initially failed to verify the correct flow rate before adjusting it. The care plan and physician's orders specified the need for 2 liters of oxygen via nasal cannula as needed, but this was not consistently provided as required.
A resident, dependent on staff for mobility, fell and fractured her leg during a Hoyer lift transfer when only one staff member assisted, contrary to the facility's two-person policy. The resident, with a history of osteoporosis and neuromuscular weakness, was transferred by a CNA who could not find additional help. The CNA attempted to prevent the fall, but the resident's leg was injured during the incident.
The facility's first floor had several environmental deficiencies, including marred walls, loose baseboards, and missing bolts around toilets, affecting multiple residents. The Maintenance Director confirmed the need for repairs.
A cognitively impaired resident was repeatedly observed wearing a hospital gown during the day, with no care plan indicating this preference. The resident, with multiple health conditions, had an incomplete Activity Assessment and lacked a care plan addressing clothing needs. The DON confirmed the absence of personal clothes and a related care plan.
Two residents in the facility did not receive adequate assistance with ADLs, including nail care, oral hygiene, and mobility. One resident had long, dirty fingernails and expressed a need for nail care, which had not been performed since late July. Another resident was observed with long fingernails and dried mucous around the lips, indicating a lack of oral care, and was not assisted out of bed despite no bed rest order. Staff interviews confirmed these deficiencies, and the DON acknowledged that care tasks should have been completed as needed.
The facility failed to provide personalized activity programs for two cognitively impaired residents. One resident, in a persistent vegetative state, received minimal engagement despite a care plan for 1:1 visits and music stimulation. Another resident, with multiple diagnoses, was observed in bed without access to activities or proper stimulation, and the care plan did not reflect the resident's current status. The Activity Director and DON acknowledged these deficiencies.
The facility failed to provide appropriate treatment and documentation for two residents with non-pressure related skin conditions. One resident did not receive consistent treatment for a finger wound as ordered, and another resident's arm discoloration was not documented or communicated among staff. The facility's Wound Management policy was not effectively followed.
The facility failed to provide necessary vision and hearing services to residents. A resident with diabetes and renal disease did not receive new glasses recommended after an eye exam, and another resident with hearing loss did not receive a hearing aid despite a recommendation. Additionally, a third resident with chronic conditions did not receive glasses as advised. The Social Service Director was unaware of these issues, and Medicaid coverage was a barrier for one resident's glasses.
A resident with multiple health conditions, including a pressure ulcer, did not receive the necessary treatment as ordered by the physician, leading to a deficiency in care. Observations revealed the absence of a bandage on the ulcer, which had worsened with necrotic tissue. Staff interviews indicated a lack of adherence to the treatment plan, and the Wound Nurse confirmed the treatment was not completed as ordered, resulting in the wound's deterioration.
A resident with a suprapubic catheter did not receive the required catheter care, as evidenced by an outdated bandage with dried blood. The resident, who has multiple medical conditions, was assessed to need assistance with personal hygiene. Despite physician orders for catheter care every shift, the facility failed to comply, as confirmed by the DON.
A resident with a PEG tube was improperly positioned during enteral feeding, contrary to the care plan requiring the head of the bed to be elevated 30-45 degrees. CNAs lowered the bed and put the feeding on hold, which was not allowed. The resident had multiple health issues and was dependent on staff for care.
A resident with COPD and other health conditions was observed receiving oxygen at 1.5 liters instead of the prescribed 2 liters. The care plan and physician orders both indicated the need for a 2-liter flow rate, but this was not followed, as confirmed by the DON.
A facility failed to maintain accurate documentation for narcotic medications, leading to a suspected diversion by a nurse. A resident prescribed Morphine Sulfate had discrepancies in the narcotic log, with doses inaccurately recorded. The issue was not reported until later, despite the medication being signed out as given twice daily. The nurse involved refused a drug screen and terminated employment.
A facility failed to document blood pressure readings for a resident receiving Hydralazine, despite a physician's order to hold the medication if systolic blood pressure was below 110. Staff interviews revealed that blood pressures were checked but not documented due to system limitations, and nursing leadership acknowledged the oversight.
A resident with Alzheimer's disease was prescribed Seroquel for behavior management without adequate documentation of its necessity or an attempt at gradual dose reduction. The resident's care plan included antipsychotic medication, but there was no approved diagnosis for its use, and the resident had not been seen by the behavioral health NP. Seroquel is not FDA-approved for dementia-related psychosis, and there is a black box warning about increased mortality in such cases.
A resident with decayed and broken teeth did not receive routine dental services due to a lack of follow-up after a dental exam in April 2024. The exam indicated non-restorable teeth and inflamed gums, but no care plan was documented. The MDS Coordinator was unaware of the issues, and the resident had not seen a dentist since the facility changed providers. The resident was reluctant to restart the dental process with the new provider.
The facility did not follow recipes for pureed diets, affecting two residents. A cook prepared pureed barbeque chicken and broccoli without using additional ingredients as specified in the recipes, such as sauce and margarine. The Dietary Manager confirmed that the recipes should have been followed, indicating a failure to adhere to dietary protocols.
The facility failed to maintain accurate clinical records for two residents. A resident with end-stage renal disease had inconsistent documentation of their dialysis access site condition, while another resident, who was NPO, had incorrect medication administration routes documented as oral instead of via peg tube. The DON and ADON acknowledged these documentation errors.
The facility failed to address a repeated deficiency related to pest control, specifically gnats in resident rooms, affecting all 60 residents. Despite regular meetings of the QAA Committee, no action plans or Performance Improvement Plans were developed. The Administrator was aware of the issue and engaged pest control services weekly, but treatments did not always target gnats.
A resident with pressure ulcers was found in a room infested with gnats, which were observed on their bed linen and wound dressing. The Wound Nurse confirmed the presence of gnats during wound care, despite pest control measures being in place for other pests. The facility's pest control program did not address gnats, contrary to its policy of maintaining a pest-free environment.
A resident with a history of falls was observed with a low bed and floor mat, but these interventions were not documented in the care plan. Despite a previous fall, the care plan only included a reach assist bar and lacked specific interventions like the low bed and mat. The DON confirmed the care plan update post-fall but acknowledged the missing documentation.
A facility failed to notify a physician of a resident's elevated blood glucose levels, despite multiple readings above 400 mg/dL. The resident, who was receiving insulin for diabetes, had no specific parameters in place for physician notification. Interviews with staff confirmed the expectation to notify physicians of such levels, but documentation was lacking.
Failure to Maintain Current, Comprehensive Care Plans for Residents With Behaviors, Falls, and Abuse Risk
Penalty
Summary
The deficiency involves the facility’s failure to develop and update comprehensive, measurable care plans with current interventions for multiple residents with behaviors, falls, schizophrenia, and abuse/neglect risk. For one resident with Alzheimer’s disease, psychotic disorder, depression, COPD, and cognitive impairment, the record showed two facility-reported incidents: a candy-related interaction with another resident where no injuries occurred, and a later verbal altercation with a different resident that resulted in the resident being found on the floor with right leg and hip pain and being sent to the hospital. Despite these events and existing care plans for elopement/wandering, abuse/neglect risk, and falls, the interventions within these care plans had not been revised for many months, with the elopement/wandering interventions last revised in June of the prior year, the abuse/neglect interventions unchanged since May of the prior year, and the fall interventions last updated in July of the prior year. Another resident with schizophrenia, dementia, dysphagia, depression, anxiety, mild cognitive impairment, mild intellectual abilities, restlessness and agitation, HIV, and alcohol abuse had multiple documented episodes of verbally aggressive behavior toward staff and residents over several dates. Nursing notes documented the use of 30‑minute checks and later 15‑minute safety checks, as well as two separate hospital transfers for evaluation and behavioral health care. The resident had a behavior care plan that included interventions such as praising progress, protecting the rights and safety of others, minimizing disruptive behaviors, and 15‑minute safety checks. However, the interventions in this behavior care plan were not updated after the series of aggressive behaviors and hospitalizations in December and January; the last intervention prior to the February incident was from September of the previous year, and the care plan interventions were only updated after a later psychiatric hospitalization. A third resident with suicidal ideations, dementia, anxiety, hypertension, major depressive disorder, and psychotic disorder was involved in the candy-related incident when another resident offered candy and this resident swatted at it, knocking it to the floor, with no injuries noted. This resident had an abuse/neglect risk care plan and a separate care plan for socially inappropriate and maladaptive behavior, but the interventions for abuse/neglect had not been revised since early August of the prior year, and the socially inappropriate/maladaptive behavior interventions had not been revised since mid‑September of the prior year. A fourth resident with hemiplegia, hypotension, paranoid schizophrenia, aphasia, epilepsy, dysphagia, and a right hand contracture was involved in an aggressive incident toward the third resident, after which both residents were assessed and one was sent to the hospital. This fourth resident had an abuse/neglect risk care plan and a schizophrenia care plan, but the abuse/neglect interventions had not been revised since May of the prior year, and the schizophrenia care plan interventions had not been updated since early May of the prior year, despite the later aggressive incident and subsequent care plan revision dates that did not include updated interventions.
Failure to Notify Responsible Party of Roommate Change
Penalty
Summary
The facility failed to notify a resident’s Responsible Party of a change in roommate, as required for situations that affect the resident. Resident B’s record, reviewed on 2/23/26, showed multiple diagnoses including Alzheimer’s disease, psychotic disorder, hypertension, depression, anemia, and COPD, and a Quarterly MDS dated 11/4/25 documented that the resident was cognitively impaired for daily decision making. A nurse’s progress note dated 1/22/26 at 12:46 a.m. stated that the resident appeared to be adjusting well to a new roommate, confirming that a roommate change had occurred. However, there was no documentation that the resident’s Responsible Party had been notified of this new roommate, and during interview the DON acknowledged that the Responsible Party was not notified of the roommate change, as she believed notification was only required for a room change. This deficiency was cited under 3.1-5(b)(1) and related to Intake 2739564.
Failure to Conduct and Document Ongoing Care Plan Meetings
Penalty
Summary
The facility failed to ensure required care plan meetings were conducted and documented for a resident, as mandated to be developed within 7 days of the comprehensive assessment and prepared, reviewed, and revised by an interdisciplinary team. Record review for Resident B, who had diagnoses including Alzheimer's disease, psychotic disorder, hypertension, depression, anemia, and COPD, showed that a Quarterly MDS dated 11/4/25 identified the resident as cognitively impaired for daily decision making. A Social Services note dated 9/23/25 documented that the Social Service Director contacted the resident's daughter to schedule a care plan meeting, and the daughter agreed to have the meeting when she arrived at the facility that day, with the SSD indicating availability to conduct it. The record showed the last care plan meeting occurred on 9/23/25, with no documentation of any subsequent care plan meetings after that date. During interview, the Nurse Consultant reported contacting the previous social worker and confirmed there was no documentation of a scheduled or rescheduled care plan meeting, and stated that any cancelled meeting should have been documented as rescheduled. This citation relates to Intake 2739564 and regulatory reference 3.1-35.
Failure to Provide Adequate Behavioral Health Interventions and Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary behavioral health care and services to a resident with a history of significant psychiatric and behavioral issues. The resident’s diagnoses included schizophrenia, dementia, depression, anxiety, mild cognitive impairment, mild intellectual abilities, restlessness and agitation, HIV, alcohol abuse, and dysphagia. A quarterly MDS showed the resident was cognitively intact for daily decision-making but had worsening verbal behaviors. On one day, multiple behavior notes documented verbal aggression toward staff and residents, and the resident was placed on 30‑minute safety checks for 72 hours. Subsequently, the resident was sent to the hospital for evaluation and later returned to the facility. Following the resident’s return, a physician ordered 15‑minute safety checks every shift with completion of a safety log, and nursing documentation indicated the resident was verbally aggressive and placed on 15‑minute checks before being sent again to a hospital behavioral health unit. However, the record lacked documentation of 15‑minute safety checks from late December through early February, despite ongoing behavior issues. During this period, multiple nurse’s notes documented repeated verbally aggressive behaviors on numerous dates. The behavior care plan, which identified aggression toward staff and residents related to mental illness, contained general interventions such as administering medications, assessing coping skills, and assessing understanding of the situation, but behavior interventions were not updated after the December incidents and hospitalizations. On a later date in February, nurse’s notes documented verbal and physical aggression toward staff and another resident, leading to the resident being isolated from others and sent to the hospital for psychological evaluation. A facility‑reported incident described staff overhearing a verbal altercation between two residents, after which one resident was found on the floor with pain in the leg and hip and was sent to the hospital, while the aggressive resident was sent for psychiatric evaluation. A physician again ordered 15‑minute safety checks for 72 hours. The behavior care plan, originally dated in 2023 and revised in early February 2026, noted a history of verbal and physical aggression and included interventions such as praising progress, protecting the rights and safety of others, and placing the resident on 15‑minute safety checks, but the interventions had not been updated between September 2024 and mid‑February 2026 despite multiple aggressive incidents and hospitalizations. Interviews with the ADON, CNAs, and DON confirmed the resident’s unpredictable, unprovoked verbal and physical aggression, the lack of effective de‑escalation techniques, and that the resident was not on 15‑minute safety checks when returning from earlier psychological evaluations.
Failure to Accurately Document 15-Minute Safety Checks
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and complete clinical records for a resident on physician-ordered 15-minute safety checks. Resident C had multiple diagnoses, including schizophrenia, dementia, dysphagia, depression, anxiety, mild cognitive impairment, mild intellectual abilities, restlessness and agitation, HIV, and alcohol abuse. A Quarterly MDS dated 11/4/25 documented that the resident was cognitively intact for daily decision-making and exhibited verbal behaviors that were worse than on the previous assessment. A physician’s order dated 2/16/26 directed staff to initiate 15-minute safety checks every shift for monitoring. On 2/24/26, review of the safety logs on the second floor showed that the 15-minute safety checks for Resident C were not signed out from 3:00 p.m. to 4:00 p.m. During interview, an LPN stated she should have charted the 15-minute checks after performing them but had not yet done so. In a separate interview, the DON stated she expected nursing staff to complete all ordered 15-minute safety checks and sign off in the logs each time, and acknowledged that the checks for the previous hour should have been signed off.
Failure to Ensure Correct Oxygen Flow Rate for Resident
Penalty
Summary
A deficiency was identified when a resident requiring oxygen therapy for conditions including COPD, heart failure, and dementia was observed with their oxygen flow rate set incorrectly on multiple occasions. On two separate days, the oxygen flow meter was set slightly above 1.5 liters per minute, rather than the physician-ordered 2 liters per minute via nasal cannula. During one observation, the nasal cannula tubing was not properly positioned under the resident's nose. An LPN, when questioned, initially stated the oxygen was set at 2 liters but upon verification, acknowledged the flow rate was incorrect and adjusted it to the prescribed level. The resident's care plan specified oxygen therapy as needed for shortness of breath, with instructions to administer oxygen as ordered by the physician. The resident's medical record confirmed the order for 2 liters of oxygen via nasal cannula as needed. The DON confirmed that nursing staff had been previously in-serviced on the correct method for checking oxygen flow rates, which involves viewing the flow meter at eye level to ensure accuracy. Despite these instructions, the oxygen was not set at the correct rate as ordered.
Inadequate Supervision During Hoyer Lift Transfer Leads to Resident Injury
Penalty
Summary
The facility failed to ensure adequate assistance and supervision during a mechanical lift transfer, resulting in a fall and injury for a dependent resident. The incident involved a single staff member assisting the resident during a Hoyer lift transfer, contrary to the facility's policy and the manufacturer's recommendation of requiring two staff members. This lapse in protocol led to the resident falling and sustaining a fracture to her leg. The resident involved in the incident was cognitively intact but dependent on staff for mobility and transfers. She had a history of conditions that increased her risk for falls, including osteoporosis and neuromuscular weakness. Despite these risk factors, the resident was transferred by only one staff member, which was insufficient to ensure her safety during the transfer process. The incident was witnessed by a CNA who admitted to transferring the resident alone because she could not find another staff member to assist, and the resident was insistent on being moved. The CNA attempted to prevent the fall by getting under the resident, but the resident's leg may have hit the lift, contributing to the injury. The facility's failure to adhere to the two-person transfer policy directly led to the resident's fall and subsequent injury.
Environmental Deficiencies on First Floor
Penalty
Summary
The facility failed to maintain a safe and well-maintained environment for residents on the first floor, as observed during an environmental tour. Several deficiencies were noted, including marred walls, loose baseboards, and missing bolts around toilets in multiple rooms. Specifically, the cove base was pulling away from the wall near the entrance of one room, and the walls were marred under the chair rail. Another room had a marred and gouged wall behind the bed. In a different room, the door frame was marred by the closet, and the cove base was loose in the entryway. Additionally, the bathroom walls were marred. In another instance, the bathroom door frame was marred, and the paint on the walls was chipped, with exposed bolts at the base of the toilet. These conditions affected several residents who shared these rooms and bathrooms. The Maintenance Director acknowledged the need for repairs during the interview.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to maintain the dignity of a cognitively impaired resident, identified as Resident 58, who was observed wearing a hospital gown during the day on multiple occasions. The resident, who was moderately impaired in daily decision-making due to conditions such as stroke, obesity, dysphagia, type 2 diabetes, high blood pressure, heart disease, and restlessness, did not have a care plan indicating a preference for wearing a hospital gown. Additionally, an Activity Assessment for the resident was incomplete, lacking information on recreation interests, habits, and preferences. During an interview, the Director of Nursing acknowledged that the resident had no clothes but confirmed there was no care plan addressing this issue.
Deficiency in ADL Assistance for Two Residents
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for two residents, specifically in the areas of nail care, oral hygiene, and mobility. Resident 45 was observed multiple times with long and dirty fingernails, despite expressing a need for nail care. The resident's care plan indicated a need for assistance with personal hygiene, but nail care had not been performed since 7/29/24. Interviews with staff revealed that nail care was not provided as needed, and the Director of Nursing confirmed that nail care should be done as required. Resident 58 was also observed with long fingernails and dried mucous around the lips, indicating a lack of oral care. The resident was dependent on staff for personal hygiene and oral care due to a recent stroke, as noted in the care plan. Despite this, there was no documentation of oral care being performed daily. Additionally, the resident was not being assisted out of bed, although there was no physician's order for bed rest. Staff interviews confirmed the lack of oral care and mobility assistance, and the Director of Nursing acknowledged that these care tasks should have been completed as needed.
Failure to Provide Personalized Activity Programs for Cognitively Impaired Residents
Penalty
Summary
The facility failed to provide a personalized activity program for two residents, both of whom were cognitively impaired and dependent. Resident 24, diagnosed with conditions including stroke and major depressive disorder, was observed multiple times over several days in a persistent vegetative state, lying in bed with no television or radio present for stimulation. The resident's care plan indicated the need for 1:1 visits and music stimulation, yet the resident only received minimal engagement, such as listening to music on two occasions and being read a story twice in early August. The Activity Director acknowledged the lack of ongoing stimulation and the absence of a radio in the resident's room. Resident 58, who had diagnoses including stroke and diabetes, was observed in bed with the television turned off and positioned in a way that the resident could not see it. The resident's care plan required encouragement for activities, but the resident had not participated in any group activities since June and had limited 1:1 visits. The Activity Director noted that the care plan did not reflect the resident's current status, and there was no radio for continuous music. The Director of Nursing mentioned that the resident was not being moved out of bed due to restlessness, although there was no care plan or physician's order for bed rest.
Failure to Provide Proper Skin Care and Documentation
Penalty
Summary
The facility failed to provide appropriate treatment and care for two residents with non-pressure related skin conditions. Resident 13, who has multiple diagnoses including COPD, diabetes, and heart disease, was observed with dry, flaky skin on her feet and an open area on her right ring finger that was not covered. The resident reported that the treatment for her finger was last done on a previous Friday and was supposed to be done every Monday, Wednesday, and Friday. However, the treatment was not completed as scheduled on 8/6/24. The Wound Physician had ordered daily treatment with betadine, but the Treatment Administration Record indicated it was not consistently administered. The Wound Nurse acknowledged the treatment was to be done daily, and the Director of Nursing confirmed the treatment should have been completed as ordered. Resident 57, who has Alzheimer's disease and other conditions, was observed with a large red and purple discoloration on his left forearm. Despite this visible condition, there was no documentation in the clinical record regarding the discoloration from 8/1-8/7/24. Staff members, including an LPN and an RN, were unaware of the discoloration, and the Director of Nursing only assessed it after being informed. The resident mentioned that such discolorations occur frequently. The facility's Wound Management policy was intended to assist in the care and documentation of wounds, but it was not effectively implemented in this case.
Failure to Provide Vision and Hearing Services
Penalty
Summary
The facility failed to ensure that residents received necessary vision and hearing services as ordered. Resident 2, who has diagnoses including type 2 diabetes and end-stage renal disease, reported needing new glasses, which were recommended after an eye exam on 12/19/23. Despite being cognitively intact and having a care plan that included arranging consultations with an eye care practitioner, there was no documentation indicating that the resident received the new glasses. The Social Service Director, who had been employed for 95 days, acknowledged the issue and noted that Medicaid would not cover the cost of the glasses, leaving the resident with a $215 out-of-pocket expense. Resident 45, with multiple diagnoses including spinal cord infarction and major depressive disorder, indicated he had been fitted for a hearing aid months ago but had not received any follow-up. An audiology exam from 9/6/23 recommended a hearing aid due to moderate to severe sensorineural hearing loss, but there was no care plan addressing hearing difficulties, and the Social Service Director was unaware of the need for a hearing aid. Similarly, Resident 34, with diagnoses including chronic kidney disease and depressive disorder, had an eye exam on 12/19/23 recommending new glasses, but had not received them. The Social Service Director confirmed that the resident should have received glasses following the recommendation.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment and services for a resident with a pressure sore, leading to a deficiency in care. During an observation, it was noted that a resident with a pressure ulcer did not have a bandage covering the affected area, and the ulcer showed signs of necrotic tissue. The resident, who was dependent on staff for repositioning and had multiple health conditions including stroke and diabetes, was observed with several ulcers on the buttocks and sacral area, which were not properly treated as per the physician's orders. The treatment plan included the application of a hydrocolloid dressing three times a week, but this was not adhered to, resulting in the deterioration of the wound. Interviews with staff revealed a lack of awareness and execution of the prescribed treatment plan. A CNA indicated the resident was last changed hours before the observation, and an LPN was unsure of the treatment required. The Wound Nurse confirmed that the treatment was not completed as ordered, and the wound had worsened since the last assessment. The resident's condition had declined, with the wound evolving into an unstageable pressure ulcer, and additional new wounds were noted. The Director of Nursing acknowledged that the treatment should have been completed as ordered.
Failure to Provide Adequate Catheter Care for a Resident
Penalty
Summary
The facility failed to provide appropriate care for a resident with a suprapubic foley catheter, as observed during a survey. Resident 45, who has a suprapubic catheter, was found with a bandage around the stoma that was dated three days prior and had dried brown blood on it. This observation was made during a random check while the resident was in bed. The resident's medical history includes conditions such as infarction of the spinal cord, heart disease, high blood pressure, type 2 diabetes, major depressive disorder, anxiety disorder, urine retention, and neuromuscular issues of the bladder. The resident was assessed to be cognitively intact and required partial to moderate assistance with personal hygiene. The care plan for the resident, revised in July, indicated that the resident was attention-seeking regarding catheter care, with an approach to provide catheter care as ordered. However, the physician's orders from July required catheter care every shift, which was not adhered to, as evidenced by the outdated bandage. The facility's policy on suprapubic site care, dated February 2021, outlines the procedure to decrease the risk of infection, including cleaning the area around the stoma and evaluating it for any signs of infection. Despite these guidelines, the facility did not ensure that the resident received the necessary catheter care, as confirmed by the Director of Nursing, who had no additional information to provide.
Improper Positioning During Enteral Feeding
Penalty
Summary
The facility failed to ensure proper positioning of a resident during enteral feeding, which is a deficiency in care. During an observation, two CNAs were asked to reposition a resident with a PEG tube to examine a pressure ulcer. One of the CNAs lowered the head of the bed to 5 degrees while the enteral feeding was infusing, which is against the care plan that requires the head of the bed to be elevated 30-45 degrees during and thirty minutes after tube feeding. The CNA then put the feeding on hold, claiming that nurses allowed them to do so, which was not appropriate according to the Director of Nursing. The resident involved had a history of stroke, obesity, dysphagia, type 2 diabetes, high blood pressure, heart disease, restlessness, and agitation, and was dependent on staff for various activities. The resident was moderately impaired in daily decision-making and received more than half of their nutrition through the PEG tube. The physician's orders specified that the resident was NPO and required enteral feeding at specific times. The deficiency was identified through observation, record review, and interviews, highlighting a lapse in following the care plan and physician's orders.
Failure to Maintain Correct Oxygen Flow Rate
Penalty
Summary
The facility failed to ensure that oxygen was set at the correct flow rate for a resident requiring respiratory care. During observations on multiple occasions, the resident was seen wearing oxygen via nasal cannula at 1.5 liters, despite physician orders specifying a flow rate of 2 liters. The resident's medical record indicated a history of chronic obstructive pulmonary disease (COPD), chronic respiratory failure, and other significant health conditions. The care plan, revised on two separate occasions, also specified the need for oxygen therapy at 2 liters. However, the observed flow rate did not align with these orders, as confirmed by the Director of Nursing during an interview.
Narcotic Documentation Discrepancy and Diversion Investigation
Penalty
Summary
The facility failed to maintain an accurate system for accounting, reconciling, and ensuring the disposition of controlled drugs, specifically narcotics, for a resident. This deficiency was identified during an investigation into a suspected narcotic diversion involving a previously employed nurse. The investigation revealed discrepancies in the documentation of narcotic medications for a resident who was prescribed Morphine Sulfate for pain and shortness of breath. The narcotic log showed inconsistencies in the recorded remaining doses, particularly on 7/6/24, where the remaining dose was inaccurately documented as higher than expected. This discrepancy was not reported until 7/31/24, despite the medication administration record indicating the medication was signed out as given twice daily throughout July. The resident involved had multiple diagnoses, including hemiplegia, a stage 4 sacral wound, and anxiety, and was using hospice services. The care plan highlighted the risks associated with opioid use, such as constipation and respiratory failure. During interviews, it was revealed that the nurse who administered the morphine on 7/6/24 did not report the discrepancy to the Director of Nursing or the Administrator. The nurse consultant acknowledged that a diversion issue likely existed before the report was filed. The nurse involved in the discrepancy refused a drug screen and subsequently signed a voluntary termination.
Failure to Document Blood Pressure Monitoring for Medication Administration
Penalty
Summary
The facility failed to appropriately monitor and document blood pressures for a resident receiving Hydralazine, a medication used to lower blood pressure. The resident, who was admitted with multiple diagnoses including stroke, obesity, type 2 diabetes, and high blood pressure, had a physician's order to hold Hydralazine if the systolic blood pressure was less than 110. However, the Medication Administration Record (MAR) for July and August 2024 showed no documented blood pressure readings prior to the administration of the medication, with the last recorded blood pressure being on July 28, 2024. Interviews with facility staff revealed that blood pressures were checked but not documented due to a lack of a designated place in the computer system. The LPN responsible for administering the medication confirmed that she checked the blood pressure but did not document it. Both the Assistant Director of Nursing and the Director of Nursing acknowledged that blood pressures should have been recorded in the clinical record before administering Hydralazine, indicating a lapse in following proper documentation protocols.
Inadequate Documentation for Antipsychotic Medication Use
Penalty
Summary
The facility failed to document an adequate indication for the use of an antipsychotic medication for a resident diagnosed with Alzheimer's disease, high blood pressure, anemia, and osteoarthritis. The resident, who was moderately impaired in daily decision-making and exhibited wandering behavior, was prescribed Seroquel, an antipsychotic medication, for behavior management without a documented attempt at gradual dose reduction (GDR). The resident's care plan indicated the use of antipsychotic medication, but there was no documentation of behaviors or an adequate indication for its use in the clinical record. The resident was initially prescribed Seroquel 25 mg at bedtime for insomnia, which was later increased to 50 mg at bedtime and 25 mg in the morning for restlessness. Despite these changes, there was no approved diagnosis for the use of Seroquel, and the resident had not been seen by the contracted behavioral health Nurse Practitioner. The FDA-approved uses for Seroquel do not include treatment for dementia-related psychosis, and there is a black box warning about increased mortality in elderly patients with dementia-related psychosis treated with antipsychotic drugs.
Failure to Provide Routine Dental Services
Penalty
Summary
The facility failed to provide routine dental services for a resident with decayed and broken teeth. The resident, who was cognitively intact and required assistance with personal hygiene, had not received dental care since a dental exam in April 2024. This exam revealed root tips, non-restorable teeth, and inflamed gums, with recommendations for further x-rays and a treatment plan. However, no care plan for dental issues was documented, and the resident had not been seen by a dentist since the facility switched dental providers. Interviews revealed that the MDS Coordinator was unaware of the resident's dental issues, relying on the MDS look-back assessment rather than direct observation. The Social Service Director confirmed the resident had not seen a dentist since April 2024, despite visits from a new dental company in June and August 2024. The resident expressed reluctance to see the new dentist, not wanting to restart the process. This lack of follow-up and coordination resulted in the resident's continued dental issues.
Failure to Follow Pureed Diet Recipes
Penalty
Summary
The facility failed to ensure that food was prepared in a form to meet individual needs, specifically for residents on a pureed diet. During an observation, it was noted that a cook prepared pureed barbeque chicken and broccoli without following the provided recipes. The cook did not use any additional ingredients as specified in the recipes, such as sauce for the chicken or margarine for the broccoli, resulting in a mixture that was pudding thick and even, but not prepared according to the guidelines. The Dietary Manager confirmed that the recipes should have been followed, indicating a lapse in adherence to dietary protocols.
Documentation Errors in Dialysis and Medication Administration
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for two residents, leading to deficiencies in documentation. For Resident 2, who had diagnoses including type 2 diabetes and end-stage renal disease, the facility did not correctly document the condition of the resident's dialysis access site. The care plan required the site to be assessed every shift for signs of infection, with abnormalities noted using specific symbols. However, the July Medication Administration Record (MAR) showed both positive and negative symbols documented on several dates, indicating inconsistencies in recording the site's condition. The Director of Nursing confirmed that the MAR should have been coded correctly. For Resident 58, who had multiple diagnoses including stroke, obesity, and dysphagia, the facility failed to accurately document the administration route for medications. Despite the resident being NPO and receiving nutrition through a peg tube, the physician's orders incorrectly indicated that medications were to be given by mouth. An LPN acknowledged awareness of the resident's NPO status but was unsure why the orders specified oral administration. The Assistant Director of Nursing confirmed that the orders should have reflected administration through the peg tube.
Failure to Address Repeated Pest Control Deficiency
Penalty
Summary
The facility failed to address unresolved quality deficiencies related to pest control, specifically concerning gnats in resident rooms. This issue was previously cited in an annual survey, indicating a repeated deficiency. The Quality Assessment and Assurance (QAA) Committee, which includes various key personnel such as the Medical Director, Administrator, and Director of Nursing, met regularly but did not develop or implement action plans to address the pest control issue. The lack of a Performance Improvement Plan (PIP) for the prevention of gnats was noted, despite the Administrator's awareness of the problem and the engagement of a pest control company. The deficiency had the potential to affect all 60 residents residing in the facility. During an interview, the Administrator acknowledged the ongoing gnat problem and mentioned that pest control services were being utilized weekly, although they did not always treat for gnats. The Administrator was in the process of reviewing the pest control contract to make necessary revisions. However, there was no evidence of continuous monitoring or corrective actions being taken to resolve the issue effectively.
Facility Fails to Maintain Pest-Free Environment
Penalty
Summary
The facility failed to maintain a pest-free environment, as evidenced by the presence of gnats in a resident's room. On the morning of August 5, 2024, a resident was observed in bed with gnats flying around the room and landing on their bed linen and wound dressing. The Wound Nurse, upon entering the room to perform wound care, noted gnats in the air, on the resident's gown, and within the bandages covering the resident's open ulcerations on the right lower leg. The Wound Nurse acknowledged the presence of gnats and mentioned that a work order had been submitted for pest treatment. Despite the presence of gnat strips in the room, the gnats continued to be a problem during the wound care process. The resident's medical record indicated diagnoses of pressure ulcers and hemiplegia following a cerebral infarction, with hospice services being provided. A review of the facility's pest control documentation revealed that while fruit flies, bed bugs, and cockroaches had been treated in various areas of the facility, gnats had not been addressed. The facility's policy on maintaining a safe environment stated that the facility should be free of pests and rodents, yet this was not achieved in the case of the resident's room. The Administrator later confirmed that the resident was moved to a different room, and the original room was deep cleaned.
Failure to Document Fall Interventions in Care Plan
Penalty
Summary
The facility failed to ensure that fall interventions were adequately care planned for a resident with a history of falls. Resident E, who was admitted with diagnoses including dysphagia, Diabetes Mellitus, and hypertension, was observed in bed with the bed in a low position and a mat on the floor next to him. Despite these observations, the resident's care plan did not include these specific interventions. The resident had previously fallen on 6/8/24 while trying to reach for something, although no injury occurred. The care plan was updated to include a reach assist bar, but it lacked the interventions of a low bed and a mat on the floor. The Director of Nursing confirmed during an interview that the care plan had been updated post-fall to include a grabbing tool, but it still did not reflect the use of a low bed or floor mat as interventions. This oversight was identified during a review of the resident's care plan, which indicated the resident was at risk for injury related to falls. The care plan included general interventions such as continuing existing interventions, educating the resident and caregivers about safety, a pharmacy consult, and physical therapy evaluation, but failed to document the specific interventions observed during the survey.
Failure to Notify Physician of Elevated Blood Glucose Levels
Penalty
Summary
The facility failed to provide necessary care and services for a resident with diabetes by not having blood glucose parameters in place and failing to notify the physician of elevated blood glucose levels. The resident, who was cognitively intact and diagnosed with Diabetes Mellitus, heart failure, and hypertension, was receiving insulin as per physician orders. However, there were no specific parameters set for when to notify the physician of abnormal blood glucose levels. Despite having several instances of blood glucose levels exceeding 400 mg/dL, there was no documentation indicating that the physician had been notified. Interviews with the RN and the Director of Nursing revealed that the general rule was to notify the physician if blood glucose levels were less than 60 or above 400, in the absence of specific physician orders. The facility's policy on Diabetes Mellitus Guidelines also required that abnormal lab or blood glucose results be communicated to the physician and recorded in the nurse's notes. The deficiency was identified during a complaint investigation, highlighting a lapse in following the facility's policy and ensuring proper communication with the physician regarding the resident's elevated blood glucose levels.
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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