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 found that staff failed to follow physician orders for several residents, including not documenting required physician notification and new insulin orders after a critically high blood glucose, not consistently obtaining or recording ordered daily weights, and administering antihypertensive and midodrine medications despite blood pressure readings outside ordered hold parameters. Documentation on the MAR and related records included unexplained "NA," "X," and blank entries for required weights, and cardiac and BP-related medications were given when systolic blood pressure was below or above specified thresholds, contrary to written orders and facility policy.
Informed consent was not documented before a psychotropic med was started for one resident with dementia and anxiety, and it was not documented before another resident's Vraylar dose was increased for aggression. The DON stated the consent form should be completed before initiation or dose increase, and the facility policy required informed consent before starting or increasing a psychotropic med.
A resident with alcohol abuse, anxiety, and major depressive disorder was transferred to the ER and later planned for transfer to another LTC facility, but no Discharge MDS was completed. The MDS coordinator stated the discharge MDS was not done at discharge and should have been completed within the required timeframe; the facility did not have a resident assessment policy and used RAI criteria for timing.
An MDS assessment failed to accurately reflect a resident's status when an antidepressant prescribed for insomnia was not documented on the admission MDS. The resident had Alzheimer's disease and major depressive disorder, and the MDS coordinator later confirmed the assessment was incorrect.
A resident was observed receiving O2 via nasal cannula on multiple occasions, but the chart had no current physician order for O2. The resident said she had been told after a recent hospitalization to use O2 for 30 days, but that time had passed and she was still using it because staff told her she needed it. The DON confirmed there was no current O2 order; the last order had already been discontinued.
A resident with documented diagnoses of CHF, atherosclerotic heart disease, and pacemaker dependence was admitted with clear record entries noting the presence and use of a cardiac pacemaker, including in the admission evaluation, skin assessment, and a physician note. However, the resident’s care plan did not address the pacemaker at all. The MDS Coordinator acknowledged that the pacemaker should have been care planned, noting that while there is no specific MDS item for pacemakers, diagnosis codes or nursing assessments should trigger care plan development. The Unit Manager confirmed that nursing, social services, and the MDS Coordinator can add items to care plans, and the facility’s care plan policy—emphasizing resident-focused, safety-oriented care—was in place but not applied to this resident’s pacemaker.
A resident with acute respiratory failure with hypoxia, pulmonary hypertension, and type 2 diabetes was observed receiving oxygen at 4.5 L/min via nasal cannula without a corresponding physician order in the clinical record. The DON acknowledged that an order should have been in place before oxygen was initiated. Facility policy on supplemental oxygen via nasal cannula requires administration only under a physician or provider order, in alignment with 410 IAC 16.2-3.1-47(a)(6).
A resident was discharged to an acute care hospital, but review of MDS listings showed that no discharge MDS assessment was completed for that resident. The MDS Coordinator acknowledged that a discharge assessment is required whenever a resident leaves the facility and could not explain why it was missed. The Executive Director reported there was no specific facility policy for MDS assessments and that staff relied on the RAI manual for guidance.
A resident with a fractured wrist returned from an orthopedic visit wearing a new black wrist splint after the cast was removed, but the clinical record lacked an updated physician order and instructions for splint use and care. Staff also did not document follow-up with the physician, and the care plan was not revised when the splint began being used; the DON acknowledged the missing order and lack of a policy for obtaining updated physician information.
The facility failed to document assessment and monitoring of a resident’s bruising and post-procedure condition, and failed to follow ordered medication hold parameters for two residents. One resident returned from an outpatient spinal injection with no nursing note or assessment, another had persistent bruising with no documentation, and two residents received Metoprolol and midodrine despite pulse or BP values outside ordered limits. A separate resident was observed with purple discolorations and a black scab, but the skin record did not reflect assessment or monitoring.
Failure to Follow Physician Orders for Insulin, Daily Weights, and BP-Related Medications
Penalty
Summary
The deficiency involves multiple failures to follow physician orders for medication administration and monitoring. For one resident with type 2 diabetes, peripheral vascular disease, and failure to thrive, a physician’s order directed use of Humalog insulin per a specific sliding scale and required physician notification if blood glucose exceeded 400. A blood sugar of 470 was recorded on one date, and the Medication Administration Record (MAR) showed that 5 units of Humalog were given, but there was no documentation in the MAR, assessment tab, or progress notes that the physician was contacted or that new insulin orders were obtained, despite the DON later stating that an additional 5 units had been ordered. Two residents with orders for daily weights did not have those weights consistently obtained or documented as ordered. One resident with heart failure, hypertension, and chronic kidney disease had a physician’s order for daily weights on dayshift, but on multiple dates in February, March, and April, the MAR/TAR and related documentation showed entries marked as “NA,” “X,” or left blank, with no recorded weights, no physician notification, and no explanation for the missing data. Another resident with hypertension, anxiety disorder, and severe protein-calorie malnutrition also had a daily weight order, yet on numerous dates in April and May, weights were marked “NA” without corresponding weights, physician notification, or explanatory documentation; one weight entry was crossed out and the re-weight was not obtained until the following day. LPNs provided differing explanations for “NA” and “X,” indicating inconsistent understanding of documentation practices. Additional deficiencies occurred in the administration of cardiac and blood pressure–related medications contrary to ordered hold parameters. One resident with hypertension had orders for amlodipine, hydralazine, and losartan potassium, each with instructions to hold the medication if systolic blood pressure (SBP) was less than 110, yet the MAR showed these medications were administered on specific dates when the SBP was below the ordered hold threshold. Another resident with hypertension and systolic and diastolic congestive heart failure had been hospitalized for severe hypotension and returned on midodrine with an order to hold the medication if SBP was greater than 110; however, the MAR showed multiple doses were given on various dates when SBP was outside the ordered hold parameter. These actions were inconsistent with the facility’s own policies requiring medications to be administered only as prescribed and weights to be accurately obtained and documented, and they formed the basis of the cited quality of care deficiency.
Informed Consent Not Documented Before Psychotropic Medication Start or Increase
Penalty
Summary
The facility failed to ensure informed consent was obtained and documented before starting or increasing psychotropic medications for 2 residents reviewed for unnecessary medications. One resident with diagnoses including dementia with psychotic behaviors and anxiety had Rexulti 1 mg initiated for dementia with agitation, with the medication started the next day, but the Psychoactive Medication Consent and Management Agreement dated after the start lacked documentation from the resident's representative giving consent for the new psychotropic medication. Another resident with diagnoses including Alzheimer's disease, major depressive disorder, psychotic disorder, and anxiety had Vraylar increased from 1.5 mg to 3 mg for aggression, with the higher dose started the next day. The Psychoactive Medication Consent and Management Agreement was dated after the increase and documented telephone consent on that later date. The DON stated the consent form should be completed prior to initiation or increase of a new psychotropic medication, and the facility policy required informed consent to be obtained and documented before initiation or an increase in dosage, including discussion of risks, benefits, and alternatives.
Discharge MDS Not Completed Timely
Penalty
Summary
The facility failed to ensure the Discharge MDS assessment was completed within the required timeframe for Resident 108. The resident’s record showed diagnoses of alcohol abuse, anxiety, and major depressive disorder. A progress note dated 12/18/25 at 12:50 a.m. documented that the resident was transferred to the emergency room, and another note dated 12/18/25 at 11:38 a.m. stated the resident would be transferred to another LTC facility upon discharge from the hospital. Review of the resident’s MDS assessments showed that no Discharge MDS assessment had been completed. The RAI 3.0 User’s Manual indicated the Discharge MDS must be completed within 14 calendar days after the discharge date and submitted within 14 days after completion. During interview, the MDS coordinator stated the discharge MDS was not completed at discharge and should have been completed within 14 calendar days of the discharge date; she also stated the facility did not have a resident assessment policy and used the RAI tool criteria for completion timeframes.
Inaccurate MDS Assessment Failed to Document Antidepressant Medication
Penalty
Summary
The facility failed to ensure an MDS assessment accurately reflected a resident's status for 1 of 32 residents reviewed for MDS accuracy. Resident 23 had diagnoses including Alzheimer's disease and major depressive disorder. Review of the April 2026 MAR showed the resident was prescribed mirtazapine at bedtime on 4/2/26 for insomnia, but the 4/9/26 admission MDS assessment did not document an antidepressant prescription. During interview, the MDS coordinator stated the 4/9/26 MDS assessment was incorrect and should have included the antidepressant medication.
Missing Current Physician Order for Oxygen
Penalty
Summary
The facility failed to ensure a current physician's order was in place for a resident receiving oxygen via nasal cannula. Resident 3 was observed in her room on multiple occasions using oxygen from a humidifying oxygen delivery machine via nasal cannula. During interview, the resident stated she had been told after her last hospitalization to use oxygen for another 30 days, but that time had passed and she was still wearing the nasal cannula and receiving oxygen because staff told her she needed it; she also stated the nasal cannula bothered her and she did not want to wear it if it was not necessary. Review of the clinical record showed diagnoses including atrial fibrillation and anxiety, but no current oxygen order. The last oxygen order had a start date of 2/2/26 and a discontinued date of 2/23/26. The DON confirmed there was no current physician's order for oxygen for the resident.
Failure to Include Cardiac Pacemaker in Comprehensive Care Plan
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and implement a comprehensive care plan addressing a resident’s cardiac pacemaker. The resident was admitted with diagnoses including presence of a cardiac pacemaker, congestive heart failure, atherosclerotic heart disease, and heart failure with reduced ejection fraction, with documentation indicating pacemaker dependence. An admission skin assessment noted no skin issues other than the pacemaker, and an admission evaluation documented that the resident utilized a cardiac pacemaker device. A physician’s note further confirmed the resident’s pacemaker dependence as part of her medical history. Despite this documented history and device use, the resident’s care plans did not include any interventions or problem statements related to the pacemaker. During interviews, the MDS Coordinator acknowledged that the pacemaker was not included in the care plan and stated it should have been, explaining that although there is no specific MDS item for pacemakers, a diagnosis code or nursing assessment documentation should trigger care plan development. The Unit Manager reported that nursing, social services, and the MDS Coordinator all have the ability to add items to a resident’s care plan. The facility’s Plan of Care policy, provided by the DON, stated that the care plan is to be resident-focused, provide optimal personalized care, and prioritize resident safety, but this was not followed for the resident’s pacemaker.
Oxygen Administered Without Required Physician Order
Penalty
Summary
The facility failed to ensure physician orders were in place for oxygen administration for one resident receiving respiratory care. During an observation on 5/8/26 at 9:45 a.m., Resident 101 was noted to be receiving oxygen at 4.5 liters per minute via nasal cannula. Review of the resident’s clinical record later that day showed diagnoses including acute respiratory failure with hypoxia, pulmonary hypertension, and type 2 diabetes, but no physician’s order for the use of oxygen could be located at the time of review. In a subsequent interview on 5/12/26 at 8:14 a.m., the Director of Nursing stated that physician orders for oxygen should have been present in the record before oxygen was initiated. The facility’s undated policy titled “Supplemental Oxygen Using Nasal Cannula,” provided on 5/13/26, specified that supplemental oxygen may be administered via nasal cannula only at the order of a physician or provider, consistent with 410 IAC 16.2-3.1-47(a)(6). These observations, interviews, and record reviews demonstrate that oxygen was administered to Resident 101 without the required physician order, contrary to both facility policy and state regulatory requirements.
Failure to Complete Required Discharge MDS Assessment
Penalty
Summary
The deficiency involves the facility’s failure to complete a required discharge Minimum Data Set (MDS) assessment for one resident. Record review showed that Resident 90 was admitted on an unspecified date and discharged on 2/10/26 to an acute care hospital, but the MDS listings contained no completed discharge assessment for this resident. During interview, the MDS Coordinator confirmed that a discharge assessment should be completed whenever a resident is discharged and could provide no reason why this assessment was missed for Resident 90. In a separate interview, the Executive Director stated there was no facility policy regarding MDS assessments and that assessments were completed using the Resident Assessment Instrument (RAI) manual. These findings were cited under 410 IAC 3.1-31(d).
Missing Physician Order and Care Plan Update for New Wrist Splint
Penalty
Summary
The facility failed to ensure follow-up was obtained for physician orders and instructions after a resident returned from an orthopedic follow-up appointment with a new left wrist splint. The resident had a fractured carpal bone from a fall that occurred while in the facility and was severely cognitively impaired on the admission MDS. After the resident’s cast was removed at the orthopedic visit, the resident returned wearing a black splint with tie string and was to wear it at all times except for bathing, but the clinical record did not contain an updated physician order or associated instructions for the splint. The record also lacked documentation that facility staff contacted the physician to obtain the updated order and instructions, and the care plan was not revised when the splint was first used. During interviews, the Unit Manager and DON acknowledged that the care plan had not been updated until later and that the record lacked a physician order showing the cast had been discontinued and the splint ordered. The DON also stated the facility lacked a policy for obtaining updated physician orders, progress notes, and specific instructions for the facility.
Failure to document assessments and follow medication parameters
Penalty
Summary
The facility failed to provide care according to orders and documented parameters for multiple residents. One resident with diagnoses including stroke, dementia, and osteoarthritis had an outpatient medial branch block at a surgery center, but there were no nursing progress notes documenting the procedure, the time the resident left the facility, the time the resident returned, or any assessment of the bandage or the resident’s condition on return. The Director of Nursing stated there was no documentation or assessment when the resident came back from the outpatient procedure. Another resident was observed with a dark purple bruise to the left antecubital area on multiple observations, but the record contained no documentation of that bruising. The resident’s diagnoses included anxiety disorder, major depressive disorder, diabetes, heart failure, high blood pressure, and acute kidney failure. The resident had care plan entries related to bruising and bleeding risk from anticoagulant use and bruising from needle sticks, and weekly skin observations documented no bruises. The DON stated the resident had a blood draw, but there was no documentation regarding the bruise to the left arm. Two residents had medications administered outside ordered parameters. One resident received Metoprolol Tartrate 50 mg twice daily for high blood pressure with instructions to hold if pulse was less than 60, but the MAR showed doses given when the pulse was below 60 on several occasions. Another resident on hospice care received midodrine 5 mg three times daily with instructions to hold if systolic blood pressure was greater than 110, but the MAR showed the medication was administered multiple times when systolic blood pressure exceeded that limit. In addition, a resident was observed with purple discolorations and a black scab on the left forearm, wrist, and hand, but the weekly skin assessment documented no bruising and there was no documentation that the discolorations were assessed or monitored.
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