Miller's Merry Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Culver, Indiana.
- Location
- 730 School St, Culver, Indiana 46511
- CMS Provider Number
- 155589
- Inspections on file
- 21
- Latest survey
- March 4, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Miller's Merry Manor during CMS and state inspections, most recent first.
Staff failed to perform appropriate hand hygiene during meal service, including after touching residents, wheelchairs, hair, and drink cups. An activities aide handled a resident’s wheelchair and food, then served additional trays and refilled multiple drink cups without washing hands. On another occasion, an RN touched her hair before serving meal trays, and two RNs and an activities aide moved residents in wheelchairs and then assisted with feeding and served additional meals without handwashing. The regional dietician confirmed staff should wash hands after such contacts, and the facility relied on a general hand hygiene policy rather than a dining-specific one.
The facility failed to implement appropriate infection prevention and control practices for a resident in isolation for suspected C. diff and for multiple residents placed in Contact Isolation during a GI outbreak. Symptomatic residents were isolated and symptomatic staff were told to stay home, but no testing was done to confirm norovirus, and entrance signage only advised ill visitors not to enter. The IP nurse and CNAs reported that gowns and gloves were used only for direct care, that staff could enter isolation rooms without full PPE for tasks such as handing a remote, and that alcohol-based hand sanitizer was used instead of soap and water for hand hygiene, including for suspected C. diff and GI cases. Isolation signage on affected rooms did not specify the requirement for soap-and-water handwashing, the IP nurse was unaware of different types of Contact Isolation or the need for soap and water in these situations, and no documented, outbreak-specific education was provided. Facility policies and CDC guidance referenced in the report required soap-and-water hand hygiene for suspected or confirmed C. diff and norovirus, but practice in the facility did not align with these standards.
A staff member posted a video of a resident, undressed in a shower room, on social media, showing the resident's face, neck, and shoulders while instructing her to speak. The incident was discovered after a former employee reported it, and the DON confirmed the violation of facility policy prohibiting staff from capturing or sharing resident images or information electronically.
A resident with multiple health conditions, including diabetes, had several instances of low blood sugar levels that were not reported to the physician as required by the facility's policy. Despite the physician's orders to notify if blood sugar was below 70 mg/dL, documentation of such notifications was missing. Interviews with staff confirmed the oversight, highlighting a lapse in following the facility's procedures for maintaining safety.
A resident was inappropriately diagnosed with schizophrenia to secure insurance coverage for risperidone, despite lacking the necessary DSM-5 criteria. The facility's policy requires medication therapy to be based on an adequate indication for use, which was not followed.
Failure to Perform Hand Hygiene During Dining Service
Penalty
Summary
The deficiency involves staff failing to follow proper hand hygiene practices during meal service in the dining room, potentially affecting all 38 residents who ate there. During a continuous observation of a lunch meal service, an activities aide served a meal tray, readjusted a resident’s wheelchair, and cut the resident’s food, then returned to the kitchen to obtain additional trays without washing her hands after touching the resident’s equipment. She then served four more resident trays without performing hand hygiene. After all meals were served, the same aide carried residents’ empty cups from dining tables to the drink station and refilled nine drink cups without performing hand hygiene between handling and refilling the cups. In a separate continuous observation of another lunch meal service, an RN touched her ponytail and then served a tray with two meals to residents without washing her hands after touching her hair. During the same meal, two RNs and the activities aide moved three residents, who had already been served their meals, from one table to another by pushing their wheelchairs; none of them washed their hands afterward, and the two RNs then began assisting residents to eat while the aide served six more meals without hand hygiene. After all trays were served, the aide refilled two resident drinks by taking the cups from the table, refilling them at the drink station, and returning them to the residents without washing her hands before or after refilling. The regional dietician stated that staff should wash their hands anytime they touch their own clothing, body, or hair, and after touching a resident’s clothing or equipment, and that staff should wash their hands if they touch resident cups while refilling them. The executive director confirmed there was no dining-specific handwashing policy but stated the facility followed a general hand hygiene policy based on CDC standards.
Failure to Implement Appropriate Hand Hygiene and Contact Precautions During GI Outbreak and Suspected C. diff
Penalty
Summary
Surveyors identified a failure to maintain appropriate infection prevention and control practices for a resident in isolation for suspected Clostridioides difficile (C. diff) and for multiple residents placed in Contact Isolation during a gastrointestinal (GI) outbreak. At the facility entrance, signage only advised ill visitors not to enter and did not address specific transmission-based precautions. The Executive Director reported that the facility believed a GI virus, thought to be norovirus, was causing nausea, vomiting, and diarrhea among residents and staff. Symptomatic residents were placed in isolation and ate meals in their rooms, and symptomatic staff were told to stay home. However, the facility had not formally tested residents or staff to confirm norovirus. The Infection Preventionist (IP) nurse stated that residents with GI symptoms were placed in Contact Isolation and that staff were required to wear gowns, gloves, and masks only when providing direct resident care. During observation of a room where a resident was in isolation for a possible C. diff infection, the posted Contact Precautions sign instructed staff to clean hands before entering and when leaving the room and to don gloves and gowns before entry and discard them before exit, but it did not specify that soap and water were required for hand hygiene. The nurse assigned to that resident confirmed the isolation was due to possible C. diff. The CNA caring for the resident reported that she wore mask, gown, and gloves only when providing resident care, but not when answering call lights or handing the resident items such as the call light or television remote, and that she used alcohol-based hand sanitizer rather than soap and water before entering and after exiting the room. The IP nurse confirmed that the room was under Contact Isolation and stated that hand sanitizer was an acceptable hand hygiene method for a resident with potential C. diff, and that she was unaware that different types of Contact Isolation existed or that soap and water were specifically required for C. diff-related hand hygiene. She also acknowledged that no C. diff-specific hand hygiene education had been provided to staff after the resident was placed in isolation. The DON later stated that the IP nurse was incorrect and that the facility’s preferred method was soap and water for all hand hygiene unless unavailable, and that all staff had been trained accordingly, but she could not provide documentation of audits or training prior to survey exit. The DON also stated that all care was considered direct care and that staff should have worn gowns, gloves, and masks any time they entered an isolation room, including when handing a resident a remote, and further indicated she had not been informed in infection control meetings that soap and water was the only acceptable hand hygiene for certain Contact Isolation situations such as potential C. diff. During continuous observation, multiple rooms were identified as being in Contact Isolation for GI symptoms, with isolation signs posted that lacked any specific instruction to use soap and water only for hand hygiene upon entering and exiting. The IP nurse reported that all residents with current or recent nausea, vomiting, or diarrhea had been placed in Contact Isolation and that Contact Isolation required gloves, mask, and gown while providing resident care, but she again stated that hand sanitizer was acceptable for hand hygiene in these rooms and that staff were not required to wear gowns or gloves when answering call lights or performing non-direct care tasks such as handing a remote or refilling water. She stated that at the start of the GI outbreak she verbally instructed staff about masks, gowns, and gloves but did not instruct them to use soap and water for hand hygiene because she did not know it was required, and she did not document this education or obtain staff signatures. Review of the facility’s infection map showed that numerous rooms had been placed on Contact Isolation over several days for residents with nausea, vomiting, and/or diarrhea. A review of the call-off list showed several staff from different departments, including CNAs, nurses, cooks, and housekeeping, had called off work with GI symptoms during the same period. The facility’s Infection Control Surveillance Program policy required education on hand hygiene, standard precautions, and isolation protocols at orientation, annually, and in response to infection control/quality improvement data. The facility’s Hand Hygiene policy stated that employees would follow CDC standards and that hand washing with soap and water was required during care of residents with suspected or confirmed C. diff, with alcohol-based hand sanitizer preferred in most other clinical situations. CDC guidance cited in the report specified that during norovirus outbreaks, soap and water should be used for hand hygiene after caring for suspected or confirmed cases, that hand sanitizer alone does not work well against norovirus, and that washing hands with soap and water is the best way to prevent spread of C. diff.
Staff Posted Resident Video on Social Media in Violation of Facility Policy
Penalty
Summary
A staff member at the facility posted a video of a resident, who was undressed in a shower room, on a social media platform. The video showed the resident from the shoulders up, including her neck and face, while a CNA instructed her to say 'Hi' multiple times. The incident was discovered when a former employee reported the video to a current staff member, who then informed the night nurse. The Director of Nursing (DON) was notified and confirmed the existence of the video, which had been posted by the CNA. The CNA initially denied posting the video but was confronted with evidence during an interview with the DON. The facility's policy explicitly prohibited employees from capturing or sharing any resident-specific information, pictures, or videos via electronic communication or social media. Despite this policy, the CNA had signed the policy upon hire but still posted the video. The incident was reported to the Department of Health, and the DON began an investigation by interviewing alert residents about staff use of phones to take videos of them.
Failure to Notify Physician of Low Blood Sugar Levels
Penalty
Summary
The facility failed to notify the physician of out-of-range blood sugar levels for a resident who was being monitored for insulin. The resident, who had a history of unspecified dementia, diabetes mellitus, epilepsy, atrial fibrillation, hypertension, hemiparesis and hemiplegia following cerebral infarction, bilateral visual field deficits, and depression, was found to have blood glucose readings below the threshold set by the physician's orders. Specifically, the resident's blood glucose levels were recorded as 57 mg/dL and 60 mg/dL on multiple occasions, which were below the threshold of 70 mg/dL that required physician notification. The clinical record for the resident lacked documentation that the physician was notified of these low blood sugar readings. Interviews with facility staff, including Employee 1 and the Director of Nursing (DON), confirmed that the physician notification should have been documented in the nursing progress notes or the medication administration record. However, there was no evidence of such documentation. The facility's policy on new order transcription, which was provided by the DON, emphasized the importance of maintaining physician orders in a manner that ensures safety, but the policy was not adhered to in this instance.
Inappropriate Schizophrenia Diagnosis for Medication Coverage
Penalty
Summary
The facility failed to ensure physician services met professional standards of quality concerning the diagnosis of schizophrenia for a resident reviewed for unnecessary medications. The resident, who was admitted without a diagnosis of delusional disorder or schizophrenia, began exhibiting distress, screaming, yelling, and delusions. Despite these behaviors, the clinical record lacked documentation of other criteria necessary for a schizophrenia diagnosis according to DSM-5 standards. The resident's care plan included interventions such as administering psychological medications like risperidone and monitoring for gradual dose reduction. The facility's actions included changing the resident's diagnosis to schizophrenia to secure insurance coverage for risperidone, as indicated by interviews with the Social Service Director and the Director of Nursing. The NP had not consulted a psychiatrist before altering the diagnosis, and the insurance company required a more appropriate diagnosis to cover the medication cost. The facility's policy on psychotropic medication use mandates that medication therapy be based on an adequate indication for use, which was not adhered to in this case.
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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