Life Care Center Of Michigan City
Inspection history, citations, penalties and survey trends for this long-term care facility in Michigan City, Indiana.
- Location
- 802 Us Highway 20 East, Michigan City, Indiana 46360
- CMS Provider Number
- 155344
- Inspections on file
- 28
- Latest survey
- October 28, 2025
- Citations (last 12 mo.)
- 26
Citation history
Health deficiencies cited at Life Care Center Of Michigan City during CMS and state inspections, most recent first.
A resident with a history of stroke and epilepsy, identified as at risk for constipation, went over five days without a documented bowel movement despite care plan interventions and a facility bowel protocol requiring action after three days. The resident experienced nausea and abdominal pain, received stool softeners and laxatives with limited effect, and ultimately required hospital transfer for severe constipation and proctitis. The facility did not consistently follow its bowel management protocol or promptly escalate care.
A resident with chronic respiratory conditions was observed receiving oxygen at 4 lpm via nasal cannula, contrary to a physician's order for 2 lpm. The resident, who was cognitively intact, confirmed the correct flow rate, and an LPN later identified and corrected the discrepancy after observation.
A resident with dementia and a history of falls experienced an unwitnessed fall resulting in a head bruise and hip/back soreness. Although the nurse assessed the resident and notified the Nurse Practitioner, the resident's responsible party was not informed until several hours later, contrary to facility policy requiring immediate notification after such incidents.
A resident with severe cognitive and physical impairments experienced multiple falls over a two-month period, resulting in injuries. Despite these incidents, the care plan was not updated to address the resident's recurrent falls from the wheelchair, and no new interventions were implemented as required by facility policy.
A resident with paraplegia and chronic conditions was discharged home without a complete discharge summary. Key sections, including medication reconciliation and oxygen therapy needs, were left blank. Although social services coordinated with home health, this was not documented. The DON acknowledged the oversight.
A resident was administered nystatin powder for skin irritation despite no documented skin conditions. The resident, dependent on staff for daily activities, had a physician's order for the antifungal powder to be applied every shift. Weekly skin assessments showed no abnormalities, and the ADON confirmed the lack of documentation and indicated the medication should have been prescribed as needed.
A resident with cognitive impairment and hearing difficulties did not receive necessary hearing aids as per physician's orders, leading to communication issues. Staff interviews revealed a lack of awareness and documentation regarding the resident's hearing aid use, and the facility had previously replaced lost hearing aids. The Director of Nursing was unsure why the order for hearing aids did not appear for documentation.
The facility failed to document food consumption for three residents with a history of weight loss. One resident experienced an 11.01% weight loss, another an 8.47% loss, and a third a 28.57% loss. Despite care plans requiring meal intake documentation and dietician alerts, numerous meals were undocumented. The DON and ADON confirmed that CNAs were expected to complete these logs.
The facility failed to administer oxygen at the correct flow rate for two residents. One resident, with a history of atrial fibrillation and dementia, was observed with an oxygen flow rate below the prescribed 2 liters per minute. Another resident, with conditions including hemiplegia and COPD, had varying flow rates above the prescribed 2 liters per minute. The discrepancies were acknowledged by the DON.
The facility failed to ensure proper assessments and Physician's Orders for residents to self-administer their medications. Four residents were found with medications at their bedside or in their possession without the necessary documentation and assessments. The DON confirmed the lack of orders and assessments for self-administration.
The facility failed to ensure a resident was sent to the hospital in a timely manner for leg pain and swelling, resulting in multiple fractures. Additionally, treatments for diabetic ulcers were not completed as ordered for another resident, and wound assessments were not documented for two other residents. The Director of Nursing confirmed that treatments should have been completed as ordered.
The facility failed to notify the Physician in a timely manner regarding a resident's increased pain and leg swelling. Despite signs of discomfort and a deformed leg, the LPN did not contact the NP immediately due to the resident's denial of pain and the NP's working hours. The delay led to a late diagnosis of multiple fractures.
A resident with a history of falling and cognitive impairment fell and hit their face in the shower after leaning in their shower chair. Despite the CNA's attempts to readjust the resident, the chair tipped over. The DON indicated that the CNA should have called for additional assistance.
Failure to Adequately Monitor and Intervene for Constipation
Penalty
Summary
The facility failed to ensure adequate monitoring and timely interventions for constipation in a resident with a history of hemiplegia, hemiparesis following a stroke, and epilepsy. The resident was identified as being at risk for constipation due to decreased mobility and medication side effects, with care plan interventions including daily bowel movement documentation, following the facility's bowel protocol, and monitoring for complications. Despite these interventions, the resident experienced a period of over five days without a documented bowel movement, during which time there were also complaints of nausea and abdominal pain. The facility's bowel protocol required interventions if a resident had not had a bowel movement in three days, but there was a delay in implementing effective treatment. During this period, the resident received docusate sodium and later Miralax, but bowel movements remained infrequent and ineffective. The resident's condition worsened, with increasing abdominal pain and continued inability to have a bowel movement, eventually requiring a Fleet enema and subsequent transfer to the hospital. Hospital evaluation revealed significant stool retention and proctitis. Documentation and interviews confirmed that the facility did not consistently follow its bowel management protocol or promptly escalate care as required by the resident's condition and care plan.
Incorrect Oxygen Flow Rate Administered
Penalty
Summary
A resident with diagnoses including chronic obstructive pulmonary disease, hypertension, and chronic cough was observed on two occasions receiving oxygen via nasal cannula at a flow rate of 4 liters per minute (lpm), despite a physician's order specifying continuous oxygen at 2 lpm. The resident, who was cognitively intact, confirmed she was supposed to be on 2 lpm of oxygen. Review of the resident's medical record corroborated the physician's order for 2 lpm. During an interview, an LPN acknowledged the resident should be on 2 lpm, observed the concentrator set at 4 lpm, and adjusted it to the correct flow rate. The facility failed to ensure the resident received the necessary care and treatment by not providing the ordered oxygen flow rate.
Delayed Notification to Responsible Party After Resident Fall
Penalty
Summary
The facility failed to ensure timely notification of a responsible party following an unwitnessed fall involving a resident with multiple medical conditions, including a history of falls, dementia, and impaired mobility. The resident was found on the floor by a CNA, assessed as alert and oriented, and noted to have a bruise and bump on the head, as well as complaints of soreness in the left hip and back. Although the nurse left a message for the Nurse Practitioner and administered pain medication, the resident's son was not notified of the incident until several hours later. The resident's medical record indicated severe impairment in daily decision-making and required significant assistance with activities of daily living. The facility's policy required immediate notification of the resident, physician, and resident representative in the event of an accident resulting in injury with potential for physician intervention. Interviews with the Executive Director and DON confirmed the delay in notification, with the nurse focusing on neurological assessments and not immediately contacting the resident's son.
Failure to Update Fall Interventions After Multiple Resident Falls
Penalty
Summary
The facility failed to update fall prevention interventions for a resident with a history of multiple falls. The resident, who had diagnoses including dementia, COPD, hypertension, stroke, and hemiplegia, was assessed as severely impaired in daily decision-making and required substantial to maximum assistance with bed mobility, transfers, and toileting. The care plan identified the resident as being at risk for falls and included interventions such as assistance with ADLs, a mattress on the floor, and keeping the call light within reach. Despite these measures, the resident experienced four falls over a two-month period, with documented injuries including bumps and abrasions to the head and elbow. After each fall, there was no documentation indicating that the care plan was reviewed or revised to address the resident's recurrent falls from the wheelchair or to implement additional interventions related to wheelchair use or positioning. The facility's fall management policy required the interdisciplinary team to review and revise the care plan after each fall event, but this was not done. The Executive Director confirmed that the care plan had not been updated following the resident's repeated falls.
Incomplete Discharge Summary for Resident Requiring Home Health Services
Penalty
Summary
The facility failed to complete a discharge summary for a resident, identified as Resident B, who was discharged home and required home health services. The resident's record review revealed that the Discharge Summary Information assessment was incomplete, with several critical sections left blank. These included the reason for discharge, the reconciliation of pre-discharge and post-discharge medications, the recapitulation of the resident's stay, and the consent from the patient or patient representative. Additionally, the discharge summary did not address the resident's need for continuous oxygen therapy, which was a significant oversight given the resident's medical condition. Resident B had multiple diagnoses, including paraplegia, chronic kidney disease stage 3, and high blood pressure, and was dependent on staff for various activities of daily living. The resident was discharged by ambulance, and although social services had communicated with the home health company to ensure the resident had the necessary equipment and support at home, this was not documented in the discharge summary. The Director of Nursing acknowledged that the discharge summary should have been completed and should have included information about the resident's oxygen therapy.
Unnecessary Antifungal Medication Administered
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications. Specifically, a scheduled antifungal powder, nystatin, was administered to a resident with no documented skin conditions. The resident, who was cognitively intact but dependent on staff for daily activities, had a physician's order for nystatin powder to be applied to skin folds every shift for skin irritation. However, weekly skin assessments conducted over several weeks showed no skin abnormalities, and there was no documentation supporting the need for the antifungal treatment. During an interview, the Assistant Director of Nursing acknowledged the lack of documentation and indicated that the nystatin powder should have been prescribed on an as-needed basis for any new skin conditions.
Failure to Administer and Document Hearing Aid Use for Resident
Penalty
Summary
The facility failed to ensure that a resident received the necessary assistive devices for hearing, as the resident's hearing aids were not administered according to the physician's order. Resident 4, who was cognitively impaired and had a history of coronary artery disease, heart failure, and hypertension, was observed without hearing aids on multiple occasions. The resident was noted to have difficulty hearing and frequently said 'huh' when others were speaking. The care plan indicated that the resident required assistance with hearing aids, which were to be put in during the morning and removed at night, with documentation of these actions. However, there was no documentation in the Medication Administration Record and Treatment Administration Record regarding the hearing aid order. Interviews with staff revealed a lack of awareness and adherence to the hearing aid protocol. A CNA was unaware if the resident wore hearing aids, and an LPN could not locate the hearing aids in the medication cart, indicating they might be lost. The LPN mentioned that the resident sometimes removed the hearing aids and misplaced them, and staff were supposed to manage and document their use daily. The Director of Nursing was unsure why the order for hearing aids did not appear for documentation purposes and acknowledged that the facility had previously replaced the resident's hearing aids due to loss. The deficiency was identified as a failure to ensure the resident's hearing aids were managed and documented as per the physician's order.
Failure to Document Food Consumption for Residents with Weight Loss
Penalty
Summary
The facility failed to ensure that food consumption logs were completed for residents with a history of weight loss, affecting three residents. Resident 59, who was cognitively impaired and required substantial assistance with eating, experienced an 11.01% weight loss over several months. Despite a care plan that required alerting the dietician and recording food intake at each meal, numerous meal consumption logs were missing documentation for breakfast, lunch, and dinner over a 30-day period. The Director of Nursing confirmed that CNAs were expected to document meal consumption percentages in the computer system. Resident 14, also cognitively impaired, experienced an 8.47% weight loss. The care plan required recording food intake at each meal, but several meals were not documented over a period of weeks. Similarly, Resident 42, who was severely impaired for daily decision-making and required assistance with eating, experienced a 28.57% weight loss in three months. The care plan required recording food intake and alerting the dietician when supplements were not consumed, yet multiple meals were not documented. The Assistant Director of Nursing acknowledged that the food consumption logs should have been completed for these residents.
Oxygen Flow Rate Discrepancies for Two Residents
Penalty
Summary
The facility failed to ensure that oxygen was administered at the correct flow rate for two residents who were reviewed for oxygen use. Resident 42 was observed multiple times with an oxygen flow rate set under 2 liters per minute, despite a physician's order indicating it should be continuously administered at 2 liters per minute for hypoxia. The resident's medical history included atrial fibrillation, dementia, depression, muscle weakness, adult failure to thrive, anxiety, and a left shoulder fracture. The resident required supervision or assistance with daily activities and was severely impaired in decision-making. Similarly, Resident 48 was observed with varying oxygen flow rates of 3.5 liters and 2.5 liters per minute, while the physician's order specified a continuous flow of 2 liters per minute for shortness of breath. This resident's medical history included hemiplegia, heart failure, stroke, diabetes, hypertension, and chronic obstructive pulmonary disease. The resident was cognitively intact for decision-making but had impairments on one side of the body and used a wheelchair. The discrepancies in oxygen administration were noted, and the Director of Nursing acknowledged the need for correction.
Failure to Ensure Proper Self-Administration of Medications
Penalty
Summary
The facility failed to ensure residents had an assessment and Physician's Orders to self-administer their own medications for four residents. Resident C was observed with Bacitracin ointment and eye drops at her bedside without a self-administration assessment or Physician's Order for the Bacitracin ointment. The resident was confused and not oriented to time and place, and the eye drops were out of her reach. The Director of Nursing (DON) indicated that the resident's son might have brought the eye drops, but the Bacitracin ointment should not have been left at the bedside. Resident F was found with a medication cup containing a Melatonin tablet on his over bed table, which he had requested but not taken. The resident had no self-administration assessment or Physician's Order to self-administer his medications. The DON was aware of the medication cups and the pill but confirmed that there was no order or assessment for self-administration. Resident G was observed with a bottle of eye drops on her over bed table, which she administered to herself every evening. There was no Physician's Order or self-administration assessment for the eye drops. Resident H was found with a medication cup containing three white pills, which she identified as her water pills. Although her care plan included orders for self-administration of certain medications, there was no order or assessment for her daily medications. The DON confirmed the lack of orders and assessments for self-administration for these residents.
Failure to Provide Timely Hospital Transfer and Complete Wound Care
Penalty
Summary
The facility failed to ensure a resident was sent to the hospital in a timely manner, related to complaints of increased pain and leg swelling. Resident D, who had a history of falling, metabolic encephalopathy, and osteomyelitis, was cognitively impaired and dependent on staff for mobility. Despite multiple complaints of leg pain and visible deformities, the resident was not sent to the hospital until the following day, resulting in a diagnosis of multiple fractures and osteoporosis. The LPN did not call the Nurse Practitioner (NP) immediately due to the resident's denial of pain and the NP's posted hours, leading to a delay in appropriate care. The facility also failed to ensure treatments were completed for diabetic ulcers and an assessment was completed for new non-pressure wounds. Resident B, who had multiple severe diagnoses including stroke, sepsis, and type 2 diabetes, had diabetic ulcers that were not treated as ordered. The Treatment Administration Record (TAR) indicated missed treatments, and there was no documentation to support that treatments were completed on the previous shift. The Wound Nurse confirmed that treatments should have been completed as ordered by the doctor. Additionally, Resident C and Resident F had issues with wound care. Resident C, who had contusions and osteoarthritis, was observed with dried blood and open areas on her toes, but there was no wound assessment documented. Resident F, who had osteomyelitis and a diabetic foot ulcer, had a necrotic area on the left foot that was not treated as ordered. The Physical Therapist (PT) only treated the left heel and not the necrotic area between the toes. The Director of Nursing confirmed that treatments were to be done as ordered by the physician.
Failure to Notify Physician of Resident's Increased Pain and Leg Swelling
Penalty
Summary
The facility failed to ensure timely notification of the resident's Physician regarding increased pain and leg swelling for Resident D. The resident, who had a history of falling, metabolic encephalopathy, and osteomyelitis, was cognitively impaired and dependent on staff for mobility. On 3/14/24, a CNA observed the resident's right leg with bruising and a stage one area, and the Nurse Practitioner (NP) was notified. The NP assessed the resident and ordered a pillow to be placed between the resident's legs. Later that evening, the resident appeared to be in pain, but the LPN did not notify the NP because it was after her working hours, and the resident denied pain despite showing signs of discomfort. The next morning, the resident's left leg appeared deformed, and the NP was notified, leading to an x-ray and subsequent diagnosis of multiple fractures and osteoporosis. The Director of Nursing indicated that the Physician should have been contacted earlier when the resident showed signs of pain and leg swelling, regardless of the NP's working hours. The facility's investigation revealed that the LPN noticed the resident's left leg looked different during wound care but did not contact the NP immediately due to the resident's denial of pain and the NP's posted working hours. The following morning, the resident's leg condition worsened, prompting the LPN to notify the NP, who then ordered an x-ray. The delay in notifying the Physician resulted in a late diagnosis of the resident's fractures. The Director of Nursing confirmed that staff should have contacted the Physician or herself for guidance when the resident first showed signs of increased pain and leg swelling.
Inadequate Supervision During Shower Leads to Resident Fall
Penalty
Summary
The facility failed to ensure adequate supervision for a resident who was leaning in their shower chair, leading to an accident. The resident, who had a history of falling, metabolic encephalopathy, and osteomyelitis, was cognitively impaired and dependent on staff for mobility and transfers. During a shower, the resident was leaning in the shower chair, and despite the CNA's attempts to readjust them, the chair tipped over, causing the resident to fall and hit their face. The resident sustained a bump on the left side of their forehead and required a three-person assist to be placed back in their wheelchair before being transported to the hospital for evaluation. The Director of Nursing (DON) indicated that the CNA should have pulled the emergency call light and waited for additional assistance. The incident was documented in the facility's fall investigation, and the CNA provided a statement confirming the events. The DON noted that the resident did not typically lean in the shower chair during baths, suggesting that the CNA's response to the situation was inadequate, leading to the resident's fall and injury.
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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