Life Care Center Of The Willows
Inspection history, citations, penalties and survey trends for this long-term care facility in Valparaiso, Indiana.
- Location
- 1000 Elizabeth Dr, Valparaiso, Indiana 46383
- CMS Provider Number
- 155158
- Inspections on file
- 28
- Latest survey
- March 25, 2026
- Citations (last 12 mo.)
- 40
Citation history
Health deficiencies cited at Life Care Center Of The Willows during CMS and state inspections, most recent first.
A resident with dementia who required staff assistance for ADLs, including bathing, was scheduled to receive showers twice weekly, but facility records showed no bathing documented on multiple scheduled shower days, and no corresponding shower sheets were completed. The resident’s care plan and MDS indicated a need for partial to moderate staff assistance with toileting hygiene, dressing, personal hygiene, and bathing, yet the resident was mistakenly left off the shower schedule on at least one of the missed days and did not receive a shower as planned.
Staff failed to follow infection control guidelines by not wearing masks when entering a resident's room marked for droplet and enhanced barrier precautions. Both a wound nurse and a CNA wore gowns and gloves but did not use masks, and staff were unclear about the resident's current isolation status despite signage and physician orders indicating the need for precautions.
Multiple areas of the facility, including three halls and the dining room, were found to have dirty and discolored vents, exposed electrical wiring, and a broken baseboard heating cover. The Maintenance Director was aware of the exposed wiring and noted that vent cleaning and repairs were still pending.
The facility did not ensure that CNAs consistently documented incontinence care every shift for three residents with cognitive impairment and incontinence, as required by facility policy. Record reviews showed multiple instances of missing documentation over a 30-day period, despite care plans and MDS assessments indicating the need for substantial assistance with toileting and hygiene.
The facility failed to maintain the privacy of residents' personal and medical records during a medication pass. An LPN was observed leaving the electronic medication record open and unlocked in the hallway while preparing medications for two residents, exposing their personal information. The LPN admitted to not knowing how to lock the screen, and the DON confirmed that screens should be locked when unattended.
A facility failed to implement care plans for a resident with severe cognitive impairment and multiple medication needs, including opioids. Despite being on hospice care and requiring maximal assistance for daily living activities, there were no care plans addressing pain management and opioid use. The DON confirmed the absence of these care plans.
A resident with a stage 4 pressure ulcer did not receive wound care as per the physician's orders. The prescribed treatment included specific steps and materials, but the observed care involved different products and procedures. The resident had significant cognitive impairment and required substantial assistance for bed mobility. The discrepancy was noted by the IP Nurse upon review.
A facility failed to provide a nutritional supplement and maintain accurate meal logs for a resident with a history of weight loss. The resident, who was at nutritional risk, did not receive the fortified soup indicated on her meal ticket, and meal consumption logs were incomplete. Staff interviews revealed a lack of awareness of the resident's dietary orders, and the Dietary Manager confirmed the importance of meal logs for assessing nutritional needs.
An LPN failed to perform proper hand hygiene during a medication pass for two residents. The LPN did not wash hands before preparing medications and only used hand sanitizer after pouring medications into a cup. The LPN misunderstood the hand hygiene protocol, believing it was only necessary to wash hands after every third resident. The facility's policy requires hand hygiene before and after resident contact and after touching objects in the resident's environment.
A facility failed to ensure timely follow-up on urine culture results for a resident with a UTI, leading to the administration of an ineffective antibiotic. The resident, who was cognitively intact and dependent on staff for toileting, was prescribed ciprofloxacin after returning from the hospital. Despite a request for hospital records, the facility did not receive the urine culture results until after the antibiotic course was completed, revealing resistance to ciprofloxacin. The delay resulted in continued symptoms for the resident.
Failure to Provide Scheduled Showers for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a dependent resident received bathing/showers at least twice weekly as required. Record review for Resident C, who had dementia and was cognitively impaired, showed a care plan updated on 1/7/26 indicating the resident required assistance with ADLs, including mobility and personal care. The Quarterly MDS dated 2/27/26 documented that the resident needed partial to moderate staff assistance with toileting hygiene, dressing, personal hygiene, and bathing. Facility Point of Care documentation from 2/4/26 through 3/24/26 indicated the resident was scheduled to receive showers on Thursdays and Sundays, but there was no bathing documented on 3/1/26, 3/12/26, and 3/19/26. Corresponding shower sheets for those dates were also missing. During interview, the ADON confirmed she could not locate completed shower sheets for those dates and stated the resident had been mistakenly left off the shower schedule on 3/12/26 and did not receive a shower on that date. This citation relates to Intake 2960382 and violations of 410 IAC 16.2-3.1-38(a)(3) and 410 IAC 16.2-3.1-38(b)(2).
Failure to Implement Proper PPE and Isolation Precautions
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices were followed, specifically regarding the use of personal protective equipment (PPE) and staff awareness of isolation precautions. During observations, staff members, including a wound nurse and a CNA, entered a resident's room that was marked for enhanced barrier precautions (EBP) and droplet precautions without wearing masks, although they wore gowns and gloves. The wound nurse was unaware of the reason for the droplet precaution signage and believed the resident was only on contact isolation. The CNA did not question the signage, assuming the resident was no longer in isolation, and indicated she was unaware of any prior droplet isolation for the resident. The resident involved had multiple diagnoses, including neuromyelitis optica, paraplegia, pressure ulcer, neuromuscular dysfunction, dysphagia, and anemia, and was cognitively intact. Physician orders indicated EBP due to wounds and a Foley catheter, and there had been a previous order for contact and droplet precautions related to a COVID-19 infection. The care plan also indicated contact isolation for prophylactic antibiotic use for C. difficile. Despite these orders and signage, staff did not consistently implement appropriate PPE use or verify the current isolation status, leading to a failure in following infection control guidelines.
Environmental Cleanliness and Safety Deficiencies
Penalty
Summary
The facility failed to maintain a clean and safe environment for residents, staff, and the public, as evidenced by multiple deficiencies observed during an environmental tour. Dirty and discolored ceiling vents were found throughout the East Hall, Center Hall, [NAME] Hall, and the dining room. In the Center Hall, exposed electrical wiring was observed both across from a resident room and hanging from a ceiling tile. Additionally, the dining room had a baseboard heating unit cover that was not attached. During an interview, the Maintenance Director acknowledged awareness of the exposed wiring and stated that the covers had been knocked off about a week prior and had not yet been replaced. The vents throughout the facility were also noted to be in need of power washing or replacement.
Failure to Maintain Complete Incontinence Care Documentation
Penalty
Summary
The facility failed to maintain complete and accurate clinical records regarding incontinence care for three residents who required assistance with activities of daily living (ADL). For each resident, the care plans and Minimum Data Set (MDS) assessments indicated varying levels of cognitive impairment and dependence on staff for toileting and hygiene, with frequent or occasional incontinence noted. Facility policy required Certified Nursing Assistants (CNAs) to document incontinence care at least every shift, three times daily, including whether the resident was continent or incontinent of bowel and bladder. Record reviews for the previous 30 days revealed multiple shifts where incontinence care documentation was missing for all three residents. Specific dates and shifts were identified for each resident where no documentation was present, despite the expectation for consistent charting. During interviews, the Regional Nurse Consultant confirmed that CNAs were required to document incontinence care every shift and was unable to provide further information regarding the missing documentation. The facility's policy on incontinence management also emphasized the need for documentation following care procedures.
Failure to Maintain Privacy of Electronic Medication Records
Penalty
Summary
The facility failed to maintain the privacy of residents' personal and medical records during a medication pass. On November 8, 2024, an LPN was observed preparing medications for two residents in the hallway using an electronic medication record on a computer. After preparing the medications for Resident 113, the LPN left the computer screen open and unlocked, exposing the resident's medications and personal information. The same incident occurred when the LPN prepared medications for Resident 6, again leaving the computer screen open and unlocked in the hallway. During an interview, the LPN admitted to not locking the screen, citing a lack of knowledge on how to unlock it. The Director of Nursing confirmed that computer screens should be locked when unattended and stated she would address the issue with the nurse.
Failure to Implement Care Plans for Pain and Opioid Use
Penalty
Summary
The facility failed to implement care plans for a resident, identified as Resident 9, who was severely cognitively impaired and required maximal to total dependence on staff for activities of daily living. The resident's diagnoses included senile degeneration of the brain and dementia, and she was receiving hospice care. According to the Quarterly Minimum Data Set (MDS) assessment, the resident was on multiple medications, including antipsychotic, anti-anxiety, antidepressant, and opioid medications. Specifically, the November 2024 Physician Order Summary indicated that the resident was prescribed morphine sulfate, an opioid pain medication, to be administered as needed every two hours, with a requirement for staff to observe for opioid side effects every shift. However, there were no care plans in place addressing pain management and opioid use for this resident. During an interview, the Director of Nursing confirmed the absence of these care plans in the resident's current care plan.
Failure to Follow Physician's Orders for Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment and services to promote healing for a resident with a stage 4 pressure ulcer. On observation, the wound care provided to the resident did not align with the physician's orders. The resident, who had significant cognitive impairment and required substantial assistance for bed mobility, was observed receiving wound care that deviated from the prescribed treatment. The physician's order specified cleansing the coccyx with wound wash, applying skin prep to the periwound, a thin layer of germ shield to the wound bed, collagen, silver alginate, and a small foam dressing. However, the observed treatment involved the application of antimicrobial gel and calcium alginate, which was not in accordance with the physician's order. The IP Nurse acknowledged the discrepancy after reviewing the physician's orders.
Failure to Provide Nutritional Supplement and Maintain Meal Logs
Penalty
Summary
The facility failed to ensure that a nutritional supplement was offered during meal service and that food consumption logs were completed for a resident with a history of weight loss. On a specific date, Resident 5, who was seated in a wheelchair in the Assisted Dining Area, did not receive the fortified soup that was indicated on her meal ticket. The resident's meal tray included mashed potatoes, ground meatballs with gravy, vegetables, and ice cream, but lacked the fortified soup. The resident's care plan, which was revised earlier in the year, indicated that she was a nutritional risk and required supplements and a mechanically altered diet. The resident's physician's orders included fortified soup at lunch and supper, which was not provided during the observed meal. Additionally, the facility did not maintain accurate meal consumption logs for Resident 5, who had experienced significant weight loss over six months. The resident's weight had decreased from 136.2 lbs to 120.2 lbs, a loss of 11.75%. The Task Meal Consumption Logs lacked documentation for several meals over the past 30 days, including specific dates for breakfast and lunch. Interviews with staff revealed a lack of awareness regarding the resident's dietary orders, and the Dietary Manager confirmed that the meal consumption logs were important for assessing the need for adjustments in the resident's enteral feeding. The failure to provide the fortified soup and maintain accurate meal logs contributed to the deficiency identified by the surveyors.
Inadequate Hand Hygiene During Medication Pass
Penalty
Summary
The facility failed to implement proper infection control measures during a medication pass, as observed with two residents. On the morning of November 8, 2024, an LPN was seen administering medications to a resident without performing hand hygiene before preparing the medication. After giving the medications to the resident, the LPN returned to the medication cart and prepared medications for another resident, again without performing hand hygiene. The LPN used hand sanitizer only after the medications were poured into the medication cup. The LPN then delivered the medications to the second resident and returned to the medication cart without performing hand hygiene. During an interview, the LPN expressed a misunderstanding of the hand hygiene protocol, believing it was only necessary to wash hands after every third resident. The Director of Nursing confirmed that hand sanitizer should be used, and hands should be washed after every third resident unless something was touched. The facility's hand hygiene policy, dated July 15, 2022, requires hand hygiene before and after contact with residents and after contact with objects and surfaces in the resident's environment.
Failure in Timely Follow-Up on Urine Culture Results
Penalty
Summary
The facility failed to promote antibiotic stewardship by not ensuring timely follow-up on urine culture results for a resident with a history of urinary tract infections (UTIs). The resident, who was cognitively intact and dependent on staff for toileting assistance, was sent to the hospital for evaluation of vaginal bleeding and returned with an order for ciprofloxacin to treat a UTI. Despite a request for hospital records being faxed on October 16, 2024, the facility did not receive the urine culture and sensitivity results until October 22, 2024, which indicated resistance to ciprofloxacin and susceptibility to cefuroxime. The resident completed the ciprofloxacin course on October 21, 2024, but continued to experience symptoms, including pain and dark amber urine. The delay in receiving the urine culture results led to the resident being prescribed an ineffective antibiotic for the UTI. The Infection Prevention Nurse acknowledged the difficulty in obtaining timely test results from the hospital, as they had to rely on fax requests, which often required multiple attempts. The facility's antibiotic stewardship policy emphasizes the importance of appropriate antibiotic use to improve resident outcomes and reduce resistance, but this was not adhered to in this instance.
Latest citations in Indiana
Surveyors observed that dietary staff repeatedly worked in kitchen and meal service areas with uncovered facial hair, despite facility policy and state sanitation requirements mandating effective hair restraints. Two dietary aides with short beards or mustaches were seen walking through food preparation areas, taking food temperatures, handling food, and plating meals at steamtables in dining rooms without any facial hair coverings, while the current policy required all hair, including facial hair, to be restrained to prevent contamination.
The facility failed to consistently provide and document required bed-hold policy notices when several residents were transferred to the hospital. In multiple cases, residents with dementia, psychotic disorders, COPD, chronic respiratory failure, altered mental status, and cerebral infarction were sent out for acute changes in condition, and while transfer notes reflected physician and family notifications, they lacked documentation that the bed-hold policy was discussed with the resident or responsible party. Notices of Transfer or Discharge often indicated a copy of the bed-hold policy was sent with the resident, but the records did not show signed and dated acknowledgment by the resident or appropriate representative, including in situations where a resident had moderate cognitive impairment, short-term memory issues, or a documented need for a proxy and a financial POA authorizing an agent for health care decisions.
Surveyors found that the facility failed to provide trauma‑informed and culturally competent care by not incorporating two residents’ extensive trauma histories and specific behavioral triggers into their care plans. One resident with documented homelessness, polysubstance abuse, severe accidents with multiple fractures, viral encephalitis with coma, physical and sexual abuse, loss of family contact, and a past suicide attempt had multiple behavior‑focused care plans that referenced identifying triggers but listed none and did not mention their physical, sexual, medical, or psychosocial trauma. Another resident with TBI from being struck by a truck, an 11‑month coma, long‑term state hospital residence, alleged shooting of a parent, and diagnoses including intermittent explosive disorder and borderline personality disorder had a PASRR identifying a specific trigger and notes of inappropriate sexual behavior, yet their care plans omitted these traumatic events, the identified trigger, and the sexual behavior. Staff interviews confirmed that residents were screened for trauma, but the trauma histories and triggers were not reflected in the individualized plans of care.
A resident with schizophrenia, post‑stroke hemiparesis, and mild cognitive impairment expressed feeling down and wanting to kill himself, but staff did not document asking about a specific plan, did not notify the physician or psychiatric NP as expected, and did not develop or update a care plan addressing depression or suicidal ideation. The SSD documented offering support and initiating 15‑minute checks once, but there was no further follow‑up or documentation of interventions after subsequent suicidal statements made in a care plan meeting with the resident’s father. The DON and Administrator reported that facility policy requires immediate notification of key staff, assessment for a plan and means of self‑harm, and thorough documentation, which were not carried out or reflected in the medical record for this resident.
A resident with schizophrenia, post-stroke hemiparesis, and mild cognitive impairment verbalized suicidal ideation, but the care plan did not address depression or suicidal thoughts, and required assessments and services were not accurately or timely documented. An SSD note recorded the resident saying he wanted to kill himself and referenced 15‑minute checks and a care plan update, yet the active care plan lacked depression/suicidal ideation interventions. Multiple late-entry Social Services notes were later added, describing follow-up visits and the resident denying suicidal ideation, but the SSD later reported she did not typically ask about a suicide plan and did not personally provide individual follow-up visits as described. These practices conflicted with the facility’s policy requiring factual, first-hand, and timely documentation of assessments and services.
A resident was observed with an Albuterol inhaler on an overbed table and later reported keeping the inhaler in a nightstand drawer, with no staff present during these observations. Record review showed the resident had no cognitive impairment on the admission MDS but lacked any documented self-medication administration assessment. The DON acknowledged that the required assessment had not been completed, despite facility policy requiring staff and the practitioner to evaluate each resident’s mental and physical abilities before allowing self-administration of medications.
Surveyors found that the facility submitted inaccurate direct care staffing data to CMS through the PBJ system over multiple days in a quarter. CASPER reports showed apparent gaps in 24-hour licensed nurse coverage, low weekend staffing, and a 1-star staffing rating, while internal staffing sheets documented that licensed nurses were present and the facility was fully staffed on those days. The Administrator reported that the discrepancies were due to PBJ data entry errors, despite a facility policy requiring all PBJ entries to be accurate, auditable, and verifiable against payroll, invoices, or contracts.
Surveyors found that the facility did not provide or document required written transfer/discharge notices and bed-hold policy information for four residents who were sent to the hospital, including individuals with conditions such as dementia, CHF, chronic respiratory failure, and CKD. In each case, progress notes showed that the resident was transferred for acute issues, but the clinical records lacked evidence that written notices were given to the residents or their representatives, and in one case lacked documentation that required information was sent to the receiving provider. Facility leadership, including the ADON, DON, and Administrator, acknowledged that the records did not contain the required documentation, despite a written policy requiring such notices and information exchange.
A resident with Alzheimer’s disease and depression, previously on an antidepressant, exhibited intermittent refusals of medications and care, occasional yelling at staff, and reports of unusual perceptions, such as believing men were in or near her room. Nursing notes over several months documented these refusals and complaints but did not show that the behaviors were evaluated or recorded as dangerous, non-redirectable, or causing significant distress, nor did they document specific non-pharmacological interventions attempted or their outcomes. Despite this, a psychiatric NP later added new diagnoses of schizoaffective disorder, borderline personality disorder, and delusional disorder and ordered an antipsychotic (Seroquel) without a comprehensive evaluation in the record to support these diagnoses. The facility’s psychotropic medication policy, which requires identification and documentation of target behaviors, use of nonpharmacological interventions, and ongoing behavior monitoring, was not followed for this resident.
The facility failed to keep PASARR Level I screenings accurate and current for three residents when new mental health diagnoses and psychoactive medications were initiated. One resident’s PASARR omitted a PTSD diagnosis and an added antidepressant, despite documentation of PTSD on the MDS and care plan and a physician order for Pristiq. Another resident’s PASARR listed only depression and dementia, even after additional diagnoses such as borderline personality disorder, delusional disorder, and schizoaffective disorder were added and an antipsychotic (quetiapine) was ordered, with the MDS later reflecting psychotic disorder, schizophrenia, and depression with antipsychotic and antidepressant use. A third resident’s PASARR did not include a depression diagnosis or newly ordered escitalopram and lorazepam, although the admission MDS documented depression with antianxiety and antidepressant use. These omissions occurred despite facility policy requiring a new Level I review after significant mental status changes, including new mental health diagnoses or new psychotropic medications.
Uncovered Facial Hair During Food Preparation and Meal Service
Penalty
Summary
The deficiency involves the facility’s failure to ensure that food was served in a sanitary and safe manner in accordance with professional standards and facility policy during multiple kitchen and meal service observations. During an initial kitchen observation, two dietary aides were seen walking through the kitchen food preparation area with uncovered facial hair. One aide had facial hair above and below the lip and along the jaw line, approximately one-fourth inch in length, and the other had a mustache of similar length; neither used any facial hair covering. These observations occurred while staff were present in the kitchen area where food was stored and prepared. During subsequent observations on the same day, the same two dietary aides were again observed with uncovered facial hair while directly involved in meal preparation and service. One aide walked through the kitchen while the noon meal was being prepared and placed into a transport cart for service in the south dining room, and later was observed plating the noon meal at the steamtable in that dining room, still without a facial hair covering. The other aide walked through the kitchen while the noon meal was being prepared and placed into the steamtable for the north dining room, took food temperatures, assisted with plating meals at the steamtable, and retrieved food items and supplies from the kitchen, all while having an uncovered mustache approximately one-fourth inch in length. The Dietary Manager stated that staff hair was to be covered when in the kitchen and during meal service, and the facility’s written policy and the cited Indiana Food Establishment Sanitation Requirements both required effective hair restraints, including for facial hair, to prevent contamination of food, equipment, and utensils.
Failure to Provide and Document Bed-Hold Policy at Time of Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure that required bed-hold policy information was provided and documented for four residents transferred to the hospital. For a resident with dementia, psychotic disorder, and autistic disorder who had a BIMS score of 0 indicating severe cognitive impairment, progress notes documented physician notification and guardian notification when the resident was sent to the hospital, but there was no documentation that the bed-hold policy was provided to the responsible party. A Notice of Transfer or Discharge later indicated a copy of the bed-hold policy was sent with the resident. Another resident with COPD and chronic respiratory failure, cognitively intact with a BIMS score of 13, experienced a decline in condition and was transferred to the hospital by ambulance; progress notes documented family notification but did not document any discussion of the bed-hold policy, although a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident. A third resident with altered mental status and cerebral infarction, with a BIMS score of 10 indicating moderate cognitive impairment and documented short-term memory impairment, experienced changes in condition and was transferred to the hospital. Progress notes stated the resident was their own responsible party and that no other notification was completed, and transfer documentation did not include the bed-hold policy, although an untimed Notice of Transfer or Discharge indicated a copy of the bed-hold policy was signed by the resident. A financial power of attorney document in the record showed the resident had designated an agent to act in consent or refusal of health care. For a fourth resident with dementia and osteomyelitis, transfer documentation and a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident, and the transfer form noted the resident required a proxy for decision making. The facility’s policy required that at the time of transfer to a hospital, written notice specifying the duration of the bed-hold policy and information on return to the next available bed be provided, and that a signed and dated copy of the bed-hold notice given to the resident or representative be kept in the resident file, which was not consistently documented for these residents.
Failure to Integrate Trauma Histories and Behavioral Triggers Into Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to identify and incorporate residents’ trauma histories and specific behavioral triggers into their care plans, despite documented histories of significant trauma and behavioral health issues. For one resident, extensive social service and progress notes documented homelessness, polysubstance abuse, major depressive and anxiety disorders, chronic pain, a history of severe car accidents with multiple fractures, viral encephalitis resulting in a three‑month coma, loss of child custody, multiple divorces, physical abuse by a spouse, the death of a fiancé who was struck by a car while in a wheelchair, lack of family contact, and a past suicide attempt by Valium overdose. Additional documentation noted a history of rape by a brother at age eight and prior placement under direct supervision and 15‑minute checks related to suicidal ideation. Despite these documented traumatic events and behavioral health concerns, the resident’s care plans did not identify a history of physical trauma, sexual trauma, homelessness, substance abuse, medical trauma, or attempted suicide. For this same resident, the MDS showed no cognitive deficit and identified behaviors such as verbal aggression and rejection of care, along with diagnoses including seizure disorder, depression, chronic pain syndrome, homelessness, and anxiety disorder. Multiple care plans addressed behaviors such as drug‑seeking, pretending to have seizures for attention or medication, making false allegations, verbal aggression when unable to smoke, and a desire for intimate relationships with consenting male residents. These care plans referenced goals such as effective coping skills, seeking staff support, and compliance with the smoking policy, and they called for identification and reduction of behavioral triggers. However, none of these care plans actually listed any specific triggers. The care plan addressing the resident’s right to consensual intimate relationships focused on assessment and education regarding consent but did not integrate the resident’s extensive trauma history. Staff interviews indicated the resident had displayed sexual behaviors since admission, including an incident where the resident expressed anger at another resident for not buying a soda after engaging in sexual acts. A second resident with a documented history of traumatic brain injury (TBI), dementia, seizure disorder, borderline personality disorder, anxiety, intermittent explosive disorder, tobacco use, and other behavioral/emotional disorders was also affected by the same deficiency. Social history and progress notes documented that this resident sustained a TBI after being hit by a semi‑truck while riding a bicycle at age 18, resulting in an 11‑month coma, followed by 13 years in a state hospital and subsequent residence in a group home. Additional documentation indicated the resident allegedly shot their father at age 26 after being sworn at and had a PASRR identifying TBI, intermittent explosive disorder, and borderline personality disorder, with a specific trigger of hearing the name of the current U.S. President. Progress notes also described inappropriate sexual behavior toward staff, including touching themselves intimately during personal care and refusing to stop when redirected. Despite this, the resident’s care plans, which addressed explosive disorder and history of altercations, risk for decreased psychosocial well‑being, and refusal to bathe or shower, did not list any specific behavioral triggers, did not reference the traumatic events such as being hit by a truck or shooting their father, and did not document the inappropriate sexual behavior. The Administrator and Social Service Director acknowledged that residents were to be screened for trauma and that trauma responses and PTSD should be added to care plans, but the specific trauma histories and triggers for these two residents were not incorporated into their plans of care.
Failure to Assess and Care Plan for Resident Suicidal Ideation
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess, investigate, and care plan for a resident’s suicidal ideation in accordance with its own policy and staff expectations. The resident had diagnoses including schizophrenia, cerebral edema, and hemiparesis/hemiplegia following a cerebral infarction, and a current MDS showed mild cognitive impairment (BIMS score 12). A progress note documented that the resident told the Social Services Director (SSD) he was feeling down and wanted to kill himself; the SSD offered assistance, activities, and initiated 15‑minute checks, and the note stated the care plan was updated. However, the note did not indicate that the SSD asked whether the resident had a plan to kill himself, and there were no additional notes regarding suicidal ideation or follow‑up. Review of the current care plan showed no problem, goal, or interventions addressing depression or suicidal ideation, and progress notes over the following month contained no documentation of physician notification related to the suicidal statement. Further record and interview evidence showed that the care plan conference summary did not document interventions for suicidal ideation, and the SSD acknowledged she did not normally ask residents expressing suicidal ideation if they had a plan. The SSD reported that the resident had admission paperwork mentioning suicidal ideation related to depression after a stroke and that the resident again vocalized suicidal ideation during a care plan meeting with his father, after which emotional support was offered and the father took the resident out on a leave of absence; no further visits or follow‑up were done. The DON stated that, upon notification of suicidal verbalization, staff should assess the resident, ask if there is a plan, remove potential means of self‑harm, immediately notify the psychiatric NP, and document the occurrence, and that a detailed progress note and updated care plan were expected but not present for this resident. The Administrator similarly stated that staff should ask about a plan, document interventions, notify the physician and family, and update the care plan, and indicated the resident should have had a care plan addressing depression with suicidal ideation. The facility’s written policy required immediate notification of the DON, SSD, and physician, an interview including asking about a plan and assessing mood and means for self‑harm, and thorough documentation of mood, behavior, and all actions taken, which were not reflected in the resident’s record.
Incomplete and Inaccurate Documentation of Suicidal Ideation and Follow-Up
Penalty
Summary
The facility failed to ensure accurate, complete, and timely documentation of assessments and services for a resident who verbalized suicidal ideation. Resident 6, who had schizophrenia, cerebral edema, and right-sided hemiparesis/hemiplegia following a cerebral infarction, had a BIMS score of 12 indicating mild cognitive impairment. The resident’s admission paperwork mentioned suicidal ideation related to depression after a stroke, and a Social Services note on 3/11/2026 documented that the resident was feeling down and said he wanted to kill himself. The Social Services Director (SSD) documented that she talked with the resident, coordinated with Activities, advised the resident to contact SSD or nursing if he wanted to talk, and that the resident was scheduled for 15-minute checks and the care plan was updated. However, the current care plan initiated on 2/26/2026 did not address depression or suicidal ideation. Multiple Social Services progress notes were later entered as late entries in April, with effective dates in March, stating that the resident had no plan and no longer had suicidal ideation, that he felt much better after 1:1 time, and that he continued his daily routine and therapy. These late entries described follow-up visits and reassessments of suicidal ideation on several consecutive days, but in interviews the SSD stated she did not normally ask residents about having a plan when they verbalized suicidal ideation and did not recall any other occurrences beyond the initial event. She further indicated she did not personally provide individual follow-up visits with this resident regarding suicidal ideation, despite the late-entry notes describing such visits. The DON acknowledged that late entries had been added to address concern about suicidal verbalization, and the Administrator stated that upon suicidal statements staff should ask about a plan, notify the physician and family, and update the care plan, and that this resident should have had a care plan addressing depression with suicidal ideation. The facility’s documentation policy required factual, first-hand, timely documentation, which was not followed in this case.
Failure to Complete Required Self-Administration Assessment for Inhaler Kept at Bedside
Penalty
Summary
Surveyors identified that a resident was allowed to keep and access an Albuterol inhaler without the facility completing the required self-administration medication assessment. During an initial tour, the resident was observed sitting in a wheelchair with a handheld Albuterol inhaler on the overbed table and no staff present in the room or hallway. On a subsequent observation, the resident again was in a wheelchair and reported that the Albuterol inhaler was stored in the top drawer of the nightstand, where it was found. Review of the clinical record showed an admission MDS indicating no cognitive impairment, but there was no documentation of a self-medication administration assessment. In an interview, the DON confirmed that the resident did not have the required self-medication assessment, despite the facility’s policy stating that staff and the practitioner must assess each resident’s mental and physical abilities to determine whether self-administering medications is clinically appropriate. This failure to complete and document a self-administration medication assessment for a resident who had an Albuterol inhaler kept at bedside constituted noncompliance with the facility’s own policy and with 410 IAC 16.2-3.1-11(a).
Inaccurate PBJ Staffing Data Submission to CMS
Penalty
Summary
The deficiency involves the facility’s failure to electronically submit complete and accurate direct care staffing information to CMS through the Payroll-Based Journal (PBJ) system for 22 days in a fiscal quarter. A CASPER report review on 4/6/26 showed that, according to PBJ data, the facility did not have licensed nursing coverage 24 hours per day on multiple specific dates across three months, had low weekend staffing, and held a 1-star staffing rating. However, review of the facility’s internal staffing sheets for that quarter indicated the facility was fully staffed and had licensed nurse coverage on all of the dates in question. During an interview, the Administrator stated that the PBJ information must have contained data entry errors, as she had verified licensed staff coverage on the timesheets. The facility’s PBJ policy in effect stated that all staffing data entered into the PBJ system would be auditable and verifiable through payroll, invoices, or contracts, but the submitted PBJ data did not accurately reflect the facility’s actual licensed nurse staffing as documented on internal records. No specific residents or clinical conditions were mentioned in the report, and the deficiency centers solely on inaccurate staffing data submission rather than direct resident care events.
Failure to Provide and Document Required Transfer/Discharge and Bed-Hold Notices
Penalty
Summary
The deficiency involves the facility’s failure to provide and document required written notices of transfer/discharge and bed-hold policies, as well as required information to receiving providers, for four residents who were transferred or discharged to the hospital. For a resident with generalized anxiety disorder, major depressive disorder, and dementia, progress notes showed that the resident was sent to the hospital via 911 for chest pain, lower back pain, and shortness of breath and later returned to the facility, but the clinical record lacked documentation that a written Notice of Transfer/Discharge and the bed-hold policy were provided to the resident or representative, and lacked documentation that required information was conveyed to the receiving facility. The ADON and the Administrator both confirmed there was no documentation that these written notices were provided. For a resident with congestive heart failure and muscle weakness who was sent to the emergency room for painful urination and bloody urine, the clinical record lacked documentation that a Notice of Transfer/Discharge or bed-hold policy was given to the resident or representative, which the DON confirmed. Another resident with chronic respiratory failure and diabetes was discharged to the hospital for respiratory failure, and a resident with chronic kidney disease and dementia was discharged to the hospital, but in both cases there was no documentation that a written notice of transfer/discharge or bed-hold policy was provided to the residents or their representatives. Review of the facility’s Transfer and Discharge policy, dated 1/15/26, showed that the policy required the facility to provide written transfer/discharge notices and bed-hold information to residents and representatives and to provide specified information to receiving providers, but the records for these four residents did not contain the required documentation.
Failure to Document Target Behaviors and Non-Pharmacological Interventions Before Initiating Antipsychotic
Penalty
Summary
The deficiency involves the facility’s failure to document how a resident’s behaviors presented danger or distress to self or others, and failure to document non-pharmacological interventions attempted prior to initiating an antipsychotic medication. Resident 6 had documented diagnoses of Alzheimer’s disease, depression, and severe cognitive impairment, and was receiving sertraline for depression. A PASSAR identified only depression and dementia, and the admission MDS listed Alzheimer’s disease and depression as active diagnoses. Over several months, nursing progress notes documented that the resident intermittently reported unusual perceptions, such as believing there were men causing trouble, a man in her room, or a man wanting to marry her and yelling through the walls, but there was no documentation that these episodes caused danger to the resident or others or that they resulted in unmanageable distress. From late April through mid-July, nursing notes primarily described the resident’s frequent refusals of evening and morning medications, blood sugar checks, blood pressure checks, insulin administration, hygiene care, and showers. Staff documented that the resident sometimes yelled at staff, said “Get out!”, was visibly upset by a room move, was leery of staff and asked to see name badges, and became upset about a pillow under her head until it was removed, after which she calmed down. The notes also recorded instances where the resident believed housekeeping had not cleaned her room or that she had not received medications when she had. However, there were no progress notes or assessments indicating that these behaviors were evaluated as dangerous, non-redirectable, or causing significant distress or functional impairment, and no detailed behavior monitoring logs were present as required by facility policy. On a psychiatric NP visit for initial psychotropic medication management, new mental health diagnoses of schizoaffective disorder, borderline personality disorder, and delusional disorder were added, and Seroquel 25 mg, an antipsychotic, was ordered. The clinical record did not contain a comprehensive evaluation to support these new diagnoses, and there was no documentation of target behaviors meeting the facility’s policy criteria for psychotropic use, such as behaviors representing danger to self or others, causing distress and impairment in functional abilities, or clearly attributable to psychosis or mania. The resident’s representative reported that the resident had no prior history of mental health disorders or psychiatric hospitalization and was unaware of the new diagnoses. The facility’s own psychotropic medication policy required identification and documentation of specific target behaviors, use and documentation of nonpharmacological interventions, and ongoing monitoring of behaviors and interventions, which were not reflected in the record for this resident.
Failure to Update PASARR Screens for New Mental Health Diagnoses and Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that Preadmission Screening and Resident Review (PASARR) Level I screenings were accurate and updated when new mental health diagnoses and psychoactive medications were initiated for multiple residents. For one resident with dementia, anxiety, depression, and post-traumatic stress disorder (PTSD), the PASARR completed on admission listed anxiety, depression, and dementia with sertraline and quetiapine, but did not include the PTSD diagnosis or the antidepressant Pristiq, despite the admission MDS and care plan documenting PTSD and a subsequent physician’s order for Pristiq. For another resident with Alzheimer’s disease, borderline personality disorder, delusional disorder, schizoaffective disorder, and depression, the PASARR only reflected depression and dementia with sertraline, even though additional mental health diagnoses were added later and an antipsychotic (quetiapine) was ordered for borderline personality disorder, and the quarterly MDS documented psychotic disorder, schizophrenia, and depression with antipsychotic and antidepressant use. A third resident had diagnoses including Alzheimer’s disease, depression, anxiety disorder, irritability and anger, and nonrheumatic aortic valve stenosis. The PASARR for this resident listed dementia and anxiety with Risperdal but omitted the diagnosis of depression and the medications escitalopram and lorazepam, although physician’s orders were in place for escitalopram for depression and lorazepam for anxiety, and the admission MDS documented depression with antianxiety and antidepressant use. Interviews with the Assistant Director of Nursing confirmed that new Level I PASARR screens should have been completed when new mental health diagnoses and psychoactive medications were added, and that the PASARR for one resident, completed prior to arrival, should have included all mental health diagnoses and medications. The facility’s own policy required notification of the state mental health authority within 14 days after a significant change in mental condition and specified that a new Level I screen is required for new mental health diagnoses or newly prescribed psychotropic medications, which was not followed in these cases.
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