Healthwin Health & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in South Bend, Indiana.
- Location
- 20531 Darden Rd, South Bend, Indiana 46637
- CMS Provider Number
- 155153
- Inspections on file
- 29
- Latest survey
- March 27, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Healthwin Health & Rehabilitation during CMS and state inspections, most recent first.
A resident with paraplegia, type 2 diabetes, osteomyelitis, pressure ulcers, and a colostomy did not have a comprehensive care plan addressing hypoglycemia, wound vac care, or ostomy care, despite physician orders and facility policy requiring such plans. The care plan lacked measurable goals and interventions for these critical areas.
A resident with diabetes and multiple wounds did not have a physician order in place for hypoglycemic care while receiving insulin, and documentation for wound and ostomy care was missing on several occasions. The DON confirmed the lack of required orders and incomplete documentation, contrary to facility policy.
The facility failed to provide sufficient nursing staff, resulting in untimely responses to call lights, missed showers, and delayed medications. Residents and families reported dissatisfaction, and CNAs described increased workloads and incomplete care tasks. The facility's staffing levels fell below the required 3.42 PPD on several occasions, leading to negative resident experiences, including accidents and unmet care needs.
The facility failed to ensure timely availability and administration of medications for several residents, leading to missed doses of critical medications such as antibiotics and insulin. The issues were exacerbated by a recent pharmacy switch, lack of communication, and inadequate procedures for obtaining medications from a backup pharmacy.
The facility failed to provide scheduled showers or bed baths to several residents, including one who had not received a shower for over two weeks due to staffing shortages. Another resident received only one bath or shower per week instead of the scheduled two, and a third resident was observed with greasy hair, indicating missed bathing. Documentation confirmed gaps in bathing records, and interviews with CNAs revealed that staffing issues prevented consistent adherence to bathing schedules.
The facility failed to follow physician orders for a resident requiring Tubi-grips for leg swelling and did not assess or document a skin condition for another resident. Despite orders, the first resident was observed without Tubi-grips, leading to swelling. The second resident had undated dressings on a skin tear, with no documentation or assessment as required by facility policy.
A resident reported verbal abuse by a nurse who allegedly yelled at her for not attending meal service. Initially dismissed by the DON as a cultural difference, the incident was later investigated and reported to the IDOH. The resident, with a history of depression and PTSD, was left tearful and distressed.
A resident with cognitive and physical impairments was observed multiple times with a fastened seat belt in a wheelchair, unable to remove it independently. Despite a physician's order and facility policy requiring the resident to be able to remove the seat belt, staff used it to prevent the resident from sliding or rising unassisted. The facility failed to conduct ongoing evaluations of the seat belt as a restraint, contrary to their policy.
A resident reported an incident of verbal abuse by a nurse to the DON, who did not report it to the state health department in a timely manner, believing it was a cultural misunderstanding. The resident, who was cognitively intact and had a history of PTSD and depression, expressed distress over the incident. The facility's policy requires immediate review and reporting of abuse allegations, which was not followed in this case.
A facility failed to develop a comprehensive care plan for a resident with osteomyelitis and an indwelling catheter. Despite physician orders and a history indicating the need for specific care, the resident's record lacked plans addressing these conditions. The DON acknowledged the oversight, which was contrary to the facility's policy requiring updates to care plans with significant changes in condition.
The facility failed to provide activities that met the interests and well-being of two residents with severe cognitive impairments. One resident, with Alzheimer's and other conditions, was observed in her room without engagement in activities despite preferences for music and religious activities. Another resident, with dementia and other health issues, was similarly observed without engagement, despite preferences for outdoor activities and music. Documentation of group activities or one-on-one visits was lacking for both residents during specified periods.
The facility failed to provide clinical justification for the continued use of an indwelling catheter for a resident with multiple health conditions. Despite a physician's order for a Foley catheter, there was no documentation supporting its necessity. A Nurse Practitioner mentioned the catheter was for wound healing, but no current open wounds were documented. The DON was unaware of the catheter's purpose, and the facility's policy lacked assessment or documentation requirements for continued catheter use.
A facility failed to follow physician's orders for a resident's enteral feeding, resulting in incomplete administration of Osmolite 1.5 over several days. The resident, who was severely cognitively impaired and dependent on the feeding tube for over 51% of caloric intake, did not receive the full prescribed volume. The facility also failed to notify the physician about the incomplete feedings, as required by their policy.
A resident with a fractured arm did not receive necessary assistance with her CPAP equipment, leading to improper use and maintenance. The CPAP mask and tubing were repeatedly observed uncovered and not sanitized, and the resident reported not wearing the CPAP due to lack of help. Despite having a care plan and physician's orders, the facility failed to ensure compliance with respiratory care standards.
The facility failed to follow infection control standards for residents using oxygen or CPAP machines. A resident's CPAP mask was improperly stored in a non-functional SoClean machine. Another resident's oxygen tubing and humidification bottle were not changed as ordered, and a third resident's oxygen equipment was undated and improperly stored. The facility's policy lacked guidance on storing unused oxygen equipment.
A resident with multiple medical conditions and high fall risk was improperly transferred using a Hoyer Lift, resulting in her slipping from the sling. Despite being caught by a CNA, the resident was lowered to the floor. Initial assessments showed no injury, but later evaluations revealed fractures. The facility's policies on lift use and fall management were reviewed, but the investigation did not clarify how the resident slipped from the sling.
Failure to Develop Comprehensive Care Plan for Resident with Complex Needs
Penalty
Summary
A deficiency was identified when the facility failed to develop and implement a comprehensive care plan for a resident with multiple complex medical needs. The resident had diagnoses including paraplegia, type 2 diabetes, osteomyelitis of the left femur requiring surgical intervention and wound vac placement, colostomy status, and multiple pressure ulcers. The clinical record review showed that the resident required extensive assistance with activities of daily living and was receiving insulin injections for diabetes management. Physician orders included specific instructions for insulin administration, wound vac care, and ostomy care. Despite these documented needs and orders, the resident's care plan did not include goals or interventions for managing low blood sugar (hypoglycemia), wound vac care for pressure ulcers, or ostomy care. The facility's policy required a baseline care plan to be developed within 48 hours of admission to address immediate care needs, but this was not completed for the resident in question. The deficiency was identified through interviews and record reviews, confirming the lack of a comprehensive, measurable care plan for the resident's conditions.
Failure to Ensure Physician Orders and Documentation for Diabetic and Wound Care
Penalty
Summary
The facility failed to ensure that physician orders were in place for the treatment of low blood glucose and did not complete documentation for wound care treatment according to physician orders for one resident. Specifically, a resident with multiple diagnoses including paraplegia, type 2 diabetes, osteomyelitis, and pressure ulcers was receiving insulin but did not have a physician's order for hypoglycemic care. Additionally, there were missing documentation entries for the administration of Santyl ointment for wound care on several dates, as well as missing documentation for ostomy care on specific shifts. Interviews with the DON confirmed the absence of a physician's order for hypoglycemic care and acknowledged missing documentation related to the resident's wound and ostomy care. Facility policies required documentation of wound assessments at the time of each treatment and the use of routine standing orders for diabetes management unless otherwise specified by a physician, but these were not followed in this case.
Inadequate Staffing Leads to Resident Care Deficiencies
Penalty
Summary
The facility failed to ensure sufficient nursing staff to meet the needs of residents, as evidenced by multiple complaints from residents and their families about untimely responses to call lights, missed showers, and delayed or missed medications. During a resident and surveyor group meeting, all 22 residents present expressed dissatisfaction with the timeliness of care, including not receiving at least two showers a week and not receiving medications on time. Family members also voiced concerns about inadequate staffing, particularly at night, during a meeting with corporate representatives and the Director of Nursing (DON). Interviews with Certified Nursing Assistants (CNAs) revealed that staffing levels had decreased, leading to increased workloads and an inability to complete essential care tasks. CNAs reported being assigned to care for up to 14 residents, which resulted in rushed care, missed showers, and incomplete charting. The DON acknowledged that the facility was adjusting to new corporate staffing patterns and had not received complaints from families or residents until media attention highlighted the issue. The facility's assessment indicated a required staffing level of 3.42 hours of direct nursing care per resident per day (PPD), but actual staffing levels on several dates fell below this requirement. Residents reported negative experiences due to insufficient staffing, including waiting long periods for assistance, which led to accidents and feelings of embarrassment. One resident described having to wait to use the toilet, resulting in back pain and an accident, while another resident was unable to get out of bed or receive basic care over a weekend. The facility's policy on nursing staffing did not specify requirements or adjustments based on resident acuity, contributing to the deficiency in meeting residents' needs.
Medication Administration and Availability Deficiencies
Penalty
Summary
The facility failed to ensure that physician-ordered medications were available and administered as prescribed for several residents. Resident 86 did not receive the antibiotic Vancomycin for a Clostridium difficile infection until two days after it was ordered, despite the positive test result and the physician's order. The delay was due to the pharmacy not delivering the medication on time, and there was no documentation that the physician was notified of the delay. Additionally, the facility's emergency drug kit did not contain the necessary medication, and there was a lack of communication with the pharmacy regarding the urgency of the situation. Resident M missed two doses of the antibiotic ertapeneum for sacral osteomyelitis, and there was no documentation of refusal or notification to the physician about the missed doses. Similarly, Resident L did not receive doses of Tamiflu for an influenza infection, and Resident N missed doses of cephalexin for a urinary tract infection, with no documentation of physician notification. Resident O also missed multiple doses of various medications, including insulin and antibiotics, without documentation of refusal or physician notification. The facility experienced ongoing issues with medication availability due to a recent switch in pharmacies, which affected the timely delivery of medications. The nursing staff and supervisors were not adequately informed about the procedures for obtaining medications from a backup pharmacy, leading to further delays. Additionally, there were instances where medications were not administered as ordered, such as Resident 47 not receiving Baqsimi for low blood sugar and Resident 71 not receiving Midodrine for low blood pressure, despite clear physician orders and care plans indicating the need for these interventions.
Failure to Provide Scheduled Showers and Baths
Penalty
Summary
The facility failed to ensure that dependent residents received showers or complete bed baths as scheduled, affecting five out of eight residents reviewed. Resident B, who was scheduled to receive three showers a week, had not received a shower for over two weeks due to staffing shortages. Despite being alert and oriented, Resident B was upset about not receiving showers, and her family member's attempts to contact the Administrator went unanswered. The Treatment Administration Record (TAR) confirmed multiple missed showers, and there was no documentation of any refusals by Resident B. Resident M also did not receive the scheduled two bed baths or showers per week, often receiving only one. Her care plan indicated she was dependent on staff for bathing, and the TAR showed missed showers on specific dates. The Director of Nursing confirmed that Resident M should have received either a shower or a complete bed bath twice a week. Similarly, Resident 55 was observed with greasy hair, and her medical record lacked documentation of bathing from mid-January to late January. Interviews with CNAs revealed that residents were supposed to be bathed or showered three times per week, but staffing issues prevented this from happening consistently. Resident D's family reported that she had not been receiving her showers regularly, and documentation confirmed gaps in bathing records. CNAs indicated that the absence of a shower aide affected their ability to provide scheduled showers. Resident E's family noted that she had not received her scheduled showers, leading to a yeast infection in her groin area. The facility's policy required residents to receive proper daily personal attention and care, including bathing at least twice weekly, but this was not adhered to, as evidenced by the lack of documentation and observations of residents' unkempt appearances.
Failure to Follow Physician Orders and Assess Skin Conditions
Penalty
Summary
The facility failed to adhere to physician orders and provide appropriate care for two residents, leading to deficiencies in their treatment. Resident J, who had diagnoses including post-polio syndrome and Parkinson's disease, was ordered to wear Tubi-grips on her legs and feet at all times to manage swelling. Despite this, observations over several days showed that Resident J was not wearing the Tubi-grips, and her right lower leg and foot were swollen. The resident was dependent on staff for dressing and had not refused the Tubi-grips, yet the facility did not ensure she wore them as prescribed. The Director of Nursing confirmed that Resident J should have been wearing the Tubi-grips, and there was no policy provided for following physician orders. For Resident 67, the facility failed to assess and document a skin condition properly. Observations revealed undated dressings on the resident's right arm, with bloody drainage and a skin tear underneath. The RN was unaware of the condition and confirmed that the dressings should have been dated and documented. Despite a physician's order for weekly skin assessments, records indicated no new skin issues, and there was no documentation of the impaired skin integrity. The facility's policy required weekly skin observations and reporting of new skin issues to the physician, which was not followed in this case.
Failure to Protect Resident from Verbal Abuse
Penalty
Summary
The facility failed to protect a resident from verbal abuse, as evidenced by an incident involving a nurse who allegedly yelled at a resident. The resident, who was cognitively intact and had a history of depression, anxiety, and post-traumatic stress disorder, reported feeling unwell and chose not to attend meal service. During this time, the nurse reportedly raised her voice, demanding the resident to get out of bed and go to the dining room, which left the resident tearful and distressed. The resident reported the incident to the Director of Nursing (DON) the following day, but the DON initially dismissed it as a cultural difference and did not report it to the Indiana Department of Health (IDOH) as abuse. Upon further discussion with a surveyor, the DON began investigating the resident's claims and subsequently reported the incident to the IDOH. The investigation revealed that the nurse denied raising her voice, and the resident later indicated to the DON that she no longer felt the nurse had yelled at her. The facility's policy on abuse, which includes verbal and mental abuse, defines abuse as the willful infliction of intimidation. However, the initial failure to recognize and report the incident as potential abuse highlights a deficiency in the facility's response to allegations of abuse.
Failure to Ensure Resident is Free from Physical Restraints
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints, as observed in the case of a resident who was unable to remove a seat belt while seated in a wheelchair. The resident, who was diagnosed with conditions including osteoarthritis, dementia, and metabolic encephalopathy, was observed multiple times with a fastened seat belt across his lap. Despite a physician's order requiring staff to command the resident to remove the seat belt and notify the therapy department of failed attempts, the resident was unable to release the seat belt on several occasions. Interviews with various CNAs and an RN revealed that the seat belt was used to prevent the resident from sliding out of the wheelchair or getting up unassisted, due to his cognitive impairments and physical limitations. However, the staff acknowledged that the resident was unable to unbuckle the seat belt independently, contradicting the facility's policy that restraints should only be used if the resident can remove them upon command. The Director of Therapy confirmed that the seat belt was intended as a positional device and should not be used if the resident could not remove it. The facility's policy on physical restraints stated that restraints should only be used for the safety and well-being of residents after other alternatives have been tried unsuccessfully. The policy also defined a restraint based on the resident's functional status, indicating that if a resident cannot remove a device, it is considered a restraint. Despite this, the facility did not conduct ongoing evaluations of the seat belt as a restraint, as the DON believed it was not a restraint since the resident could remove it when asked. This oversight led to the continued use of the seat belt without proper re-evaluation, contrary to the facility's policy.
Failure to Timely Report Allegation of Verbal Abuse
Penalty
Summary
The facility failed to report a resident's allegation of verbal abuse in a timely manner to the Indiana Department of Health. A resident, who was cognitively intact and had a history of post-traumatic stress disorder and depression, reported to the Director of Nursing (DON) that an agency nurse had yelled at her during an evening shift. The incident reportedly occurred two to three weeks prior to the resident's interview with the surveyor. The resident expressed distress over the incident, indicating that the nurse had raised her voice when the resident did not want to attend meal service due to feeling unwell. The resident reported the incident to the DON the day after it occurred, but the DON did not report it to the state health department, believing it was a cultural misunderstanding rather than abuse. The DON recalled the incident but did not take immediate action to report it as an allegation of abuse. It was only after a discussion with the surveyor that the DON began investigating the claims and reported the allegation to the Indiana Department of Health. The facility's policy on abuse requires immediate review and investigation of all allegations, with reporting to occur within 24 hours if the events do not result in serious bodily injury. The delay in reporting the incident to the appropriate authorities constituted a failure to adhere to this policy, as the allegation was reported weeks after the resident initially brought it to the DON's attention.
Failure to Develop Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to ensure a comprehensive care plan was developed and implemented for a resident diagnosed with osteomyelitis and using an indwelling catheter. The resident, identified as Resident Q, had multiple diagnoses including osteomyelitis of the right foot/ankle, diabetes mellitus type 2, anxiety, depression, hypertension, and chronic kidney disease stage 3. Despite a physician's order for ceftazidime IV for osteomyelitis and a history and physical evaluation indicating chronic osteomyelitis, the resident's record lacked a care plan addressing this condition. Additionally, there was a physician's order for a Foley catheter, but the resident's record did not include a care plan for its use. During an interview, the Director of Nursing (DON) acknowledged that care plans should be updated with new orders identified during the morning clinical meeting and confirmed that the care plan should be current. However, she was unaware of why Resident Q did not have a care plan for osteomyelitis or the Foley catheter. The facility's policy on comprehensive person-centered care planning requires the interdisciplinary team to review and update care plans with significant changes in resident condition, changes in needs, and upon return from a hospital stay. This policy was not adhered to in the case of Resident Q, leading to the deficiency.
Failure to Provide Adequate Activities for Residents
Penalty
Summary
The facility failed to provide activities that met the interests and well-being of two residents, as observed during a survey. Resident 55, who has severe cognitive impairment due to Alzheimer's disease and other conditions, was observed multiple times in her room either in a Broda chair or lying in bed, with the television on but not actively engaged in any activities. Despite having preferences for activities such as visiting with pets, listening to music, and participating in religious activities, there was no documentation of her attending group activities or receiving one-on-one visits from 2/3/2025 to 2/10/2025. The care plan for Resident 55 indicated she was unable to initiate activities and required one-on-one visits twice weekly, which were not documented during the specified period. Similarly, Resident 83, who also has severe cognitive impairment and other health issues, was observed in her room in a Broda chair or lying in bed with the television or radio on but not engaged in any activities. Her care plan indicated a goal of participating in one to two group or individual activities weekly, with preferences for going outside, listening to music, and being around pets. However, there was no documentation of her attending any group activities or receiving one-on-one visits from 2/2/2025 to 2/10/2025. The Activities Director mentioned having completed one-on-one visits with both residents, but these visits were not documented in the electronic medical record as required.
Lack of Justification for Indwelling Catheter Use
Penalty
Summary
The facility failed to ensure there were clinical indications to support the continued use of an indwelling catheter for a resident reviewed for catheters. The resident, who had diagnoses including osteomyelitis, diabetes mellitus type 2, anxiety, depression, hypertension, and chronic kidney disease stage 3, had a physician's order for a Foley catheter. However, there was no documentation justifying the need for the catheter. A Nurse Practitioner noted the catheter was in place for wound healing, but there was no evidence of any current open wounds that could be contaminated by urine. During an interview, the Director of Nursing was unaware of the reason for the catheter's use. Additionally, the facility's urinary catheter care policy did not include any assessment or documentation requirements to support the continued use of an indwelling catheter.
Failure to Administer Prescribed Enteral Feedings
Penalty
Summary
The facility failed to adhere to the physician's orders regarding enteral feedings for a resident with a gastronomy tube (G-tube). Observations over three consecutive days revealed that the resident's enteral feeding bottles were not fully administered as per the prescribed amount. Specifically, bottles of Osmolite 1.5 were found disconnected and hanging on an IV pole with significant amounts of formula remaining, indicating that the resident did not receive the full prescribed volume of 1200 mLs per day. The bottles were also not properly dated, and there was no documentation that the physician was notified about the incomplete feedings. The resident in question, who was severely cognitively impaired, relied on the feeding tube for more than 51% of their caloric intake. Despite the clear physician's order to administer 75 mLs per hour for sixteen hours, the facility's records lacked evidence of communication with the physician regarding the shortfall in feeding. The facility's policy on enteral feedings required documentation of the administration details, which was not followed, contributing to the deficiency.
Failure to Assist Resident with CPAP Use and Maintenance
Penalty
Summary
The facility failed to provide necessary assistance to a resident with a fractured arm in applying and maintaining her CPAP equipment. Observations revealed that the CPAP mask and tubing were left uncovered on an opened SoClean machine, and the resident reported that she did not receive help to wear the CPAP due to her broken arm. Despite having a physician's order for CPAP use at bedtime and a care plan in place, the resident indicated she was unable to use the CPAP because no assistance was provided, and the equipment was not cleaned as required. The resident, who has chronic obstructive pulmonary disease and obstructive sleep apnea, was observed multiple times without her CPAP equipment being properly stored or sanitized. The Treatment Administration Record indicated inconsistencies in the documentation of CPAP use and cleaning. Interviews with staff confirmed that the CPAP was not always in the sanitizer when not in use, contrary to the facility's policy. The facility's policy on CPAP/BIPAP guidance was provided, but it was undated and did not ensure compliance with professional standards of practice.
Infection Control Deficiencies in Oxygen and CPAP Equipment Management
Penalty
Summary
The facility failed to adhere to infection control standards for three residents using supplemental oxygen or CPAP machines. Resident 27's CPAP mask was observed in a SoClean machine that was not operational, lacked a lid, and contained dust. Despite a physician's order to disinfect the CPAP mask using the SoClean machine, the equipment was not maintained properly, as confirmed by the Unit Manager. Resident 27's medical conditions included Parkinson's disease, sleep apnea, anxiety, and dysphagia. Resident 95 reported that her oxygen tubing and humidification bottle had not been changed in over a month, contrary to a physician's order for weekly changes. Observations showed the tubing was unbagged and undated. The Unit Manager confirmed the equipment should have been dated and stored properly. Similarly, Resident 11's oxygen tubing and nebulizer were found undated and improperly stored. The facility's policy on oxygen administration did not specify storage procedures for unused equipment, as noted by the Director of Nursing and the Infection Prevention Nurse.
Improper Use of Hoyer Lift Leads to Resident Injury
Penalty
Summary
The facility failed to ensure the safe use of a Hoyer Lift for a resident, identified as Resident D, who was at high risk for falls due to multiple medical conditions including a non-traumatic brain injury, insulin-dependent diabetes, seizure disorder, and aphasia. The resident was non-verbal and fully dependent on staff for transfers, as indicated in her care plan, which required the use of a mechanical lift with two staff members. During a transfer from a recliner to a bed, the resident slipped from the Hoyer sling, and although caught by a CNA, was lowered to the floor. The incident occurred when two CNAs were conducting the transfer. CNA 3 attached the sling to the Hoyer lift while CNA 2 operated the controls. Despite the sling being attached, the resident began to slip out of it during the transfer. CNA 3 managed to catch the resident, preventing her from hitting the floor, but the resident was still lowered to the ground. The CNAs reported that the resident did not hit her head or limbs on any objects, and the sling remained attached to the lift. However, there was uncertainty about whether the sling was properly positioned or secured, as CNA 2 assumed the sling was crossed from previous use. Following the incident, the resident was assessed and initially showed no signs of pain or injury. However, subsequent medical evaluations revealed fractures in the resident's left tibia, fibula, and left thumb, as well as bone demineralization. The facility's policies on lift use and fall management were reviewed, but the investigation did not clarify how the resident slipped from the sling if it was properly attached. The incident was self-reported by the facility after the fractures were discovered during a hospital evaluation.
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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