Lowell Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Lowell, Indiana.
- Location
- 710 Michigan St, Lowell, Indiana 46356
- CMS Provider Number
- 155448
- Inspections on file
- 20
- Latest survey
- February 13, 2026
- Citations (last 12 mo.)
- 21
Citation history
Health deficiencies cited at Lowell Healthcare during CMS and state inspections, most recent first.
A dignity-related deficiency occurred when a resident with cognitive impairment and an indwelling urinary catheter was repeatedly observed in bed with an uncovered catheter collection bag containing visible urine hanging from the side of the bed and visible from the hallway. The resident’s care plan, which addressed obstructive uropathy, required that the catheter bag be stored inside a protective dignity pouch, but this intervention was not followed. During interview, the DON acknowledged the visibility of the catheter bag and stated that dignity covers were available and expected to be used by staff.
A cognitively impaired resident with multiple diagnoses, including hypertension and mental health conditions, was given oral medications and Miralax by an LPN, who left the partially consumed Miralax at the bedside and returned to the nurse's station without ensuring it was taken. The resident had no documented assessment for self-administration of medications and no physician order authorizing self-administration, despite facility policy requiring an IDT assessment and a physician order before allowing residents to self-administer medications.
A deficiency was cited when a dependent female resident with Alzheimer's disease, care planned to need assistance with ADLs and documented as severely cognitively impaired, was repeatedly observed with visible facial hair on her chin despite receiving regular baths and showers. Records showed she had not been assisted with shaving for several days, and there were no documented refusals on shower sheets, even though leadership reported she frequently refused shaving. This failure to provide and document needed shaving care was inconsistent with the facility’s AM care policy requiring shaving when needed and documentation of the procedure.
Surveyors found that three residents with COPD and other respiratory diagnoses did not consistently receive oxygen therapy and equipment management as ordered and per facility policy. One resident used oxygen via nasal cannula from a concentrator with a humidity bottle that remained in use well beyond the facility’s 7‑day change requirement, despite orders to change humidity and tubing weekly. Another resident, care planned for impaired gas exchange and ordered oxygen at 2 L/min every shift, was observed with a nasal cannula on the floor and with varying concentrator flow rates that did not match the order. A third cognitively impaired resident, ordered oxygen at 2 L/min every shift, was seen with oxygen on one day and then without oxygen on multiple subsequent days. The ADON reported no additional information regarding these discrepancies.
Surveyors observed an LPN preparing oral medications for a resident by popping multiple pills from medication cards directly into her hand and then placing them into a medication cup before administration. This practice was later reported to the DON. The facility’s Medication Administration policy required that medications be opened without contaminating, and the LPN’s method of handling the pills with bare hands did not comply with that standard.
The facility was found to have improper glove use in food handling, as observed in the main kitchen. Staff members, including a dietary food manager, handled food and other items without changing gloves or performing hand hygiene, contrary to the facility's policy. This failure to maintain sanitary conditions had the potential to affect residents receiving food from the kitchen.
The facility failed to maintain infection control standards during medication administration and equipment cleaning. A QMA was observed touching pills with her hands before administering them to three residents, violating the facility's policy. Additionally, a blood pressure machine was used on two residents without being disinfected before or after use, contrary to the facility's cleaning policy.
A resident with edema did not receive the necessary care as Medigrips were not applied as ordered. Despite a physician's order to apply Eucerin cream and Medigrips daily, the resident was observed multiple times without them, and her legs were discolored and swollen. The Medication Administration Record indicated the treatment was signed out as completed, with no documentation of discontinuation or refusal. The RN and DON were unaware of the current order status.
A facility failed to follow physician's orders for a resident with a stage 4 pressure ulcer. During wound care, the wound nurse did not apply Sureprep to the surrounding skin as ordered, admitting to forgetting this step. The resident, who has multiple sclerosis and diabetes, requires moderate assistance for bed mobility and is dependent on staff for transfers.
A medication was left unsecured on top of a medication cart by a QMA during administration rounds. The QMA was preparing medications for a resident and could not find the Miralax, which was later retrieved by an RN. The QMA placed the Miralax on top of the cart and proceeded to administer medications to another resident, leaving the Miralax unattended. The facility's policy requires medications to be stored in a locked cabinet or cart.
Failure to Maintain Dignity by Leaving Catheter Bag Uncovered and Visible
Penalty
Summary
Surveyors identified a dignity-related deficiency when a resident with an indwelling urinary catheter was repeatedly observed with an uncovered urinary catheter bag visible from the hallway. On three separate observations over consecutive days, the resident was lying in bed with the catheter collection bag hanging from the side of the bed, containing visible urine and lacking any cover, making it observable to anyone passing by. Record review showed the resident had diagnoses including hypertension, osteoarthritis, and obstructive uropathy, and a Quarterly MDS indicated cognitive impairment and the presence of an indwelling urinary catheter. The resident’s care plan, updated prior to the observations, specified that the catheter collection bag should be stored inside a protective dignity pouch, but this intervention was not implemented during the observed times. During an interview, the DON acknowledged that the catheter bag was visible from the hallway and stated that the facility had dignity covers that staff were supposed to use. This failure to follow the care-planned intervention to store the catheter collection bag in a protective dignity pouch resulted in the resident’s urinary catheter bag being exposed and visible from the hallway on multiple occasions.
Failure to Assess and Obtain Order for Self-Administration Before Leaving Medication at Bedside
Penalty
Summary
The deficiency involves a nurse leaving a medication at a cognitively impaired resident's bedside without an assessment or physician order for self-administration. During observation, an LPN prepared the resident's medications, including 17 grams of Miralax dissolved in water, and brought them to the resident's room. The resident took his pills and only a few sips of the Miralax, then placed the cup on the bedside table. The LPN stated she would return later to assist the resident with finishing the Miralax but left the room and returned to the nurse's station, leaving the Miralax in the resident's room and not remaining to ensure the medication was taken. Record review showed the resident had diagnoses including hypertension, generalized anxiety disorder, and major depressive disorder, and the most recent Quarterly MDS indicated the resident was cognitively impaired. There was no documentation of any physician's orders authorizing self-administration of medications and no assessment for self-administration in the record. The facility's policy on self-administration of medications required an interdisciplinary team assessment of the resident's competence and a physician order specifying the resident's ability to self-administer and which medications were included, but these steps had not been completed for this resident when the medication was left at the bedside.
Failure to Provide and Document ADL Assistance With Shaving for Dependent Resident
Penalty
Summary
Surveyors identified a deficiency in providing ADL assistance when a dependent female resident with Alzheimer's disease was repeatedly observed with visible facial hair on her chin over several days. On three separate observations, the resident was seen sitting in her wheelchair watching television with facial hair present, despite being care planned as needing assistance with ADLs, including bathing and personal hygiene. Her MDS assessment documented severe cognitive impairment and a need for partial/moderate assistance with personal hygiene and substantial/maximal assistance with bathing. Record review showed that the resident’s care plan included assistance with showers twice weekly in the morning and partial baths in between per her preference, but the shower sheets for the prior 60 days indicated she had last been assisted with shaving on 2/3/26. She had received a bed bath or shower on 2/5/26 and 2/10/26, with no refusals for shaving documented. The ADON reported that the resident frequently refused shaving, but this was not reflected in the care plan, and the Administrator stated that staff were supposed to document refusals on the shower sheets, which had not been done. This was inconsistent with the facility’s AM Care policy, which required shaving the resident if needed or requested and documenting the procedure.
Failure to Provide Ordered Oxygen Therapy and Maintain Oxygen Equipment
Penalty
Summary
The deficiency involves the facility’s failure to provide proper respiratory care and oxygen administration for three residents with orders for oxygen therapy. One resident with COPD was observed multiple times in bed using oxygen via nasal cannula from a concentrator set at 1.5 L/min, with a humidity bottle attached that was dated several weeks earlier than allowed by facility policy, which required humidity bottles to be changed every seven days. This resident’s physician orders included changing oxygen tubing and humidity once a day on Sunday and allowing the resident, who was cognitively intact, to apply oxygen at 2 L/min via nasal cannula when feeling short of breath. Despite these orders and the policy, the humidity bottle remained outdated on repeated observations, and the ADON reported having no further information. Another resident with COPD and respiratory failure, care planned as being at risk for impaired gas exchange and requiring oxygen therapy, was observed with inconsistent oxygen use and handling. On one occasion, the resident’s nasal cannula was seen lying on the floor while still connected to an oxygen concentrator; on other occasions, the resident wore a nasal cannula connected to either a portable concentrator set at 3 L/min or a concentrator set at 1.5 L/min, despite a physician order for oxygen at 2 L/min via nasal cannula every shift. A third resident with COPD and asthma, assessed as severely cognitively impaired and requiring oxygen therapy, had a physician order for oxygen at 2 L/min via nasal cannula every shift but was observed with oxygen in use on one day and then without oxygen on three subsequent days. In all three cases, the facility did not ensure that oxygen therapy and related equipment were managed in accordance with physician orders and the facility’s oxygen concentrator policy.
Improper Handling of Oral Medications During Medication Pass
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control practices during medication administration. On 2/11/26 at 9:12 a.m., an LPN was observed preparing medications for Resident 60, which included 10 pills. The LPN popped each pill out of the medication cards one at a time directly into her hand and then transferred them from her hand into a medication cup before administering them to the resident. Later that morning, at 11:17 a.m., the DON was informed that the LPN had touched the medications with her hands. The facility’s written Medication Administration (Medication Pass Procedure) policy stated that medications are to be opened without contaminating, indicating that the observed practice did not follow the facility’s established infection control standards.
Improper Glove Use in Food Handling
Penalty
Summary
The facility failed to maintain sanitary conditions in food handling, as observed during a follow-up tour of the main kitchen. An individual, referred to as [NAME] 1, was seen wearing gloves while handling various items, including a box of cellophane wrap and a cardboard box containing frozen sausage patties. Without changing gloves or performing hand hygiene, he proceeded to scoop out sausage patties with the same gloved hands and placed them on a baking sheet. This action was contrary to the facility's policy, which requires handwashing before and after glove use and changing gloves when they become contaminated. Additionally, the Dietary Food Manager (DFM) was observed preparing food for lunch without adhering to proper glove use protocols. The DFM manipulated cellophane wrap, handled bread, and covered a baking sheet without changing gloves or performing hand hygiene. Although the DFM indicated that the food touched with the gloves would be disposed of, the actions observed were not in compliance with the facility's glove use policy, which emphasizes that gloves are not a substitute for handwashing and should be changed between tasks or when contaminated.
Infection Control Deficiencies in Medication Administration and Equipment Cleaning
Penalty
Summary
The facility failed to maintain proper infection control practices during medication administration for three residents. A Qualified Medication Aide (QMA) was observed touching pills with her hands before placing them into medication cups for administration to the residents. This practice was observed with three residents during medication administration rounds. The facility's Medication Administration policy specifies that medications should be opened without contamination, which was not adhered to in these instances. Additionally, the facility did not ensure that reusable equipment was disinfected after use on residents. A blood pressure machine was used on two residents without being cleaned or disinfected before or after use. Both the QMA and a Registered Nurse (RN) failed to clean the blood pressure cuff between uses, contrary to the facility's Equipment Cleaning policy, which requires the use of germicidal/disinfectant spray on all surfaces of electrical equipment.
Failure to Apply Medigrips as Ordered for Resident with Edema
Penalty
Summary
The facility failed to provide necessary care and treatment for a resident with edema, as the Medigrips (elastic type stockings) were not applied as ordered. The resident, who had diagnoses including venous insufficiency, hypertensive heart disease with heart failure, and dementia, was observed multiple times without the Medigrips in place. Her legs were noted to be discolored and swollen during these observations. Despite the physician's order from November 2023 to apply Eucerin cream and Medigrips daily, the Medigrips were not observed on the resident during the survey period. The Medication Administration Record for November and December 2024 indicated that the Eucerin and Medigrips were signed out daily as completed, with no documentation of the order being discontinued or the resident refusing the treatment. The RN and the Director of Nursing were both unaware of the current status of the order, with the RN initially indicating uncertainty about who was responsible for the application of the Medigrips. The DON believed the order had been discontinued due to resident refusal, but there was no documentation to support this belief, and the order was still active.
Failure to Follow Wound Care Orders for Pressure Ulcer
Penalty
Summary
The facility failed to provide the necessary treatment for a pressure ulcer for one resident. On December 11, 2024, during an observation of wound care, the wound nurse did not apply Sureprep to the surrounding skin of a stage 4 pressure ulcer on the resident's sacral area, as was ordered by the physician. The resident, who has multiple sclerosis, diabetes mellitus, and a stage 4 pressure ulcer, was observed to be cognitively intact and required moderate assistance for bed mobility and was dependent on staff for transfers. The physician's order from November 26, 2024, specified the use of Sureprep, but the wound nurse admitted to forgetting this step during the wound care process.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure that a medication was kept in a locked medication cart at all times for one of the residents observed during medication administration. On the morning of December 11, QMA 1 was preparing medications for a resident and could not find the resident's Miralax, a laxative medication. She informed RN 1, who then retrieved the medication from the Pyxis, a medication dispensing machine. RN 1 handed the Miralax to QMA 1, who wrote the resident's name on it and placed it on top of the medication cart instead of securing it inside the cart. QMA 1 then proceeded to prepare and administer medications for another resident, leaving the Miralax unattended on top of the cart and out of her sight. After completing the medication administration for the second resident, QMA 1 returned to the cart, retrieved the Miralax, and administered it to the first resident. The Director of Nursing was informed of the incident, and the facility's Medication Storage and Expiration Policy was reviewed, which mandates that medications should be stored in a locked cabinet or cart inaccessible to residents and visitors.
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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