Munster Med-inn
Inspection history, citations, penalties and survey trends for this long-term care facility in Munster, Indiana.
- Location
- 7935 Calumet Ave, Munster, Indiana 46321
- CMS Provider Number
- 155131
- Inspections on file
- 35
- Latest survey
- January 28, 2026
- Citations (last 12 mo.)
- 44 (2 serious)
Citation history
Health deficiencies cited at Munster Med-inn during CMS and state inspections, most recent first.
A facility failed to prevent resident-to-resident abuse when a resident with vascular dementia, psychotic and delusional disorders, and a documented history of escalating aggressive behaviors, including yelling, spitting, and threatening outbursts, remained roomed with a cognitively impaired, dependent roommate. Despite repeated episodes of the aggressive resident yelling at his roommate and one documented incident where he was found standing over the roommate while yelling, staff only administered PRN anxiolytics and returned him to bed, without implementing additional interventions, separating the residents, or reporting the behavior to leadership as required by behavior management and abuse policies. Later, an unwitnessed physical altercation occurred in their shared memory care room, after staff had heard yelling but did not assess the situation, and the dependent resident was found with facial bruising, a bloody nose, swelling, and was diagnosed with a depressed maxillary fracture and associated hemorrhage.
Staff failed to report escalating verbal and threatening behaviors by a resident with dementia and psychiatric diagnoses toward his roommate to administration or key clinical leaders, despite documentation of repeated yelling episodes and an incident where the resident was found standing and hovering over the roommate while yelling and was treated with PRN lorazepam. The resident’s care plan and the facility’s behavior management policy required monitoring, documentation, reporting of disruptive behaviors, and separation from others when necessary, but no new interventions were implemented and both residents remained in the same room. Subsequently, the two residents were involved in a physical altercation that resulted in one resident sustaining a fractured jaw and associated hemorrhage.
The deficiency involves multiple residents for whom staff did not follow physician orders or facility protocols. A resident with dementia and stroke history sustained skin tears, but ordered daily wound care was not completed and no wound assessment was documented as required. A resident with diabetes and CHF developed hypoglycemia; staff obtained a low blood sugar and applied oxygen, but did not document notifying the physician or attempting glucose interventions before calling 911 and transferring the resident. An LPN withheld ordered antihypertensive medications from a resident based on a low diastolic BP despite no hold parameters in the orders. Another resident with diabetes and ischemic cardiomyopathy had multiple blank MAR entries for scheduled insulin and sliding-scale insulin, and repeated held doses of Entresto and metoprolol without any documented physician parameters or orders to justify holding these medications.
Two residents did not receive ordered pressure ulcer prevention and treatment interventions. For one resident with a sacral pressure ulcer, a wound nurse cleansed the wound and applied a hydrocolloid dressing but omitted the ordered skin prep to the surrounding skin. For another resident with a sacral/buttocks pressure ulcer and significant mobility impairment, staff left the resident in bed with heels resting on the mattress, without boots or a pillow to offload the heels, despite a physician order requiring heel suspension or offloading while in bed.
A resident with cancer-related pain, chronic pain syndrome, arthritis, and a stage 3 pressure ulcer had a physician’s order for a fentanyl 50 mcg/hr transdermal patch to be applied every 72 hours, but the patch was not administered on multiple scheduled occasions. MAR entries documented that the medication was unavailable, that a prescription refill was needed, or that there was no script, and the DON later acknowledged that although a new prescription had been obtained, the pharmacy did not receive it. This resulted in repeated failures to provide the ordered opioid pain medication as specified in the resident’s pain care plan.
CNAs and QMAs performed and documented wound care for residents with advanced pressure ulcers, despite facility policy and state guidelines restricting these tasks to licensed nursing staff. Residents with complex medical conditions were affected, and the DON confirmed that only minor skin treatments are permitted for QMAs, while CNAs are not allowed to remove dressings.
Surveyors found that a resident received blood pressure medications despite physician orders to hold them for low pulse, and two residents did not receive wound and skin treatments as ordered, with outdated or incorrect dressings observed and incomplete documentation of care. The DON confirmed that treatments and medication administration did not follow physician instructions.
Three residents with pressure ulcers did not receive wound care as ordered by their physicians, including missed or incorrect treatments, use of outdated bandages, and lack of documentation. Wound care staff were sometimes unaware of updated orders, and treatments were not consistently performed or documented, as confirmed by the DON.
During wound care for three residents, a nurse failed to consistently perform hand hygiene before and after glove removal and did not always wear required PPE, such as gowns, when providing care under enhanced barrier precautions. These lapses occurred despite facility policy and were confirmed by both observation and staff interviews.
A resident at high risk for falls, requiring total assistance for bed mobility, fell and fractured their left femur due to inadequate supervision. While being repositioned, the resident was left with only one staff member when the other went to get towels. The resident began to slide off the bed, and the CNA, unfamiliar with the resident, had to run around the bed to assist, resulting in the resident being eased to the floor. The facility did not provide a relevant policy before the surveyors' exit.
A resident suffered a femur fracture after falling from a mechanical lift due to uninspected sling straps. Additionally, hot water temperatures exceeded safe levels on two floors, with temperatures reaching up to 137°F. The facility lacked adequate procedures for equipment inspection and environmental safety.
The facility's main kitchen was found to be in poor sanitary condition, with dirty ovens, food preparation areas, and transportation carts. Improper food handling practices were observed, including the use of the same gloves for multiple tasks and stacking wet dishes. The Food Service Manager and Administrator acknowledged these issues, which had the potential to affect nearly all residents.
The facility failed to conduct and document care planning conferences for several residents, including those with cognitive impairments. Some residents and their families were not invited to these meetings, and care plans were not updated to reflect current preferences, such as wearing a hospital gown. Staff interviews revealed a lack of awareness and follow-up on the necessity of holding these meetings.
The facility failed to provide adequate ADL care for four residents, resulting in long and dirty fingernails and untrimmed facial hair. Despite documentation indicating nail care was provided, observations confirmed the residents' complaints. Interviews revealed that staff were unaware of the residents' conditions, and the Unit Manager clarified that the activity department was not responsible for nail care. The DON acknowledged that grooming should have been performed.
The facility failed to properly prepare pureed diets for residents, affecting 10 residents who required such diets. A dietary staff member prepared pureed bread and baked chicken without following the provided recipes, while the Food Service Manager did not intervene. The Administrator noted the dietary cook was new and should have been guided by the dietary manager.
The facility was found to have multiple cleanliness and maintenance issues, including dirty floors, toilets, and tube feeding poles, as well as overflowing garbage cans and debris in light fixtures across several floors. Family members reported persistent odors and unclean conditions, with some cleaning rooms themselves. The kitchen also had significant cleanliness issues, with dirty floors and walls. These deficiencies were noted during an Environmental Tour and a Kitchen Sanitation Tour.
The facility failed to maintain the dignity of three residents by allowing them to be exposed and inadequately dressed during the day. A resident was seen in a wheelchair wearing only a shirt and brief, visible from the hallway, without a care plan addressing this. Another resident was observed in bed with minimal clothing and no privacy curtain, despite a care plan indicating this preference. A third resident wore a hospital gown without a care plan, although dependent on staff for dressing. The facility lacked appropriate care plans to ensure resident dignity.
A facility failed to create a comprehensive care plan for a resident receiving anti-anxiety medication for agitation and aggressive behavior. Despite the resident's mild cognitive impairment and use of ABH gel as prescribed, there was no specific care plan addressing these issues. The DON confirmed the absence of a care plan for the anti-anxiety medication, although other related care plans existed.
The facility failed to assess and monitor non-pressure skin injuries for three residents, leading to deficiencies in care. A resident had a bruise on his hand without a care plan, another had an open jaw wound with no plan for his behavior of removing dressings, and a third had a bruise on her arm that was not documented despite being on anticoagulant therapy. These issues were only addressed after being observed by staff.
A resident with a history of COPD and dependence on oxygen developed pressure ulcers behind the ears and on the nose due to tight oxygen tubing without protective padding. The facility failed to implement preventative measures despite a care plan indicating the potential for pressure ulcers. The resident reported pain, and the ulcers were not identified until observed by staff, highlighting a lapse in monitoring and communication.
A resident with multiple health issues, including hemiplegia and dysphagia, did not receive tube feeding at the correct times as per physician's orders. The feeding was observed running with a bottle from the previous day, despite a new bottle being available. The QMA confirmed the new feeding was started later than scheduled. The DON acknowledged the issue without further comment.
A facility failed to maintain the correct oxygen flow rate for a resident with COPD and other conditions, as prescribed by the physician. The resident was observed multiple times with the oxygen concentrator set below the required 4 liters per minute, despite the care plan indicating the need for continuous oxygen therapy. The Assistant DON suggested the resident might have been adjusting the flow rate themselves.
The facility failed to maintain accurate clinical records for two residents. A resident received ABH gel without documented strength or dosage, while another resident, who was NPO, had oral medications documented as administered. The DON acknowledged these discrepancies.
A facility failed to implement updated wound care orders for a resident with stage 3 and stage 4 pressure ulcers. Despite a care plan and physician's orders, there was no documentation of the updated treatment being carried out. The Director of Nursing confirmed the lack of documentation, which was contrary to the facility's policy on pressure ulcer care.
A facility failed to implement a Registered Dietician's (RD) recommendations for a resident with a gastrostomy tube. The resident, who had dysphagia and aphasia, experienced weight loss and had a recent amputation. Despite the RD's recommendation to increase the feeding rate, there was no documentation of action taken until a new physician's order was issued. The Director of Nursing indicated that recommendations should be implemented within 72 hours, but the facility's policy allowed for five working days, leading to a deficiency.
Failure to Prevent Resident-to-Resident Abuse Resulting in Facial Fracture
Penalty
Summary
The deficiency involves the facility’s failure to implement measures to prevent resident-to-resident verbal and physical abuse involving a cognitively impaired, dependent resident and his roommate, who had a documented history of behavioral disturbances. Resident B had multiple diagnoses including vascular dementia with behaviors, delusional disorder, psychotic disorder with delusions, intellectual disabilities, anxiety, chronic kidney disease, and a prior traumatic subdural hemorrhage. Behavior documentation over several months showed repeated episodes of verbal aggression, physical aggression toward staff, spitting on staff, yelling aggressive words in common areas, and making outbursts about killing. The Annual MDS documented that his behaviors significantly interfered with care and activities and posed a significant risk of physical injury and disruption of the living environment, and that his behaviors had worsened since the prior assessment. Despite this history, the care plan only identified verbal behavioral symptoms not directed toward others and included an approach to separate the resident from others as needed, without updating or expanding interventions in response to escalating behaviors. Behavior notes and medication administration records showed that Resident B repeatedly yelled at his roommate on multiple occasions, with PRN lorazepam administered for agitation and anxiety, but there was no documentation of additional non-pharmacological interventions or environmental changes. On one occasion, staff documented that Resident B was standing up, hovering over his roommate while yelling; staff assisted him back to bed and gave PRN lorazepam, but did not implement further interventions, did not move him to another room, and did not report this incident up the chain of command. The Memory Care Director, DON, and Nurse Consultant later indicated they were unaware of this event, even though facility policy required staff to report new or worsening behaviors and to document and address disruptive behaviors. Subsequently, Resident B and his cognitively impaired roommate, Resident C, who had dementia, anxiety, and Alzheimer’s disease and required substantial to maximal assistance with ADLs, were involved in an unwitnessed physical altercation in their shared memory care room. Staff discovered the incident when a CNA doing rounds found Resident B with blood on his clothing and Resident C with blood around his nose and redness and discoloration to the side of his face. Facility documentation and a police report indicated that Resident C was found in bed with a bloody face, multiple bruises, and swelling to the face and mouth area, and that he was initially unable to articulate what had happened. Hospital imaging later confirmed a depressed fracture of the anterior wall of the left maxilla with associated hemorrhage. Interviews revealed that the CNA assigned to the residents had heard yelling from Resident B earlier but did not check on him, believing nurses in the hallway would respond, and that the LPN on duty heard Resident B yell but did not assess him. Key leadership staff, including the DON and Memory Care Director, confirmed they had not been informed of the earlier hovering/yelling incident, despite existing behavior and abuse policies requiring reporting and intervention when behaviors were disruptive or potentially abusive. The facility’s own policies on behavior management and abuse prevention required staff who witnessed behaviors to report them to the resident’s care staff, document them, and, when disruptive to others, temporarily separate the resident from others. Policies also required that any incident or allegation involving abuse or neglect be investigated and reported to the Administrator within specified time frames. In this case, after the documented incident of Resident B hovering over and yelling at his roommate, there was no evidence that staff escalated the concern, updated the care plan, implemented separation or other protective measures, or ensured that leadership responsible for behavior oversight was informed. This lack of action and failure to follow policy allowed a resident with known, worsening aggressive behaviors to remain in the same room with a cognitively impaired, dependent roommate, culminating in a physical altercation in which Resident C sustained facial bruising, a bloody nose, swelling, and a fractured facial bone.
Removal Plan
- Implemented a plan of correction and held a quality assurance meeting with department heads
- Inserviced all staff on the different types of abuse and reporting abuse
- Inserviced staff on the behavior management program for residents with new or worsening behaviors, including when and who to report those behaviors to
- Separated the residents and moved Resident B to a private room on a different floor
Failure to Report and Intervene on Escalating Resident Behaviors Leading to Resident-to-Resident Injury
Penalty
Summary
Facility staff failed to report resident-to-resident verbal abuse and escalating behaviors by a resident with known behavioral issues (Resident B) toward his roommate (Resident C) to administration or appropriate supervisory staff. Resident B had multiple diagnoses including vascular dementia with behaviors, delusional and psychotic disorders, anxiety, and intellectual disabilities, and his most recent Annual MDS showed physical, verbal, and other behaviors that significantly interfered with care and activities and posed significant risk of physical injury and disruption to others. His care plan called for monitoring and documenting target behaviors such as violence or aggression toward others and separating him from others as needed when behaviors were disruptive. In early December, medication administration notes documented that Resident B was yelling at his roommate on at least two occasions and was given PRN lorazepam for agitation and anxiety. On 12/11/25, a behavior note documented that staff heard Resident B yelling, found him standing and hovering over Resident C while yelling, and assisted him back to bed, again administering PRN lorazepam. Despite this, there were no new interventions implemented, no change in room assignment, and no documented notifications to the DON, Administrator, charge nurse, Memory Care Director, or other responsible leadership regarding these behaviors. Staff later reported that Resident B “yelled all the time” and that the nurse on duty did not report the incident of hovering over the roommate to anyone, and key staff including the Memory Care Director, Nurse Consultant, and primary day-shift RN were unaware of the 12/11/25 incident. Both residents remained in the same room, and on 12/28/25 an incident note documented that Resident B and Resident C were involved in a physical altercation. The residents were separated and assessed; Resident B had no injuries, but Resident C was sent to the hospital and diagnosed with a depressed fracture of the anterior wall of the left maxilla with associated maxillary hemorrhage. The facility’s behavior management policy in effect at the time required staff who witnessed behaviors to report them to the resident’s care staff and document accordingly, and to temporarily separate residents if behaviors were disruptive to others. The failure to report and act on the earlier verbal and threatening behaviors, including the hovering and yelling over the roommate, led to a lack of interventions to prevent the later physical altercation that caused injury.
Removal Plan
- Implemented a plan of correction and held a quality assurance meeting with department heads
- Inserviced all staff on the different types of abuse and reporting abuse
- Inserviced staff on the behavior management program for residents with new or worsening behaviors, including when and who to report those behaviors
Failure to Follow Treatment Orders, Hypoglycemia Protocol, and Medication Parameters
Penalty
Summary
The deficiency involves multiple failures to provide treatment and care according to physician orders and facility policy for several residents. For one resident with dementia, stroke history, and ADL self-care deficits, physician orders required the use of geri-sleeves on arms and legs to prevent skin tears and, after an incident in which the resident struck her arm on a bed rail and sustained two skin tears and an abrasion, daily wound care with normal saline, Xeroform, dry gauze, and kerlix until healed. Although incident and wound care notes documented the new skin condition and that wound care was to complete the treatment, the treatment administration record showed the ordered arm treatment coded as “9 (see nurse’s notes)” on two days, indicating it was not completed by the nurse, and there was no wound assessment documented in the wound round section as required by facility policy. Another deficiency occurred when a resident with diabetes and congestive heart failure experienced hypoglycemia. An alert note documented that the resident was found clammy and not his normal self, oxygen was applied, and a blood sugar of 47 mg/dl was obtained, after which 911 was called and the resident was transferred to the hospital with a diagnosis of hypoglycemia. The record did not show that the physician was notified or that any hypoglycemia interventions, such as providing carbohydrates or administering glucagon, were attempted prior to transfer, despite the facility’s hypoglycemia protocol directing staff to give glucose if the resident is conscious and to contact the physician when blood sugar is below 60 unless specific call parameters exist. Additional deficiencies involved medication administration and holding medications without physician parameters. During a medication pass, an LPN withheld ordered metoprolol and amlodipine for a resident with chronic respiratory failure, diabetes, breast cancer, blindness, and congestive heart failure because the diastolic blood pressure was below 60, even though there were no physician-ordered blood pressure parameters to hold these medications. For another resident with hemiplegia after stroke, diabetes, and ischemic cardiomyopathy, the medication administration record showed multiple blank entries for scheduled Lantus insulin and Humalog sliding scale doses with no notes or orders explaining the omissions, and repeated held doses of Entresto and metoprolol without any physician orders or parameters authorizing these holds, despite care plans directing that insulin and cardiac medications be administered as ordered.
Failure to Follow Pressure Ulcer Treatment Orders and Heel Offloading Interventions
Penalty
Summary
The deficiency involves failure to follow ordered pressure ulcer treatment for one resident and failure to implement ordered heel offloading interventions for another resident. For one resident with diagnoses including a left humerus fracture and cellulitis of the left lower extremity, surveyors observed wound care to a small sacral pressure ulcer measuring approximately 0.5 cm. The physician’s order directed staff to cleanse the sacrum with normal saline and/or wound cleanser, apply skin prep to the surrounding skin, and cover with a hydrocolloid dressing. During the observed dressing change, the wound nurse cleansed the area with normal saline, patted it dry, and applied a hydrocolloid dressing, but did not apply the ordered skin prep. In a subsequent interview, the wound nurse confirmed that she had not applied the skin prep as ordered. The deficiency also includes failure to ensure heel offloading for another resident with a sacral/buttocks pressure ulcer and diagnoses including multiple sclerosis, cerebral infarction, and peripheral vascular disease. This resident was observed in bed on two occasions with a standard mattress and padded overlay, but without any pillow or padded boots in place to offload the heels; the resident’s feet were resting directly on the mattress. The resident’s MDS indicated cognitive intactness, bilateral range of motion impairment, and dependence for toileting and transfers. A physician’s order directed that the resident’s heels be suspended or offloaded while in bed. During an interview, the Unit 2 Manager acknowledged that the resident’s heels were not offloaded, stating that the resident did not like to wear the boots but that there should have been a pillow in place for offloading.
Failure to Provide Ordered Fentanyl Patch for Pain Management
Penalty
Summary
The facility failed to ensure that a scheduled opioid pain medication was available and administered as ordered for a resident with significant pain-related conditions. The resident, who was cognitively intact, had diagnoses including diabetes mellitus, repeated falls, unspecified protein calorie malnutrition, and a stage 3 pressure ulcer, and had a pain care plan indicating use of pain medication for cancer of the left breast, chronic pain syndrome, and arthritis, with interventions to administer analgesics as ordered. A physician’s order directed that a fentanyl 50 mcg/hr transdermal patch be applied every 72 hours for pain, but the Medication Administration Records for November and December showed that the fentanyl patch was not administered on multiple scheduled dates, with Order Administration notes documenting that the medication was unavailable, a prescription refill was needed, or there was no script, despite indications that a new prescription had been obtained but not received by the pharmacy. During interview, the DON stated that the Nurse Practitioner should have been notified and a prescription obtained, and acknowledged that although a new prescription was received, the pharmacy did not receive it, resulting in missed doses of the ordered fentanyl patch.
Unqualified Staff Performed Pressure Ulcer Wound Care
Penalty
Summary
The facility failed to maintain professional standards of quality in the care of residents with pressure ulcers. Certified Nursing Assistants (CNAs) were observed removing dressings from pressure ulcers, a task outside their scope of practice, as confirmed by both the Director of Nursing and the Indiana Nurse Aide Curriculum. In one instance, a CNA removed a soiled dressing from a resident's sacral wound prior to wound care being performed by the Wound Nurse, despite facility policy and state guidelines prohibiting CNAs from performing such actions. Additionally, Qualified Medication Aides (QMAs) were documented as having signed out and, according to interviews and records, performed wound care treatments for residents with stage 3 and stage 4 pressure ulcers. Physician orders specified detailed wound care regimens for multiple residents, but the Treatment Administration Records (TARs) showed that QMAs completed and documented these treatments on several occasions. The DON confirmed that QMAs are not permitted to perform pressure ulcer treatments, and facility policy only allows QMAs to perform minor skin treatments, such as those for stage 1 pressure ulcers. The residents involved had significant medical histories, including diagnoses such as osteomyelitis, vascular dementia, major depressive disorder, bone cancer, and diabetes, and were dependent on staff for care. The deficiencies were identified through observation, record review, and interviews, including a family member's report of witnessing QMAs performing pressure ulcer treatments. These findings demonstrate that unqualified staff performed wound care tasks, contrary to professional standards and facility policy.
Failure to Follow Physician Orders for Medication and Wound Care
Penalty
Summary
Surveyors identified that a resident with heart failure and hypertension received blood pressure medications, Coreg and Hydralazine, despite physician orders specifying these medications should be held if the resident's pulse was below 60. The Medication Administration Record showed that the medications were administered on multiple occasions when the resident's pulse was under the specified threshold. The Director of Nursing confirmed that the medications should have been withheld according to the orders. In another instance, a resident with multiple diagnoses, including bone cancer and diabetes, was observed with undated and soiled bandages on his feet and hip, with visible dried and fresh drainage. The resident's skin was noted to be very dry and scaly, and the Wound Nurse was unaware of any cream ordered for the dry skin, despite a physician's order for Aquaphor ointment. Review of the Treatment Administration Record revealed that a prescribed wound treatment for the left hip was not documented as completed for one evening shift, although the Aquaphor application was signed out as completed. Additionally, a third resident with vascular dementia and multiple pressure ulcers was found with outdated and incorrect wound dressings on the left knee and hand. The Wound Nurse discovered that the foam dressing in place was not the oil emulsion bandage ordered by the physician, and the bandages were not dated. The Treatment Administration Record indicated that treatments were signed out as completed, but the actual dressings in place did not match the physician's orders. The Director of Nursing acknowledged that wound and skin treatments should be performed as ordered.
Failure to Complete Pressure Ulcer Treatments as Ordered
Penalty
Summary
The facility failed to ensure that pressure ulcer treatments were completed as ordered for three residents with pressure ulcers. For one resident with a history of osteomyelitis and stage 4 sacral pressure ulcer, the wound nurse was observed using Dakin's solution instead of the physician-ordered Anasept for wound care, and the treatment administration record (TAR) showed missed documentation of treatments on several days. The wound nurse also did not follow the correct treatment protocol for the resident's right ankle, and the director of nursing confirmed that the treatments should have been completed as ordered. Another resident, who was dependent on staff for bed mobility and had multiple comorbidities including bone cancer and diabetes, was observed with undated and soiled bandages on his left hip and both feet. The left heel bandage, which should have been changed according to updated physician orders, was found to be old, with dried blood and necrotic tissue present. The wound nurse could not verify if the bandage had been changed since the order update, and indicated that wound care was not consistently performed on weekends. The director of nursing acknowledged that wound and skin treatments should be done as ordered. A third resident with vascular dementia and multiple pressure ulcers was observed with outdated bandages and received incorrect wound care. The wound nurse was unaware of a recent change in the treatment order for the right medial distal foot and did not apply the newly ordered Mupirocin ointment. The TAR indicated that treatments were signed out as completed on days when the correct treatment was not provided. The director of nursing confirmed that treatments should be administered as ordered by the physician.
Failure to Follow Hand Hygiene and PPE Protocols During Wound Care
Penalty
Summary
The facility failed to implement and follow infection prevention and control guidelines during wound care for three residents. Observations revealed that the Wound Nurse did not consistently perform hand hygiene before and after glove removal, as required by facility policy. For example, during wound care for one resident, the nurse donned gloves without sanitizing or washing her hands, changed gloves multiple times without hand hygiene, and at times failed to wear a gown when enhanced barrier precautions were indicated. Supplies were also retrieved from outside the room without appropriate hand hygiene upon re-entry. In another instance, the Wound Nurse washed her hands and donned PPE at the start of wound care for a different resident but repeatedly changed gloves without performing hand hygiene between glove changes. The nurse was observed to be unaware of the requirement to perform hand hygiene every time gloves were removed, as confirmed during an interview. The Director of Nursing confirmed that hand hygiene should be performed before and after glove removal, in accordance with facility policy. A third resident's wound care was also observed with similar lapses. The Wound Nurse performed hand hygiene at the start and at certain points but failed to do so consistently between glove changes throughout the treatment of multiple wounds. The facility's hand hygiene policy, provided by the Director of Nursing, clearly stated that hand hygiene is required before and after glove removal, but this was not followed during the observed wound care procedures.
Inadequate Supervision Leads to Resident Fall and Fracture
Penalty
Summary
The facility failed to provide adequate supervision and assistance to a dependent resident, resulting in a fall and a left femur fracture. Resident B, who required total assistance for bed mobility, was being repositioned by only one staff member when the incident occurred. The resident had a history of falls and was at high risk, as indicated by a Fall Risk Evaluation and a Care Plan that noted the need for staff to anticipate and meet the resident's needs. During the incident, two staff members, a CNA and a QMA, were initially present to provide care. However, the QMA left the room to get more towels, leaving the CNA alone with the resident. The resident, who was on an air mattress, began to slide off the bed. The CNA, who was not familiar with the resident, attempted to assist but was on the opposite side of the bed and had to run around to help ease the resident to the floor. The resident was found sitting on the floor with complaints of knee pain and was later diagnosed with an acute fracture of the left femur. Interviews with staff revealed that the CNA was a float CNA and not familiar with the resident's care needs, which required care in pairs. The Director of Nursing confirmed that the CNA should have moved to the resident's side of the bed when the QMA left the room. The facility did not provide a policy related to the incident prior to the exit of the surveyors.
Deficiencies in Equipment Safety and Environmental Conditions
Penalty
Summary
The facility failed to ensure the safety of mechanical lift straps before transferring a dependent resident, resulting in a significant accident. During a transfer, the sling straps of a mechanical lift broke, causing a resident to fall and sustain a left femur fracture. The resident, who was cognitively impaired and dependent on staff for mobility, had a care plan indicating a risk for falls. However, there was no documentation that the mechanical lift sling straps were checked for damage prior to the transfer, and the facility's investigation revealed that the straps were not inspected before use. Additionally, the facility did not maintain safe hot water temperatures on two of its floors. Observations revealed that the water temperature in several rooms exceeded 120 degrees Fahrenheit, reaching as high as 137 degrees. The Maintenance Supervisor acknowledged that the water was hotter on the upper floors due to the boiler's location and admitted to checking the water temperatures daily. However, the thermostats were set incorrectly, leading to dangerously high water temperatures. The facility's policies and procedures were insufficient in ensuring the safety of residents, as evidenced by the lack of specific guidelines for inspecting mechanical lift slings and maintaining appropriate water temperatures. The failure to properly inspect equipment and regulate environmental conditions contributed to the incidents, highlighting deficiencies in the facility's safety protocols.
Kitchen Sanitation and Food Handling Deficiencies
Penalty
Summary
The facility failed to maintain cleanliness and proper sanitation in the main kitchen, which had the potential to affect 154 of 155 residents. During a kitchen sanitation tour, surveyors observed several issues, including dirty convection ovens with grease and burned food spillage, a scoop left inside a sugar bin, and dirty sides of food preparation and steam tables. Additionally, transportation carts were found with dried food spillage, and the freezer had significant ice buildup. Reach-in coolers were also dirty, with dusty vents. The Food Service Manager acknowledged the need for cleaning, and the Maintenance Director suggested the ice buildup might be due to improper door closure. Further observations revealed improper food handling practices. A dietary staff member used the same pair of gloves to handle various items, including bread and milk cartons, without changing them, which was observed by the Food Service Manager. Another dietary aide was seen stacking clean but wet plates and dome lids, which was against the facility's policy. The Administrator was aware of the kitchen's condition and acknowledged that the Food Service Manager should have intervened during the improper glove usage. The facility's infection control policy emphasized proper handwashing and avoiding contamination, which was not adhered to in these instances.
Failure to Conduct and Document Care Planning Conferences
Penalty
Summary
The facility failed to invite and hold care planning conferences for residents and/or their family members, and did not update care plans to reflect residents' preferences, such as wearing a hospital gown. For instance, Resident 1 was observed wearing a hospital gown during multiple observations, but the care plan was outdated and did not reflect the current preference. Interviews revealed that the care plan had not been updated in the new computer system due to time constraints. Resident 9's son reported receiving few invitations to care conferences, and the facility did not attempt to reschedule when he was unavailable. The resident's record showed no documentation of a care planning conference in the past year. Staff interviews indicated a misunderstanding that care plan meetings were not necessary if the family did not attend, even for cognitively impaired residents. Other residents, such as Residents 129, 141, 72, and 31, also lacked documentation of care planning conferences. Some residents had not had a care plan meeting since admission, and there was no evidence of invitations being extended. Staff interviews highlighted a lack of awareness and follow-up regarding the necessity of holding care plan meetings, regardless of family attendance or resident cognitive status.
Failure to Provide Adequate ADL Care for Residents
Penalty
Summary
The facility failed to provide adequate ADL care for four residents, resulting in long and dirty fingernails and untrimmed facial hair. Resident 1, who was severely impaired for daily decision-making and dependent on staff for personal hygiene, was observed multiple times with long fingernails despite documentation indicating nail care was provided. Interviews revealed that the CNA responsible had not cut the resident's fingernails, and the Unit Manager was unaware of the issue. Resident 6, who was cognitively intact but required substantial assistance with personal hygiene, reported having long and dirty fingernails and facial hair. Despite documentation of nail care being completed, observations confirmed the resident's complaints. The CNA was unaware of the resident's condition, and the Unit Manager clarified that the activity department was not responsible for nail care. Resident 129, who was cognitively intact but needed maximal assistance for personal hygiene, was observed with long and dirty fingernails and facial hair. Although nail care was documented, there was no record of shaving. The Unit Manager confirmed that nails and facial hair should be groomed as needed. Similarly, Resident 116, who was severely impaired and dependent on staff for all ADLs, was observed with long, dirty fingernails and facial hair. Despite documentation of nail care, the DON acknowledged that grooming should have been performed.
Improper Preparation of Pureed Diets
Penalty
Summary
The facility failed to properly prepare pureed diets for residents, which could potentially affect all 10 residents who required such diets. During an observation, a dietary staff member was seen preparing pureed bread without a recipe, using 27 slices of bread and 32 ounces of milk, which deviated from the recipe provided by the Food Service Manager. The recipe specified 10 slices of bread, 3 cups of milk, and 1/2 cup of melted margarine for 10 servings. The Food Service Manager was present but did not intervene during the preparation. In another instance, the same dietary staff member prepared pureed baked chicken without a recipe, using 4 cups of chicken broth for 4 cups of diced chicken, contrary to the recipe which called for 2.5 pounds of chicken and 1 cup of broth for 10 servings. The Food Service Manager again did not intervene. The facility's Administrator acknowledged that the dietary cook was new and that the dietary manager should have instructed her to follow the recipe.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a clean and well-repaired environment for residents, staff, and the public, as evidenced by multiple observations and interviews. Dirty floors, toilets, walls, tube feeding poles, ceiling vents, overflowing garbage cans, and debris in light fixtures were noted across various rooms on the 2nd, 3rd, 4th, and 5th floors. Specific instances included an overflowing garbage can with personal protective equipment in a resident's room, dried bowel movement on a toilet seat, and dirty tube feeding poles. Family members reported persistent urine odors and unclean floors, with some resorting to cleaning the rooms themselves. The Environmental Tour further revealed issues such as gouged door frames, debris in light fixtures, and stained, sticky floors. The kitchen was also found to be in poor condition, with dirty floors, walls, and piping under the dish machine. Observations during the Kitchen Sanitation Tour highlighted adhered dirt, dried food substances, and black scuff marks on the kitchen floor, as well as dried food spillage on walls and ceilings. The Food Service Manager acknowledged the need for cleaning. These deficiencies were documented in relation to Complaint IN00445179, indicating a systemic issue with cleanliness and maintenance throughout the facility.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to maintain the dignity of three residents by allowing them to be exposed from their doorways and wearing inappropriate clothing during the day. Resident 91 was observed multiple times seated in his wheelchair wearing only a shirt and an incontinence brief, visible from the hallway with the door open. Despite being moderately impaired for daily decision-making and requiring assistance for dressing, there was no care plan addressing his preference for not wearing pants. The Assistant Director of Nursing acknowledged the absence of a care plan for this resident. Resident 120 was repeatedly observed in bed wearing a t-shirt and an incontinence brief, with his legs uncovered and visible from the hallway due to the privacy curtain not being pulled. Although his care plan indicated a preference for minimal clothing, it lacked specific interventions to ensure his dignity. The Assistant Director of Nursing noted the need to update the care plan if the resident preferred the privacy curtain to be pulled. Resident 92 was found wearing a hospital gown during the day without a care plan indicating this preference, despite being dependent on staff for dressing. Interviews revealed that the Social Service was responsible for updating care plans, but no such plan existed for this resident.
Lack of Comprehensive Care Plan for Anti-Anxiety Medication
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident receiving anti-anxiety medications. Resident 139, who has diagnoses including type 2 diabetes mellitus, hypertension, and depression, was noted to be mildly cognitively impaired and was receiving anti-anxiety and antipsychotic medications as per the Quarterly Minimum Data Set (MDS) assessment. A Physician's Order indicated the resident was to receive ABH gel, a hospice medication for agitation, applied topically twice a day for agitation and aggressive behavior. The Medication Administration Record confirmed the administration of this medication. However, there was no current care plan addressing the use of anti-anxiety medication for agitation or aggressive behaviors. During an interview, the Director of Nursing acknowledged the absence of a specific care plan for the anti-anxiety medication, despite the existence of an antipsychotic medication use care plan and an asthma care plan that mentioned anxiety medication as needed.
Failure to Monitor and Document Non-Pressure Skin Injuries
Penalty
Summary
The facility failed to properly assess and monitor non-pressure skin injuries for three residents, leading to deficiencies in care. Resident 56 was observed with a reddish/purple discoloration on his left hand, but there was no care plan addressing this bruising. The Weekly Skin Observation form did not document the bruising, and it was only after an observation by the Assistant Director of Nursing that a physician's order was obtained to monitor the bruise every shift. Resident 79 had a large open area on his left upper jaw, which was not covered during multiple observations. Despite having a care plan for a scabbed area due to a history of cancer, there was no care plan addressing the resident's behavior of removing the dressing. The resident was noted to pick at the area, increasing the risk of infection, and refused to keep the dressing on, which was not addressed in a care plan until 10/16/24. Resident 6 was observed with a bruised area on her left upper arm, but there was no documentation of this in the nursing progress notes. The resident, who was on anticoagulant therapy, had a care plan to observe and report bruising, but the CNA task section showed no areas checked for over two weeks. The bruise was only assessed after it was brought to the attention of the RN and the Second Floor Unit Manager, who noted the bruise matched the height of the wheelchair armrest.
Failure to Prevent Pressure Ulcers Due to Improper Oxygen Tubing Use
Penalty
Summary
The facility failed to implement preventative measures to avoid the development of pressure ulcers in a resident, specifically behind the ears and on the left side of the nose, due to the improper use of oxygen tubing. During an observation, the resident was seen without shoes and not wearing his oxygen, and upon further inspection, dried blood was found behind both ears. The resident reported pain in these areas, which had been present for some time. The oxygen tubing was noted to be tight, causing indentations on the resident's face, and there were no padded protectors on the tubing to prevent skin breakdown. The resident's medical history includes chronic obstructive pulmonary disease, chronic respiratory failure, heart failure, heart disease, anxiety, palliative care, dependence on oxygen, and chronic pain. Despite having a care plan indicating the potential for pressure ulcers, the facility did not have an order for protective padding for the oxygen tubing. The last skin assessment did not mention any pressure ulcers, and the facility's policy required daily observation for skin breakdown, which was not effectively carried out. The wound nurse and unit manager were unaware of the pressure ulcers until they were pointed out, indicating a lapse in communication and monitoring.
Failure to Administer Tube Feeding at Correct Times
Penalty
Summary
The facility failed to ensure that enteral tube feedings were administered at the correct times for a resident who relied on a PEG tube for nutrition. On the morning of the observation, the resident's tube feeding was running at 70 ml/hr with a bottle dated from the previous day, indicating it should have been stopped at 6:00 a.m. A new bottle, dated for the current day, was present but not in use until later that morning. The Qualified Medication Aide (QMA) confirmed that she had started the new tube feeding and changed the tubing during the medication pass. The resident in question had multiple diagnoses, including hemiplegia, stroke, depression, dementia, anxiety, dysphagia, and diabetes, and was severely impaired in daily decision-making. The care plan indicated the resident was at risk for malnutrition and required tube feeding for all nutrition and hydration. Physician's orders specified the tube feeding schedule, which was not adhered to, as evidenced by the discrepancy in the feeding times. The Director of Nursing acknowledged the concern but did not provide additional information.
Failure to Maintain Correct Oxygen Flow Rate for Resident
Penalty
Summary
The facility failed to ensure that a resident's oxygen was maintained at the correct flow rate as per the physician's order. Resident 120, who has diagnoses including dementia with behavior disturbance, psychotic disorder with delusions, chronic obstructive pulmonary disease (COPD), and is oxygen dependent, was observed multiple times with the oxygen concentrator set below the prescribed 4 liters per minute. Observations on different days showed the oxygen concentrator set at 3 liters, 3 1/2 liters, and below 4 liters, which did not comply with the physician's order for continuous oxygen at 4 liters per minute. The resident's care plan, which was reviewed and dated earlier in the year, indicated the need for oxygen therapy due to conditions such as congestive heart failure (CHF), COPD, and a recent history of pneumonia. Despite this, the Assistant Director of Nursing, during an interview, mentioned that he had been checking the resident's oxygen daily and found it set at 4 liters, suggesting the possibility that the resident might have been adjusting the flow rate themselves. This inconsistency in maintaining the prescribed oxygen flow rate led to the deficiency noted in the report.
Incomplete and Inaccurate Documentation of Medication Orders
Penalty
Summary
The facility failed to ensure complete and accurate documentation of clinical records for two residents. For Resident 139, the medication order for ABH gel, a hospice medication for agitation, lacked documentation of the strength, dosage, or amount to be administered. Despite this, the Medication Administration Record (MAR) indicated that the medication was administered twice daily. The Director of Nursing confirmed that the medication label contained the necessary information, but the Physician's Order in the computer system was not updated to reflect this. For Resident 113, the facility did not update medication orders to reflect the resident's NPO (nothing by mouth) status. The resident, who was severely impaired and reliant on tube feeding, had orders for oral medications, including Xanax and Norco, which were documented as administered despite the NPO status. The Director of Nursing acknowledged the discrepancy and indicated that the orders would be changed to align with the resident's dietary restrictions.
Failure to Implement Updated Wound Care Orders
Penalty
Summary
The facility failed to ensure that a resident received the necessary treatment and services to promote healing for pressure ulcers. Resident D, who had diagnoses including heart failure, chronic obstructive pulmonary disease, and peripheral vascular disease, was discharged to the hospital with two stage 3 and two stage 4 pressure ulcers. The care plan for Resident D, dated March 26, 2024, included interventions such as administering treatments as ordered and monitoring for effectiveness. However, a physician's order dated April 11, 2024, for treating a stage 4 pressure ulcer on the right heel was not updated or implemented as required. A wound physician note from April 18, 2024, indicated the need for an additional treatment order for a daily oil emulsion, but there was no documentation of this updated order being implemented. During an interview, the Director of Nursing confirmed the absence of documentation for the updated treatment order. The facility's policy on treatment and services to prevent and heal pressure ulcers emphasized the need for necessary treatment and services consistent with professional standards to promote healing and prevent new ulcers. This deficiency was related to a specific complaint, IN00436912.
Failure to Implement RD Recommendations for Tube Feeding
Penalty
Summary
The facility failed to follow dietary recommendations for a resident with a gastrostomy tube, identified as Resident H. The resident had a history of dysphagia, presence of a gastrostomy, and aphasia, and was severely impaired in daily decision-making. The care plan required quarterly evaluations by a Registered Dietician (RD) and adjustments to the tube feeding as needed. A physician's order initially prescribed Glucerna 1.2 at 55 ml/hr for 20 hours, which was later discontinued. On 6/13/24, the RD recommended increasing the feeding rate to 65 ml/hr due to the resident's weight loss and recent above-the-knee amputation. However, there was no documentation indicating that this recommendation was addressed. Further review revealed that by 6/27/24, the RD again noted the potential benefit of increasing the feeding rate to meet the resident's nutritional needs. Despite this, the feeding rate remained unchanged until a new physician's order on 6/29/24, which implemented the RD's earlier recommendation. The Director of Nursing stated that new treatment orders or RD recommendations should be implemented within 72 hours, but the facility's policy allowed for implementation within five working days. This discrepancy in following the RD's recommendations contributed to the deficiency cited in the complaint.
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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