Lincolnshire Health & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Merrillville, Indiana.
- Location
- 8380 Virginia St, Merrillville, Indiana 46410
- CMS Provider Number
- 155650
- Inspections on file
- 40
- Latest survey
- February 26, 2026
- Citations (last 12 mo.)
- 39
Citation history
Health deficiencies cited at Lincolnshire Health & Rehabilitation Center during CMS and state inspections, most recent first.
A resident with hemiparesis, hemiplegia post-CVA, and COPD was discharged home without complete discharge documentation. Although the resident was notified of the last covered day and signed a discharge planning form, key sections addressing medications and follow-up visits were left blank. The SSD reported a home health referral, but this was not documented in the medical record, only referenced in an email. The DON indicated residents should receive a discharge summary, medication list, and equipment orders with a corresponding progress note, but these were not present, contrary to the facility’s discharge summary policy requiring a recapitulation of the stay and medication reconciliation.
A resident with Parkinson’s disease and dementia, documented as dependent for eating and requiring one-person physical assistance, was left with an uncovered breakfast tray for an extended period without timely feeding assistance. The resident, who had hand tremors and was unable to communicate the need for help, made no attempts to self-feed while food remained in front of her. A CNA later acknowledged the resident was a new admission needing assistance and attempted to feed her but did not obtain a fresh or reheated tray despite the delay. A family member later confirmed the resident was dependent for meal intake.
A resident with significant cognitive deficits, adult failure to thrive, and pressure ulcers on the coccyx and left heel did not consistently receive ordered wound care. Physician orders directed specific cleansing and dressing regimens for both wounds, including daily and scheduled treatments with normal saline, calcium alginate, and, at one point, triple antibiotic ointment. Treatment Administration Records for two consecutive months showed multiple dates on which these wound treatments were not signed out as completed. During interview, the wound nurse could not explain the missed treatments and noted some dates coincided with hospice visits, but hospice documentation was not available, contrary to facility policy requiring documentation of dressing changes.
Two residents with significant clinical needs did not receive timely nutritional assessments, resulting in incomplete medical records. One resident with diabetes had documented poor appetite and frequent meal refusals, and another resident with dementia had a deep tissue injury pressure ulcer along with difficulty chewing and swallowing some foods. In both cases, care plans identified nutritional concerns, but no corresponding nutritional assessments were documented. The RD reported being behind and lacking sufficient hours to complete assessments on time.
A resident with diabetes and a skin condition was found lying on a soiled sheet covered in dry skin flakes and discoloration, reporting she had not received care since the previous night. CNAs confirmed that no care had been provided that morning, despite the resident's need for maximum assistance with hygiene and bed mobility.
A resident with diabetes mellitus and psoriasiform dermatitis was observed with scaly, shedding skin and dry skin flakes on bed linens. Although a physician's order for Tacrolimus cream was present, the care plan did not address the skin condition, and no interventions or monitoring were documented.
A dependent resident with diabetes and skin conditions did not receive timely incontinence care, as observed by surveyors who found her with a saturated brief and significant drainage on her incontinence pad. The resident, who required maximum assistance for ADLs and was frequently incontinent, reported not having received care since the previous night. Staff documentation and interviews confirmed a lapse in care, and facility policy required more frequent incontinence checks and assistance.
A resident with multiple pressure ulcers was found without required dressings in place, despite physician orders for scheduled and as-needed wound care. Staff were unaware that dressings were missing, and documentation showed that some treatments were not completed as ordered. The deficiency involved failure to ensure pressure ulcer treatments were provided as prescribed.
Three residents with diabetes did not receive blood sugar monitoring, insulin, or hypoglycemic medications as ordered by their physicians. Documentation showed multiple missed or undocumented blood sugar checks and medication administrations, with staff unable to verify completion of these tasks as required.
The facility failed to prepare pureed food correctly, affecting five residents on a pureed diet. A cook did not follow the recipe for pureed broccoli, resulting in a watery consistency despite adding thickening powder. The Dietary Manager confirmed the puree was not at the correct consistency, highlighting a need for staff training on proper preparation.
The facility failed to implement proper infection control measures, including the lack of clothing protectors for laundry aides, improper cleaning of a shared blood pressure cuff between residents, and incorrect signage for a resident on contact isolation. These deficiencies were observed during a survey, highlighting lapses in adherence to infection prevention protocols.
A facility failed to ensure a resident had the necessary physician's orders and assessments for self-administration of medication. A cognitively intact resident was observed with a fluticasone nasal spray on her bedside table, which she used independently without documented physician's orders, care plan, or self-administration assessments. The facility's policy requires an IDT evaluation and physician's order for self-administration, which were not documented.
A facility failed to notify a resident's family or representative about new medication orders, despite the resident being severely cognitively impaired. The resident had multiple diagnoses and received several new medications, but the facility did not inform the family as required by policy. Attempts to contact the resident's daughter were unsuccessful, yet the policy mandates such notification.
The facility failed to conduct quarterly care plan meetings and invite family representatives for three residents. One resident's POA was not invited due to possible address issues, while another resident, who was cognitively intact, was unfamiliar with care plan meetings. A third resident had no care plan meeting since admission, and the Social Service Director admitted to not holding the required meeting. The facility's policy to include residents and representatives in care planning was not followed.
The facility failed to provide adequate ADL care for three residents, as evidenced by a lack of documentation and observed deficiencies. A resident reported that staff never checked his brief, and records showed multiple instances of undocumented urinary continence care. Another resident experienced delays in incontinence care, with inconsistent documentation of her continence status. A third resident was observed with long, dirty fingernails and toenails, despite records indicating nail care was part of his routine. The DON confirmed the need for regular checks and documentation.
The facility failed to administer blood pressure medication within prescribed parameters for a resident with heart conditions, neglected to assess and document a bandage on a resident at risk for bleeding, and did not ensure a resident wore heel protectors as ordered. These deficiencies highlight lapses in medication administration, monitoring, and adherence to care plans.
A resident with impaired hearing was not provided necessary services, despite being observed to be hard of hearing and expressing a need for hearing aids. Facility staff were aware of the resident's hearing difficulties, but no care plans or audiology visits were documented, contrary to facility policy.
A resident with a contracted right hand was observed without the recommended splint over several days, despite an Occupational Therapy Discharge Summary advising its use. The facility lacked a current physician's order for the splint, and the recommendation was not communicated to nursing staff, leading to a failure in providing necessary treatment to prevent decreased range of motion.
A resident with dysphagia and severe cognitive impairment did not receive the prescribed adaptive equipment during meals. Despite the dietary care plan specifying no straws and the use of a 2 handled mug, the resident was observed with a Styrofoam cup with a straw and other inappropriate drinking vessels. The resident's medical conditions, including hemiplegia and hemiparesis, required the use of adaptive equipment to aid in self-feeding.
A resident with cognitive impairment and multiple diagnoses was observed with inconsistent oxygen administration, as the nasal cannula was often misplaced while the oxygen concentrator was running. Despite the use of oxygen, there were no physician orders or documentation in the resident's records. Interviews with staff confirmed the absence of current oxygen orders, contrary to the facility's policy requiring such orders.
A resident with hemiplegia and vascular dementia did not receive scheduled doses of hydrocodone-acetaminophen due to medication unavailability at the facility. Despite being cognitively intact and having a care plan for pain management, the resident missed multiple doses over June and July. Progress notes showed the facility was aware and had communicated with the pharmacy and doctor, but delays persisted due to the need for a new prescription.
The facility failed to ensure correct PPE was used by a CNA when providing care to a resident on Enhanced Barrier Precautions (EBP). The CNA was unaware of EBP requirements and initially only donned gloves without a gown. The resident had diagnoses including stroke and end-stage kidney disease with a dialysis port, necessitating EBP. The facility had conducted inservice training on EBP, but staff attendance was inconsistent.
The facility failed to provide timely incontinence care for two residents, both of whom were severely impaired and dependent on staff for toileting hygiene. Observations revealed that the residents were not checked or changed at least every two hours as required, leading to them being found in soiled briefs with bowel movements and urine. Documentation for incontinence care was also found to be inconsistent and lacking.
Failure to Provide Complete Discharge Information and Documentation
Penalty
Summary
The facility failed to provide required discharge information and documentation to a resident at the time of discharge. Resident G, who had diagnoses including hemiparesis and hemiplegia following a cerebrovascular accident and chronic obstructive pulmonary disease, was admitted on an unspecified date and discharged on 2/14/26. A psychosocial note dated 2/11/26 documented that the resident was notified their last covered day would be 2/13/26, but there were no additional notes regarding the resident actually being discharged or what discharge instructions were provided. A Discharge Planning Review dated 2/14/26 was signed by the resident, but only the first two sections were completed; the remaining sections, including medications and follow-up visits, were left blank. During interviews, the Social Service Director stated the resident was discharged home and that a home health referral had been made, but there was no documentation of this referral in the resident’s record, only an email related to the referral. The Director of Nursing stated that at discharge, residents should receive a discharge summary, a list of medications, any equipment orders, and there should be a progress note in the record, but such documentation was not present for this resident. The facility’s “Discharge summary” policy required that when discharge is anticipated, the resident must have a discharge summary including a recapitulation of the stay and reconciliation of pre-discharge and post-discharge medications, which was not fully completed or documented for Resident G.
Failure to Provide Timely Eating Assistance to Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide timely assistance with activities of daily living, specifically eating, to a dependent resident. On the morning of 2/26/26, the resident was observed in bed with an uncovered breakfast tray containing scrambled eggs, hot cereal, a muffin, milk, and orange juice placed on a tray table. At 8:16 a.m., the tray was present and there were no attempts by the resident to feed herself. By 8:24 a.m., the tray remained in front of her; her left hand fingers were in the scrambled eggs, and she exhibited hand tremors when raising her fingers from the plate. She was unable to communicate whether she required help to eat, and there were still no attempts made by her to feed herself. At 8:45 a.m., the tray was still in place, the hand tremors continued, the scrambled eggs had been mixed into the hot cereal bowl, and there continued to be no attempts by the resident to feed herself. CNA 1 later indicated that the resident was a new admission who required assistance with meal intake and stated she would assist the resident. At 8:49 a.m., CNA 1 was observed at the bedside attempting to feed the resident and reported that the resident did not seem like she wanted to eat, though the resident did take a sip of orange juice. CNA 1 did not reheat the food or obtain a new breakfast tray despite the elapsed time. Later that day, a family member was observed assisting the resident with her lunch meal and stated the resident was dependent for meal intake. Record review showed the resident had diagnoses including Parkinson’s disease and dementia and had been admitted on 2/25/26. A Baseline Care Plan dated 2/25/26 documented that the resident required physical assistance of one person for eating, and a Functional Abilities and Goals assessment from the same date indicated the resident was dependent for eating.
Failure to Provide and Document Ordered Pressure Ulcer Treatments
Penalty
Summary
The facility failed to provide ordered pressure ulcer treatments for a resident with pressure ulcers on the coccyx and left heel who had adult failure to thrive, significant cognitive deficits, and required substantial to maximum assistance for bed mobility. A physician’s order dated 12/20/25 directed daily cleansing of the coccyx wound with normal saline, application of calcium alginate, and coverage with a dry dressing; however, the January 2026 Treatment Administration Record showed this treatment was not signed out as completed on 1/5 and 1/7. For the left heel wound, multiple physician’s orders were in place over time, including orders for cleansing with normal saline, application of calcium alginate, securing with Kerlix on specific days of the week, and later adding triple antibiotic ointment to the peri-wound area before applying calcium alginate and a dry dressing. These orders were revised and discontinued on several dates, with a final order for daily treatment starting 1/31/26. The January and February 2026 Treatment Administration Records indicated the left heel wound treatments were not signed out as completed on 1/5, 1/7, 1/25, 1/31, 2/9, 2/16, and 2/17. During interview, the Wound Nurse stated she did not know why the treatments were not completed on those dates and noted that some February dates corresponded with hospice visits, but hospice records requested were not received. The facility’s Wound Dressing Change policy required documentation of dressing changes on the treatment record.
Failure to Complete Timely Nutritional Assessments for Two Residents
Penalty
Summary
The facility failed to complete timely nutritional assessments for two residents, resulting in incomplete medical records that did not meet accepted professional standards. Resident B, who had diabetes mellitus, was admitted on 1/28/26 and discharged on 2/13/26; a care plan dated 2/10/26 documented poor appetite and frequent refusals of meals, yet there was no documentation in the record that a nutritional assessment had been completed to evaluate this resident’s nutritional needs. Resident C, who had dementia, was admitted on 1/19/26 and discharged on 2/5/26; an admission MDS dated 1/26/26 indicated a deep tissue injury pressure ulcer was present on admission, and a care plan dated 2/2/26 documented difficulty chewing and swallowing some foods with a moderate appetite, but there was likewise no documentation of a nutritional assessment to evaluate this resident’s nutritional needs. During an interview, the RD stated she was behind and did not have enough hours at the facility to ensure nutritional assessments were completed in a timely manner.
Resident Left on Soiled Bedding Without Timely Care
Penalty
Summary
A resident with diagnoses including diabetes mellitus and psoriasiform dermatitis was observed lying on a bed with a soiled bottom sheet containing dry skin flakes, dark specks, and discoloration spots. The resident reported needing to be changed and stated she had not received care since the previous night. Observations revealed her skin was scaly and shedding from her shoulders, arms, torso, and legs, with a significant amount of dried skin present on the sheet. Certified Nursing Assistants (CNAs) confirmed that care had not been provided to the resident prior to the observation that morning, despite the resident requiring maximum assistance for bathing, hygiene, and bed mobility as documented in her assessment. The electronic medical record indicated the last incontinence check was the previous evening, with no applicable care documented for the early morning hours.
Lack of Comprehensive Care Plan for Resident with Skin Condition
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident diagnosed with psoriasiform dermatitis. During observations, the resident was found lying in bed with scaly, shedding skin on her shoulders, arms, torso, and legs, and there were visible dry skin flakes and dark discoloration spots on the bed linens. The resident expressed a need to be changed and indicated discomfort. Certified Nursing Assistants confirmed the presence of a skin condition and provided care, but the resident's record review revealed no care plan addressing the skin condition. The resident's diagnoses included diabetes mellitus and psoriasiform dermatitis, and a physician's order was in place for the application of Tacrolimus cream to affected areas twice daily. Despite this, the care plan did not reflect interventions or monitoring related to the skin condition. The deficiency was confirmed when the Director of Nursing was notified, and no care plan had been provided by the end of the survey.
Failure to Provide Timely Incontinence Care for Dependent Resident
Penalty
Summary
A dependent resident with diagnoses including diabetes mellitus and psoriasiform dermatitis did not receive timely assistance with activities of daily living, specifically incontinence care. On the morning of the survey, the resident was observed lying in bed, expressing discomfort and stating she had not received care since the previous night. Upon entering the room, two CNAs found the resident with a saturated incontinence brief and a large amount of dried, dark, and reddish/pink drainage on the incontinence pad. The resident exhibited pain during care and requested to be left alone. The CNAs reported the resident's pain and request to an LPN, who confirmed that routine pain medication had been administered earlier that morning. Further review of the resident's care plan indicated that incontinence care was to be provided after each episode and during routine rounds. The resident's assessment showed she required maximum assistance for bathing, hygiene, and bed mobility, and was dependent for toileting, with frequent incontinence. Documentation revealed the last recorded incontinence check was the previous evening, with no applicable entry for the early morning. The wound nurse later clarified that the drainage from the resident's pressure ulcer would not have been sufficient to account for the amount observed on the pad. Facility policy required routine assistance with incontinence care, including changing briefs, providing peri-care, and changing clothing and bed linens.
Failure to Provide Ordered Pressure Ulcer Treatments
Penalty
Summary
A deficiency was identified when a resident with a history of diabetes mellitus and psoriasiform dermatitis was observed to have multiple pressure ulcers without the required dressings in place. During care, staff noted open areas on the left hip, lower back/sacrum, and right buttock, with the right buttock showing bloody drainage. Certified nursing assistants (CNAs) reported that they were not informed by the previous shift about missing dressings, and no dressings were found in the resident's brief or linens. The wound nurse stated that treatments had last been completed several days prior, and the physician's orders required dressings to be changed if soiled or dislodged, as well as on a scheduled basis. Record review revealed that physician's orders specified wound care regimens for the sacrum, right buttock, and left hip, including cleansing, drying, and application of hydrocolloid or foam dressings at specific intervals and as needed. Documentation showed that some scheduled treatments were not completed as ordered, and there was no record of as-needed treatments being performed when dressings were missing. The care plan indicated that wound care should be provided as ordered, but observations and interviews confirmed that the required treatments were not consistently in place, resulting in a failure to follow physician orders for pressure ulcer care.
Failure to Administer Diabetes Management as Ordered
Penalty
Summary
The facility failed to ensure that three residents with diabetes mellitus received blood sugar monitoring, insulin, and hypoglycemic medications as ordered by their physicians. For one resident, multiple instances were documented where blood sugar levels were not obtained at scheduled times, and insulin was either not administered or marked as refused without corresponding blood sugar results. In several cases, the Medication Administration Record (MAR) indicated that blood sugar monitoring was not completed or not documented, and insulin doses were coded as non-applicable or refused without supporting evidence. The Director of Nursing (DON) and Corporate RN Consultant confirmed that blood sugar results were not available for the dates in question, and the resident was later transferred to the hospital. Another resident's records showed that blood sugar monitoring was scheduled four times daily, but the MAR reflected that monitoring was marked as completed without actual results documented for numerous days. The Corporate RN Consultant acknowledged the lack of documentation for blood sugar results prior to a certain date. A third resident's records indicated missed blood sugar monitoring and missed administration of Metformin, a hypoglycemic medication, on several occasions. The DON was unable to verify that blood sugar testing or medication administration had been completed as ordered. These findings were confirmed through record review and staff interviews.
Failure to Prepare Pureed Food Correctly
Penalty
Summary
The facility failed to ensure that food was prepared in a form to meet individual needs, specifically concerning the preparation of pureed food. During an observation, a cook was seen preparing pureed broccoli for five residents on a pureed diet. The cook did not follow the recipe correctly, as she added an unknown amount of liquid and thickening powder to the broccoli, resulting in a watery consistency. Despite adding more thickener, the puree remained too thin. The Dietary Manager (DM) confirmed that the puree was not at the correct consistency and indicated that the cook should have added more thickening agent. The recipe for Pureed Broccoli specified the use of a certain amount of broccoli and margarine, with instructions to blend until smooth and add a thickening agent if necessary to achieve a pudding or soft mashed potato consistency. The facility's policy on pureed diets also emphasized the importance of achieving the correct texture by adding a measured amount of fluid or thickening agent. The DM acknowledged the error and mentioned plans to in-service the staff on proper preparation of pureed foods.
Infection Control Deficiencies in Laundry, Equipment Use, and Signage
Penalty
Summary
The facility failed to implement proper infection control measures in three distinct areas. Firstly, during an observation in the laundry room, it was noted that the Laundry Aide did not use any clothing protector while sorting soiled laundry, despite wearing gloves. The Laundry Aide mentioned she had never been instructed to use a clothing protector, and the facility's laundry policy did not address this issue. This lack of protective clothing could potentially expose staff to contaminants from the soiled laundry. Secondly, a Qualified Medication Aide (QMA) was observed using a shared blood pressure cuff on multiple residents without cleaning or disinfecting it between uses. The QMA acknowledged that she should have used a sani wipe to clean the cuff between residents, as per the facility's Infection Prevention and Control Program policy. Lastly, there was an issue with incorrect signage for a resident who was on contact isolation due to conjunctivitis. The signage did not clearly indicate the required personal protective equipment, and there was confusion about the resident's isolation status, as confirmed by interviews with staff members.
Failure to Ensure Proper Self-Administration of Medication Procedures
Penalty
Summary
The facility failed to ensure that a resident had the necessary physician's orders and assessments for self-administration of medication. Specifically, a bottle of fluticasone nasal spray was observed on the bedside table of a resident who indicated she used it independently whenever she felt the need. Upon review of the resident's records, it was found that there were no physician's orders for the fluticasone spray, no care plan for its self-administration, and no self-administration of medication assessments completed. The resident involved was noted to be cognitively intact for daily decision-making, as indicated by the Quarterly MDS assessment. Despite this, the facility's policy on self-administration of medication requires an interdisciplinary team (IDT) to determine the safety of self-administration, completion of a Self-Administration of Medication Evaluation, and obtaining a physician's order. None of these steps were documented in the resident's care plan, indicating a lapse in following the facility's established procedures.
Failure to Notify Family of Medication Changes
Penalty
Summary
The facility failed to notify the family or representative of a resident regarding new medication orders, which is a requirement when there is a significant change in treatment. The resident in question, who was severely cognitively impaired, had multiple diagnoses including schizoaffective disorder, anxiety disorder, dementia with behavioral disturbance, and bipolar disorder. Despite the resident being aware of the new medication orders, the facility did not inform the family or legal representative as required by their policy. The resident's medical record showed several instances of new medication orders, including an antidepressant, a dementia treatment, and a smoking patch, as well as changes in dosage for anxiety medication. The Director of Nursing indicated that the resident was her own responsible party, and attempts to contact the resident's daughter had been unsuccessful. However, the facility's policy mandates notification of a family member or legal representative when there is a significant change in treatment, which was not adhered to in this case.
Failure to Conduct Care Plan Meetings and Invite Representatives
Penalty
Summary
The facility failed to ensure that quarterly care plan meetings were completed and that family representatives were invited for three residents. Resident D's Power of Attorney (POA) indicated that they had not been invited to a care plan meeting for a long time, and there was no documentation of a care plan meeting in 2024. The Social Service Director mentioned that invitations were sent out, but there might have been an issue with the address for the POA. Resident E, who was cognitively intact, stated he had not attended a care plan meeting and was unfamiliar with the process. The Social Service Director acknowledged that the resident was due for meetings in March and June, but they were not rescheduled after the resident's hospitalization. Resident B's record showed no documentation of a care plan meeting since admission, and there was no evidence of an invitation being sent to the resident or their representative. The Social Service Director admitted that no care plan meeting had been held with Resident B or their representative, despite the expectation to hold one within 72 hours of admission. The facility's policy emphasized the importance of including residents and their representatives in the care planning process, but this was not adhered to in these cases.
Deficiencies in ADL Care and Documentation
Penalty
Summary
The facility failed to provide adequate care for activities of daily living (ADLs) for three residents, as evidenced by a lack of documentation and observed deficiencies. Resident 10, who was cognitively intact and always incontinent of bladder, reported that staff never checked his brief for changes. The facility's records showed multiple instances where urinary continence care was not documented across various shifts. Interviews with staff, including a CNA and the Director of Nursing (DON), confirmed that residents were supposed to be checked every two hours and documentation was required at least once per shift. Resident 4, also cognitively intact, reported delays in receiving incontinence care, with staff often turning off her call light and taking hours to return. Her records indicated she was always incontinent of bladder and frequently incontinent of bowel, requiring substantial assistance for personal hygiene. Documentation showed inconsistencies in marking her as incontinent, with some days only showing records twice per day, contrary to the expected frequency of every shift. The DON confirmed the expectation for CNAs to check and change residents every two hours and document accordingly. Resident C, who required total assistance with personal hygiene, was observed with long, dirty fingernails and toenails. He reported needing his nails trimmed and having to manually disimpact his stool, leading to dirty fingernails. Despite records indicating nail care was part of his routine, there was no documentation of toenail care. The DON acknowledged the need for staff to document nail care and confirmed that the resident required assistance for this task, although there was no record of him digging stool out or having constipation.
Deficiencies in Medication Administration and Resident Care
Penalty
Summary
The facility failed to ensure that a resident received the necessary care and treatment by administering a blood pressure medication, midodrine hcl, outside of the prescribed parameters. The medication was given to a resident with a history of atrial fibrillation, heart failure, hypertension, and orthostatic hypotension, despite the systolic blood pressure being above the threshold of 130 on multiple occasions. This oversight occurred repeatedly over a period of time, as documented in the Medication Administration Records for June and July 2024. Another deficiency involved a resident who had a bandage placed above her right wrist following a blood transfusion at the hospital. The facility did not have any documentation related to an assessment, monitoring, or physician's order for the bandage, nor was there a record of the reason for the bandage. The resident, who was on anticoagulant medication and at risk for abnormal bleeding, was observed with the bandage over several days without any intervention or removal by the facility staff. Additionally, the facility failed to ensure that a resident wore preventative heel protectors as ordered. The resident, who had hemiplegia, hemiparesis, and vascular dementia, was observed without heel protectors on multiple occasions, despite a physician's order for their use while in bed. The facility's records lacked documentation of whether the heel protectors were on, off, or refused, indicating a failure to monitor and adhere to the prescribed care plan for pressure relief and wound prevention.
Failure to Provide Necessary Hearing Services
Penalty
Summary
The facility failed to ensure that a resident with impaired hearing received the necessary services. Resident C, who was observed to be hard of hearing and reading lips during conversations, indicated a need for hearing aids. Despite this, there were no care plans related to hearing loss in the resident's records. The Annual Minimum Data Set (MDS) assessment had previously indicated that the resident was cognitively intact and had adequate hearing, which was inconsistent with the current observations and resident's statements. Interviews with facility staff, including the Social Service Director, Director of Nursing, LPN, and CNA, revealed that the resident's hearing impairment was known, yet no actions had been taken to address it. The Social Service Director was unaware of the resident's desire to see an audiologist, and the Director of Nursing acknowledged the resident's hearing difficulties but provided no further information. The CNA and LPN both noted the resident's reliance on lip-reading and difficulty hearing, yet no prior audiology visits were documented. The facility's policy required communication of hearing needs to the Director of Social Services, which was not followed in this case.
Failure to Implement Recommended Splint Use for Resident
Penalty
Summary
The facility failed to ensure that a resident received the necessary treatment to prevent decreased range of motion. This deficiency was identified when Resident D, who had a contracted right hand, was observed multiple times without the recommended hand splint in place. The observations occurred over several days, and the splint was noted to be hanging on the wall next to the resident's bed instead of being worn. The resident's medical history included hemiplegia, hemiparesis following a cerebral vascular accident, dysphagia, and a contracture of the right hand. The Occupational Therapy Discharge Summary from the previous year recommended that the resident wear a splint on the right hand with an established wearing schedule of four hours on and four hours off. However, there was no current or discontinued physician's order for the splint, and the recommendation was not communicated effectively to the nursing staff. The Therapy Director acknowledged that the recommendation was made by a PRN Occupational Therapist and was missed, indicating a lapse in communication and follow-up on the therapy recommendations.
Failure to Provide Adaptive Equipment for Resident with Dysphagia
Penalty
Summary
The facility failed to provide a resident with dysphagia the necessary adaptive equipment during meals, as ordered by the physician. On two separate occasions, the resident was observed without the prescribed 2 handled mug, which was intended to aid in self-feeding. Instead, the resident was provided with a Styrofoam cup with a straw, a cup of juice, and a cup of coffee, contrary to the dietary care plan that specified no straws and the use of a 2 handled mug. The resident's medical history included severe cognitive impairment, hemiplegia, hemiparesis following a cerebral vascular accident, dysphagia, and a contracture of the right hand, necessitating the use of adaptive equipment for safe and effective self-feeding. The oversight was noted despite clear instructions on the tray ticket and the dietary care plan.
Failure in Oxygen Administration for a Resident
Penalty
Summary
The facility failed to ensure proper respiratory care for a resident, specifically regarding oxygen administration. Observations over several days revealed inconsistencies in the use of the nasal cannula and oxygen concentrator. On multiple occasions, the nasal cannula was either not in place or improperly positioned, such as lying on the floor or hanging on a tube feeding pole, while the oxygen concentrator was running at 2 liters. These observations indicate a lack of adherence to proper oxygen administration protocols. The resident in question had diagnoses including atrial fibrillation, hypertension, and Parkinson's disease, and was noted to be cognitively impaired. Despite the use of oxygen, the resident's records, including the Physician's Order Summary and Medication Administration Record for July 2024, lacked any orders or documentation for oxygen administration. Interviews with the Director of Nursing and the Unit Manager confirmed that there were no current oxygen orders for the resident. The facility's policy on oxygen administration requires an order specifying the oxygen flow rate, delivery device, and indication for use, which was not followed in this case.
Failure to Administer Pain Medication as Prescribed
Penalty
Summary
The facility failed to ensure that pain medications were available and administered to a resident as per the physician's orders. Resident C, who was cognitively intact and diagnosed with hemiplegia, hemiparesis, and vascular dementia, reported missing scheduled doses of hydrocodone-acetaminophen due to the medication not being available at the facility. The resident's care plan included administering analgesia as per orders, but the June and July 2024 Medication Administration Records (MAR) showed multiple instances where the resident did not receive the prescribed medication. Progress notes indicated that the facility was aware of the medication unavailability and had communicated with the pharmacy and the doctor to obtain a new prescription. Despite these efforts, there were repeated delays in receiving the medication, as noted in several progress notes. The Director of Nursing confirmed that the delay was due to waiting for a new script from the doctor. This deficiency was related to a specific complaint, highlighting the facility's failure to provide timely pain management for the resident.
Failure to Use Correct PPE for Resident on Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure correct Personal Protective Equipment (PPE) was used by a staff member when providing care to a resident who was in Enhanced Barrier Precautions (EBP). During an observation, a sign indicating EBP was posted outside the resident's door, but no PPE was available either inside or outside the room. A Certified Nursing Assistant (CNA) entered the room, donned gloves, and began incontinence care without the required gown. Upon being stopped and reviewing the EBP sign, the CNA indicated she was unsure what EBP was and noted that PPE was usually available on a cart outside the door. The Administrator confirmed that more PPE containers had been ordered and that PPE was located at the end of the hallways. The Administrator also mentioned that inservice training on PPE/EBP had been completed and was mandatory, though attendance was inconsistent among staff. The CNA later donned a gown and gloves to complete the care after being informed of the requirements. Resident D, who was involved in the incident, had diagnoses including stroke and end-stage kidney disease with dependence on renal dialysis. A physician's order indicated that EBP was to be followed due to the resident having a dialysis port. The facility's EBP inservice, completed a few days prior, indicated that EBP required the use of gown and gloves during high-contact resident care activities. The facility's EBP guidelines, provided by the Administrator, also specified the use of gown and gloves during high-contact activities such as transfers, bathing assistance, and other close physical contact.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to ensure dependent residents received timely assistance with activities of daily living (ADLs), specifically incontinence care, for two residents. During a random observation, a CNA was found to have neglected Resident B, who was severely impaired and dependent on staff for toileting hygiene. The resident was found with a large amount of bowel movement on the bed and his body, indicating he had not been checked or changed for several hours. The CNA admitted to not checking the resident at least every two hours as required. The resident's care plan indicated the need for assistance with toileting and routine care rounds at night, which was not adhered to, as evidenced by the lack of documentation on bladder elimination tasks for several days in the past month. Similarly, Resident C, who was also severely impaired and frequently incontinent, was found in a soiled brief with dark-colored urine and bowel movement. The CNA admitted to not checking the resident during the shift because she was sleeping. The resident's care plan required assistance with toileting and routine care rounds, which were not followed. Documentation for urinary incontinence was also found to be inconsistent and lacking for several days. Both the Nurse Consultant and the A wing Unit Manager confirmed that residents should be checked and/or changed at least every two hours, which was not done in these cases.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
