Miller's Merry Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Plymouth, Indiana.
- Location
- 635 Oakhill Ave, Plymouth, Indiana 46563
- CMS Provider Number
- 155102
- Inspections on file
- 23
- Latest survey
- March 10, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Miller's Merry Manor during CMS and state inspections, most recent first.
The facility failed to follow physician orders for two residents, leading to deficiencies in care. A resident with multiple diagnoses did not have daily weights recorded as ordered, and another resident received an incorrect dosage of sertraline due to a transcription error. The facility lacked documentation and policy adherence in both cases.
The facility restricted access to resident trust funds to business hours, affecting all residents with such accounts. A resident reported being unable to access funds outside these hours, and staff interviews confirmed this practice. The facility's policy stated funds should be readily available, but it acknowledged limited access during weekends and evenings.
A facility failed to notify a physician of abnormal blood sugar levels for a resident with diabetes, despite care plan and physician orders requiring such notification. The resident's blood sugar levels were consistently below the ordered parameters over several months, yet there was no documentation of physician notification. The DON acknowledged the oversight, which violated the facility's policy on condition change notifications.
A facility failed to provide adequate activities for a resident with severe cognitive impairment and other health issues. Observations showed the resident was often left without visual or auditory stimulation, despite a care plan emphasizing the need for socialization and group activities. The Activity Director acknowledged the resident should have had activities in her room, highlighting a lapse in following the facility's Life Enrichment Program Guidelines.
The facility failed to comply with regulations regarding PRN antianxiety and antipsychotic medication use for two residents. A resident received lorazepam beyond the 14-day limit without proper documentation, and another resident was prescribed Seroquel without a documented medical indication. The DON was unable to provide a rationale for these deficiencies.
The facility failed to properly label and date over-the-counter medications in one of the medication storage areas. During an observation, several medications, including ibuprofen, CoQ10, and Vitamin D3, were found unlabeled or without an opened date. RN 5 acknowledged the oversight, and the DON provided the facility's policy requiring compliance with labeling standards.
A facility failed to implement enhanced barrier precautions (EBP) for a resident with a Stage 2 pressure ulcer. Despite a physician's order for wound care, there was no indication of EBP being in place, and a nurse assisted the resident without wearing a gown. Staff interviews revealed a lack of adherence to the facility's EBP policy, as there was no signage or physician's order for EBP, contrary to the facility's guidelines for residents with wounds.
The facility failed to provide staff-directed activities in the evening and on weekends due to staffing limitations, affecting 52 out of 70 residents. The Activity Director confirmed the lack of activities, citing that the last scheduled activity during the week was at 1:30 P.M. or 2 P.M., with limited weekend activities primarily consisting of church services on alternate Saturdays.
The facility failed to notify the physician of critical blood sugar readings and significant weight changes for a resident with diabetes and heart failure. Despite multiple instances of out-of-range blood sugar levels and notable weight fluctuations, the required notifications were not made, as confirmed by the RN and documented in the resident's care plan.
A facility failed to provide ordered nutritional supplements for a resident with significant weight loss, despite a care plan indicating the need for such supplements. The resident, who had multiple diagnoses including hemiplegia and diabetes, experienced a notable weight loss, and the ordered Glucerna shakes were not consistently administered as documented in the Medication Administration Record.
The facility failed to provide safe side rails and complete an assessment for a resident. The resident's bed had a side rail with an unsafe opening size, and no bed rail screen or assessment was found in the medical record. The Executive Director and Maintenance Director were unaware of safe measurements, and the resident reported previous incidents of getting caught in the side rails. The facility's policy requiring an assessment before using assistive devices was not followed.
The facility failed to ensure it was free of medication errors greater than 5 percent, resulting in a medication error rate of 9.68 percent. An LPN administered insulin to three residents without following physician orders, and the residents did not receive snacks or meals within the required 15 minutes after insulin administration. The facility also lacked a policy for following physician orders.
The facility failed to follow proper infection control practices during blood glucose monitoring for two residents. An LPN used an alcohol prep pad instead of a commercial disinfectant wipe to clean the glucometer between uses, contrary to the facility's policy. The DON confirmed the improper cleaning method and provided the correct procedure.
The facility failed to maintain a sanitary room environment for a resident, with inconsistent cleaning practices leading to dusty blinds, picture frames, and shelves. The resident reported inadequate cleaning, and observations confirmed the deficiencies. Housekeeping staff had varying cleaning routines, and the facility's policy was not consistently followed.
A resident reported $25.00 missing from her purse, but the facility failed to report the incident to the State Survey Agency within the required time frame. The Social Services Director began an investigation and provided a lock box, but there was no documentation in the resident's progress notes, and the resident was not updated on the investigation. The Administrator only reported the incident to the Indiana Department of Health after the survey team inquired about it, several days later.
The facility failed to thoroughly investigate a resident's missing $25.00, with lapses in communication and documentation. The investigation only began after surveyor inquiries, contrary to the facility's policy on abuse prohibition and reporting.
The facility failed to update the care plan for a resident with functional quadriplegia and contractures, despite physician's orders for the use of splints during nighttime hours. The care plan contained outdated interventions and did not reflect the current orders.
Failure to Follow Physician Orders and Transcribe Medication Accurately
Penalty
Summary
The facility failed to adhere to physician orders for two residents, leading to deficiencies in care. For Resident 55, who had diagnoses including diabetes, dementia, depression, and anxiety, the facility did not consistently record daily weights as ordered by the physician. The resident's care plan highlighted the importance of monitoring weights due to nutritional risks and fluid shifts. However, there were multiple instances in November, December, and January where daily weights were not documented, nor was there any explanation provided for these omissions. The Director of Nursing acknowledged the oversight and confirmed the absence of a facility policy regarding weight documentation. For Resident 267, who had conditions such as depression, end-stage renal disease, dysphagia, and diabetes mellitus type two, there was a failure in accurately transcribing a medication order. The discharge medication order from the hospital specified sertraline 25 mg, but the facility's records incorrectly listed it as 50 mg. This error led to the resident receiving the incorrect dosage for six consecutive days. Although the Nurse Practitioner had clarified other medication orders, there was no documentation of a review or change in the sertraline dosage. The Assistant Director of Nursing mentioned a conversation with the Nurse Practitioner about the dosage but did not document it in the medical record.
Resident Trust Fund Access Limited to Business Hours
Penalty
Summary
The facility failed to ensure that resident funds were immediately available during non-business hours, affecting all 24 residents with trust funds. Resident 12 reported being informed that funds could only be accessed when the business office was open. Observations confirmed that a sign at the front desk indicated limited availability of funds, with access restricted to business hours on weekdays and a short window on weekends. Interviews with staff, including the Business Office Manager, Executive Director, CNA, and RN, revealed a consistent practice of restricting access to resident trust funds outside of designated hours. The facility's policy, provided by the Director of Nursing, stated that funds should be readily available but acknowledged that money was not accessible when the business office was closed, including weekends and evenings. This practice contradicted the policy's intent and led to the deficiency.
Failure to Notify Physician of Abnormal Blood Sugar Levels
Penalty
Summary
The facility failed to notify the physician of abnormal blood sugar results for a resident with multiple diagnoses, including diabetes. The resident's care plan and physician orders required notification if blood sugar levels were outside specified parameters. Despite this, the facility did not document any physician notification for numerous low blood sugar readings recorded in November, December, and January. The Director of Nursing confirmed that the physician should have been notified of these abnormal results. The facility's policy mandates notifying the physician of any condition changes or monitored values outside ordered parameters. However, the nursing progress notes lacked documentation of such notifications, indicating a failure to adhere to the policy.
Failure to Provide Adequate Activities for a Resident
Penalty
Summary
The facility failed to provide adequate activities for a dependent resident, identified as Resident 40, who was reviewed for activities. Observations over several days revealed that Resident 40 was frequently left in her room without visual or auditory stimulation. Specifically, on multiple occasions, she was seen in her room either in a reclined position in her Broda chair or sleeping, without any engagement in activities. This lack of stimulation occurred despite the resident's care plan, which emphasized the importance of socialization and involvement in group activities to enhance her quality of life. Resident 40 had a history of severe cognitive impairment, cerebral infarction, hemiplegia, dementia, and delirium, and was receiving hospice care. Her care plan, initiated in November 2022 and updated in May 2024, outlined various interventions to prevent loneliness and isolation, such as attending sensory activities, receiving invitations to readings, and being encouraged to participate in group activities. However, these interventions were not observed to be implemented during the survey period. The Activity Director confirmed that Resident 40 should have had visual or auditory activities in her room, indicating a failure to adhere to the facility's Life Enrichment Program Guidelines.
Failure to Document Justification for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure compliance with regulations regarding the use of PRN antianxiety medications and the documentation of antipsychotic medication use for two residents. For Resident 19, a PRN order for lorazepam, an antianxiety medication, was initiated and continued beyond the 14-day limit without proper documentation justifying its extended use. The nurse practitioner noted terminal agitation as a reason for continuation, but there was no supporting documentation in the medical record to substantiate this claim. Additionally, nursing progress notes did not indicate any behaviors or symptoms that would warrant the use of lorazepam, and the Director of Nursing was unable to provide a rationale for the extended use of the medication. For Resident 39, the facility failed to document a medical indication for the use of Seroquel, an antipsychotic medication, which was prescribed for anxiety and combative behaviors. The resident's record lacked documentation to support the use of this medication, and during an interview, the Director of Nursing acknowledged the absence of an appropriate diagnosis for its use. The facility's policy on psychotropic medication use requires documentation of the supporting diagnosis at the time the order is received, which was not adhered to in this case.
Medication Labeling and Dating Deficiency
Penalty
Summary
The facility failed to ensure that over-the-counter medications were properly labeled and that opened medications were dated when opened in one of the four medication storage areas observed. During an observation of the ICF 3 medication cart, several medications were found to be either unlabeled or lacking an opened date. These included a bottle of ibuprofen, CoQ10, Vitamin D3, aspirin, Ferrosol, Milk of Magnesia (MOM), Men's multivitamins, daily probiotic pills, and Guaifenesin liquid. RN 5 confirmed that these medications should have been labeled and dated according to the facility's policy. The Director of Nursing provided the facility's medication labeling policy, which mandates compliance with facility requirements and state and federal laws.
Failure to Implement Enhanced Barrier Precautions for Resident with Pressure Ulcer
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for a resident with a pressure ulcer, identified as Resident 46. The resident, who was cognitively intact, had a Stage 2 pressure ulcer on the left mid-buttock, as noted in a Pressure Injury Note dated 1/2/2025. Despite a physician's order to cover the wound with Duoderm every Tuesday and as needed, there was no indication of EBP being in place. During an observation, a registered nurse (RN 5) assisted the resident without wearing a gown, although gloves were used. This was contrary to the facility's policy, which required EBP for residents with wounds to prevent the spread of multi-drug resistant organisms (MDROs). Interviews with staff revealed a lack of adherence to the facility's EBP policy. A certified nursing assistant (CNA 4) and RN 5 both acknowledged that EBP should be in place for residents with wounds beyond Stage 1. However, there was no signage on Resident 46's door to indicate the need for EBP, nor was there a physician's order for such precautions. The Director of Nursing provided a current policy that emphasized the use of gowns and gloves during high-contact care activities for residents with wounds and indwelling devices, which was not followed in this case.
Lack of Evening and Weekend Activities
Penalty
Summary
The facility failed to ensure staff-directed activities were provided in the evening and on the weekends for residents. This deficiency was identified during an interview with a resident who expressed a desire for evening and weekend activities, noting that such activities were only available on holidays like Easter and Christmas. A review of the activity calendar for March and April 2024 confirmed that the last scheduled activity during the week was at 1:30 P.M. or 2 P.M., with limited activities on weekends, primarily church services on alternate Saturdays. No activities were scheduled for several weekend days in both months for the long-term care and rehab units, although two activities were provided in the dementia unit on Sundays. The Activity Director (AD) confirmed the lack of evening and weekend activities, citing staffing limitations as the primary reason. The AD had one full-time assistant working Monday through Friday and a part-time assistant working Tuesday, Wednesday, and Thursday. The AD herself came in on Saturdays for church services but did not schedule other activities unless it was a holiday. The facility's policy, dated 10/13/2010, required at least two activities daily for each of three resident groups, but this was not being met due to the staffing constraints. This deficiency had the potential to affect 52 out of 70 residents residing in the facility.
Failure to Notify Physician of Critical Health Changes
Penalty
Summary
The facility failed to notify the physician of blood sugars outside the ordered parameters for a resident with diabetes and heart failure. The resident had multiple instances of blood sugar readings below 70 mg/dL and above 400 mg/dL, but there was no documentation of physician notification for these out-of-range readings. Additionally, the resident experienced significant weight changes, which were not reported to the physician as required by the care plan. The resident's weight fluctuated significantly, with a five-pound gain over five days and a two-pound gain in one day, but these changes were not communicated to the physician. The resident was readmitted to the facility after a hospitalization for acute on chronic combined systolic and diastolic congestive heart failure. Despite the care plan's requirement to notify the physician of significant weight changes, the facility failed to do so on multiple occasions. Interviews with the RN confirmed that the physician should have been notified of both the blood sugar readings and the weight changes, but this did not occur. The facility's policies on blood glucose monitoring and weight management were not adequately followed, leading to the deficiencies noted in the report.
Failure to Provide Ordered Nutritional Supplements
Penalty
Summary
The facility failed to provide ordered nutritional supplements for a resident with significant weight loss. Resident 10, who had diagnoses including hemiplegia, diabetes mellitus type 2, and dysphagia, was observed lying in bed with a note indicating to see the nurse before giving fluids. The resident's care plan, dated 8/1/2019, indicated that she was at nutritional risk due to a stroke and anemia, with interventions including offering replacement foods/beverages if meal consumption was less than 50 percent and monitoring weights and intakes. The weight record showed a decrease from 154.8 pounds on 3/5/2025 to 146.2 pounds on 4/8/2024. A Nurse's Note on 4/8/2024 indicated a Nurse Practitioner ordered a Glucerna shake 237 milliliters twice daily due to the weight loss, which was also noted in a Progress Note on 4/12/2024. However, the Medication Administration Record for April 2024 indicated multiple instances where the resident did not receive the Glucerna shake as ordered. During an interview on 4/23/2024, RN 3 confirmed that Resident 10 should be receiving the Glucerna shake twice a day and that the shake had not been out of stock, nor had the resident refused it. The RN indicated that she would notify the physician or nurse practitioner if the resident did not receive or refused the shake. The facility's policy on Weight Management Program, provided by the Director of Nursing, indicated that residents' weight status would be monitored and that interventions, including nutritional oral supplements, would be assessed for residents experiencing unplanned weight changes. Despite this policy, the facility failed to ensure that Resident 10 received the ordered nutritional supplements consistently, leading to a deficiency in providing adequate nutrition to maintain the resident's health.
Failure to Provide Safe Side Rails and Complete Assessment
Penalty
Summary
The facility failed to provide safe side rails and complete an assessment for Resident 19. During an observation, it was noted that Resident 19's bed had a side rail with an opening larger than the recommended dimensions for safety. The resident's medical record indicated various diagnoses, including bipolar disorder, functional quadriplegia, and unspecified dementia. Despite a physician's order and care plan indicating the need for side rails, no bed rail screen or assessment was found in the medical record. Additionally, the Nurse's Note lacked documentation for the need for side rails. The Executive Director and Maintenance Director were unaware of the safe measurements for side rails, and the Maintenance Director confirmed that the side rail opening measured 7 inches by 7.5 inches. Resident 19 reported that his arms had been caught in the side rails during jerking movements. Both the Director of Nursing and the Clinical Service Coordinator confirmed that no side rail assessment had been completed. The facility's policy required an assessment before the initiation of an assistive device, which was not followed in this case.
Medication Error Rate Exceeds 5 Percent
Penalty
Summary
The facility failed to ensure it was free of medication errors greater than 5 percent, resulting in a medication error rate of 9.68 percent. During an observation, LPN 7 administered insulin to three residents (Residents 24, 56, and 60) without following the physician's orders. Resident 56 received 8 units of Novolog for a blood sugar result of 313 but did not receive a snack or lunch 15 minutes after the insulin injection. Similarly, Resident 60 received 2 units of Flasp for a blood sugar result of 154 but also did not receive a snack or lunch 15 minutes after the insulin injection. Resident 24 received 8 units of Novolin R for a blood sugar of 340, and LPN 7 failed to sign off on the electronic medical record that the insulin was administered. Resident 24 also did not receive a snack after the insulin injection. During interviews, the residents confirmed they had not received snacks or meals within the required 15 minutes after insulin administration. LPN 7 admitted to not offering snacks to the residents and indicated that the meal did not start until 11:30 A.M. The Director of Nursing confirmed that the facility did not have a policy for following physician orders. This lack of adherence to physician orders and the absence of a relevant policy contributed to the observed medication errors.
Inadequate Infection Control During Blood Glucose Monitoring
Penalty
Summary
The facility failed to ensure proper infection control practices during blood glucose monitoring for two residents. During an observation, an LPN checked the blood sugar of Resident 56 and cleaned the glucometer with a single alcohol prep pad before placing it back on the medication cart. The same glucometer was then used to check the blood sugar of Resident 60, again cleaned with only one alcohol prep pad. The LPN admitted to not knowing the facility's policy for cleaning the glucometer. The Director of Nursing (DON) confirmed that using an alcohol prep pad was not appropriate for cleaning the glucometer and provided the facility's policy, which required the use of a commercial disinfectant wipe and specific procedures to ensure proper disinfection. The policy detailed steps such as ensuring the glucometer is visibly wet with the disinfectant, avoiding the screen, and allowing the device to air dry for the manufacturer's recommended contact time. The DON also noted that none of the residents requiring glucometer use had any communicable diseases.
Failure to Maintain Sanitary Room Environment
Penalty
Summary
The facility failed to ensure housekeeping maintained a sanitary room environment for Resident 42. The resident reported that her room was not being cleaned adequately, with housekeepers only cleaning the toilet, bathroom sink, and taking out the trash. The resident noted that the floors were seldom swept or mopped, and dusting was not performed regularly. Observations confirmed that the blinds, picture frames, and shelves in the bathroom were dusty over multiple days. The resident's medical history includes chronic obstructive pulmonary disease, type 2 diabetes, hypertension, and major depressive disorder. Interviews with housekeeping staff revealed inconsistencies in cleaning practices. One housekeeper indicated that she dusted twice a week, while another stated she only dusted when a resident discharged, died, or switched rooms. The Environmental Supervisor expected daily cleaning, including sweeping and mopping, with a more thorough cleaning once a week. The facility's policy outlined daily and monthly cleaning procedures, but these were not being followed consistently, leading to the observed deficiencies in maintaining a clean and sanitary environment for Resident 42.
Failure to Timely Report Missing Property
Penalty
Summary
The facility failed to ensure an allegation of a resident's missing property was reported immediately or within 2 hours after the allegation was made to the State Survey Agency. Resident 42 reported $25.00 missing from her purse, which she last saw the previous Friday. She informed the Social Services Director, who began an investigation and provided her with a lock box. However, there was no documentation of the missing money in the resident's progress notes, and the resident had not been updated on the investigation's progress. The Administrator only reported the missing money to the Indiana Department of Health (IDOH) after the survey team inquired about it, several days after the initial report by the resident. The facility's policy required immediate reporting, but the Administrator was unsure of the exact time frame and believed it should have been reported within 24-48 hours. The Social Worker acknowledged that the missing money could be considered misappropriation and should have been reported immediately, with a follow-up investigation. The Administrator eventually reported the incident to IDOH and initiated an investigation, but this was done only after the survey team raised questions about the incident. The facility's policy, dated 11/29/2017, clearly stated that incidents involving suspicion of a crime or abuse should be reported immediately, but no later than 2 hours, and misappropriation of resident property should be reported within 24 hours.
Failure to Investigate Missing Property
Penalty
Summary
The facility failed to ensure a thorough investigation was initiated for an allegation of a resident's missing property. Resident 42 reported $25.00 missing from her purse, which she last saw the previous Friday. Despite informing the Social Services Director and receiving a lock box, the resident had not been updated on the investigation's progress. The Administrator only began investigating after the survey team inquired about the incident, and there was no documentation of the missing money in the resident's progress notes. The Social Worker admitted to not completing the investigation or interviewing other residents, and the Administrator reported the incident to the Indiana Department of Health and local law enforcement only after the survey team raised concerns. Resident 42, who is cognitively intact and has diagnoses including chronic obstructive pulmonary disease, type 2 diabetes, hypertension, and major depressive disorder, expressed frustration over the lack of communication regarding the investigation. The facility's policy on abuse prohibition, reporting, and investigation mandates thorough investigations and reporting of reasonable suspicions of crime, which was not adhered to in this case. The Administrator and Social Worker both acknowledged lapses in the investigation process, highlighting a failure to follow established protocols for handling allegations of missing property.
Failure to Update Care Plan for Splint Use
Penalty
Summary
The facility failed to update the care plan for a resident regarding the use of splints. The resident, who has diagnoses including functional quadriplegia, lobster-claw hand, contracture of muscle right hand, and muscle weakness, was observed to have contractures on both hands and indicated that he wears splints during nighttime hours. Despite a physician's order for the resident to wear a left palm protector with finger separators and a right-handed splint during sleeping hours, the care plan had not been updated to reflect these orders. The care plan, dated 6/2/2020, included outdated interventions for the application of the left-hand brace and right-hand splint, which did not align with the current physician's orders. During an interview, the MDS Coordinator confirmed that care plans should be updated at least quarterly and with any new medication or change in the resident's status. The facility's policy on care plan development and review, provided by the Director of Nursing, indicated that care plans should be revised daily and as needed based on changes in the resident's condition, including changes in physician orders. However, the care plan for this resident had not been updated to reflect the new orders, leading to a deficiency in the care provided.
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.
The facility failed to ensure timely electronic transmission of MDS assessment data to CMS for a resident. Record review showed an annual MDS that was more than 120 days overdue for submission. The MDS coordinator reported that two care area assessments on the annual MDS had remained incomplete until just before surveyor review, at which time the MDS was finished and submitted. The Administrator acknowledged there was no facility policy in place governing MDS transmissions.
Surveyors found that MDS assessments were inaccurately coded for two residents. One resident with a prior Level II PASARR for serious mental illness was incorrectly coded on the Annual MDS as not having a serious mental illness or related condition. Another resident with generalized anxiety disorder, major depressive disorder, and dementia, who was receiving Lorazepam for anxiety, was not coded with an active anxiety disorder diagnosis on the Quarterly MDS, despite active orders documented on the MAR. The MDS coordinator acknowledged both coding errors, and leadership reported there was no facility-specific MDS policy, relying instead on the RAI manual.
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 Timely Transmit MDS Assessment Data to CMS
Penalty
Summary
The facility failed to ensure timely electronic transmission of MDS (Minimum Data Set) assessment data to the CMS system for one resident. Review of the clinical record for Resident 36 on 4/9/26 showed an annual MDS assessment dated 2/23/26 that was more than 120 days overdue for submission to CMS. During an interview on 4/10/26 at 11:22 a.m., the MDS coordinator stated she still had two care area assessments left to complete on the annual MDS assessment and that she had just finished them and submitted the MDS to CMS, indicating the assessment had not been completed and transmitted within the required timeframe. In a separate interview on 4/10/26 at 12:05 p.m., the Administrator reported that the facility did not have a policy regarding MDS transmissions, further demonstrating the lack of an established process to ensure that MDS data were encoded and transmitted to the State and CMS within the required time limits.
Inaccurate MDS Coding for Mental Health and PASARR Status
Penalty
Summary
The deficiency involves the facility’s failure to ensure that MDS assessments accurately reflected residents’ clinical status for two residents. For one resident with diagnoses including bipolar disorder and anxiety, the Annual MDS dated 3/11/26 indicated the resident was not considered by the state Level II PASARR process to have a serious mental illness or intellectual disability/related condition, despite a Level II PASARR having been completed on 3/31/23. This discrepancy was identified through record review and confirmed in an interview with the MDS coordinator, who acknowledged that the MDS assessment did not accurately reflect the existing Level II PASARR information. For another resident with generalized anxiety disorder, major depressive disorder, and dementia, the Quarterly MDS dated 3/30/26 did not code anxiety as an active diagnosis. However, review of the MAR showed active orders as of 2/27/26 for Lorazepam, prescribed for generalized anxiety disorder, and the RAI manual specifies that active diagnoses should be identified using sources such as medication sheets and physician orders during the 7-day look-back period. In an interview, the MDS coordinator confirmed that the resident did have an active anxiety disorder diagnosis and that the MDS should have been coded “yes” for anxiety disorder but was incorrectly coded “no.” The Administrator and MDS coordinator also stated the facility did not have an MDS policy and relied on the RAI manual for completing assessments.
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