Miller's Merry Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Portage, Indiana.
- Location
- 5909 Lute Rd, Portage, Indiana 46368
- CMS Provider Number
- 155299
- Inspections on file
- 23
- Latest survey
- March 6, 2026
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Miller's Merry Manor during CMS and state inspections, most recent first.
A resident dependent on staff for transfers, with severe cognitive impairment and multiple medical conditions, sustained a significant skin tear requiring ER treatment and sutures after a CNA manually transferred the resident from a chair to a bed without using the required mechanical lift. The CNA did not follow the care plan or physician's orders due to the absence of the lift pad and uncertainty about how to proceed, and the Pocket Guide detailing transfer requirements was reportedly unavailable at the time.
A resident with multiple chronic conditions was prescribed Levaquin for a urinary tract infection, but the antibiotic was not administered as ordered on the third day. Documentation indicated the medication was unavailable, though the DON later confirmed it was present in the Pyxis dispensing system, and the reason for the missed dose was unclear.
The facility's main kitchen failed to properly label and date food items, including pickles, mayonnaise, sweet corn nuggets, and a bag of white powder, which were observed during a kitchen sanitation tour. The Assistant Kitchen Manager confirmed the labeling requirements, and the Kitchen Manager began re-educating staff. The facility's policy mandates proper labeling and storage of food items.
The facility failed to implement proper infection control practices, including hand hygiene after glove removal, handling of soiled linens, and adherence to enhanced barrier precautions (EBP) for residents with wounds. An LPN did not sanitize hands before donning PPE, a CNA carried uncontained soiled linens, and staff did not wear isolation gowns during high-contact care for residents requiring EBP.
The facility failed to maintain a sanitary environment on the ICF wing, where a strong urine odor was consistently present. Observations over several days confirmed the issue, and a resident's family member noted the persistent smell. An LPN attempted to address the odor by removing garbage and using air freshener, but the smell remained. The Maintenance Director had noticed the odor for weeks but assumed it was from a resident. The Administrator was informed and planned to investigate further.
A resident developed a venous stasis foot ulcer, and the facility failed to promptly notify the responsible party. The ulcer was first identified and treated on 12/15/24, but the family was not informed until 12/19/24. This delay in communication was contrary to the facility's policy requiring timely notification of condition changes.
A resident reported multiple grievances regarding pain management, inappropriate comments by a nurse, and room arrangements to the Administrator, who failed to document these concerns on a grievance form. Despite the resident being cognitively intact and having a complex medical history, there was no follow-up documentation to indicate resolution, violating the facility's grievance policy.
The facility failed to provide scheduled showers and oral care for residents requiring assistance with ADLs. A resident with a feeding tube did not receive scheduled showers or mouth care, and another resident with hemiplegia also missed scheduled showers and oral care. A third resident reported not receiving showers due to staffing shortages. Observations confirmed their disheveled appearances, and facility records showed missed showers and lack of documentation for mouth care. The DON acknowledged these failures.
A facility failed to manage constipation for a resident with multiple health issues, resulting in ineffective treatment. Another resident missed a medical appointment due to inadequate transportation scheduling, and a third resident's care plan for wound management was not followed, leading to potential skin issues. The facility lacked a backup transportation plan and did not adhere to care plans for effective treatment.
The facility failed to provide adequate nutritional support and monitoring for two residents. One resident with a PEG tube and significant weight fluctuations was not assisted with meals, leading to untouched trays and unmonitored intake. Another resident undergoing dialysis did not consistently receive breakfast before sessions, and post-dialysis weights were not documented. The lack of staff assistance and oversight in providing meals and monitoring nutritional status contributed to the deficiencies.
A resident with chronic respiratory failure and COPD was observed receiving oxygen at an incorrect flow rate of 3 liters per minute, contrary to the physician's order of 2 liters per minute. This discrepancy was confirmed by the Nurse Case Manager and acknowledged by the DON, indicating a failure to adhere to the prescribed care plan.
A resident with a fractured tibia experienced severe pain that was not managed effectively by the facility. Despite the resident's consistent reports of high pain levels, the nursing staff failed to notify the physician until several days later, resulting in inadequate pain management. The facility's pain management policy was not properly implemented, leading to a deficiency in care.
The facility failed to monitor and document blood pressure for two residents prescribed medications with specific parameters. One resident, with dementia and hypertension, was not consistently monitored for blood pressure before receiving Midodrine. Another resident, with dementia and heart conditions, had inconsistent blood pressure documentation while on Metoprolol Tartrate. An LPN cited workload issues, and the DON confirmed the need for proper documentation.
The facility recorded a 12% medication error rate during administration for two residents. An LPN included an extra Potassium Chloride tablet for a resident, while another LPN failed to dilute Potassium Chloride for a resident with a gastrostomy tube, leading to uncertainty about the correct dose after a spill. The DON confirmed the errors and highlighted the need for careful review of medication orders.
A facility failed to document meal consumption for a resident with cognitive impairment and nutritional risk. The resident, diagnosed with stroke, dysphagia, and dementia, required supervision with eating. The Food Consumption Log showed missing entries for several meals, which the DON confirmed should have been documented.
Failure to Use Mechanical Lift Results in Resident Injury During Transfer
Penalty
Summary
A resident with diagnoses including rheumatoid arthritis and osteoporosis, and who was dependent on staff for activities of daily living, was injured during a transfer from a chair to a bed. The resident's care plan and physician's orders specified that a mechanical lift was to be used for all transfers, and this requirement was also documented in the Nurse Aide Pocket Guide. However, on the day of the incident, a CNA transferred the resident without using the mechanical lift because the lift pad was not under the resident and the CNA was unsure how to place it while the resident was in the chair. The CNA proceeded to manually transfer the resident, resulting in the resident's left lower leg being snagged on a piece of the wheelchair, causing a significant skin tear. The injury was severe, with a 14 cm by 5.5 cm skin tear on the left lower leg, continuous bleeding, and a pool of blood on the floor. The resident required emergency medical attention, including a visit to the ER and 19 sutures to close the wound. Documentation indicated that the CNA was aware the resident required a mechanical lift for transfers but did not follow the care plan due to the absence of the lift pad and uncertainty about how to proceed. The CNA also reported that the Pocket Guides, which inform staff of required care, were not available that night due to updates, and she had previously been told by other staff that the resident could be manually lifted. Interviews with other staff indicated that the mechanical lift requirement was consistently listed in the Pocket Guide and that these guides were supposed to be always available. The resident's assessment confirmed severe cognitive impairment and total dependence on staff for transfers. The failure to follow the established care plan and use the mechanical lift directly led to the resident's injury during the transfer.
Antibiotic Not Administered as Ordered for UTI
Penalty
Summary
A resident with diagnoses including hypertension, type 2 diabetes mellitus, and atrial fibrillation was admitted to the facility and had a physician's order to receive Levaquin 500 mg by mouth every 24 hours for three days to treat a urinary tract infection. The Medication Administration Record showed that the antibiotic was administered on the first two days, but on the third day, the medication was not given, with documentation indicating it was unavailable and had been ordered from the pharmacy. However, the Director of Nursing later confirmed that the medication was actually available in the Pyxis dispensing machine at the time, and could not explain why the nurse did not administer the antibiotic as ordered. There was no documentation of further administrations of the medication after the missed dose.
Failure to Label and Date Food Items in Kitchen
Penalty
Summary
The facility failed to maintain proper labeling and dating of food items in the main kitchen, which could potentially affect all residents receiving food from this kitchen. During an initial kitchen sanitation tour, surveyors observed several issues: a tray of individual cups of pickles and mayonnaise in the refrigerator was not labeled, an opened bag of sweet corn nuggets in the freezer was undated, and an opened bag of white powder in a cabinet was unlabeled. The Assistant Kitchen Manager confirmed that all items should be labeled with the date they were received, the date they were opened, and the contents if removed from their original container. The unlabeled items were discarded, and the white powder was identified as food thickener taken from a larger container. The Kitchen Manager acknowledged the labeling requirements and indicated that re-education of staff had begun. The facility's policy on food protection and storage mandates that open boxes and containers of food should be securely enclosed, labeled, and dated, and that food not in original containers should be clearly labeled for contents, dated, and stored in food-rated containers with tight-fitting lids.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure proper infection control practices during medication administration for a resident. An LPN was observed preparing medications and placing them into cups while wearing gloves. After removing the gloves, the LPN did not perform hand hygiene before donning personal protective equipment (PPE) to administer medication via a gastrostomy tube. The Director of Nursing confirmed that the LPN should have sanitized his hands after glove removal and before donning PPE. In another instance, a CNA was observed leaving a resident's room with uncontained soiled linens while wearing gloves. The CNA responded to another resident's call for help while still carrying the soiled linens, which is against the facility's linen handling policy. The Director of Nursing acknowledged that the CNA should not have left the room with uncontained soiled linens, as it could contribute to the spread of infection. Additionally, the facility did not adhere to enhanced barrier precautions (EBP) for residents requiring such measures. During a wound treatment, the ADON and an RN did not wear isolation gowns as required for a resident with a venous ulcer. Similarly, an agency CNA and an RN failed to don isolation gowns while providing incontinence care to a resident with a pressure ulcer. The Infection Control Nurse and the Director of Nursing confirmed that the residents were on EBP, and staff were expected to wear gowns and gloves during high-contact care activities.
Persistent Urine Odor on ICF Wing
Penalty
Summary
The facility failed to maintain a sanitary and comfortable environment on the ICF wing, as evidenced by a persistent strong odor of urine detected on one of the three halls. This issue was observed during multiple random checks over several days. A resident's family member confirmed that the entire ICF wing consistently smelled of urine. An LPN suggested the odor might be emanating from garbage in the dirty utility room and attempted to mitigate it by removing garbage bags and using air freshener. Despite these efforts, the odor persisted. The Maintenance Director acknowledged noticing the odor for weeks but assumed it was related to a resident. The Administrator was informed of the situation and indicated plans to investigate the source and clean the carpets.
Failure to Notify Family of Resident's Wound Development
Penalty
Summary
The facility failed to promptly notify the responsible party of a resident's change in condition, specifically the development of a venous stasis foot ulcer. During a wound treatment observation, it was noted that the resident had an open area on the left great toe and a new non-blanchable area on the bottom of the foot. The resident's medical record indicated that the ulcer was first identified on 12/15/24, and a physician's order was given to monitor and treat the wound. However, there was no documentation that the resident's family was notified of the ulcer's development on that date. The Director of Nursing confirmed that the staff nurse assessed the resident's wound on 12/15/24 but failed to document family notification. The Assistant Director of Nursing, who was also the Wound Nurse, only notified the family on 12/19/24 when she assessed the wound and obtained new orders. The facility's policy requires notifying the resident and responsible party of any condition changes, but this protocol was not followed in a timely manner for this resident.
Failure to Document and Address Resident Grievances
Penalty
Summary
The facility failed to properly document and address grievances reported by a resident, identified as Resident 32, who had multiple complaints upon arrival at the facility. These complaints included issues with pain medication, inappropriate comments made by a nurse, and concerns about room arrangements. Despite the resident reporting these concerns to the Administrator, there was no official grievance form filed, and no follow-up documentation was provided to indicate that the issues were resolved. Resident 32, who was cognitively intact according to the Admission Minimum Data Set assessment, had a medical history that included a fracture of the right tibia, end-stage renal disease, dependence on renal dialysis, heart failure, high blood pressure, type 2 diabetes, diabetic neuropathy, major depressive disorder, and anxiety. The Administrator acknowledged writing down the resident's concerns on yellow ledger paper but admitted to not documenting them on a grievance form as required by the facility's grievance procedure policy. This lack of documentation and follow-up represents a failure to adhere to the established grievance policy, which mandates prompt investigation and resolution of resident complaints.
Failure to Provide Scheduled Showers and Oral Care
Penalty
Summary
The facility failed to ensure that activities of daily living (ADLs) were completed for dependent residents, specifically in providing showers and oral care. Resident 24, who had a feeding tube and required assistance with ADLs, reported not receiving showers twice a week as scheduled and not having her dentures or mouth cleaned since admission. Observations confirmed her disheveled appearance over several days, and the facility's records indicated missed showers and lack of documented mouth care. Interviews with staff revealed a misunderstanding of responsibilities regarding oral care, with the LPN assuming CNAs would brush the residents' teeth. Resident 40, also with a feeding tube, reported not receiving scheduled showers or mouth care. Observations over multiple days showed her in the same clothing and unkempt, with crumbs on her shirt. She confirmed that she was finally assisted with mouth care after several days. Her care plan required maximum assistance with ADLs due to hemiplegia following a stroke, but the facility's records showed missed showers and no documentation of mouth care. The DON acknowledged the failure to provide scheduled showers and mouth care. Resident 8 reported not receiving showers as frequently as scheduled, citing staffing shortages as a reason. Her care plan indicated she required moderate assistance with ADLs due to heart failure and other conditions. Facility records showed multiple missed showers, and a nurse's note confirmed she was not on the shower schedule. The DON was unaware of the resident's complaints about missed showers. Overall, the facility's failure to adhere to care plans and schedules for showers and oral care resulted in deficiencies in meeting the residents' ADL needs.
Deficiencies in Constipation Management, Transportation, and Wound Care
Penalty
Summary
The facility failed to address signs and symptoms of constipation for Resident 7, who had a history of stroke, chronic kidney disease, Alzheimer's disease, high blood pressure, anxiety, and constipation. Despite being on a care plan for potential constipation, the resident experienced multiple episodes without documented bowel movements and received Polyethylene Glycol Powder as needed. However, the effectiveness of the treatment was often unknown or ineffective, and the facility did not follow its bowel elimination policy, which required further intervention if the initial treatment was ineffective. Resident 32 missed an orthopedic surgeon appointment due to late arrival, as the facility's transportation plan was inadequate. The maintenance associate, responsible for driving residents to appointments, failed to manage the schedule effectively, resulting in the resident arriving 20 minutes late and missing the appointment. The facility did not have a backup transportation plan in place, and the Director of Nursing was aware of the missed appointment but did not provide additional information. Resident 51, who had atrial fibrillation, high blood pressure, and high cholesterol, was observed with her heels not floated as required by her care plan for an arterial wound on her left great toe. Despite multiple observations and wound treatment, the resident's heels remained flat on the bed, contrary to the care plan's instructions to float the heels. A new non-blanchable red area was identified on the resident's foot, indicating a failure to adhere to the care plan and potentially contributing to the development of new skin issues.
Failure to Provide Adequate Nutritional Support and Monitoring
Penalty
Summary
The facility failed to provide adequate nutritional support and monitoring for two residents, leading to deficiencies in their care. Resident 19, who had a history of stroke, hemiplegia, aphasia, dysphagia, and a PEG tube, was observed multiple times with untouched meal trays and no staff assistance. Despite her inability to feed herself, staff did not assist her, and her nutritional intake was not monitored. Her weight fluctuated significantly, and there were no readmission weights documented after hospital returns, nor were there recent assessments by a registered dietitian. Resident 32, who was undergoing dialysis and had end-stage renal disease and type 2 diabetes, reported not consistently receiving breakfast before his dialysis sessions. He left for dialysis without a meal and returned very hungry. Despite a care plan indicating the need for double protein at breakfast and monitoring of weights and intakes, there were no post-dialysis weights documented, and meal consumption logs were incomplete. The dietary food manager prepared early breakfasts, but CNAs did not pick them up, and the Director of Nursing was unaware of the missed meals. The facility's failure to assist residents with eating, monitor nutritional intake, and ensure proper documentation and communication regarding residents' nutritional needs and weights contributed to the deficiencies observed. The lack of staff assistance and oversight in providing meals and monitoring residents' nutritional status highlights significant gaps in the facility's care processes.
Incorrect Oxygen Flow Rate for Resident
Penalty
Summary
The facility failed to ensure that a resident's oxygen was administered at the correct flow rate. The resident, who was diagnosed with chronic respiratory failure and COPD, was observed multiple times with an oxygen concentrator set at 3 liters per minute, despite a physician's order specifying a flow rate of 2 liters per minute. This discrepancy was confirmed by the Nurse Case Manager and acknowledged by the Director of Nursing. The resident's care plan included administering oxygen as ordered, but the facility did not adhere to the prescribed flow rate, leading to the deficiency.
Failure to Manage Resident's Pain Effectively
Penalty
Summary
The facility failed to manage and monitor the pain of a resident, identified as Resident 32, who was admitted with a fracture of the right tibia, among other diagnoses. Upon admission, the resident experienced severe pain, consistently rating it between 6 and 10 on a scale of 1 to 10, with 10 being the worst pain imaginable. Despite the resident's complaints and the ineffectiveness of the prescribed Acetaminophen, there was no communication with the physician regarding the resident's severe pain levels from December 7 to December 10, 2024. The resident's pain was not adequately addressed until December 10, 2024, when the Director of Nursing was informed by the resident and his sons, leading to a new prescription for Norco. The resident's care plan included monitoring for pain and administering medications as ordered, but these measures were not effectively implemented. The facility's Pain Management Program policy aimed to assist residents in achieving optimal comfort, yet the nursing staff failed to notify the physician about the resident's severe pain over the weekend or before December 10, 2024. This oversight resulted in the resident enduring significant pain without appropriate intervention for several days, highlighting a deficiency in the facility's pain management practices.
Failure to Monitor Blood Pressure for Medications with Parameters
Penalty
Summary
The facility failed to ensure proper management and monitoring of medication regimens for two residents, leading to a deficiency in medication administration. Resident 21, who had diagnoses including dementia and hypertension, was prescribed Midodrine with specific blood pressure parameters. However, the resident's blood pressure was not consistently monitored before each dose as required, with documentation missing for several days. An LPN admitted to not always documenting the blood pressure unless the medication was held, citing a heavy workload as the reason. Similarly, Resident 29, with diagnoses including dementia, heart attack, and atrial fibrillation, was prescribed Metoprolol Tartrate with parameters to hold the medication if the blood pressure was below a certain threshold. The resident's blood pressure was not consistently documented, with several days lacking any records of monitoring. The Director of Nursing confirmed that vitals should be taken and documented with each scheduled dose of medication with parameters, indicating a lapse in adherence to this protocol.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in a 12% error rate during medication administration for two residents. The first incident involved an LPN who prepared medications for a resident and mistakenly included an extra Potassium Chloride tablet in the medication cup, totaling 12 pills instead of the prescribed 11. The LPN acknowledged the error upon review of the resident's medication order, which specified only one Potassium Chloride tablet was to be administered. In the second incident, another LPN prepared medications for a resident with a gastrostomy tube, including Potassium Chloride, which was not diluted as required. During the administration, one of the medication cups was knocked over, and the LPN was unable to determine which medication was spilled due to all medications being diluted. The Director of Nursing later confirmed that the Potassium Chloride should have been diluted and expressed concern about ensuring the correct dose was administered. Additionally, the Director noted that medication rolls should be checked to prevent extra pills from being included.
Incomplete Documentation of Meal Consumption for a Resident
Penalty
Summary
The facility failed to ensure complete and accurate documentation of clinical records related to meal consumption for a resident experiencing a decline in activities of daily living (ADL). The resident, who had diagnoses including stroke, dysphagia, and dementia without behavior disturbance, was cognitively impaired and required supervision with eating. The care plan indicated the resident was at nutritional risk and required monitoring of weights and intakes. However, the Food Consumption Log for December 2024 and January 2025 showed missing documentation of the resident's meal intake on several occasions. The Director of Nursing confirmed that the resident's food consumption should have been documented for each meal.
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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