Spring Mill Health Campus
Inspection history, citations, penalties and survey trends for this long-term care facility in Merrillville, Indiana.
- Location
- 101 W 87th Ave, Merrillville, Indiana 46410
- CMS Provider Number
- 155764
- Inspections on file
- 33
- Latest survey
- December 9, 2025
- Citations (last 12 mo.)
- 22
Citation history
Health deficiencies cited at Spring Mill Health Campus during CMS and state inspections, most recent first.
A resident receiving hospice care with multiple complex medical conditions was administered PRN Lorazepam and Morphine Sulfate without proper documentation of the specific indications for use prior to administration. Nursing notes did not consistently record the resident's symptoms or reasons for giving the medications, and there was no explanation for administering both drugs simultaneously. The DON was unable to provide further information regarding the missing documentation.
A facility failed to implement its admission policy by not ensuring an Admission Agreement was explained and signed by a resident. Despite having an intact cognitive status, the resident's file lacked a signed agreement detailing consent for treatment, resident rights, and financial responsibilities. The Admission's Manager did not complete the agreement, citing the resident's confusion post-dialysis, and the Administrator confirmed the agreement should be completed for all admissions.
A facility failed to monitor a resident's blood sugar levels as required, impacting insulin administration. The resident, with a history of stroke and diabetes, had a Physician's Order for blood sugar checks before meals and at bedtime, with insulin to be given if levels were 151 or higher. However, records showed multiple instances where blood sugar was not checked, violating facility policies.
A resident in contact isolation due to MRSA was confined to her room, despite being cognitively intact and previously leaving her room regularly. Staff, including an LPN and CNA, were unsure about isolation protocols, leading to the resident's misunderstanding that she could not leave her room. The ADON later clarified that the resident could leave if her wound was covered, but the resident had been told otherwise by the wound nurse.
The facility failed to ensure staff were aware of the code status for three residents due to missing documentation in their records. The Social Service Director found signed POST forms for these residents, but they were not included in the residents' charts or communicated to the nursing staff, contrary to facility policy.
A resident was observed with caried and broken teeth, yet their records inaccurately indicated no dental issues. The resident's MDS assessments showed cognitive intactness and no oral problems, and there was no dental care plan. Interviews with staff revealed unawareness of the dental issues.
Two residents in the facility did not receive the required number of baths and hair washes as part of their ADLs. One resident, dependent on staff for all ADLs, reported not receiving a bed bath twice a week and not having his hair washed weekly, with observations confirming greasy hair. Another resident, also dependent on staff for bathing, reported not having her hair washed since admission, with records indicating missed bed baths. Interviews with nursing staff confirmed the expectation for residents to receive at least two complete bed baths weekly and to be offered hair washing.
A resident's surgical bandage was not changed as ordered by the physician, with the bandage observed to be dated several days prior to the scheduled change. The resident, who was dependent on staff for daily activities, had specific physician orders for bandage changes that were not followed. The Treatment Administration Record inaccurately showed the treatment as completed, and the Director of Nursing confirmed the oversight.
A resident with multiple health issues, including a stage 2 pressure ulcer, was not provided with proper care as their heels were not floated off the bed, contrary to a physician's order. Despite the care plan indicating impaired skin integrity and the need for heel offloading every shift, observations revealed non-compliance, which was acknowledged by the DON.
A resident with a PEG tube for decompression was found with dried blood under the flange, indicating a lack of daily cleaning as required by facility policy. Interviews revealed that the wound nurse cleaned the tube when changing bandages but did not document this care, and the LPN assumed the wound nurse was responsible. There were no physician's orders or care plans for the PEG tube, despite the DON stating it should be cleaned daily.
A facility failed to ensure proper care and monitoring of a resident's PICC line due to the absence of Physician's Orders. Observations revealed the PICC line bandage was outdated and peeling, and the resident's record lacked a Care Plan or active orders for PICC line care. The resident had multiple health issues and was severely impaired in decision-making. The DON confirmed the lack of PICC line orders.
A facility failed to limit the use of a PRN psychotropic medication for a resident with multiple health conditions, including paranoid schizophrenia and depressive disorder. The resident was prescribed Alprazolam as needed for anxiety, which was administered beyond the 14-day limit without documented clinical rationale for extended use, contrary to the facility's policy.
A resident was found with Diclofenac cream improperly stored at the bedside without a care plan or physician's order, and an LPN had 10 loose pills in a medication cart. The facility's medication storage policy was not followed, leading to deficiencies in medication management.
The facility failed to ensure a clean and sanitary environment by leaving an uncontained bed pan on a chair in a resident's room. The resident had used the bed pan multiple times due to diarrhea. The DON confirmed that the bed pan should have been stored properly after use, as per the facility's policy on storing continence devices.
Lack of Documentation for PRN Medication Administration in Hospice Resident
Penalty
Summary
The facility failed to ensure that as-needed (PRN) medications were administered with proper documentation of the specific indication for use for a resident receiving hospice care. The resident, who had multiple diagnoses including stroke, dysphagia, chronic kidney disease, quadriplegia, vascular dementia, and heart failure, was cognitively impaired and at risk for pain as noted in the care plan. Physician orders were in place for Lorazepam for anxiety, restlessness, and insomnia, and for Morphine Sulfate for pain or shortness of breath, both to be given as needed. The Medication Administration Record showed that both medications were administered on several occasions. However, the nurses' notes did not consistently document the specific reason or indication for administering these medications prior to their use. In several instances, there was no documentation that the resident had experienced pain, anxiety, or restlessness before receiving the medications, nor was there an explanation for administering both medications at the same time. The Director of Nursing was unable to provide additional information regarding the lack of documentation. This deficiency was identified during a complaint investigation.
Failure to Implement Admission Policy for Resident
Penalty
Summary
The facility failed to implement its admission policy by not ensuring that an Admission Agreement was explained and signed by a resident, identified as Resident D, who was admitted to the facility. Resident D's record review revealed multiple admissions and discharges to an acute care hospital, with the most recent discharge to another facility. Despite having an intact cognitive status as per a Quarterly Minimum Data Set assessment, there was no signed Admission Agreement on file. This agreement should have included consent for treatment, explanations of resident rights, and details about financial responsibilities, among other important information. During an interview, the Admission's Manager admitted that the Admission Agreement was not explained or signed by Resident D. The manager expressed discomfort in going over the paperwork with the resident, citing the resident's confusion after returning from dialysis as a reason for not completing the agreement. The facility's Administrator confirmed that the Admission Agreement should be completed for all admissions, indicating a lapse in following the facility's admission procedures for Resident D.
Failure to Monitor Blood Sugar for Insulin Administration
Penalty
Summary
The facility failed to ensure proper blood sugar monitoring for a resident with a history of stroke and diabetes mellitus, which is crucial for determining the need for insulin administration. The resident's record indicated a severely impaired cognitive status and a requirement for insulin based on blood sugar levels, as per a Physician's Order dated 11/13/24. This order specified that blood sugars should be checked before meals and at bedtime, with Humalog insulin to be administered if the blood sugar was 151 or higher, following a sliding scale. However, the Medication Administration Records (MAR) for December 2024 and January 2025 showed multiple instances where blood sugar levels were not obtained, thus failing to determine if insulin was required. The Director of Nursing (DON) was informed of these missed blood sugar monitoring instances, but no further information was provided at the end of the Exit Conference. The facility's glucose testing policy, dated 1/2/21, required that the Physician's Order be reviewed prior to testing and that all results be recorded on the MAR. Additionally, the facility's medication administration policy, dated 2/17/20, mandated that medications be administered in accordance with the Prescriber's orders. This deficiency was related to a specific complaint, IN00452516.
Failure to Honor Resident's Choice During Contact Isolation
Penalty
Summary
The facility failed to honor a resident's preferences regarding leaving her room while in contact isolation. Resident 261, who was cognitively intact and used a wheelchair, was placed in contact isolation due to Methicillin-resistant Staphylococcus aureus (MRSA) in a wound. Despite her cognitive ability to make decisions, she was confined to her room, which she expressed to staff. The resident had a history of leaving her room regularly, but due to the isolation status, she was unsure if she could continue to do so. Staff members, including LPN 3 and CNA 1, were uncertain about the requirements of contact isolation and whether the resident could leave her room. The Assistant Director of Nursing (ADON) later clarified that the resident could leave her room as long as her wound was covered. However, the resident had been told by the wound nurse that she did not need to leave her room for activities, which may have led to a misunderstanding. The Director of Nursing (DON) and Nurse Consultant acknowledged the issue of staff not understanding contact isolation protocols but did not provide additional information.
Failure to Document and Communicate Residents' Code Status
Penalty
Summary
The facility failed to ensure staff were knowledgeable regarding the residents' code status for three residents reviewed for advanced directives. For Resident 160, the Assistant Director of Nursing was unaware of the resident's code status due to a lack of documentation in the clinical record or the advance directive binder. The Social Service Director (SSD) found a POST form on his desk, signed by the resident and nursing staff but not by a physician or nurse practitioner, indicating the resident was a full code. The SSD could not explain why this information was not communicated to the nursing staff. Resident 50's record lacked a code status order and advanced directives documentation. RN 1 was unaware of the resident's code status, and the SSD found a POST form in his office, signed by the resident and physician, but it was not in the resident's chart. Similarly, Resident 261's record had no code status order or POST form in the electronic medical record. RN 1 was unaware of the resident's code status, and the SSD confirmed that POST forms for all three residents were signed but not included in their charts or communicated to the nursing staff. The facility's policy required documentation of advance directives in the resident's medical record, which was not followed.
Inaccurate Dental Assessment for a Resident
Penalty
Summary
The facility failed to ensure an accurate comprehensive assessment of a resident's dental status. During an observation, a resident was found to have caried and broken teeth, and the resident mentioned the need for new dentures. However, the resident's record, including the Annual Minimum Data Set (MDS) assessment and a subsequent Quarterly MDS assessment, indicated that the resident was cognitively intact and had no oral or dental problems. Additionally, there was no care plan in place for dental care. Interviews with the MDS Coordinator and MDS Nurse Consultant revealed a lack of awareness regarding the resident's dental issues.
Failure to Provide Required Bathing and Hair Washing for Residents
Penalty
Summary
The facility failed to ensure that dependent residents received the required number of baths and hair washes as part of their activities of daily living. Resident 41, who was cognitively intact but dependent on staff for all ADLs, reported not receiving a bed bath twice a week and not having his hair washed weekly. Observations confirmed that the resident's hair was greasy. The resident's care plan indicated the need for assistance with bathing, and the facility's records showed missed bed baths on specific dates. Interviews with the Assistant Director of Nursing and the Director of Nursing confirmed the expectation for residents to receive at least two complete bed baths weekly and to be offered hair washing. Similarly, Resident 158, who was also cognitively intact and dependent on staff for bathing, reported not having her hair washed since admission. Her care plan required assistance with bathing, and facility records indicated missed bed baths on specified dates. The Assistant Director of Nursing was unaware of the resident's lack of hair washing and confirmed the expectation for residents to receive complete bed baths at least twice a week. These deficiencies highlight the facility's failure to adhere to care plans and ensure proper hygiene for dependent residents.
Failure to Change Surgical Bandage as Ordered
Penalty
Summary
The facility failed to ensure that surgical bandages were changed as ordered by the physician for a resident with a non-pressure skin condition. On September 3, 2024, a resident was observed with a surgical bandage on the abdomen dated August 30, 2024, indicating it had not been changed according to the physician's orders. The Assistant Director of Nursing confirmed that the bandage was supposed to be changed three times a week on Monday, Wednesday, and Friday. However, the bandage was not changed on September 2, 2024, as required. The resident, who was cognitively intact but dependent on staff for all activities of daily living, had a surgical wound upon admission. The physician's orders specified a detailed procedure for changing the bandage, which was not followed. The Treatment Administration Record inaccurately indicated that the treatment was completed on September 2, 2024. The Wound Nurse, who was responsible for changing the bandage, was off on that day, and the nursing staff did not perform the task in her absence. The Director of Nursing acknowledged that the bandage should have been changed as per the physician's orders.
Failure to Float Heels for Resident with Pressure Ulcer
Penalty
Summary
The facility failed to ensure proper pressure ulcer care for a resident with a history of pressure ulcers. Resident 31, who has multiple diagnoses including diabetes, hemiplegia, encephalopathy, dementia, and hypertension, was observed on multiple occasions without their heels floated off the bed, despite a physician's order to do so. The resident, who is severely impaired in daily decision-making and uses a wheelchair, had a stage 2 pressure ulcer and a history of a resolved deep tissue pressure injury to the left heel. The care plan indicated impaired skin integrity, and the physician's order required the heels to be offloaded every shift. However, observations on consecutive days showed that the resident's heels were not floated, and the Director of Nursing confirmed this oversight.
Failure to Ensure Daily Cleaning of PEG Tube
Penalty
Summary
The facility failed to ensure proper care and cleaning of a PEG tube for a resident, identified as Resident 41, who was observed with dried crusty blood under the flange of the tube. The resident, who was cognitively intact and dependent on staff for all activities of daily living, had a PEG tube placed for decompression purposes and not for feeding. Despite this, there was no care plan or physician's orders for the care or monitoring of the PEG tube, which is a violation of the facility's policy. Interviews with the wound nurse and other staff revealed a lack of clarity and responsibility regarding the cleaning of the PEG tube. The wound nurse indicated that she cleaned around the tube when changing bandages but did not document this care in the clinical record. Additionally, the LPN was aware of the PEG tube but assumed the wound nurse was responsible for its care. The Assistant Director of Nursing confirmed the absence of orders for daily monitoring or cleaning of the PEG tube, while the Director of Nursing stated that the tube should be cleaned at least daily, as per the facility's policy.
Failure to Ensure Proper PICC Line Care and Monitoring
Penalty
Summary
The facility failed to ensure proper care and monitoring of a resident's PICC line, as there were no Physician's Orders for its care and monitoring. During observations on two separate occasions, the PICC line bandage was noted to be dated several days prior and was peeling off, indicating a lack of timely maintenance. The resident, who had multiple diagnoses including diabetes, hemiplegia, encephalopathy, dementia, and hypertension, was severely impaired in daily decision-making and used a wheelchair. The resident's record lacked a Care Plan for the PICC line or intravenous therapy, and there were no active orders for their care. The Director of Nursing acknowledged the absence of PICC line orders during an interview.
Failure to Limit PRN Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a PRN psychotropic medication was not ordered for longer than 14 days for a resident. The resident, who was cognitively intact, had multiple diagnoses including left lung cancer, type 2 diabetes, stroke, osteoarthritis, heart disease, depressive disorder, repeated falls, high blood pressure, paranoid schizophrenia, and atrial fibrillation. The resident's medication regimen included insulin, an antipsychotic, an anxiolytic, an antidepressant, an anticoagulant, and hypoglycemic medications. A physician's order dated July 17, 2024, prescribed Alprazolam 0.5 mg to be given every 8 hours as needed for anxiety. The Medication Administration Record (MAR) indicated that Alprazolam was administered five times in August 2024 and twice in September 2024. During an interview, the Assistant Director of Nursing confirmed that the scheduled dose of Xanax was discontinued in July and was then ordered as PRN. The resident requested the medication, and the resident's daughter would call to ensure it was administered. The facility's policy on psychotropic medication gradual dosage reduction stated that PRN hypnotic, antianxiety, or antidepressant medications should not be used beyond 14 days unless the prescribing practitioner provides a clinical rationale for extended use, which was not documented in this case.
Improper Storage of Medicated Creams and Loose Pills
Penalty
Summary
The facility failed to properly store medicated creams and loose pills, leading to deficiencies in medication management. During observations, a resident was found with a tube of Diclofenac cream on the over-bed table and later inside the nightstand drawer. The resident, who was severely contracted and unable to use his extremities, was cognitively intact but dependent on staff for all activities of daily living. There was no care plan or physician's order to keep the medicated cream at the bedside, and the nursing staff were unaware that the family had brought in the creams. The facility's medication storage policy required all medications to be securely stored in a locked cabinet or cart, which was not followed in this case. Additionally, during a medication pass, an LPN was observed with 10 loose pills of varying sizes, shapes, and colors in the bottom drawers of a medication cart. The LPN acknowledged that the pills should not be loose and disposed of them in a drug buster container. The facility's policy on medication storage emphasized the need for medications to be stored in an orderly manner to prevent crowding, which was not adhered to in this instance.
Uncontained Bed Pan Found in Resident's Room
Penalty
Summary
The facility failed to maintain a clean and sanitary environment for residents, as evidenced by the presence of an uncontained bed pan in one of the units. During observations on September 5, 2024, at various times, a bed pan was found lying on a cloth chair in a resident's room. The resident reported experiencing diarrhea eight times the previous day and night, necessitating the use of the bed pan. The Director of Nursing confirmed that the bed pan should have been contained and stored away after each use. The facility's policy, dated March 21, 2021, requires designated storage areas for devices and supplies used for continence, which was not adhered to in this instance.
Latest citations in Indiana
Surveyors observed that dietary staff repeatedly worked in kitchen and meal service areas with uncovered facial hair, despite facility policy and state sanitation requirements mandating effective hair restraints. Two dietary aides with short beards or mustaches were seen walking through food preparation areas, taking food temperatures, handling food, and plating meals at steamtables in dining rooms without any facial hair coverings, while the current policy required all hair, including facial hair, to be restrained to prevent contamination.
The facility failed to consistently provide and document required bed-hold policy notices when several residents were transferred to the hospital. In multiple cases, residents with dementia, psychotic disorders, COPD, chronic respiratory failure, altered mental status, and cerebral infarction were sent out for acute changes in condition, and while transfer notes reflected physician and family notifications, they lacked documentation that the bed-hold policy was discussed with the resident or responsible party. Notices of Transfer or Discharge often indicated a copy of the bed-hold policy was sent with the resident, but the records did not show signed and dated acknowledgment by the resident or appropriate representative, including in situations where a resident had moderate cognitive impairment, short-term memory issues, or a documented need for a proxy and a financial POA authorizing an agent for health care decisions.
Surveyors found that the facility failed to provide trauma‑informed and culturally competent care by not incorporating two residents’ extensive trauma histories and specific behavioral triggers into their care plans. One resident with documented homelessness, polysubstance abuse, severe accidents with multiple fractures, viral encephalitis with coma, physical and sexual abuse, loss of family contact, and a past suicide attempt had multiple behavior‑focused care plans that referenced identifying triggers but listed none and did not mention their physical, sexual, medical, or psychosocial trauma. Another resident with TBI from being struck by a truck, an 11‑month coma, long‑term state hospital residence, alleged shooting of a parent, and diagnoses including intermittent explosive disorder and borderline personality disorder had a PASRR identifying a specific trigger and notes of inappropriate sexual behavior, yet their care plans omitted these traumatic events, the identified trigger, and the sexual behavior. Staff interviews confirmed that residents were screened for trauma, but the trauma histories and triggers were not reflected in the individualized plans of care.
A resident with schizophrenia, post‑stroke hemiparesis, and mild cognitive impairment expressed feeling down and wanting to kill himself, but staff did not document asking about a specific plan, did not notify the physician or psychiatric NP as expected, and did not develop or update a care plan addressing depression or suicidal ideation. The SSD documented offering support and initiating 15‑minute checks once, but there was no further follow‑up or documentation of interventions after subsequent suicidal statements made in a care plan meeting with the resident’s father. The DON and Administrator reported that facility policy requires immediate notification of key staff, assessment for a plan and means of self‑harm, and thorough documentation, which were not carried out or reflected in the medical record for this resident.
A resident with schizophrenia, post-stroke hemiparesis, and mild cognitive impairment verbalized suicidal ideation, but the care plan did not address depression or suicidal thoughts, and required assessments and services were not accurately or timely documented. An SSD note recorded the resident saying he wanted to kill himself and referenced 15‑minute checks and a care plan update, yet the active care plan lacked depression/suicidal ideation interventions. Multiple late-entry Social Services notes were later added, describing follow-up visits and the resident denying suicidal ideation, but the SSD later reported she did not typically ask about a suicide plan and did not personally provide individual follow-up visits as described. These practices conflicted with the facility’s policy requiring factual, first-hand, and timely documentation of assessments and services.
A resident was observed with an Albuterol inhaler on an overbed table and later reported keeping the inhaler in a nightstand drawer, with no staff present during these observations. Record review showed the resident had no cognitive impairment on the admission MDS but lacked any documented self-medication administration assessment. The DON acknowledged that the required assessment had not been completed, despite facility policy requiring staff and the practitioner to evaluate each resident’s mental and physical abilities before allowing self-administration of medications.
Surveyors found that the facility submitted inaccurate direct care staffing data to CMS through the PBJ system over multiple days in a quarter. CASPER reports showed apparent gaps in 24-hour licensed nurse coverage, low weekend staffing, and a 1-star staffing rating, while internal staffing sheets documented that licensed nurses were present and the facility was fully staffed on those days. The Administrator reported that the discrepancies were due to PBJ data entry errors, despite a facility policy requiring all PBJ entries to be accurate, auditable, and verifiable against payroll, invoices, or contracts.
Surveyors found that the facility did not provide or document required written transfer/discharge notices and bed-hold policy information for four residents who were sent to the hospital, including individuals with conditions such as dementia, CHF, chronic respiratory failure, and CKD. In each case, progress notes showed that the resident was transferred for acute issues, but the clinical records lacked evidence that written notices were given to the residents or their representatives, and in one case lacked documentation that required information was sent to the receiving provider. Facility leadership, including the ADON, DON, and Administrator, acknowledged that the records did not contain the required documentation, despite a written policy requiring such notices and information exchange.
The facility failed to ensure timely electronic transmission of MDS assessment data to CMS for a resident. Record review showed an annual MDS that was more than 120 days overdue for submission. The MDS coordinator reported that two care area assessments on the annual MDS had remained incomplete until just before surveyor review, at which time the MDS was finished and submitted. The Administrator acknowledged there was no facility policy in place governing MDS transmissions.
Surveyors found that MDS assessments were inaccurately coded for two residents. One resident with a prior Level II PASARR for serious mental illness was incorrectly coded on the Annual MDS as not having a serious mental illness or related condition. Another resident with generalized anxiety disorder, major depressive disorder, and dementia, who was receiving Lorazepam for anxiety, was not coded with an active anxiety disorder diagnosis on the Quarterly MDS, despite active orders documented on the MAR. The MDS coordinator acknowledged both coding errors, and leadership reported there was no facility-specific MDS policy, relying instead on the RAI manual.
Uncovered Facial Hair During Food Preparation and Meal Service
Penalty
Summary
The deficiency involves the facility’s failure to ensure that food was served in a sanitary and safe manner in accordance with professional standards and facility policy during multiple kitchen and meal service observations. During an initial kitchen observation, two dietary aides were seen walking through the kitchen food preparation area with uncovered facial hair. One aide had facial hair above and below the lip and along the jaw line, approximately one-fourth inch in length, and the other had a mustache of similar length; neither used any facial hair covering. These observations occurred while staff were present in the kitchen area where food was stored and prepared. During subsequent observations on the same day, the same two dietary aides were again observed with uncovered facial hair while directly involved in meal preparation and service. One aide walked through the kitchen while the noon meal was being prepared and placed into a transport cart for service in the south dining room, and later was observed plating the noon meal at the steamtable in that dining room, still without a facial hair covering. The other aide walked through the kitchen while the noon meal was being prepared and placed into the steamtable for the north dining room, took food temperatures, assisted with plating meals at the steamtable, and retrieved food items and supplies from the kitchen, all while having an uncovered mustache approximately one-fourth inch in length. The Dietary Manager stated that staff hair was to be covered when in the kitchen and during meal service, and the facility’s written policy and the cited Indiana Food Establishment Sanitation Requirements both required effective hair restraints, including for facial hair, to prevent contamination of food, equipment, and utensils.
Failure to Provide and Document Bed-Hold Policy at Time of Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure that required bed-hold policy information was provided and documented for four residents transferred to the hospital. For a resident with dementia, psychotic disorder, and autistic disorder who had a BIMS score of 0 indicating severe cognitive impairment, progress notes documented physician notification and guardian notification when the resident was sent to the hospital, but there was no documentation that the bed-hold policy was provided to the responsible party. A Notice of Transfer or Discharge later indicated a copy of the bed-hold policy was sent with the resident. Another resident with COPD and chronic respiratory failure, cognitively intact with a BIMS score of 13, experienced a decline in condition and was transferred to the hospital by ambulance; progress notes documented family notification but did not document any discussion of the bed-hold policy, although a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident. A third resident with altered mental status and cerebral infarction, with a BIMS score of 10 indicating moderate cognitive impairment and documented short-term memory impairment, experienced changes in condition and was transferred to the hospital. Progress notes stated the resident was their own responsible party and that no other notification was completed, and transfer documentation did not include the bed-hold policy, although an untimed Notice of Transfer or Discharge indicated a copy of the bed-hold policy was signed by the resident. A financial power of attorney document in the record showed the resident had designated an agent to act in consent or refusal of health care. For a fourth resident with dementia and osteomyelitis, transfer documentation and a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident, and the transfer form noted the resident required a proxy for decision making. The facility’s policy required that at the time of transfer to a hospital, written notice specifying the duration of the bed-hold policy and information on return to the next available bed be provided, and that a signed and dated copy of the bed-hold notice given to the resident or representative be kept in the resident file, which was not consistently documented for these residents.
Failure to Integrate Trauma Histories and Behavioral Triggers Into Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to identify and incorporate residents’ trauma histories and specific behavioral triggers into their care plans, despite documented histories of significant trauma and behavioral health issues. For one resident, extensive social service and progress notes documented homelessness, polysubstance abuse, major depressive and anxiety disorders, chronic pain, a history of severe car accidents with multiple fractures, viral encephalitis resulting in a three‑month coma, loss of child custody, multiple divorces, physical abuse by a spouse, the death of a fiancé who was struck by a car while in a wheelchair, lack of family contact, and a past suicide attempt by Valium overdose. Additional documentation noted a history of rape by a brother at age eight and prior placement under direct supervision and 15‑minute checks related to suicidal ideation. Despite these documented traumatic events and behavioral health concerns, the resident’s care plans did not identify a history of physical trauma, sexual trauma, homelessness, substance abuse, medical trauma, or attempted suicide. For this same resident, the MDS showed no cognitive deficit and identified behaviors such as verbal aggression and rejection of care, along with diagnoses including seizure disorder, depression, chronic pain syndrome, homelessness, and anxiety disorder. Multiple care plans addressed behaviors such as drug‑seeking, pretending to have seizures for attention or medication, making false allegations, verbal aggression when unable to smoke, and a desire for intimate relationships with consenting male residents. These care plans referenced goals such as effective coping skills, seeking staff support, and compliance with the smoking policy, and they called for identification and reduction of behavioral triggers. However, none of these care plans actually listed any specific triggers. The care plan addressing the resident’s right to consensual intimate relationships focused on assessment and education regarding consent but did not integrate the resident’s extensive trauma history. Staff interviews indicated the resident had displayed sexual behaviors since admission, including an incident where the resident expressed anger at another resident for not buying a soda after engaging in sexual acts. A second resident with a documented history of traumatic brain injury (TBI), dementia, seizure disorder, borderline personality disorder, anxiety, intermittent explosive disorder, tobacco use, and other behavioral/emotional disorders was also affected by the same deficiency. Social history and progress notes documented that this resident sustained a TBI after being hit by a semi‑truck while riding a bicycle at age 18, resulting in an 11‑month coma, followed by 13 years in a state hospital and subsequent residence in a group home. Additional documentation indicated the resident allegedly shot their father at age 26 after being sworn at and had a PASRR identifying TBI, intermittent explosive disorder, and borderline personality disorder, with a specific trigger of hearing the name of the current U.S. President. Progress notes also described inappropriate sexual behavior toward staff, including touching themselves intimately during personal care and refusing to stop when redirected. Despite this, the resident’s care plans, which addressed explosive disorder and history of altercations, risk for decreased psychosocial well‑being, and refusal to bathe or shower, did not list any specific behavioral triggers, did not reference the traumatic events such as being hit by a truck or shooting their father, and did not document the inappropriate sexual behavior. The Administrator and Social Service Director acknowledged that residents were to be screened for trauma and that trauma responses and PTSD should be added to care plans, but the specific trauma histories and triggers for these two residents were not incorporated into their plans of care.
Failure to Assess and Care Plan for Resident Suicidal Ideation
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess, investigate, and care plan for a resident’s suicidal ideation in accordance with its own policy and staff expectations. The resident had diagnoses including schizophrenia, cerebral edema, and hemiparesis/hemiplegia following a cerebral infarction, and a current MDS showed mild cognitive impairment (BIMS score 12). A progress note documented that the resident told the Social Services Director (SSD) he was feeling down and wanted to kill himself; the SSD offered assistance, activities, and initiated 15‑minute checks, and the note stated the care plan was updated. However, the note did not indicate that the SSD asked whether the resident had a plan to kill himself, and there were no additional notes regarding suicidal ideation or follow‑up. Review of the current care plan showed no problem, goal, or interventions addressing depression or suicidal ideation, and progress notes over the following month contained no documentation of physician notification related to the suicidal statement. Further record and interview evidence showed that the care plan conference summary did not document interventions for suicidal ideation, and the SSD acknowledged she did not normally ask residents expressing suicidal ideation if they had a plan. The SSD reported that the resident had admission paperwork mentioning suicidal ideation related to depression after a stroke and that the resident again vocalized suicidal ideation during a care plan meeting with his father, after which emotional support was offered and the father took the resident out on a leave of absence; no further visits or follow‑up were done. The DON stated that, upon notification of suicidal verbalization, staff should assess the resident, ask if there is a plan, remove potential means of self‑harm, immediately notify the psychiatric NP, and document the occurrence, and that a detailed progress note and updated care plan were expected but not present for this resident. The Administrator similarly stated that staff should ask about a plan, document interventions, notify the physician and family, and update the care plan, and indicated the resident should have had a care plan addressing depression with suicidal ideation. The facility’s written policy required immediate notification of the DON, SSD, and physician, an interview including asking about a plan and assessing mood and means for self‑harm, and thorough documentation of mood, behavior, and all actions taken, which were not reflected in the resident’s record.
Incomplete and Inaccurate Documentation of Suicidal Ideation and Follow-Up
Penalty
Summary
The facility failed to ensure accurate, complete, and timely documentation of assessments and services for a resident who verbalized suicidal ideation. Resident 6, who had schizophrenia, cerebral edema, and right-sided hemiparesis/hemiplegia following a cerebral infarction, had a BIMS score of 12 indicating mild cognitive impairment. The resident’s admission paperwork mentioned suicidal ideation related to depression after a stroke, and a Social Services note on 3/11/2026 documented that the resident was feeling down and said he wanted to kill himself. The Social Services Director (SSD) documented that she talked with the resident, coordinated with Activities, advised the resident to contact SSD or nursing if he wanted to talk, and that the resident was scheduled for 15-minute checks and the care plan was updated. However, the current care plan initiated on 2/26/2026 did not address depression or suicidal ideation. Multiple Social Services progress notes were later entered as late entries in April, with effective dates in March, stating that the resident had no plan and no longer had suicidal ideation, that he felt much better after 1:1 time, and that he continued his daily routine and therapy. These late entries described follow-up visits and reassessments of suicidal ideation on several consecutive days, but in interviews the SSD stated she did not normally ask residents about having a plan when they verbalized suicidal ideation and did not recall any other occurrences beyond the initial event. She further indicated she did not personally provide individual follow-up visits with this resident regarding suicidal ideation, despite the late-entry notes describing such visits. The DON acknowledged that late entries had been added to address concern about suicidal verbalization, and the Administrator stated that upon suicidal statements staff should ask about a plan, notify the physician and family, and update the care plan, and that this resident should have had a care plan addressing depression with suicidal ideation. The facility’s documentation policy required factual, first-hand, timely documentation, which was not followed in this case.
Failure to Complete Required Self-Administration Assessment for Inhaler Kept at Bedside
Penalty
Summary
Surveyors identified that a resident was allowed to keep and access an Albuterol inhaler without the facility completing the required self-administration medication assessment. During an initial tour, the resident was observed sitting in a wheelchair with a handheld Albuterol inhaler on the overbed table and no staff present in the room or hallway. On a subsequent observation, the resident again was in a wheelchair and reported that the Albuterol inhaler was stored in the top drawer of the nightstand, where it was found. Review of the clinical record showed an admission MDS indicating no cognitive impairment, but there was no documentation of a self-medication administration assessment. In an interview, the DON confirmed that the resident did not have the required self-medication assessment, despite the facility’s policy stating that staff and the practitioner must assess each resident’s mental and physical abilities to determine whether self-administering medications is clinically appropriate. This failure to complete and document a self-administration medication assessment for a resident who had an Albuterol inhaler kept at bedside constituted noncompliance with the facility’s own policy and with 410 IAC 16.2-3.1-11(a).
Inaccurate PBJ Staffing Data Submission to CMS
Penalty
Summary
The deficiency involves the facility’s failure to electronically submit complete and accurate direct care staffing information to CMS through the Payroll-Based Journal (PBJ) system for 22 days in a fiscal quarter. A CASPER report review on 4/6/26 showed that, according to PBJ data, the facility did not have licensed nursing coverage 24 hours per day on multiple specific dates across three months, had low weekend staffing, and held a 1-star staffing rating. However, review of the facility’s internal staffing sheets for that quarter indicated the facility was fully staffed and had licensed nurse coverage on all of the dates in question. During an interview, the Administrator stated that the PBJ information must have contained data entry errors, as she had verified licensed staff coverage on the timesheets. The facility’s PBJ policy in effect stated that all staffing data entered into the PBJ system would be auditable and verifiable through payroll, invoices, or contracts, but the submitted PBJ data did not accurately reflect the facility’s actual licensed nurse staffing as documented on internal records. No specific residents or clinical conditions were mentioned in the report, and the deficiency centers solely on inaccurate staffing data submission rather than direct resident care events.
Failure to Provide and Document Required Transfer/Discharge and Bed-Hold Notices
Penalty
Summary
The deficiency involves the facility’s failure to provide and document required written notices of transfer/discharge and bed-hold policies, as well as required information to receiving providers, for four residents who were transferred or discharged to the hospital. For a resident with generalized anxiety disorder, major depressive disorder, and dementia, progress notes showed that the resident was sent to the hospital via 911 for chest pain, lower back pain, and shortness of breath and later returned to the facility, but the clinical record lacked documentation that a written Notice of Transfer/Discharge and the bed-hold policy were provided to the resident or representative, and lacked documentation that required information was conveyed to the receiving facility. The ADON and the Administrator both confirmed there was no documentation that these written notices were provided. For a resident with congestive heart failure and muscle weakness who was sent to the emergency room for painful urination and bloody urine, the clinical record lacked documentation that a Notice of Transfer/Discharge or bed-hold policy was given to the resident or representative, which the DON confirmed. Another resident with chronic respiratory failure and diabetes was discharged to the hospital for respiratory failure, and a resident with chronic kidney disease and dementia was discharged to the hospital, but in both cases there was no documentation that a written notice of transfer/discharge or bed-hold policy was provided to the residents or their representatives. Review of the facility’s Transfer and Discharge policy, dated 1/15/26, showed that the policy required the facility to provide written transfer/discharge notices and bed-hold information to residents and representatives and to provide specified information to receiving providers, but the records for these four residents did not contain the required documentation.
Failure to Timely Transmit MDS Assessment Data to CMS
Penalty
Summary
The facility failed to ensure timely electronic transmission of MDS (Minimum Data Set) assessment data to the CMS system for one resident. Review of the clinical record for Resident 36 on 4/9/26 showed an annual MDS assessment dated 2/23/26 that was more than 120 days overdue for submission to CMS. During an interview on 4/10/26 at 11:22 a.m., the MDS coordinator stated she still had two care area assessments left to complete on the annual MDS assessment and that she had just finished them and submitted the MDS to CMS, indicating the assessment had not been completed and transmitted within the required timeframe. In a separate interview on 4/10/26 at 12:05 p.m., the Administrator reported that the facility did not have a policy regarding MDS transmissions, further demonstrating the lack of an established process to ensure that MDS data were encoded and transmitted to the State and CMS within the required time limits.
Inaccurate MDS Coding for Mental Health and PASARR Status
Penalty
Summary
The deficiency involves the facility’s failure to ensure that MDS assessments accurately reflected residents’ clinical status for two residents. For one resident with diagnoses including bipolar disorder and anxiety, the Annual MDS dated 3/11/26 indicated the resident was not considered by the state Level II PASARR process to have a serious mental illness or intellectual disability/related condition, despite a Level II PASARR having been completed on 3/31/23. This discrepancy was identified through record review and confirmed in an interview with the MDS coordinator, who acknowledged that the MDS assessment did not accurately reflect the existing Level II PASARR information. For another resident with generalized anxiety disorder, major depressive disorder, and dementia, the Quarterly MDS dated 3/30/26 did not code anxiety as an active diagnosis. However, review of the MAR showed active orders as of 2/27/26 for Lorazepam, prescribed for generalized anxiety disorder, and the RAI manual specifies that active diagnoses should be identified using sources such as medication sheets and physician orders during the 7-day look-back period. In an interview, the MDS coordinator confirmed that the resident did have an active anxiety disorder diagnosis and that the MDS should have been coded “yes” for anxiety disorder but was incorrectly coded “no.” The Administrator and MDS coordinator also stated the facility did not have an MDS policy and relied on the RAI manual for completing assessments.
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