Miller's Merry Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Warsaw, Indiana.
- Location
- 1630 S County Farm Rd, Warsaw, Indiana 46580
- CMS Provider Number
- 155049
- Inspections on file
- 24
- Latest survey
- May 12, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Miller's Merry Manor during CMS and state inspections, most recent first.
A resident with chronic pain, anxiety, and depression experienced two falls—one during a transfer without a gait belt and another while attempting to toilet independently. Although new interventions were identified, such as using a gait belt and keeping the bed in the lowest position, these were not added to the resident's care plan as required. The DON confirmed the care plan should have been updated to reflect these changes.
A resident with advanced cognitive impairment and end-of-life care needs was repeatedly observed without access to sensory or leisure activities, despite documented preferences for music and religious services. Staff interviews and record reviews confirmed that the resident was not regularly included in activity programs and received sensory activities infrequently, contrary to the facility's policy and the resident's care plan.
A resident with chronic kidney disease and high protein supplementation did not receive the recommended laboratory monitoring after a dietician's assessment. The dietician's recommendation to monitor kidney function was not communicated to the medical provider, and the dietician was unaware of existing lab results. Facility policy requiring interdepartmental communication of such recommendations was not followed.
A medication cart was observed to contain an opened and undated bottle of dorzolamide eye drops without resident identifiers, an unsealed and unlabeled petrolatum gauze dressing, and an open, undated bottle of lactulose. A QMA confirmed these items should have been labeled, dated, and sealed according to facility policy, which was not followed.
A nurse did not perform hand hygiene after removing a dressing and gloves while providing a skin treatment to a resident, and another nurse failed to use a barrier when placing a glucometer on a bedside table during blood glucose monitoring. Both staff acknowledged the lapses in infection control practices during interviews.
The facility failed to ensure proper storage and labeling of food brought in by outside sources in resident nourishment refrigerators. Observations revealed unlabeled food items and ice packs used for residents stored inappropriately, affecting all 67 residents on the units. The Dietary Manager confirmed the lack of adherence to food storage policies and professional standards for food safety.
The facility failed to provide adequate ADL assistance for a resident, specifically in relation to shaving and nail care. The resident was observed with long facial hair and untrimmed fingernails with debris, despite expressing a preference for being clean-shaven and having a care plan indicating the need for maximum assistance with grooming. Staff interviews and documentation revealed inconsistencies in the provision of these services.
The facility failed to provide appropriate care for a central venous catheter for a resident and did not follow physician orders for another resident with skin conditions. The central venous catheter dressing was not changed as required, and the tubigrip for the left lower extremity was not applied as ordered, leading to deficiencies in care.
The facility failed to properly store and clean respiratory equipment for two residents. One resident's CPAP machine and another's nebulizer were found uncovered and uncleaned, with staff showing confusion about cleaning responsibilities and inconsistent practices.
The facility failed to ensure pharmacy recommendations were communicated to the physician for review in a timely manner for a resident with overactive bladder, allergies, and insomnia. Recommendations to reduce dosages of Loratadine, Myrbetriq, and Melatonin were not acted upon promptly due to a communication issue with the new pharmacy representative.
A medication cart in Windsor Hall was left unattended with keys in the drawer for about 8 minutes. The RN left the cart to respond to a call for help and forgot to take the keys. The DON confirmed that the cart should have been locked and the keys taken by the nurse.
The facility failed to keep physician orders current with a resident's advanced directive instructions, resulting in conflicting directives for Resident B, who was receiving hospice services. Despite multiple advanced directive forms with differing instructions, the facility did not ensure that the physician orders were consistent with the resident's current wishes.
Failure to Update Care Plan After Resident Falls
Penalty
Summary
The facility failed to update the care plan for a resident who was at risk for falls, as required following significant changes in the resident's condition and incidents. The resident, who had diagnoses including chronic pain, anxiety, and depression, experienced two falls. The first fall occurred during a transfer from bed to wheelchair when a staff member did not use a gait belt, resulting in the resident falling onto her right knee. The root cause was identified as the lack of gait belt use, and the staff member involved was counseled on proper transfer technique. The second fall happened when the resident attempted to toilet herself and was found on the bathroom floor. After this incident, a new intervention to keep the resident's bed in the lowest position was identified as necessary. Despite these incidents and the identification of new interventions, the resident's care plan was not updated to include the use of a gait belt during transfers or the intervention to keep the bed in the lowest position. The existing care plan only included general fall prevention measures such as keeping the call light within reach, encouraging the use of assistive devices, and monitoring for changes in gait. The Director of Nursing confirmed that the care plan should have been updated with the new interventions following the falls, in accordance with the facility's policy requiring care plan revisions as changes in the resident's condition dictate.
Failure to Provide Individualized Sensory Activities for Cognitively Impaired Resident
Penalty
Summary
A deficiency was identified when a resident with Alzheimer's disease, seizures, aphasia, mood disorder, and altered mental status, who was receiving end-of-life care, was repeatedly observed without access to independent leisure or sensory activities. Over several days, the resident was seen either in bed or in a Broda chair with her eyes closed, and there were no visual or auditory sensory activities present in her environment. The resident's care plan indicated a need for sensory-related activities and noted preferences for music, religious services, and fresh air, but these interventions were not consistently provided. Interviews with staff revealed that the resident was not regularly included in activity programs and typically received sensory activities only once a week due to limited staffing. The facility's policy required daily sensory stimulation for residents with low cognitive function, as well as regular musical and spiritual activities, but these were not implemented as outlined. Documentation and staff accounts confirmed that the resident's activity needs and preferences were not being met according to her care plan and facility policy.
Failure to Monitor Kidney Function Following Dietician Recommendation
Penalty
Summary
The facility failed to provide the recommended laboratory monitoring for a resident with chronic kidney disease who was receiving high protein supplementation. The resident had diagnoses including a left femur fracture, mild cognitive impairment, and stage 3b chronic kidney disease, and was noted to have developed stage 2 and 3 pressure ulcers after admission. Laboratory results from an earlier date showed significantly elevated blood urea nitrogen and creatinine levels. The registered dietician assessed the resident and recommended monitoring kidney function due to the increased protein intake, which exceeded 107 grams per day with supplementation. Despite the dietician's recommendation, there was no evidence that the medical provider (MD or NP) was informed of the increased protein supplementation or the need for closer kidney function monitoring. The dietician was also unaware of the available laboratory results in the medical record, and the nurse practitioner would not have ordered new labs until six months after the previous results. Facility policy required communication of dietician recommendations to other departments for follow-up, but this did not occur, resulting in a lack of appropriate monitoring for the resident's kidney function.
Failure to Properly Label and Store Medications
Penalty
Summary
During a medication storage observation, a medication cart was found to contain an opened and undated bottle of dorzolamide eye drops with no resident identifiers, an unsealed and unlabeled package of petrolatum gauze dressing, and an open and undated bottle of lactulose. The Qualified Medication Aide (QMA) present confirmed that the eye drops should have been labeled and dated, the lactulose should have been dated, and the gauze dressing should have been sealed and labeled. The facility's policy requires all medications to be stored in containers with pharmacy labels, and for opened medications to be dated and labeled accordingly. These findings indicate that the facility failed to ensure medications and biologicals were properly labeled, dated, and stored as per policy and professional standards.
Failure to Follow Infection Control Practices During Skin Treatment and Blood Glucose Monitoring
Penalty
Summary
A deficiency was identified when a nurse failed to follow proper infection control practices during a skin treatment for a resident. The nurse removed a dressing from the resident's inner left gluteal cleft, changed gloves, and applied wound gel and a new dressing. However, the nurse did not perform hand hygiene after removing the old dressing and after removing gloves, as confirmed during an interview. The nurse also assisted with repositioning the resident and applied skin prep to other areas without appropriate hand hygiene between tasks. In a separate incident, another nurse failed to use a barrier when obtaining a blood glucose sample for a resident. The nurse disinfected her hands, donned personal protective equipment, and placed the glucometer directly on the bedside table without a barrier. After obtaining the blood sample, the glucometer was again placed on the table without any protective barrier. The nurse acknowledged during an interview that a barrier should have been used.
Improper Food Storage and Labeling in Resident Nourishment Refrigerators
Penalty
Summary
The facility failed to ensure that food brought in by outside sources and placed in resident nourishment refrigerators was stored in accordance with professional standards for food safety. During an observation, the Boulevard unit pantry had an opened container with five slices of cheesecake, an opened package of milk chocolate morsels, and three full containers of Culver's ice cream in the refrigerator without a label. Additionally, the Windsor unit pantry had a large blue ice pack in the freezer compartment, which was used for a resident and should not have been stored there. The Heritage unit freezer also had three ice packs and bags of frozen green beans, with the large blue ice pack placed directly on top of one of the bags of green beans. The Dietary Manager confirmed that all food should be labeled with a date and the resident's name, and that ice packs used for residents should not be in the pantry refrigerators on the units. The Dietary Manager indicated that there was no policy on the storage of residents' ice packs in the nourishment freezers. The facility's policy titled 'Resident Food From Outside Source,' dated 11/28/2023, stated that items for a resident must be labeled with the name, room number, and date the food was brought into the facility. This deficiency had the potential to affect all 67 residents residing on the units, as the improper storage of food and ice packs could lead to food safety issues. The observations and interviews revealed a lack of adherence to the facility's food storage policies and professional standards for food safety.
Failure to Provide Adequate ADL Assistance
Penalty
Summary
The facility failed to provide adequate activities of daily living (ADL) assistance for a resident, specifically in relation to shaving and nail care. During multiple observations, the resident was noted to have long facial hair and long fingernails with a brown/black substance underneath them. The resident expressed a preference for not having a beard and indicated that his wife had requested for him to be shaved. Despite this, the resident's beard was only partially shaved by his wife, and his fingernails remained untrimmed with debris underneath them. The resident's medical records indicated that he had moderate cognitive impairment and required partial to moderate assistance for grooming and personal hygiene. The care plan also specified that the resident needed maximum assistance with dressing, grooming, and bathing. However, the documentation showed inconsistencies in the provision of these services, with no record of shaving or nail care on certain shower days. Interviews with staff revealed that male residents were typically shaved on their scheduled shower days or upon request, and nails were evaluated for trimming on shower days. However, the shower sheets reviewed did not consistently document the provision of these services. Additionally, it was noted that CNAs were not permitted to trim the nails of diabetic residents, and the responsibility fell to the nurses, who were to be informed by the CNAs if nail care was needed. The facility's policies on morning care and diabetic nail care were reviewed, indicating that residents should be assisted with shaving and have their nails inspected weekly. Despite these policies, the resident's grooming needs were not adequately met, leading to the observed deficiencies.
Failure to Provide Appropriate Care and Follow Physician Orders
Penalty
Summary
The facility failed to provide appropriate care for a central venous catheter for one resident and did not follow physician orders for another resident with skin conditions. For Resident 234, the central venous catheter dressing was observed to be dated 4/19 and was not adhered to the skin in the 6 o'clock position, despite a physician order to change the dressing every 7 days. The LPN indicated that the dressing was not changed on 4/25 as required because the facility did not have a new bio-patch in stock. This was confirmed during an observation on 5/2, where the dressing was still dated 4/19 and not properly adhered. The facility's policy required dressing changes every 7 days or when the integrity of the dressing was compromised, which was not followed in this case. For Resident 236, who had diagnoses including cellulitis, chronic venous hypertension with ulcer, peripheral vascular disease, and lymphedema, the physician ordered a single tubigrip to be applied to the left lower extremity daily. However, during multiple observations, the left lower extremity was found bare and swollen, indicating that the tubigrip was not applied as ordered. The RN confirmed that the tubigrip was supposed to be placed in the morning and removed in the evening, but the resident indicated it had not been placed all day. The facility's policy required that physician orders be transcribed and maintained to ensure safety, which was not adhered to in this instance.
Failure to Properly Store and Clean Respiratory Equipment
Penalty
Summary
The facility failed to ensure proper storage and cleaning of respiratory equipment for two residents. Resident 42's CPAP machine, tubing, and mask were observed uncovered and uncleaned on multiple occasions. Despite a physician's order to disinfect the equipment monthly, the task was not completed as documented. Interviews with staff revealed confusion about responsibilities for cleaning the equipment, with both QMAs and LPNs indicating it was not their duty to clean the CPAP equipment for Resident 42. Similarly, Resident 62's nebulizer machine and mask were found uncovered and not properly stored. The resident reported that the equipment was rinsed every other day, but it was not placed in a plastic bag as required. Staff interviews indicated inconsistent practices in cleaning and storing the nebulizer equipment. The facility's policies for CPAP and nebulizer care were not followed, leading to the observed deficiencies.
Failure to Act on Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure pharmacy recommendations were communicated to the physician for review in a timely manner for one resident. Resident 47, who had diagnoses including overactive bladder, allergies, and insomnia, was prescribed Loratadine, Myrbetriq, and Melatonin. Pharmacy recommendations to reduce the dosages of these medications were made on three separate occasions but were not acted upon promptly. Specifically, recommendations to reduce Loratadine to every other day, Myrbetriq to 25mg daily, and Melatonin to 5mg at bedtime were not documented as being addressed in a timely manner. During an interview, the Director of Nursing (DON) indicated that the new pharmacy representative was using a different communication portal, which she was unaware of, leading to the delay in addressing the recommendations. The facility's policy on responding to pharmacist recommendations, which includes monitoring for physician response and resubmitting recommendations within specified timeframes, was not followed. This lapse resulted in the failure to ensure the resident's drug regimen was free from unnecessary medications.
Unattended Medication Cart with Keys Left in Drawer
Penalty
Summary
The facility failed to ensure medications were kept in a locked cart when unattended. During an observation, the medication cart for Windsor Hall was found with the keys in the drawer and no licensed nursing staff in sight. The nurse left the cart unattended for approximately 8 minutes. In an interview, the RN indicated she left the cart to respond to a call for help and forgot to take the keys with her. The Director of Nursing confirmed that the cart should have been locked and the keys taken by the nurse. The facility's policy on the storage of medications, dated 4/24/19, states that medications should be stored securely and only accessible to authorized personnel.
Failure to Update and Clarify Advanced Directive Status
Penalty
Summary
The facility failed to keep physician orders current with a resident's advanced directive instructions. Resident B, who was cognitively intact and receiving hospice services, had multiple advanced directive forms with conflicting instructions. An Out of Hospital Do Not Resuscitate (DNR) was signed by the Medical Director on 2/9/2024. A POST form dated 3/13/2024 indicated Do Not Attempt Resuscitation, comfort measures, use of antibiotics for infection only, and no artificial nutrition, signed by Resident B and the facility Nurse Practitioner. However, another POST form dated 3/15/2024 indicated Cardiopulmonary Resuscitation (CPR) to be provided, comfort measures, use of antibiotics for infection only, and no artificial nutrition, signed by Resident B and the hospice Medical Director. Despite these conflicting directives, a physician's order dated 2/17/2024 indicated Do Not Resuscitate, and the care plan dated 2/8/2024 also indicated no resuscitation. During an interview, an LPN indicated that if Resident B's heart stopped beating or she stopped breathing, she would follow the advanced directives and keep Resident B comfortable, believing Resident B had a DNR order. The facility's policy on advanced directives stated that any changes in the resident's preferences should be reflected in the medical record documentation. The failure to update and clarify the advanced directive status led to the deficiency, as the facility did not ensure that the physician orders were consistent with Resident B's current advanced directive instructions.
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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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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