South Shore Health & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Gary, Indiana.
- Location
- 353 Tyler St, Gary, Indiana 46402
- CMS Provider Number
- 155530
- Inspections on file
- 34
- Latest survey
- February 17, 2026
- Citations (last 12 mo.)
- 38
Citation history
Health deficiencies cited at South Shore Health & Rehabilitation Center during CMS and state inspections, most recent first.
A resident with multiple chronic conditions, including kidney failure, heart failure, epilepsy, COPD, and diabetes, was transferred to the hospital for low hemoglobin without a documented nursing assessment or current vital signs on the SBAR at the time of transfer. Nursing notes recorded that an order was received to send the resident out for abnormal hemoglobin and that the resident was sent out, but the chart lacked documentation of the actual transfer time. Vital signs were taken earlier in the day, including post-dialysis, and another set was later documented as taken in the afternoon even though, according to the DON, the resident had already left the facility by that time. The DON acknowledged that the SBAR was incomplete and that the later vital signs were entered after the resident’s departure.
The facility did not notify physicians in a timely manner when two residents failed to receive ordered medications, including an IV antibiotic for a wound infection and an antiviral for COVID-19. In both cases, the residents' records lacked documentation of physician notification, and facility policy requiring such notification was not followed.
Three residents did not receive medications and laboratory tests as ordered, including blood pressure medications not held or given per parameters, PRN medications not administered when indicated, and required labs and potassium not completed or given. The DON confirmed that orders were not followed and clarifications were not obtained.
Two residents did not receive prescribed medications for infections and COVID-19 as ordered, including missed doses of IV antibiotics and Paxlovid, with no documentation or explanation for the omissions. Facility staff were unable to account for the missed administrations, and there was a lack of follow-up or communication regarding the errors.
An LPN entered a shared room to provide incontinence care without knocking or announcing herself, contrary to facility policy requiring staff to request permission before entry. A resident in the room was cognitively impaired, dependent for all ADLs, and had multiple complex medical conditions. The LPN admitted to forgetting to knock when questioned.
A resident with significant mobility and cognitive impairments, identified as high risk for falls, did not have required fall precautions in place, including a missing bed bolster and improperly placed fall mats. The resident suffered a fall and injury in the shower room due to a broken shower bed, with staff confirming the equipment malfunction and lack of proper monitoring.
A resident with severe cognitive impairment and multiple medical conditions did not receive scheduled pain medication on time, as documented in the MAR and reported by the resident's family. Pain medication was administered several hours late on multiple occasions, contrary to physician orders.
The facility failed to maintain sanitary conditions during food preparation and service. A CNA used bare hands to serve a resident's meal, contrary to guidelines. Additionally, a kitchen inspection revealed unsanitary conditions, including greasy equipment and dirty fans. The Dietary Manager acknowledged the need for cleaning.
The facility failed to administer medications according to physician's orders for two residents, did not assess and monitor skin conditions for two others, and failed to provide transportation for medical appointments for three residents. These deficiencies involved improper medication administration, lack of timely skin assessments, and missed medical appointments due to transportation issues.
A facility failed to honor a resident's preference for television volume, impacting their ability to engage in activities. The resident, with a history of stroke and other conditions, was found unable to hear the television due to it being placed on a tall wardrobe with the volume off and a loud vent nearby. Despite expressing the importance of keeping up with the news and enjoying television, the facility did not ensure the resident could hear the television, failing to support their self-determination and choice.
The facility failed to notify responsible parties of significant changes for two residents. A resident's POA was not informed of a large bruise until three days after it was observed, following a fall. Another resident's guardian was not notified of medication changes despite increased agitation and hallucinations. The facility did not adhere to its policy requiring immediate notification of significant changes.
A resident with multiple medical conditions experienced a decline in ambulation ability due to the facility's failure to implement a Functional Maintenance Program (FMP) after discharge from physical therapy. Despite recommendations for a restorative nursing program, there was no documentation of necessary exercises being provided, and staff interviews revealed communication gaps and lack of access to therapy notes.
A resident, who was dependent on staff for personal hygiene due to mobility impairments, was observed with unwanted facial hair on multiple occasions. Despite the resident's expressed preference for facial hair removal, the facility did not provide timely assistance, failing to adhere to the resident's care plan which required extensive assistance with personal hygiene.
A facility failed to complete meal consumption logs for a resident with significant weight loss and medical conditions including lung cancer, dysphagia, and vascular dementia. The resident, who required assistance with eating and a mechanically altered diet, experienced notable weight loss over several months. Missing documentation for multiple meals was identified, and the DON confirmed that logs should have been completed for each meal.
A resident with respiratory issues did not receive oxygen at the prescribed flow rate and missed a pulmonologist appointment due to transportation issues. Observations showed inconsistent oxygen flow rates, contrary to the physician's order for 3 liters per minute. The resident's appointment for CPAP evaluation was missed due to the facility's transportation coordinator resigning without notice.
A resident with a history of stroke, hypertension, and opioid abuse reported pain but was not offered pain relief due to discontinued medication and lack of documented interventions. Despite care plans requiring pain monitoring and comfort measures, these were not implemented. Staff interviews confirmed the absence of pharmacological or non-pharmacological interventions.
The facility failed to provide annual dental services for two residents, despite their requests and signed consents. One resident had decayed teeth and another was missing top teeth, yet neither had seen a dentist in over a year. Both residents were cognitively intact and had multiple health conditions, but the facility's dental action plan was not effectively implemented.
The facility failed to maintain a clean and safe environment, with observations revealing dirt, debris, and poor maintenance in resident rooms and bathrooms. Issues included dirty floors, cobwebs, trash, and unlabeled personal care items. The Administrator acknowledged these findings and confirmed the lack of a deep cleaning policy.
The facility failed to maintain an effective pest control program, as evidenced by the presence of dead bugs, water bugs, and mice droppings in resident rooms and bathrooms. The Administrator was unsure who was responsible for checking the traps, despite the facility's pest control policy indicating that a qualified pest control service would be contracted and a report system maintained for issues arising between scheduled visits.
A resident's legal guardian refused the administration of Remeron, an antidepressant, but the medication continued to be given from 3/8/24 to 4/28/24 due to a miscommunication between the DON and the Psychiatric NP. This violated the resident's right to direct their own medical treatment.
A resident with dementia and osteoarthritis did not receive routine pain medication as ordered due to the facility's failure to re-order the medication in a timely manner. The resident missed doses of acetaminophen-codeine from 3/6/24 at 12 a.m. until 3/9/24 at 12 a.m., and the Director of Nursing confirmed the lapse was due to a delay in re-ordering the medication.
The facility failed to ensure residents were free from unnecessary medications. A resident had multiple undated Lidocaine patches applied contrary to physician's orders, and another resident was administered Midodrine HCI despite blood pressure readings being outside the prescribed parameters.
The facility failed to ensure the posted Nurse Staffing Information was up-to-date and current. The responsible staff member was on vacation, and no one else had access to update the information. Past postings were found in a box for papers to be shredded, and the Scheduler was unaware of the need to retain them. A review revealed missing postings and a lack of actual hours worked documented. The Regional Nurse Consultant confirmed the omission of actual hours worked.
The facility failed to notify residents and their Responsible Parties in writing of room changes and new roommate assignments. Two residents were moved without proper documentation or notification, contrary to the facility's policy requiring advance notice and documentation of such changes.
The facility failed to complete meal consumption logs for a resident with significant weight loss and multiple health issues. The resident's weights fluctuated, and meal logs were incomplete on several dates. The DON confirmed that logs should be completed after every meal.
Failure to Assess Change in Condition and Accurately Document Vitals Before Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to assess a resident experiencing a change in condition prior to transfer and to accurately document vital signs at the time of transfer. The resident had multiple significant diagnoses, including kidney failure, heart failure, epilepsy, COPD, and diabetes, and was documented as severely impaired for daily decision making and dependent in all ADLs and transfers. An SBAR completed for the resident’s transfer due to a low hemoglobin contained no vital signs or assessment data other than a prior weight from two days earlier. Nursing notes documented that an order was received to send the resident to the hospital for evaluation of an abnormal hemoglobin level of 6.5 and later that the resident had been sent out for low hemoglobin, but there was no documentation of an assessment at the time of transfer. Vital signs were recorded in the chart at 8:17 a.m. and 3:17 p.m. on the day of transfer, and an additional set of vitals was taken at 11:00 a.m. after dialysis, before the order to send the resident out was received. The record lacked documentation of the actual time the resident left the facility, and the DON reported that they could only infer the departure time from the census, which showed the resident removed at 12:17 p.m. The DON also confirmed that the vital signs documented as taken at 3:17 p.m. were entered hours after the resident had already left the facility and that the SBAR should have included a complete assessment and vitals at the time of transfer. The resident was later documented as admitted to the hospital with a hemoglobin of 6.2 and having received a blood transfusion.
Failure to Notify Physician of Missed Medication Administration
Penalty
Summary
The facility failed to ensure timely physician notification when residents did not receive prescribed medications as ordered. For one resident with a history of left below the knee amputation, diabetes, hypertension, pressure ulcers, and heart failure, an IV antibiotic (Flagyl) was ordered for a wound infection but was not available and never administered. There was no documentation that the physician was notified of the missed doses, and interviews confirmed that the physician was not informed until several days later. The resident's record also lacked evidence of appropriate documentation regarding the missed medication and physician notification. In another case, a resident with Alzheimer's, diabetes, and COVID-19 was prescribed Paxlovid for COVID-19 treatment, but only received 3 out of 10 scheduled doses due to the medication not arriving. The record did not show that the physician was notified about the missed doses, and facility leadership confirmed that the nurse should have notified the physician and documented this in the record. The facility's policy required physician notification when there was a need to alter treatment, but this was not followed in these instances.
Failure to Administer Medications and Labs per Physician Orders
Penalty
Summary
The facility failed to administer blood pressure medications and laboratory tests according to physician orders and established parameters for three residents. For one resident with end stage renal disease, hypotension, and hypertension, the care plan required medications to be given per physician order, including Midodrine HCl to be held if systolic blood pressure was less than or greater than 110 or heart rate was less than 60. However, the medication was administered on multiple occasions when the resident's blood pressure readings were outside the specified parameters, and the DON acknowledged the need for order clarification. Another resident with Alzheimer's disease, hypertensive heart disease, and hypotension had orders for Lisinopril to be held if blood pressure was less than 100/60, and for PRN Midodrine if systolic blood pressure was less than 90. The resident received Lisinopril on several occasions when blood pressure was below the hold threshold, and did not receive PRN Midodrine when blood pressure was low enough to warrant it. Additionally, blood pressure monitoring was not performed at the frequency specified in the order. The DON confirmed that the medication administration did not follow the orders and that clarification should have been obtained. A third resident with hemiplegia, diabetes, and atrial fibrillation had handwritten orders for repeat laboratory tests and potassium administration, but these were not entered into the electronic record. There was no evidence that the repeat lab was completed or that potassium was given as ordered. The DON confirmed that these actions were not carried out as required.
Failure to Administer Prescribed Medications for Infection and COVID-19
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically related to the administration of prescribed antibiotics and antiviral medications. For one resident with multiple diagnoses including a recent below-the-knee amputation, diabetes, and pressure ulcers, a physician ordered intravenous Flagyl for a wound infection. The medication was not available and was never administered, with no documentation of physician notification or follow-up. The resident's condition deteriorated, and the wound doctor was not informed of the missed doses until after the resident was hospitalized and subsequently expired. The facility's staff, including the DON and corporate nurse, were unable to explain why the medication was not given as ordered. Another resident with Alzheimer's disease, diabetes, and COVID-19 was prescribed Paxlovid for a confirmed COVID-19 infection. Although the medication was delivered as a single unit from the pharmacy, the resident received only 3 out of 10 scheduled doses, with no documentation explaining the missed doses. The DON and corporate nurse confirmed that the medication should have been available and could not account for the failure to administer it as prescribed. The records lacked evidence of appropriate follow-up or communication regarding the missed medication doses.
Failure to Maintain Resident Dignity During Room Entry
Penalty
Summary
A deficiency was identified when an LPN failed to knock or announce herself before entering a resident's room during incontinence care, despite facility policy requiring staff to knock and request permission prior to entry. The incident occurred in a shared room with two residents present. The resident involved had multiple diagnoses, including Parkinson's disease, dementia, a stage 4 sacral pressure ulcer, heart disease, bladder dysfunction, hypertension, gastrostomy status, and a psychotic disorder. The resident was noted to be cognitively impaired and dependent on staff for all activities of daily living and transfers. The LPN acknowledged forgetting to knock when interviewed at the time of the incident.
Failure to Maintain Equipment and Implement Fall Precautions Leads to Resident Injury
Penalty
Summary
A resident with multiple diagnoses, including heart disease, hypertension, congestive heart failure, psychotic disorder, depression, and anemia, was identified as being at risk for falls due to impaired mobility and cognitive impairment. The care plan required the use of a fall mat, a bed bolster, and monitoring of these interventions every shift. However, observations revealed that the bed bolster was missing, and fall mats were placed on the floor rather than next to the bed. Documentation showed that the bed bolster was not listed on the Treatment Administration Record (TAR) for August, and there was no evidence of monitoring from the beginning of the month through the date of observation. The resident experienced a witnessed fall in the shower room, resulting in a forehead injury and subsequent transfer to the hospital. The post-fall evaluation identified that the shower bed was broken, which contributed to the fall. Staff interviews confirmed that the shower bed moved unexpectedly during care, leading to the resident's fall. The facility's policy required identification and mitigation of hazards, but the broken equipment and lack of proper fall precautions were not addressed, resulting in the incident.
Failure to Administer Pain Medication as Ordered
Penalty
Summary
The facility failed to ensure that a resident's pain medication was administered as ordered and in a timely manner. A resident with diagnoses including dementia, Alzheimer's, hypertension, depression, anxiety, COPD, and adult failure to thrive was assessed as severely cognitively impaired and required scheduled pain medication for lower back pain. Physician's orders specified Acetaminophen-Codeine 300-30 mg to be given by mouth three times daily. However, the Medication Administration Record showed that the medication was administered late on multiple occasions, with doses given several hours after the scheduled times on two consecutive days. The resident's daughter reported that the pain medication was not received on time, and a nurse consultant confirmed that the medication should have been administered as scheduled.
Sanitation Deficiencies in Food Preparation and Service
Penalty
Summary
The facility failed to maintain sanitary conditions during food preparation and service, as observed in two separate incidents. In the first incident, a CNA was observed serving a resident a hot dog on plain white bread and used her bare hands to break the hot dog and bread in half before handing it to the resident. The CNA acknowledged that she was aware of the requirement to use utensils instead of bare hands for such tasks. The Dietary Manager confirmed that staff were instructed to use utensils for cutting residents' food. In the second incident, a kitchen sanitation tour revealed multiple unsanitary conditions. The deep fryer had a heavy accumulation of grease and burned food, while the convection oven had a large amount of burned food on the bottom and greasy, dirty doors. The steam table wells were rusted with peeling metal pieces, and the shelf under the table was dirty with food crumbs and grease. Additionally, two standing fans were dirty and dusty, blowing towards the steam table and dish machine. The Dietary Manager acknowledged the need for cleaning these areas.
Medication Administration and Monitoring Failures in LTC Facility
Penalty
Summary
The facility failed to administer medications according to physician's orders for two residents. Resident H, who has hypertension, type 2 diabetes, and vascular dementia, was prescribed Metoprolol Succinate with specific parameters for administration based on blood pressure and pulse. However, the facility did not document the resident's pulse from late June to late July, potentially leading to improper medication administration. Similarly, Resident J, who has end-stage renal disease and hypotension, was not administered Midodrine HCl as needed when blood pressure parameters were met, and Irbesartan was not held when blood pressure was below the required threshold. The facility also failed to assess and monitor skin conditions for two residents. Resident C, who has multiple health issues including respiratory failure and dementia, developed a large bruise after a fall, which was not assessed or documented in a timely manner. The bruise was only noted days later, and there was a lack of communication among staff regarding its presence. Resident G, who has fibromyalgia and lupus, was observed with a facial rash that was not documented in skin assessments, and there was no physician order for the ointment being used. Additionally, the facility did not provide transportation for medical appointments for three residents. Resident D missed a urology appointment, Resident E missed a nephrology appointment, and Resident F missed a pulmonary appointment due to the facility's inability to provide transportation. This was attributed to issues with the payer source for Medicaid residents and the resignation of the facility driver, leading to outsourcing transportation needs and resulting in missed appointments.
Failure to Honor Resident's Television Preferences
Penalty
Summary
The facility failed to honor a resident's preferences regarding television volume, impacting the resident's ability to engage in activities. During multiple observations, the resident was found in his room with the television on top of a tall wardrobe closet, but the volume was turned off, and a loud air return vent was nearby. The resident expressed during an interview that he could not hear the television. The resident's medical record indicated a history of stroke, type 2 diabetes mellitus, epilepsy, vascular dementia, anemia, major depressive disorder, and high blood pressure. The resident was not cognitively intact for daily decision-making but had expressed that it was somewhat important to keep up with the news and enjoy activities like watching television. Activity assessments confirmed the resident's enjoyment of television, yet the facility did not ensure the resident could hear the television, thus failing to support the resident's self-determination and choice.
Failure to Notify Responsible Parties of Significant Changes
Penalty
Summary
The facility failed to notify the responsible parties of two residents about significant changes in their conditions. For Resident C, the facility did not inform the Power of Attorney (POA) about a large bruise that appeared on the resident's chest until three days after it was first observed. The bruise was likely related to a fall that occurred on 7/14/24, but there was no documentation of any injury immediately following the fall. The bruise was first noticed by a CNA on the day of the fall, but the information was not properly communicated to the nursing staff or documented until 7/17/24. Interviews with staff revealed a lack of communication and documentation regarding the bruise, leading to a delay in notifying the resident's POA. For Resident B, the facility did not document notifying the resident's brother, who is the guardian, about changes in the resident's medication regimen. The resident, who has a history of Alzheimer's disease, schizophrenia, and other conditions, was experiencing increased agitation and hallucinations. A nurse practitioner adjusted the resident's medications, discontinuing some and starting others, but there was no record of the guardian being informed of these changes. The facility's policy requires immediate notification of significant changes in a resident's physical status to the resident's representative, which was not followed in this case.
Failure to Implement Functional Maintenance Program Post-Discharge
Penalty
Summary
The facility failed to implement a Functional Maintenance Program (FMP) for a resident after discharge from physical therapy, leading to a decline in the resident's ability to ambulate. The resident, who had a history of respiratory failure, joint stiffness, COPD, Parkinson's disease, chronic bronchitis, and dementia, was previously able to walk 50 feet with standby assistance using a walker at the time of discharge from physical therapy. The discharge recommendation included 24-hour nursing care and a restorative nursing program (RNP) to maintain the resident's current level of performance and prevent decline. However, there was no documentation of passive range of motion or ambulation exercises being provided from the time of discharge until several months later. Interviews with facility staff revealed a lack of communication and access to necessary information regarding the resident's need for a restorative program. The Restorative Nurse indicated that the RNP did not resume until a month after discharge, and the Unit Manager and Director of Nursing confirmed that they were not informed of the therapy department's recommendations. Additionally, nursing staff did not have access to therapy progress notes, which contributed to the oversight in providing the necessary care to maintain the resident's functional abilities.
Failure to Assist Resident with Personal Hygiene Needs
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for a resident who was dependent on staff for personal hygiene. The resident, who was cognitively intact but had impairments in both upper and lower extremities and used a wheelchair, was observed multiple times with long black facial hair above her top lip. Despite the resident expressing a desire to not have facial hair, the facility did not address this need in a timely manner. The resident's care plan indicated a need for extensive assistance with personal hygiene, yet the staff did not maintain the resident's facial hair as preferred by the resident.
Failure to Document Meal Consumption for Resident with Weight Loss
Penalty
Summary
The facility failed to ensure that meal consumption logs were completed for a resident with a history of significant weight loss. Resident 68, who has diagnoses including lung cancer, dysphagia, and vascular dementia with behavior disturbance, was observed eating lunch with his fingers. The resident's medical records indicated a severe impairment in daily decision-making and a need for assistance with eating, as well as a mechanically altered diet due to swallowing difficulties. The resident experienced a 9.4% weight loss in one month and a 14.5% weight loss over six months. The food consumption logs for Resident 68 showed missing documentation for several meals over a month-long period. Specifically, there was no dinner intake recorded on one date, and no breakfast or lunch intake documented on three other dates, with a complete lack of documentation for any meal on another date. During an interview, the Director of Nursing confirmed that the food consumption logs should have been completed for each meal, indicating a lapse in the facility's monitoring of the resident's nutritional intake.
Failure in Respiratory Care and Transportation Coordination
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident, identified as Resident C, by not ensuring the oxygen was set at the correct flow rate and failing to transport the resident to a scheduled pulmonologist appointment. Observations revealed inconsistencies in the oxygen flow rate administered to the resident, with the rate set at 0.75 liters per minute during some observations and 2 liters per minute during others, despite a physician's order for continuous oxygen at 3 liters per minute. This discrepancy indicates a failure to adhere to the prescribed treatment plan for the resident, who has a medical history including respiratory failure, COPD, Parkinson's disease, chronic bronchitis, heart disease, atrial fibrillation, and dementia. Additionally, the resident missed a crucial cardio/pulmonologist appointment due to transportation issues, as the facility's transportation coordinator resigned without notice, leaving some residents without transportation to their appointments. The appointment was initially scheduled to evaluate the resident for a CPAP machine, which is essential for managing her respiratory condition. The resident's power of attorney was informed of the missed appointment and the need to reschedule, highlighting a lapse in the facility's coordination of care and transportation services.
Failure to Provide Appropriate Pain Management
Penalty
Summary
The facility failed to provide safe and appropriate pain management for a resident, identified as Resident 45, who required such services. The resident, who had a history of stroke, hypertension, anxiety, hemiplegia, benign prostatic hyperplasia, and opioid abuse, reported experiencing pain in his stomach and penis. Despite expressing his pain to the nursing staff, he was not offered Tylenol or any other pain relief. The resident's care plan included monitoring for pain and offering comfort measures, but these interventions were not documented or implemented. A physician's order required monitoring pain levels every shift and trying non-pharmacological interventions before medicating, but these were not followed. The resident's ibuprofen prescription was discontinued due to findings of drug-seeking behavior, as indicated by a nurse's progress note. The Medication Administration Record (MAR) showed that pain assessments were signed off as completed, but they lacked documentation of pain levels or interventions. Interviews with staff revealed that the resident's pain medication had been discontinued, and there were no pharmacological or non-pharmacological interventions documented or in place. The Director of Nursing confirmed the discontinuation of ibuprofen and the absence of new orders from the resident's urologist and pain clinic.
Failure to Provide Annual Dental Services
Penalty
Summary
The facility failed to ensure that each resident received dental services at least annually, as evidenced by the cases of Residents K and D. Resident K, who was cognitively intact and had multiple health conditions including heart failure and diabetes, was observed with decayed teeth and had requested to see a dentist. Despite signing a dental consent in April 2024 and having an oral assessment indicating dental issues, Resident K had not been seen by a dentist in the past year. The facility had a dental action plan dated February 2024, but it was not effectively implemented to ensure timely dental care for Resident K. Similarly, Resident D, who was also cognitively intact and had a history of heart failure, stroke, and other health issues, expressed a desire to see a dentist for missing top teeth. Despite having a care plan addressing oral and dental problems and signing a dental consent in April 2024, Resident D had not been seen by a dentist since admission in February 2022. The facility's failure to provide timely dental services for these residents highlights a deficiency in meeting the required standard of care.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to ensure the residents' environment was clean and in good repair. Observations revealed dirt and debris in the corners and along the baseboards of resident rooms and bathrooms. Specific issues included stained and dirty floors, cobwebs, trash on the floor, and dirty privacy curtains. Additionally, there were instances of dried liquid feeding on pump poles and floors, and personal care items stored in bathrooms were unlabeled and uncovered. These conditions were noted in multiple rooms across different halls, indicating a widespread issue with cleanliness and maintenance in the facility. In the 200 Hall, rooms were found with dirt and debris along baseboards, cobwebs, and dried liquid feeding on equipment. Bathrooms shared between rooms had unlabeled and uncovered personal care items stored on the floor. Similar conditions were observed in the 300 Hall, where privacy curtains were dirty, and there was dirt and debris under beds and behind closets. Bathrooms had holes in the floor, missing tiles, and dim lighting, contributing to an overall unclean and poorly maintained environment. The 400 and 500 Halls also exhibited significant cleanliness and maintenance issues. Rooms had stained and dirty privacy curtains, dirt and debris on floors, and cobwebs. In one instance, a resident used a water pitcher liner for urine elimination due to the absence of a proper urinal. The Administrator acknowledged these findings during an environmental tour and confirmed the lack of a policy for deep cleaning rooms. The facility's policy for routine cleaning was not effectively implemented, leading to the observed deficiencies.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of dead bugs, water bugs, and mice droppings in resident rooms and bathrooms. Specifically, dead bugs and mice droppings were found in room 310, mouse droppings were observed in room 408, mouse droppings and a dead bug were found in room 402, and multiple bugs were seen in a glue trap in room 213. The Administrator was unsure who was responsible for checking the traps, despite the facility's pest control policy indicating that a qualified pest control service would be contracted and a report system maintained for issues arising between scheduled visits. This deficiency was noted during observations and interviews conducted on 4/29/24 and 4/30/24.
Failure to Discontinue Medication Despite Guardian's Refusal
Penalty
Summary
The facility failed to respect the right of a resident's legal guardian to direct medical treatment. Resident B, diagnosed with dementia and osteoarthritis, had two Permanent Co-Guardians appointed. A Physician's Order dated 3/8/24 prescribed Remeron, an antidepressant, to be administered nightly due to significant weight loss, comments about wanting to die, and decreased appetite. The Co-Guardian was informed of the new medication order and expressed refusal of the treatment. Despite this, the Remeron was not discontinued, and the medication continued to be administered from 3/8/24 to 4/28/24. The Psychiatric Nurse Practitioner (NP) noted the family's refusal of the treatment on 3/12/24 and again on 3/14/24, but no order to discontinue the medication was written. The Director of Nursing (DON) assumed the nurse had already discontinued the medication, but the NP usually entered their own orders into the computer. This miscommunication led to the continued administration of Remeron against the Co-Guardian's wishes, violating the resident's right to direct their own medical treatment.
Failure to Administer Pain Medication as Ordered
Penalty
Summary
The facility failed to ensure a resident with pain received routine pain medication as ordered by the physician. Resident B, who had diagnoses including dementia and osteoarthritis, was supposed to receive acetaminophen-codeine (acetaminophen #3) every eight hours. However, the medication was not re-ordered from the pharmacy in a timely manner, resulting in the resident missing doses from 3/6/24 at 12 a.m. until 3/9/24 at 12 a.m. The Medication Administration Record (MAR) and Controlled Drug Records indicated that the medication was not available for administration during this period, and there was no documentation that the resident's family had administered the medication during this time. Interviews with the Director of Nursing (DON) confirmed that the medication had not been re-ordered until 3/7/24, and the pharmacy required a prescription to refill the controlled substance. The prescription was received on 3/8/24, and the medication was delivered early morning on 3/9/24. The DON acknowledged that the medication should have been re-ordered when it was getting low to prevent the lapse in administration. This deficiency was related to complaints IN00429414 and IN00429590.
Failure to Ensure Residents Were Free from Unnecessary Medications
Penalty
Summary
The facility failed to ensure residents were free from unnecessary medications. In the case of Resident B, multiple undated Lidocaine patches were observed on various parts of her body, contrary to the physician's order which specified only one patch should be applied to the lower back daily. The resident's care plan indicated that her Guardian was responsible for placing the patches, and staff were to check for and remove any extra patches upon her return from visits outside the facility. However, this protocol was not followed, leading to the application of multiple patches simultaneously. The resident's pain management plan included acetaminophen-codeine and repositioning, but the presence of multiple patches indicated a failure to adhere to the prescribed regimen. For Resident F, the facility administered Midodrine HCI despite the resident's blood pressure being outside the prescribed parameters. The physician's order specified that the medication should be held if the systolic blood pressure was greater than 120 and diastolic blood pressure was greater than 80. However, the medication was administered on several occasions when the resident's blood pressure readings exceeded these limits. The Director of Nursing confirmed that the medication was given outside of the physician's ordered parameters, indicating a failure to follow the prescribed medication regimen for Resident F.
Failure to Update and Maintain Nurse Staffing Information
Penalty
Summary
The facility failed to ensure the posted Nurse Staffing Information was up-to-date and current. During an observation, it was found that the Nurse Staffing Information was dated 4/19/24, despite the observation occurring on 4/28/24. The Administrator indicated that the staff member responsible for updating the information was on vacation, and no one else had access to the locked frame. Additionally, the Director of Nursing (DON) found past postings in a box for papers to be shredded, and the Scheduler was unaware that the postings needed to be retained. A review of nursing schedules and posting information revealed missing postings for specific dates and a lack of actual hours worked documented on the postings. The Regional Nurse Consultant confirmed that the actual hours worked were not included on the postings. This deficiency was related to complaints IN00429414 and IN00429590.
Failure to Notify Residents and Responsible Parties of Room Changes
Penalty
Summary
The facility failed to notify residents and/or their Responsible Parties in writing of intrafacility transfers and new roommate assignments for two residents. Resident B, who had diagnoses including dementia, Alzheimer's disease, and anxiety, received a new roommate without documentation in the clinical record. When the new roommate tested positive for COVID-19, Resident B was moved to a different room without an intrafacility transfer form or proper documentation. The Infection Preventionist confirmed that the resident's Responsible Party was informed verbally, but this was not documented in the clinical record. The Director of Nursing also confirmed the lack of documentation and the absence of an intrafacility transfer form for the room change on 12/8/23. Resident H, who had diagnoses including stroke, heart disease, and major depressive disorder, tested positive for COVID-19 and was moved to a private room. The resident was later moved to another room and then back to the original room after isolation, but there was no documentation of these transfers or notification to the resident's Responsible Party. The Director of Nursing confirmed that the Responsible Party was not informed of the second transfer or the return to the original room, and no intrafacility transfer forms were completed for these moves. The facility's policy required advance notice and documentation of room changes, which was not followed in these cases.
Failure to Complete Meal Consumption Logs for Resident with Significant Weight Loss
Penalty
Summary
The facility failed to ensure meal consumption logs were completed for a resident with a history of significant weight loss. Resident C, who had multiple diagnoses including a right humerus fracture, heart disease, high blood pressure, heart failure, a pressure ulcer of the sacrum, a cardiac pacemaker, vision loss in both eyes, and a history of falls, experienced fluctuating weights from 88 pounds to 101 pounds over a period of time. The meal consumption logs for Resident C were incomplete on multiple dates for breakfast, lunch, and dinner. During an interview, the Director of Nursing confirmed that meal consumption logs were supposed to be completed after every meal.
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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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