Ignite Medical Resort Dyer Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Dyer, Indiana.
- Location
- 1532 Calumet Avenue, Dyer, Indiana 46311
- CMS Provider Number
- 155840
- Inspections on file
- 44
- Latest survey
- November 20, 2025
- Citations (last 12 mo.)
- 7 (1 serious)
Citation history
Health deficiencies cited at Ignite Medical Resort Dyer Llc during CMS and state inspections, most recent first.
A deficiency was cited due to the presence of accident hazards in an area and insufficient staff supervision to prevent accidents. Surveyors observed that the environment was not maintained to ensure resident safety, and staff oversight was inadequate.
A crash cart was found with an empty oxygen tank during a review, and staff were unsure of the frequency for checking oxygen levels, despite facility policy requiring nightly checks. The DON confirmed that oxygen should be checked daily.
A resident with multiple lower limb wounds and complex medical history did not have updated wound care orders implemented after receiving new instructions from wound care and podiatry appointments. Although the new orders were documented in progress notes, they were not transcribed into the physician order summary or carried out in the treatment administration record, resulting in the resident not receiving the prescribed wound care regimen.
Nursing staff failed to consistently verify G-tube placement, check and document residuals, and flush feeding tubes as required by physician orders and facility policy for three residents receiving enteral nutrition. In multiple observed and documented instances, tube placement and residuals were not checked prior to bolus feedings, post-feeding flushes were omitted, and required documentation was missing from the MAR.
Surveyors found multiple instances of unlabeled and improperly stored food items in the kitchen, including unlabeled powders, liquids, and open bags of food in storage areas, as well as uncovered and unlabeled prepared foods. The Kitchen Manager confirmed that facility policies requiring labeling, dating, and covering of food items were not followed, potentially affecting all residents receiving meals from the kitchen.
Staff failed to assess and monitor bruises for two residents on anticoagulant therapy, did not adequately monitor or document constipation for a resident on opioid medication, and did not properly assess or document edema or the use of a compression glove for another resident. Additionally, medications were administered outside of prescribed blood pressure parameters for a resident with cardiovascular conditions.
A resident with COPD, chronic respiratory failure, and dementia was left to complete nebulizer treatments independently without a physician's order or assessment confirming safe self-administration. The resident had moderate cognitive impairment and required assistance with daily living, yet staff did not remain present during treatments, contrary to facility policy requiring evaluation and physician authorization.
The facility did not notify physicians when three residents experienced significant changes, including elevated blood sugars, withheld blood pressure medication, and missed insulin doses. Documentation and interviews confirmed that required notifications to the physician or NP were not made when residents' conditions changed or medications were not administered as ordered.
A resident with multiple diagnoses, including Alzheimer's disease, was admitted to hospice care with a terminal prognosis, but the MDS assessment failed to reflect the resident's hospice status and terminal condition. MDS nurses later confirmed the resident was receiving hospice care and had a terminal prognosis.
A resident with hypertension, end stage renal disease, and diabetes was observed using oxygen and had right hand edema with a compression glove at bedside. The care plan addressed only general edema prevention and did not include specific interventions for the right hand edema, compression glove use, or oxygen therapy.
A CNA placed a tube feeding pump on hold for a resident with a gastrostomy and severe cognitive impairment before performing incontinence care, despite state guidelines requiring a nurse to handle the pump. The CNA's action was observed, and a nurse resumed the feeding after care.
A resident with multiple chronic conditions and moderate cognitive impairment was not assisted by facility staff in obtaining an eye doctor appointment, despite requests from the resident and his daughter. There was no documentation of vision care in the resident's record, and a staff member informed the family that arranging such care was not part of the facility's responsibilities.
A resident received a G-tube flush that was pushed through the tube using a syringe plunger by an LPN, instead of being administered by gravity as required by facility policy. The LPN later confirmed the correct procedure should have been to allow the flush to flow by gravity.
A resident with multiple chronic conditions was observed receiving oxygen therapy without a current physician order or care plan in place, despite facility policy requiring such documentation. The DON confirmed that no current orders for oxygen were found in the resident's chart.
A medication error rate above 5% was observed when an LPN administered insulin to a resident with type 2 diabetes, failing to prime the insulin pen and giving 20 units instead of the ordered 18 units, in violation of facility policy.
An LPN prepared medications for a resident and left a pill card of multivitamin, a pill card of ferrous sulfate, and a medication cup with the resident's morning medications on top of the medication cart. The LPN then left the cart unattended and out of sight while going to the Nurse's Station, leaving the medications unsecured until returning several minutes later. The LPN acknowledged that medications should not have been left unattended.
A resident with multiple medical conditions, including COPD and dementia, reported ill-fitting dentures and difficulty chewing, but had not received a dental evaluation since admission. When the resident's daughter requested help from a social worker to arrange dental care, she was told the facility could not assist. No documentation of dental care was found in the resident's record.
A resident with diabetes and heart failure had incomplete documentation on the MAR for several doses of Droxidopa, with staff confirming the medication was given but not recorded. Additionally, an order for Midodrine lacked required blood pressure parameters, and the DON was unable to locate these in the record.
A resident with heart failure did not receive their prescribed medication, Vericiguat, due to unavailability. The facility failed to notify the physician of this delay in a timely manner, as required by policy. The Director of Nursing confirmed the oversight, noting that the physician should have been informed after 48 hours. The issue was eventually resolved without the family's involvement.
A facility failed to ensure correct PPE usage by a CNA when providing care to a resident under Enhanced Barrier Precautions (EBP). The CNA assisted the resident, who had a feeding tube, without wearing a gown, despite the facility's policy requiring it for high-contact care. The incident was observed during a complaint investigation.
A facility failed to provide necessary treatment for a resident with a pressure ulcer. Observations revealed the resident's heels were not offloaded as required, and a low air loss mattress was not used as intended. Additionally, a skin barrier cream was not applied during incontinent care, contrary to the care plan. The resident had a DTI on the right heel, and the care plan included specific interventions that were not followed, leading to inadequate care.
Two LPNs failed to use the correct PPE while providing care to a resident under Enhanced Barrier Precautions (EBP) due to a Deep Tissue Injury (DTI) on the right heel. Despite a sign indicating the need for PPE and the availability of PPE in the room, the LPNs only wore gloves and did not don gowns as required by the facility's EBP policy.
A facility failed to notify a resident's responsible party of significant changes in the resident's medical status, including IV site placement, medication changes, and treatment for high potassium levels. The resident, who was cognitively impaired, experienced changes such as the insertion of a PICC line and adjustments in medication without the responsible party being informed, as required by facility policy.
A facility failed to assist a resident with personal hygiene needs, specifically in trimming long fingernails. The resident, who was cognitively intact and required supervision with personal hygiene, expressed a lack of access to nail clippers and indicated that staff had not offered assistance. Despite the resident's request for help, their fingernails remained untrimmed until a later observation confirmed they had been cut. The resident's medical history included a fracture of the left femur, osteoarthritis, and lack of coordination.
A facility failed to assess and monitor bruising in a resident on anticoagulant therapy. The resident, with a history of multiple health conditions, was observed with discolorations on their forearms and hands. Despite orders for regular skin checks and anticoagulant use, there was no care plan for the bruising, and skin assessments lacked documentation of new concerns.
The facility failed to properly maintain and monitor IV catheters for two residents. One resident did not receive documented saline flushes before and after antibiotic administration due to an error in the MAR listing. Another resident experienced discomfort from an IV site that was not monitored for infection, and there were no orders for saline flushes to maintain patency. The facility's policy on IV site monitoring was not followed, leading to inadequate care.
The facility failed to document wound care treatments for a resident with a surgical wound and pressure ulcer, as the Wound Nurse did not sign off on the TAR despite completing the treatments. Additionally, a resident with dementia experienced a fall, but the required fall risk evaluation was not completed immediately, leading to incomplete documentation. The CNO had to facilitate the evaluation over the phone after the incident.
A facility failed to document and communicate necessary information for a resident with metabolic encephalopathy being transferred to the ER. The resident's discharge status was not recorded, and there was no documentation of a change of condition or transfer in the Nurses' Progress Notes. The DON confirmed that a family member called 911 for the transfer, but there was no transfer sheet completed, and it was unclear if the hospital ER received the resident's information.
The facility failed to accurately complete MDS assessments for two residents, leading to discrepancies in recorded information about falls, medications, and behaviors. One resident's MDS inaccurately indicated no falls or antipsychotic medication use, despite documented falls and behaviors. Another resident's MDS incorrectly reported no falls, although a fall was documented. These inaccuracies were identified during a complaint review.
The facility failed to create and implement individualized care plans for two residents, resulting in deficiencies. A resident with a knee immobilizer developed a pressure sore due to improper management, and there was no care plan to prevent this. Another resident with dementia had multiple behavioral episodes documented without a care plan to address these behaviors. The absence of care plans was confirmed by the DON and Social Service Director.
A resident with diabetes and an abdominal wall abscess did not receive necessary care as prescribed. Antibiotics were not administered as ordered, and blood glucose levels were not monitored or reported to the physician when elevated. The DON confirmed these deficiencies during interviews.
A resident with severe cognitive impairment and high fall risk was found on the floor, but the facility failed to conduct a thorough investigation or determine the root cause of the fall. The care plan required identifying and addressing potential fall causes, but this was not done. The facility's fall prevention policy lacked a post-fall protocol, and the only intervention was placing a fall mat by the bedside.
A resident with dementia exhibited ongoing behavioral issues without proper input from the IDT and Social Services. The facility failed to develop a care plan or document interventions for behaviors such as restlessness, exit-seeking, and aggression. Despite physician's orders for non-pharmacological interventions before administering PRN medications, these were often not documented or attempted, leading to inadequate management of the resident's condition.
The facility failed to ensure correct PPE use by LPNs during wound care for a resident with pressure sores. No sign indicated the need for Enhanced Barrier Precautions (EBP), and EBP was not implemented, contrary to facility policy. This oversight potentially affected 13 residents requiring wound treatments.
The facility did not ensure the Nurse Staffing Information was current and accurate, as it was outdated and included Assisted Living staff instead of only Long Term Care staff. The Director of Nursing left the information for the Weekend Manager to post, leading to a lapse in updates. The Administrator realized the error after reviewing the postings.
The facility failed to provide timely access to medical records for two residents after requests were made by the residents and their POAs. For one resident, the records were delayed due to the process involving the Corporate Office and third-party departments. For the other resident, the delay was due to late receipt of therapy records. The facility's policy required records to be provided within two working days, which was not met.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a urinary catheter. During an observation, a CNA was seen emptying a urinary catheter drainage bag without wearing a gown, and there was no EBP sign or PPE cart present. Interviews with staff revealed a lack of adherence to EBP protocols, and the Infection Control Nurse admitted to missing the urinary catheter during rounds. The resident's care plan and physician's order confirmed the need for EBP, but these measures were not implemented.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, and supervision was insufficient to prevent potential or actual accidents. Specific actions or inactions leading to this deficiency include the presence of hazards in the area and a lack of appropriate oversight by staff, as directly observed by surveyors.
Crash Cart Oxygen Tank Found Empty
Penalty
Summary
The facility failed to ensure that oxygen was available on the crash cart for one of two crash carts reviewed. During an observation of the A Wing crash cart near Room A160, it was found that the oxygen tank on the cart was empty. The A Wing Unit Manager confirmed the oxygen tank was empty and was unsure how often the oxygen tank level was checked, although she stated that crash cart supplies were checked daily. The DON later indicated that the crash cart oxygen should be checked daily. Facility policy required that oxygen on the crash cart be checked nightly.
Failure to Update and Implement Wound Care Orders
Penalty
Summary
The facility failed to ensure that treatment orders were updated and completed as ordered for a resident with multiple non-pressure related skin conditions. The resident had a history of orthopedic aftercare following surgical amputation, chronic osteomyelitis, cellulitis of both lower limbs, and type 2 diabetes mellitus. The resident was cognitively intact and had documented skin integrity impairment, with care plan interventions requiring evaluation and treatment per physician orders. Initial physician orders specified wound care regimens for various areas of the right foot, including cleansing, application of Xeroform, and dressing changes on specific days. Subsequent to wound care and podiatry appointments, new orders were provided, including the use of Iodosorb, Betadine, and changes to dressing frequency and materials. These updated orders were documented in after-visit summaries and progress notes but were not transcribed into the physician order summary or implemented in the medication and treatment administration records. The wound care nurse acknowledged entering the updates in progress notes but not updating the official physician order summary, resulting in the failure to carry out the new wound care instructions as directed.
Failure to Verify G-Tube Placement, Check Residuals, and Document Care During Tube Feedings
Penalty
Summary
The facility failed to ensure proper care and documentation for residents with gastrostomy tubes (G-tubes) during tube feeding administration. In one instance, an LPN administered a bolus G-tube feeding to a resident without checking tube placement or residual immediately prior to the feeding, as required by physician orders and care plan interventions. Additionally, the LPN did not flush the G-tube with water after the feeding was completed, contrary to the physician's order for scheduled flushes. The resident's diagnoses included gastrostomy status, dysphagia, and protein calorie malnutrition, and the care plan specified the need to check tube placement and residual volume per protocol and record the findings. For another resident, the facility failed to document the amount of G-tube residual on multiple dates, despite a physician's order to check and record residual every shift. The resident's care plan also required checking tube placement and residual volume per protocol. The medication administration record (MAR) for the relevant month did not include a place to document residuals, and the DON confirmed the omission during an interview. A third resident received a bolus tube feeding without verification of tube placement or checking for residual prior to administration. The nurse administering the feeding acknowledged not performing these checks, despite the facility's policy requiring verification of placement and residual. The resident's care plan and physician orders included instructions for enteral nutrition and specified the need to check tube placement and residual volume per protocol. The facility's policy on tube feeding also required checking tube placement and flushing the tube with water at the end of the feeding.
Failure to Label, Date, and Properly Store Food Items in Kitchen
Penalty
Summary
Surveyors observed multiple instances of improper food storage and labeling in the facility's main kitchen during an initial sanitation tour. In the dry storage room, there was a large unlabeled storage bin containing a white powder and an unlabeled container partially filled with yellow liquid. In the walk-in cooler, a partially full, unlabeled squeeze bottle with a red/brown substance was found, along with an uncovered bucket of cut-up potatoes in water and trays of desserts that were uncovered and unlabeled. The walk-in freezer contained an open, unlabeled bag of fish patties and an open, unlabeled bag of corn. Additionally, in the food prep area, both a large plastic bin and a smaller plastic container filled with white powder were found to be unlabeled. During an interview, the Kitchen Manager confirmed that all food items should have been labeled and dated when opened, and that uncovered items should have had lids. Facility policies provided by the Kitchen Manager required that bulk foods removed from original packaging be labeled with the common name, date opened, and use-by or discard date, and that opened products be tightly covered and labeled. These policies were not followed, resulting in the cited deficiency. The issue had the potential to affect all 86 residents who received food from the kitchen.
Failure to Assess and Monitor Bruises, Constipation, Edema, and Medication Administration Parameters
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, resident preferences, and goals for multiple residents. For two residents on anticoagulant therapy, staff did not assess or monitor bruises as required by care plans and facility policy. In one case, a resident with a history of diabetes, sepsis, and heart disease was observed with reddish/purple discoloration on the forearm, but there was no documentation or assessment of this new skin condition. Another resident was observed with multiple bruises on the hands and arm, attributed to lab draws, but again, there was no documentation or monitoring of these bruises as required. For a resident receiving opioid pain medication following a surgical amputation, staff failed to adequately monitor and document signs and symptoms of constipation. The resident experienced several days without a bowel movement, followed by vomiting and abdominal pain, which led to further medical intervention. Documentation was incomplete, and the facility's bowel protocol was not followed, as there was a lack of timely assessment and intervention for constipation related to opioid use. Additionally, the facility did not properly monitor or assess edema for a resident with end stage renal disease and hypertension. The use of a compression glove for hand swelling was not clearly documented, and there was no care plan or intervention specific to the right hand edema. The documentation on the use of the compression glove was unclear, with no explanation of the symbols used to indicate skin assessment findings. Furthermore, for another resident with cardiovascular conditions, medications intended to be held for low blood pressure were administered outside of the prescribed parameters on multiple occasions, contrary to physician orders.
Failure to Assess and Authorize Self-Administration of Nebulizer Treatments
Penalty
Summary
A resident with diagnoses including COPD, chronic respiratory failure with hypoxia, and dementia was observed receiving a nebulizer treatment alone in his room. The resident reported that staff initiated the nebulizer treatment but did not remain in the room, and he independently removed the face mask and stored it in his nightstand when he believed the treatment was complete. Review of the resident's record showed moderate cognitive impairment and a need for partial/moderate assistance with activities of daily living and transfers. The most recent self-administration assessment did not indicate the resident was safe to self-administer nebulizer treatments, and there was no physician's order authorizing self-administration. The DON confirmed that the resident had not been evaluated for self-administration of nebulizers, and facility policy required a physician order and assessment of the resident's ability prior to self-administration.
Failure to Notify Physician of Changes in Condition and Medication Administration
Penalty
Summary
The facility failed to ensure timely and appropriate notification of physicians regarding significant changes in residents' conditions and medication administration. For one resident with type 2 diabetes and end stage renal disease, blood sugar readings exceeded 400 on two occasions, but there was no documentation that the physician or nurse practitioner was notified as required by the physician's order. Another resident with dementia, diabetes, hypertension, and acute kidney failure had a blood pressure medication withheld on two occasions without any documented notification to the physician or nurse practitioner, despite the absence of parameters for holding the medication. Additionally, a third resident with congestive heart failure and diabetes had insulin doses either refused or held, but there was no documentation that the physician was informed of these missed doses. In each case, interviews with the Director of Nursing confirmed that the appropriate notifications to the physician or nurse practitioner were not made as required by facility policy and physician orders.
Inaccurate MDS Assessment for Hospice Resident
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessment for a resident with a terminal prognosis who was receiving hospice care. Record review showed that the resident had diagnoses including hypertension, atrial fibrillation, and Alzheimer's disease, and had been admitted to hospice services with a documented terminal end stage prognosis and a life expectancy of six months or less. Despite this, the resident's quarterly MDS assessment indicated that the resident was not receiving hospice care and did not have a terminal condition. This discrepancy was confirmed during interviews with MDS nurses, who acknowledged the resident was on hospice and had a terminal prognosis.
Failure to Develop Comprehensive Care Plan for Edema and Oxygen Use
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan addressing all of a resident's needs, specifically for edema, compression glove use, and oxygen therapy. Observation revealed that the resident was using oxygen via nasal cannula at a flow rate of 1.5 liters, had a slightly swollen right hand, and a compression glove was present at the bedside. The resident reported using oxygen, typically at 2 liters, and wearing the compression glove on her right hand only at night. Record review showed diagnoses of hypertension, end stage renal disease, and type 2 diabetes mellitus. The most recent MDS assessment did not indicate oxygen therapy, and the existing care plan addressed only renal insufficiency and general edema prevention, without specific interventions for right hand edema, compression glove use, or oxygen therapy. There was no current care plan in place for these specific needs at the time of the survey.
CNA Operates Tube Feeding Pump Outside Scope of Practice
Penalty
Summary
A certified nursing assistant (CNA) placed a tube feeding pump on hold for a resident receiving enteral nutrition, prior to performing incontinence care and lowering the head of the bed. The resident had a gastrostomy, adult failure to thrive, dysphagia, and was dependent on tube feeding for the majority of her nutrition. The resident also had significant cognitive impairment, with both short and long term memory problems and severely impaired decision-making abilities. According to the Indiana State Department of Health Nurse Aide Curriculum, CNAs are not permitted to operate tube feeding pumps and must seek a nurse's assistance to turn off or resume the pump. The CNA's action of placing the pump on hold was observed during care, and a nurse later resumed the feeding after care was completed.
Failure to Assist Resident in Accessing Vision Services
Penalty
Summary
A resident with diagnoses including COPD, chronic respiratory failure with hypoxia, and dementia, who required partial to moderate assistance with activities of daily living and transfers, reported being unable to see with his current glasses and not having been evaluated by an eye doctor since before admission to the facility. The resident's daughter stated she had requested assistance from the facility's social worker to arrange an eye doctor appointment, but was told that seeing an eye doctor was not part of the resident's care and that the facility could not make such arrangements. Review of the resident's record revealed no documentation of vision or eye care. The Director of Social Services later confirmed that residents should be able to see an eye doctor if needed and that the facility would assist in making those arrangements.
G-Tube Flush Administered Incorrectly by Syringe Plunger
Penalty
Summary
A deficiency was identified when a licensed practical nurse (LPN) failed to administer a gastrostomy tube (G-tube) flush by gravity for a resident during medication administration. The LPN prepared the resident's medications by crushing each pill and diluting them in water, then placed the G-tube syringe into a medication cup, drew up 30 cc of water, and pushed the water down the G-tube using the syringe plunger, rather than allowing it to flow by gravity as required. The remaining medications and flushes were administered by gravity. The LPN later acknowledged that the G-tube flush should have been administered by gravity, in accordance with the facility's policy, which specifies that water and medications should be allowed to flow down the tube via gravity.
Failure to Ensure Physician Orders and Care Plan for Oxygen Therapy
Penalty
Summary
A resident with diagnoses including hypertension, end stage renal disease, and type 2 diabetes mellitus was observed on two occasions using oxygen via nasal cannula at a flow rate of 1.5 liters, while the resident reported it was usually set at 2 liters. Review of the resident's medical record revealed no current physician's order for oxygen therapy and no care plan addressing oxygen use. The Admission MDS assessment indicated the resident was moderately cognitively impaired and did not receive oxygen therapy. The facility's policy required that residents on oxygen have physician orders specifying the route and liter flow, but no such orders were found in the resident's chart. The DON confirmed the absence of current oxygen orders for the resident.
Medication Error Rate Exceeds Acceptable Threshold During Insulin Administration
Penalty
Summary
A medication error rate of 7.69% was identified during medication administration observations, exceeding the acceptable threshold of less than 5%. Specifically, two medication errors were observed out of 26 opportunities. One incident involved an LPN preparing and administering insulin to a resident with type 2 diabetes mellitus. The LPN failed to prime the insulin pen before injection, contrary to facility policy, and administered 20 units of Lantus insulin instead of the physician-ordered dose of 18 units. The LPN acknowledged not priming the insulin pen prior to administration, stating that pens were only primed when first opened. The facility's insulin administration policy requires priming the pen before each use to ensure proper dosing and avoid injecting air. The errors were brought to the attention of the Director of Nursing, and the relevant policy was reviewed.
Medications Left Unattended on Medication Cart
Penalty
Summary
A deficiency occurred when an LPN prepared medications for a resident and placed a pill card of multivitamin, a pill card of ferrous sulfate, and a medication cup containing the resident's morning medications on top of the medication cart. The LPN then left the medication cart unattended and out of sight while she went to the Nurse's Station, leaving the medications unsecured on the cart. The medications remained unattended until the LPN returned several minutes later. During an interview, the LPN acknowledged that medications should not have been left unattended. The Director of Nursing was informed of the incident, and a medication storage policy was requested, but no further information was provided.
Failure to Assist Resident in Obtaining Dental Care
Penalty
Summary
The facility failed to assist a resident in obtaining necessary dental care. The resident, who had diagnoses including COPD, chronic respiratory failure with hypoxia, and dementia, reported that his dentures did not fit well and made chewing difficult. He had not been evaluated by a dentist since before his admission. The resident's daughter stated that when she requested assistance from the social worker to arrange a dental appointment, she was told that dental care was not part of the resident's care at the facility and that arrangements could not be made. Review of the resident's record showed no documentation of dental care provided. The Director of Social Services later confirmed that the resident should be able to see a dentist if needed and that the facility would help make those arrangements.
Incomplete Medication Documentation and Missing Administration Parameters
Penalty
Summary
The facility failed to ensure complete and accurate medical record documentation for a resident with diagnoses including diabetes and heart failure. A physician's order for Droxidopa every 8 hours was present, but the April Medication Administration Record (MAR) had blank documentation boxes for three scheduled doses, despite the Assistant Director of Nursing stating the medication was administered but not recorded. Additionally, a physician's order for Midodrine every 8 hours as needed for hypotension lacked specific blood pressure parameters for administration, and the Director of Nursing confirmed that no such parameters could be found in the record.
Failure to Timely Notify Physician of Medication Unavailability
Penalty
Summary
The facility failed to notify the physician in a timely manner regarding the unavailability of a medication for a resident diagnosed with heart failure, gout, muscle weakness, and COPD. The resident was prescribed Vericiguat, a medication for chronic heart failure, to be taken daily. However, the medication was not available, and the pharmacy was aware of this issue. Despite this, there was no documentation indicating that the physician was informed of the delay until four days later, on February 16, 2025. The Director of Nursing (DON) confirmed that the physician should have been notified of the medication delay after 48 hours of non-receipt. The facility's policy required staff to contact the physician for an alternative if a medication was unavailable. The DON only received notification from the pharmacy about the medication's high cost and the need for approval on February 18, 2025, which he approved the same day. The resident's family was initially asked to supply the medication due to its cost, but this was later resolved without their involvement.
Failure to Use Correct PPE for Resident Under EBP
Penalty
Summary
The facility failed to ensure correct Personal Protective Equipment (PPE) usage by a staff member, CNA 1, when providing care to a resident, Resident G, who was under Enhanced Barrier Precautions (EBP). During an observation, CNA 1 was seen assisting Resident G without wearing a gown, despite the presence of a container with PPE and a sign indicating the need for EBP. Resident G, who had a feeding tube, was lying in bed and required high-contact care, which necessitated the use of a gown and gloves according to the facility's EBP policy. CNA 1 acknowledged the need for a gown after the care was provided. Resident G's medical record indicated a diagnosis of stroke and a physician's order for EBP due to the feeding tube. This incident was related to a complaint investigation.
Failure to Implement Pressure Ulcer Care Plan
Penalty
Summary
The facility failed to provide necessary treatment and services to promote healing for a resident with a pressure ulcer. During observations, it was noted that the resident's heels were resting directly on a regular mattress instead of being offloaded as required. Heel protectors were not in use, and a low air loss mattress intended for pressure reduction was found on the floor instead of on the resident's bed. Additionally, during incontinent care, a skin barrier cream was not applied as ordered, which was part of the care plan to prevent further skin breakdown. The resident, identified as having a deep tissue injury (DTI) on the right heel, had a care plan that included the use of an air mattress and offloading devices to prevent pressure on the heels. Despite these orders, the interventions were not implemented, and the treatment for the DTI was not completed as prescribed. The resident's medical history included diabetes mellitus, peripheral vascular disease, and stroke, which could contribute to the risk of pressure ulcers. The facility's failure to adhere to the care plan and physician's orders resulted in inadequate care for the resident's pressure ulcer.
Failure to Use Correct PPE for Resident Under Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that correct Personal Protective Equipment (PPE) was used by staff members when providing care to a resident who was under Enhanced Barrier Precautions (EBP). During an observation, two Licensed Practical Nurses (LPNs) entered the room of a resident to provide incontinent care without donning gowns, despite the requirement for PPE due to the resident's EBP status. The LPNs only wore gloves while assisting the resident, which was not in compliance with the facility's EBP policy that mandates the use of both gowns and gloves during high-contact resident care. The resident in question had a medical history that included diabetes mellitus, peripheral vascular disease, and stroke, and was noted to have a Deep Tissue Injury (DTI) on the right heel. The facility's policy required EBP PPE for residents with wounds, including any skin opening that required a dressing. The LPNs acknowledged the presence of a sign indicating the need for PPE and the availability of PPE in the room, but failed to utilize it. This oversight occurred despite a physician's order specifying the use of EBP due to the resident's wound condition.
Failure to Notify Responsible Party of Significant Changes in Resident's Status
Penalty
Summary
The facility failed to promptly notify the responsible party of a resident after significant changes in the resident's medical status, including the placement of an intravenous (IV) site, changes in medications, and medication times. The resident, who was cognitively impaired and had multiple diagnoses including dementia, acute kidney failure, and chronic kidney disease, was admitted to the facility and later discharged home. During the resident's stay, new orders for IV fluids were received, and a peripheral inserted central catheter (PICC) line was inserted after attempts to place a peripheral IV failed. Additionally, there were changes in the resident's medication regimen, including a decrease in Gabapentin dosage and the addition of Lyrica, as well as the administration of a medication to lower high potassium levels. Despite these significant changes, there was no documentation indicating that the resident's responsible party was informed about the PICC line insertion, the administration of IV fluids, the changes in medication, or the treatment for high potassium levels. The Chief Nursing Officer confirmed the lack of documentation regarding the notification of the responsible party. The facility's policy required that nursing staff notify the resident's physician of significant changes and subsequently inform the resident and their family, documenting these communications in the resident's record. This deficiency was identified in relation to a specific complaint.
Failure to Assist Resident with Personal Hygiene Needs
Penalty
Summary
The facility failed to ensure that activities of daily living (ADLs) were completed for a resident who required assistance, specifically related to the maintenance of fingernails. Resident F, who was cognitively intact and required supervision with personal hygiene, was observed with long fingernails on multiple occasions. The resident expressed that they did not have nail clippers and would have managed their nails themselves if they had the tools. Additionally, the resident indicated that staff had not offered assistance in trimming their nails. Despite the resident's request for help, their fingernails remained untrimmed until a later observation confirmed they had been cut. The resident's medical history included a fracture of the left femur, osteoarthritis, and lack of coordination, which may have contributed to their need for assistance with personal hygiene tasks.
Failure to Monitor Bruising in Resident on Anticoagulant Therapy
Penalty
Summary
The facility failed to ensure proper assessment and monitoring of bruising for a resident who was on anticoagulant therapy. The resident, who was cognitively intact, had a history of orthopedic aftercare following surgical amputation, cellulitis, type 2 diabetes, and atherosclerotic heart disease. They were observed with reddish/purple discolorations on their forearms and hands. Despite having a physician's order for skin checks twice a week and being on Rivaroxaban for DVT prevention, there was no care plan addressing the bruising or anticoagulant use. Additionally, the skin assessment was marked as completed without documentation of any new skin concerns.
Failure to Maintain and Monitor IV Catheters for Two Residents
Penalty
Summary
The facility failed to ensure proper maintenance and monitoring of peripheral intravenous (IV) catheters for two residents, leading to deficiencies in their care. Resident G had a peripheral IV catheter in the right upper arm, with physician's orders to receive Meropenem intravenously and flush the IV with normal saline before and after medication administration. However, the Medication Administration Record (MAR) did not reflect the administration of the saline flushes as routine, leading to a lack of documentation of the flushes from November 6 to November 14, 2024. The Chief Nursing Officer acknowledged the error, indicating the flush order was incorrectly listed as PRN (as needed) instead of routine. Resident D experienced discomfort due to an IV inserted in the deltoid, which was found to be bloody and red. The resident's record indicated attempts to insert a peripheral IV, which infiltrated, leading to the insertion of a midline by a PICC line nurse. However, there were no physician's orders to monitor the PICC line site for infection or to maintain patency with saline flushes. The Chief Nursing Officer confirmed the absence of such orders. The facility's policy required monitoring of IV sites for signs of infiltration, but this was not adhered to, resulting in inadequate care for Resident D.
Incomplete Documentation of Wound Care and Fall Evaluations
Penalty
Summary
The facility failed to ensure complete and accurate documentation of clinical records for two residents. For Resident K, the Treatment Administration Record (TAR) did not reflect that wound care treatments were completed as ordered on specific dates in October 2024. Although the Wound Nurse indicated that the treatments were performed, they were not signed off in the TAR, leading to incomplete documentation. Resident K had multiple diagnoses, including a surgical wound and a Stage 3 pressure ulcer, requiring specific wound care interventions. For Resident E, the facility did not properly document falls and related evaluations. The resident, who had dementia and was at high risk for falls, experienced a fall that was not immediately followed by a completed fall risk evaluation. The Chief Nursing Officer (CNO) noted that the evaluation was completed late and not initially included in the resident's clinical record. The fall occurred on a weekend, and the CNO had to facilitate the completion of the evaluation over the phone with the nurse on duty. The facility's fall protocol required evaluations to be completed immediately after a fall, which was not adhered to in this case.
Failure to Document and Communicate Resident Transfer to ER
Penalty
Summary
The facility failed to provide and document sufficient information for a resident being transferred to the hospital emergency room (ER). The deficiency involved Resident E, who had a diagnosis of metabolic encephalopathy. On the date of the incident, the resident was discharged from the facility, but the discharge status was not listed on the Minimum Data Set assessment. There was no documentation in the Nurses' Progress Notes indicating a change of condition, transfer to the ER, or discharge from the facility. Additionally, there was no Transfer Form or Discharge Form completed. The hospital ER notes indicated the resident lost consciousness during a transfer from bed to chair, but there was no prolonged loss of consciousness. The Director of Nursing (DON) confirmed that a family member called 911 for the transfer, and there was no documentation of the change of condition or completion of a transfer sheet. The DON was unable to verify if any paperwork was sent with the resident or if the hospital ER was notified with the resident's information.
Inaccurate MDS Assessments for Falls and Medications
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were accurately completed for two residents, leading to discrepancies in recorded information regarding falls, medications, and behaviors. Resident G's Admission MDS assessment inaccurately indicated no behaviors, no falls, and no antipsychotic medication use, despite multiple falls documented in the Nurse's Progress Notes and the administration of olanzapine for bipolar disorder with behaviors. The resident experienced several falls and exhibited aggressive behaviors, which were not reflected in the MDS assessment. An interview with MDS LPN 2 confirmed that the Admission MDS had not been coded correctly. Similarly, Resident J's Admission MDS assessment incorrectly reported no falls since admission, although a Nurse's Progress Note documented an unwitnessed fall. The Director of Nursing was informed of the incorrect MDS, but no further information was provided. These inaccuracies in the MDS assessments were identified during a review related to a specific complaint, highlighting the facility's failure to maintain accurate resident assessments.
Failure to Implement Individualized Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement individualized care plans for two residents, leading to deficiencies in care. Resident J, who had a left knee immobilizer due to a fracture, developed a pressure sore that began as a blister. Observations revealed that the immobilizer was not properly managed, as it slid down and caused pressure issues despite the use of padding. The facility did not have a care plan in place to address the use of the immobilizer and prevent pressure ulcers, as confirmed by the Director of Nursing. Resident G, diagnosed with dementia, exhibited multiple episodes of behavioral issues over several days. The Medication Administration Record documented these episodes and the interventions attempted, such as redirection and one-on-one care. However, there was no care plan to address the resident's behaviors, and the outcomes of interventions were inconsistently documented. The Social Service Director confirmed the absence of a care plan for managing Resident G's behaviors.
Failure to Administer Antibiotics and Monitor Blood Glucose Levels
Penalty
Summary
The facility failed to provide necessary care and services for a resident with diabetes mellitus and an abdominal wall abscess. The resident was prescribed ceftriaxone sodium, an antibiotic, to be administered once daily for seven days, but it was not given on one of the days, resulting in only six days of treatment. Additionally, another antibiotic, cephalexin, was not administered as ordered for a urinary tract infection. Furthermore, the resident's blood glucose levels were not monitored as required, and insulin was not administered according to the sliding scale protocol. The physician was not notified of elevated blood glucose levels, which were recorded multiple times above the threshold of 351, as specified in the physician's order. The Director of Nursing confirmed during interviews that the antibiotics were not administered and blood glucose levels were not obtained as ordered. There was also no documentation indicating that the physician had been notified of the elevated blood glucose results. These deficiencies were identified during a review of the resident's records and interviews conducted on specific dates, and they relate to complaints IN00438865 and IN00439585.
Failure to Investigate Fall and Implement Interventions
Penalty
Summary
The facility failed to conduct a thorough investigation of a fall involving a resident with severe cognitive impairment and high fall risk. The resident, diagnosed with dementia, was found on the floor and claimed to have wanted to see the world from the bottom up, denying a fall. Despite this, the investigation did not determine the root cause of the fall or document when the resident was last observed before the incident. The care plan had indicated that potential causes of falls should be identified and addressed, but this was not done. The Director of Nursing (DON) and an LPN involved in the incident did not provide a clear account of the circumstances leading to the fall. The facility's fall prevention policy lacked a post-fall protocol, and the only intervention noted was the placement of a fall mat by the bedside. The investigation and documentation were insufficient, as they did not include critical details such as the last observation time of the resident or a comprehensive analysis of the fall's root cause.
Inadequate Management of Dementia-Related Behaviors
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident diagnosed with dementia, leading to ongoing behavioral issues without proper input from the Interdisciplinary Team (IDT) and Social Services. The resident, identified as having severe cognitive impairment and requiring assistance with mobility, exhibited behaviors such as restlessness, exit-seeking, verbal abuse, and physical aggression. Despite these behaviors, there was no care plan in place to address them, and interventions were not consistently documented or attempted before administering medication. The resident's medical records indicated multiple instances of behavioral episodes, including attempts to leave the facility, verbal hostility, and physical aggression towards staff. Although there were physician's orders for non-pharmacological interventions prior to administering PRN psychotropic medications, these interventions were often not documented or attempted. The facility's failure to document specific targeted behaviors and the outcomes of interventions further compounded the issue, as it hindered the development of a person-centered care plan. Interviews with facility staff revealed a lack of communication and documentation regarding the resident's behaviors. The Social Service Director acknowledged the absence of a care plan and social service involvement, while the Director of Nursing admitted that not all behaviors were documented. The facility's behavioral management policy required monitoring and documentation of behaviors to develop individualized care plans, but this was not adhered to, resulting in inadequate management of the resident's dementia-related behaviors.
Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to ensure the correct use of Personal Protective Equipment (PPE) by staff members during wound care treatments, specifically involving two LPN Wound Nurses. During an observation, it was noted that there was no sign on Resident J's door indicating the need for Enhanced Barrier Precautions (EBP), despite the resident having pressure sores on the left heel and left posterior ankle. The LPN Wound Nurses applied gloves but did not implement EBP, as one nurse incorrectly stated that EBP was only necessary if the wounds had drainage. This oversight was contrary to the facility's policy, which required EBP for any wounds needing a dressing, potentially affecting 13 residents who required wound treatments.
Inaccurate Nurse Staffing Information Posting
Penalty
Summary
The facility failed to ensure that the posted Nurse Staffing Information was current and accurately reflected only the staff scheduled for Long Term Care. On August 5, 2024, it was observed that the Nurse Staffing Information posted at the Receptionist Desk was dated August 1, 2024, indicating it had not been updated for several days. During an interview, the Director of Nursing mentioned that the posting information was left in a binder for the Weekend Manager to post, suggesting a lapse in the updating process. Additionally, a review of the schedules and postings for July 2024 revealed that the Nurse Staffing Information included staff from Assisted Living, which was not intended. The Administrator acknowledged this oversight during an interview on August 6, 2024, indicating that they had just realized the inclusion of Assisted Living staff in the postings. This deficiency was related to a specific complaint, IN00439585.
Delayed Access to Medical Records for Residents
Penalty
Summary
The facility failed to provide timely access to medical records for two residents, G and H, after requests were made by the residents and their Power of Attorneys (POAs). For Resident G, the request for the complete medical record was made on 5/31/24, but the records were not received until 6/7/24. The delay was attributed to the process of scanning the request to the Corporate Office, where the Legal Department reviewed it before contacting the facility for release. Additionally, the facility had to wait for therapy and other third-party departments to provide their records, as they were not accessible through the facility's system. Similarly, Resident H's medical records were requested on 5/14/24 and were not received until 5/19/24. The Business Office Manager indicated that the delay was due to not receiving therapy records until 5/17/24, which were then printed and added to the medical record on 5/19/24. The facility's policy, dated 5/2023, stated that records should be provided within two working days of the request, which was not adhered to in these cases. This deficiency was related to a complaint identified as IN00431978.
Failure to Implement Enhanced Barrier Precautions for Resident with Urinary Catheter
Penalty
Summary
The facility failed to ensure the correct use of Personal Protective Equipment (PPE) by a staff member when handling a urinary catheter drainage bag for a resident under Enhanced Barrier Precautions (EBP). During a random observation, a Certified Nursing Assistant (CNA) was seen emptying a urinary catheter drainage bag without wearing a gown, despite the resident having a urinary catheter, which required EBP. The CNA acknowledged the lack of a gown and indicated that she believed there should have been a sign on the door and a PPE cart available if the resident was under EBP. However, there was no EBP sign or PPE cart present. Interviews with other staff members, including Licensed Practical Nurses (LPNs) and the Infection Control Nurse, revealed a lack of adherence to EBP protocols. The LPNs indicated that residents with certain conditions, such as urinary catheters, should be placed under EBP, with appropriate signage and PPE available. The Infection Control Nurse admitted to missing the presence of the urinary catheter during rounds and stated that the admitting nurse was responsible for initiating EBP signage and PPE. The resident's care plan and physician's order confirmed the need for EBP due to the urinary catheter, but these measures were not implemented, leading to the deficiency.
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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