Aperion Care Demotte
Inspection history, citations, penalties and survey trends for this long-term care facility in Demotte, Indiana.
- Location
- 10352 N 600 E County Line Rd, Demotte, Indiana 46310
- CMS Provider Number
- 155572
- Inspections on file
- 34
- Latest survey
- March 17, 2026
- Citations (last 12 mo.)
- 26
Citation history
Health deficiencies cited at Aperion Care Demotte during CMS and state inspections, most recent first.
A resident with diabetes and documented dependence for toileting and frequent bowel and bladder incontinence did not have a comprehensive care plan for urinary incontinence. The ADL care plan noted an ADL deficit but did not document the resident’s usual toileting performance or specify the amount of assistance needed. A separate care plan identified potential skin integrity impairment related to incontinence but lacked any defined interventions for incontinence care. The MDS assessment showed the resident was frequently incontinent, and the MDS Coordinator acknowledged that there was no specific incontinence care plan in place.
Surveyors found that the facility did not consistently provide scheduled bathing for three residents who were dependent on staff for ADLs. One resident with bilateral lower extremity fractures, another with seizures and bipolar disorder, and a third with diabetes and a below-the-knee amputation all had care plans and MDS assessments indicating dependence or extensive assistance needs for bathing, along with specified preferred bathing days on day shift. Review of shower sheets and task forms over multiple months showed several missed baths for each resident, and the DON acknowledged that one resident was supposed to receive baths three times weekly due to poor hygiene and was unable to find documentation or confirm completion of several missed baths for another resident.
A facility failed to protect residents from the misappropriation of narcotic medications, affecting three residents. A nurse admitted to taking oxycodone tablets from a resident, and further investigation revealed discrepancies in narcotic counts for other residents. Over 300 narcotic tablets were unaccounted for due to a nurse's actions, who would sign for medications and take them along with the narcotic count records.
The facility failed to provide a complete 5-Day follow-up report to the IDOH regarding a narcotic misappropriation incident. A resident's oxycodone was unaccounted for, and RN 4 admitted to taking it. The report lacked details about two other residents with missing narcotics and the exoneration of RN 3. The Regional President acknowledged the missing information.
A facility failed to investigate the root cause of multiple skin tears in a resident with vascular dementia and diabetes mellitus, who was receiving hospice care. The resident was observed with dressings on the right arm and hand, and despite the presence of skin tears, no investigation was conducted. The ADON noted the resident's tendency to pick at her skin when uncomfortable, but there was no care plan addressing this behavior. The Corporate RN Consultant confirmed that the skin tears should have been investigated.
A facility failed to properly assess and manage a resident's pressure ulcers, leading to a decline in the resident's condition. The ADON was unaware of changes in treatment orders, and there was a lack of communication between staff and hospice care. Weekly skin assessments were inconsistent, and the care plan did not accurately reflect the resident's condition. This deficiency highlights a breakdown in communication and adherence to the facility's skin condition assessment policy.
The facility failed to ensure correct PPE was used by staff when caring for a resident under Enhanced Barrier Precautions. CNAs and an LPN provided care to a resident with an indwelling urinary catheter and skin conditions without wearing gowns, despite facility policy and signage indicating the need for such precautions.
The facility failed to properly store medications in two medication carts, with loose pills found in the drawers. An Agency QMA and an RN were observed with the carts, and it was noted that nursing staff were responsible for cleaning them. The Assistant Director of Nursing indicated that the DON was usually responsible for ensuring the carts were cleaned.
The facility failed to ensure proper assessment and authorization for self-administration of medications for two residents. An LPN administered a nebulizer treatment to a resident without checking vital signs or staying with the resident, and another resident was left with medications to self-administer without proper authorization. Facility policies requiring physician authorization and observation were not followed.
A resident with severe cognitive impairment was involved in a physical altercation with another resident. Although the aggressor was sent to the hospital, the affected resident was not monitored for psychosocial distress as per the facility's usual protocol. The facility's policy lacked specific guidelines for such monitoring.
A facility failed to provide written notification to a resident's Responsible Party regarding a hospital transfer. The resident, with type 2 diabetes and elevated liver enzymes, was sent to the hospital without the State-approved transfer form or written notice to the Responsible Party. The Regional President confirmed the lack of documentation, violating the facility's policy requiring written notification and communication with the State Ombudsman.
A facility failed to notify a resident and their Responsible Party of the bed-hold policy before a hospital transfer. The resident, with type 2 diabetes and elevated liver enzymes, was moderately impaired in decision-making. Despite notifying the Responsible Party of the transfer, the facility did not document sending the bed-hold policy, as confirmed by the Regional President of Operations.
A facility failed to provide timely intervention for a resident with abnormal lab results, leading to hospitalization for renal failure. Two residents did not receive medications as ordered, with one resident's medications not held despite low blood pressure readings, and another resident's medications not administered as ordered. Additionally, a resident's skin discolorations were not assessed or documented, contrary to facility policy.
A resident with encephalopathy, legal blindness, and hearing loss did not receive timely vision and hearing services due to the facility's failure to facilitate access. Despite a physician's order and verbal consent for services, the resident was not on the list for audiology and optometry services, as the Ancillary Service Company required a signed consent. The facility's policy to assist residents in arranging health services was not effectively implemented for this resident.
A resident with a history of falls was found without necessary fall precautions, such as non-skid strips, in her room and bathroom, despite these being identified as necessary interventions. The resident, who was cognitively impaired, had previously fallen and sustained a major injury. The facility's failure to implement these safety measures contributed to an incident where the resident slipped on spilled iced tea, resulting in a fracture.
A resident with acute and chronic respiratory failure did not receive continuous oxygen as ordered. Observations showed the oxygen concentrator was not in use, and the resident stated she only used it at night. The MAR lacked documentation of oxygen administration or refusal, and an LPN was unaware of the continuous order, believing it was as needed.
A facility failed to monitor a dialysis access site for a resident with end-stage renal disease, who had a catheter for hemodialysis. The resident's records lacked current physician orders for dialysis and catheter monitoring after readmission, and there was no documentation of monitoring from 9/13/24 to 9/17/24, contrary to facility policy.
A resident with chronic kidney disease and other conditions had abnormal lab results that were not communicated to the Physician as required. The lab results, which included elevated BUN, creatinine, and potassium levels, were only reviewed by the Nurse Practitioner the following day, leading to the resident being sent to the ER for renal failure. The facility's policy to notify the Physician of significant changes was not followed.
A facility failed to disinfect a blood pressure cuff used on a resident during a medication pass. An LPN used the cuff without cleaning it before or after use, contrary to facility policy. The LPN acknowledged the oversight, and the Regional President of Operations confirmed the requirement for cleaning between uses.
A resident admitted on hospice care with a full code status did not receive CPR as requested by their Health Care Representative (HCR) when they showed signs of actively dying. Despite the care plan and physician's orders indicating a full code, facility staff did not initiate CPR or transfer the resident to the hospital. The resident expired before the HCR could arrive, and no policy regarding CPR initiation was provided during the survey.
Failure to Develop Comprehensive Care Plan for Urinary Incontinence
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan addressing urinary incontinence care for one resident. Record review showed that this resident, who had diagnoses including diabetes mellitus, had an ADL care plan dated 2/15/26 that documented a deficit in activities of daily living, but the toileting hygiene section did not include the resident’s usual performance and lacked any interventions specifying the level of care required. A separate care plan dated 2/15/26 identified a potential impairment of skin integrity related to incontinence, yet it did not include interventions describing what incontinence care should be provided. An admission MDS assessment dated 2/18/26 documented that the resident was dependent for toileting and was frequently incontinent of bowel and bladder. During interviews, the MDS Coordinator acknowledged that the care plans needed to be tightened up and confirmed there was no care plan in place for incontinence care. This deficiency was cited under 410 IAC 16.2-3.1-35(a) and related to Intake 2707235.
Failure to Provide Scheduled Bathing Assistance for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide scheduled bathing and showers for residents who required assistance with activities of daily living (ADLs). Resident B, who had fractures of the right and left lower extremities, had an ADL self-care deficit and was dependent on staff for bathing per the care plan dated 12/11/25 and the admission MDS dated 12/16/25. His plan of care indicated a preference for bathing on the day shift on Wednesdays and Saturdays, yet the January 2026 shower sheets and task forms showed that bathing did not occur on 1/3/26. Resident C, with diagnoses including seizures and bipolar disorder, required moderate to extensive assistance from one to two staff for bathing per the annual MDS dated 3/6/26 and a care plan revised on 3/17/26. Her preferred bathing days were on the day shift on Mondays, Wednesdays, and Fridays, but shower sheets and task forms for January, February, and March 2026 showed missed baths on January 14 and 30, February 23, and March 2 and 4. The DON stated that bathing was supposed to occur three times a week due to the resident’s poor hygiene. Resident D, diagnosed with diabetes mellitus and a below-the-knee amputation, had an ADL self-care deficit and was dependent on staff for bathing per a care plan revised 10/1/25 and a quarterly MDS dated 3/2/26, with preferred bathing days on the day shift on Tuesdays and Fridays. Shower sheets and task forms for January, February, and March 2026 indicated missed baths on January 24, February 14, 24, and 28, and March 10, and during interview the DON could not locate documentation that these baths had been completed or confirm that they occurred.
Misappropriation of Narcotic Medications in LTC Facility
Penalty
Summary
The facility failed to protect residents from the misappropriation of their narcotic pain medications, specifically hydrocodone and oxycodone, affecting three residents. The issue was identified when the facility could not account for Resident B's oxycodone tablets. An investigation revealed that a registered nurse admitted to taking Resident B's medication. Further review of medication records showed discrepancies in the narcotic counts for Residents B, F, and G, indicating a significant number of tablets were unaccounted for. Resident B, diagnosed with peripheral neuropathy and diabetes mellitus, had a physician's order for oxycodone 15 mg to be administered as needed for pain. However, the narcotic count records for several deliveries were missing, and a total of 273 tablets were unaccounted for. Resident F, with diabetes mellitus and dementia, had a physician's order for hydrocodone-acetaminophen for breakthrough pain. The investigation found that 22 tablets were unaccounted for, as they were signed out but not documented as administered. Resident G, diagnosed with osteoarthritis, had a physician's order for hydrocodone-acetaminophen, and 25 tablets were unaccounted for, despite being signed as given. The investigation revealed that RN 4 was involved in the misappropriation of medications. RN 4 would volunteer to come in early on days when narcotics were delivered, sign for the medications, and then take them along with the narcotic count records. This practice led to over 300 narcotics being unaccounted for over the course of a year. The facility's failure to maintain accurate narcotic counts and prevent drug diversion resulted in the misappropriation of residents' medications.
Incomplete 5-Day Follow-Up on Narcotic Misappropriation
Penalty
Summary
The facility failed to provide a thorough and complete 5-Day follow-up report to the Indiana Department of Health (IDOH) regarding an incident of misappropriation of narcotic medication. The incident involved the unaccounted narcotic pain medication, oxycodone 15 mg, belonging to a resident, which was reported to the Assistant Director of Nursing and the Administrator. The follow-up report, dated 1/3/25, confirmed the drug diversion was substantiated due to RN 4's admission of taking the oxycodone. However, the report lacked critical information from the investigation, including the discovery that two other residents also had missing narcotic medication, the total number of unaccounted narcotics, and the clarification that RN 3 was not involved in the misappropriation. During an interview, the Regional President acknowledged the missing information in the 5-day follow-up report.
Failure to Investigate Skin Tears in Resident
Penalty
Summary
The facility failed to ensure a resident received necessary care and services by not investigating the root cause of multiple skin tears. During an observation, a resident was found with dressings on the right arm and hand due to skin tears. The resident, who had vascular dementia and diabetes mellitus and was receiving hospice care, was noted to have memory problems and was dependent on others for all activities of daily living. Despite the presence of skin tears identified on the resident's forearm and hand, there was no investigation conducted to determine the cause. The Assistant Director of Nursing acknowledged the lack of investigation and noted that the resident would pick at her skin when uncomfortable, yet there was no care plan addressing this behavior. The Corporate RN Consultant confirmed that the skin tears should have been investigated to determine their cause.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure thorough and timely assessment of a resident's pressure ulcers, notify the physician of a decline in the condition, and implement interventions to prevent further pressure ulcers. During an observation, a resident was found with a large dressing on the left hip with copious bloody drainage and a foul odor, indicating a decline in the wound's condition. The Assistant Director of Nursing (ADON), who also served as the Wound Nurse, was unaware of the changes in treatment orders made by the Hospice Nurse and had not been informed of the decline in the resident's condition. The resident's medical record revealed inconsistencies and lack of documentation regarding the assessment and treatment of pressure ulcers. Weekly skin assessments were not consistently completed, and there were no thorough descriptions or measurements of the pressure areas. The care plan did not accurately reflect the presence of pressure ulcers, and there was a lack of communication between the facility staff and the hospice care team regarding the resident's condition. Interviews with facility staff highlighted a lack of communication and coordination in the management of the resident's pressure ulcers. The ADON indicated that the nurses were responsible for obtaining treatment orders and notifying her of concerns, but there was a failure to do so. Additionally, the facility's skin condition assessment policy was not followed, as pressure ulcers were not assessed and measured weekly as required. This lack of adherence to policy and communication breakdown contributed to the deficiency in providing appropriate pressure ulcer care.
Failure to Use Correct PPE for Resident Under Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure correct Personal Protective Equipment (PPE) was used by staff members when providing care to a resident under Enhanced Barrier Precautions (EBP). During an observation, two Certified Nursing Assistants (CNAs) entered the room of a resident with an indwelling urinary catheter, skin tears, and pressure ulcers, without wearing gowns, despite a sign indicating the need for EBP and available PPE in the hallway. The CNAs acknowledged the requirement for gowns during care. In a separate observation, a CNA and a Licensed Practical Nurse (LPN) were repositioning the same resident without wearing gowns, although the LPN confirmed that EBP PPE should have been used. The facility's policy indicated that EBP was necessary for residents with chronic wounds and indwelling catheters.
Improper Medication Storage in Facility Carts
Penalty
Summary
The facility failed to ensure proper storage of medications in two of the four medication carts observed. On September 20, 2024, at 2:33 p.m., the ACU Medication Cart was found with multiple loose pills of different sizes and colors scattered throughout the bottoms of the drawers. The Agency QMA working with the cart indicated it was her first day on the cart. Similarly, at 2:47 p.m., the [NAME] 1 Medication Cart was observed with the same issue of loose pills, and the RN present stated that nursing staff were responsible for cleaning the carts. During an interview, the Assistant Director of Nursing mentioned that the Director of Nursing was typically responsible for ensuring the carts were cleaned.
Failure to Ensure Proper Assessment and Authorization for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that residents were properly assessed for self-administration of medications and lacked the necessary Physician's Orders for such self-administration. In the case of Resident 9, during a medication pass observation, an LPN administered a nebulizer breathing treatment without checking the resident's oxygen saturation or lung sounds. The LPN left the resident alone during the treatment, unaware of whether a self-administration assessment had been completed. The resident's records did not contain a Physician's Order or assessment for self-administration, and the facility's policy required staff to remain with residents during treatments unless they were assessed and authorized to self-administer. For Resident 32, the resident was observed with a medication cup containing pills and nasal sprays on her dresser and bathroom counter, respectively. The resident indicated that she self-administered these medications, which were left by an LPN. However, the resident's records only authorized self-administration of supplements, eye drops, and saline nasal spray, not the prescribed oral medications or Fluticasone Propionate Suspension. The facility's policy required specific authorization from the attending physician for self-administration and mandated observation to ensure complete ingestion of medications, which was not adhered to in this case.
Failure to Monitor Resident for Psychosocial Distress After Altercation
Penalty
Summary
The facility failed to provide psychosocial follow-up care to a resident involved in a physical altercation with another resident. Resident 136, who had severe cognitive impairment and diagnoses including unspecified dementia, hypertension, and depression, was involved in an incident where another resident struck him multiple times. Although the residents were separated and assessed for injuries, and the aggressor was sent to the hospital for evaluation, there was no documentation that Resident 136 was monitored for psychosocial distress following the incident. The facility's Social Service Director acknowledged that residents are typically monitored for 72 hours after such events, but this protocol was not triggered in this case. The facility's current Abuse Prevention and Reporting policy lacked specific guidelines for monitoring psychosocial distress.
Failure to Provide Written Notification for Hospital Transfer
Penalty
Summary
The facility failed to ensure that a resident and their Responsible Party were notified in writing regarding a transfer to the hospital. This deficiency was identified for one of the three residents reviewed for hospitalization. The resident in question, who had diagnoses including type 2 diabetes mellitus and elevated liver enzymes, was moderately impaired in daily decision-making according to a recent assessment. On a specific date, a physician ordered the resident to be sent to the hospital due to elevated liver enzymes, nausea, emesis, and epigastric pain. Although the Responsible Party was notified verbally, there was no documentation indicating that the State-approved transfer form was completed or that written notification was provided to the Responsible Party. During an interview, the Regional President of Operations confirmed the absence of documentation related to the State transfer form and written notification to the Responsible Party. The facility's policy requires that residents and their representatives be notified in writing of transfers or discharges, with a copy sent to the State Long-term Care Ombudsman. The lack of documentation and failure to follow this policy resulted in the identified deficiency.
Failure to Notify Resident of Bed-Hold Policy
Penalty
Summary
The facility failed to ensure that a resident and/or their Responsible Party were provided with the facility's bed-hold and reserve bed payment policy before and upon transfer to the hospital. This deficiency was identified for one of the three residents reviewed for hospitalization. The resident in question, who had diagnoses including type 2 diabetes mellitus and elevated liver enzymes, was moderately impaired in daily decision-making according to a recent MDS assessment. On a specific date, the resident was sent to the hospital due to elevated liver enzymes, nausea, emesis, and epigastric pain. Although the Responsible Party was notified of the hospital transfer, there was no documentation indicating that the bed-hold policy was communicated to them. This was confirmed during an interview with the Regional President of Operations, who acknowledged the lack of documentation regarding the bed-hold policy notification.
Deficiencies in Timely Intervention, Medication Administration, and Skin Monitoring
Penalty
Summary
The facility failed to ensure timely intervention for a resident with abnormal lab results, leading to hospitalization. Resident 68, who had diagnoses including cerebral infarction, chronic kidney disease, and type 2 diabetes mellitus, was observed receiving intravenous fluids. Despite being at risk for decreased cardiac output and dehydration, lab results collected on 7/1/24 were not communicated to the physician or nurse practitioner until 7/2/24. The delayed communication resulted in the resident being sent to the emergency room for renal failure after elevated lab values were finally reviewed. The facility also failed to administer medications as ordered for two residents. Resident 24, diagnosed with dementia and hypertension, had orders to hold certain medications if blood pressure was below a specified level. However, the medications were not held on multiple occasions despite low blood pressure readings. Similarly, Resident 55, with diagnoses including hypertension and chronic kidney disease, did not receive medications as ordered on numerous dates. Additionally, midodrine was not held as ordered when blood pressure readings were above the specified threshold. Furthermore, the facility did not assess and monitor skin discolorations for Resident 37, who had large discolorations on her forearms following unsuccessful intravenous line attempts. Despite the presence of these discolorations, weekly skin observations did not document any skin problems. The lack of documentation and monitoring of the bruising was acknowledged during an interview, indicating a failure to adhere to the facility's policy on skin condition assessment and monitoring.
Failure to Provide Timely Vision and Hearing Services
Penalty
Summary
The facility failed to ensure that a resident received necessary vision and hearing services in a timely manner. Resident 27, who was diagnosed with encephalopathy, legal blindness, and hearing loss, expressed during an interview that he could not hear or see and required outside services. Despite his needs, the facility had not facilitated access to these services. The resident's Quarterly Minimum Data Set (MDS) assessment indicated moderate impairment in daily decision-making, moderate difficulty with hearing, and highly impaired vision, yet he did not have hearing aids or corrective lenses. Care plans from earlier in the year noted behavior problems related to hearing difficulties and impaired communication due to hearing deficits. The facility's process for arranging ancillary services was not effectively implemented for Resident 27. Although a physician's order was made to add the resident to the eye doctor list, and verbal consent for ancillary services was documented, the Ancillary Service Company required a signed consent and order to treat, which had not been provided. The Social Services Director acknowledged that the resident was not on the current list for audiology and optometry services and planned to address this at the next Care Plan Meeting. The facility's policy stated that it would assist residents in arranging health services on-site as needed, but this was not executed for Resident 27, leading to the deficiency.
Failure to Implement Fall Precautions for Resident
Penalty
Summary
The facility failed to implement fall precautions for a resident with a history of falls, leading to a deficiency in ensuring a safe environment. The resident, who was cognitively impaired and had a history of falls, was observed in her room and bathroom without non-skid strips, which were previously identified as necessary interventions. Despite a care plan update indicating the need for non-skid strips in front of the bed and in the bathroom, these safety measures were not in place during observations on two separate occasions. The resident had a history of falls, including one with a major injury, and was involved in an incident where she slipped on spilled iced tea in the bathroom, resulting in a fracture. The facility's policy required safety interventions for residents at risk of falls, but the necessary interventions were not implemented for this resident. The lack of non-skid strips, as previously recommended by the interdisciplinary team, contributed to the unsafe conditions that led to the resident's fall and subsequent injury.
Failure to Administer Continuous Oxygen as Ordered
Penalty
Summary
The facility failed to provide necessary respiratory care for a resident, as observed and documented by surveyors. Resident 7, who has diagnoses including acute and chronic respiratory failure, was observed with an oxygen concentrator that was not in use as ordered. The resident's physician had ordered continuous oxygen administration at 3 liters per minute via nasal cannula, but the oxygen tubing was found on the floor or stored in a plastic bag during observations. The resident indicated she only used oxygen at night, contrary to the continuous order. The September 2024 Medication Administration Record lacked documentation of oxygen administration or refusal. An LPN interviewed was unaware of the continuous oxygen order and stated the resident refused oxygen, noting there was no place on the MAR to document its use or refusal.
Failure to Monitor Dialysis Access Site
Penalty
Summary
The facility failed to provide necessary care and services for a resident receiving hemodialysis by not monitoring the dialysis access site. Resident 231, who was cognitively intact and diagnosed with end-stage renal disease, hypertension, and type 2 diabetes mellitus, had a catheter in his right chest for dialysis. The resident attended dialysis sessions on Mondays, Wednesdays, and Fridays. Upon review, it was found that there were no current physician orders for dialysis or monitoring of the dialysis catheter after the resident's readmission to the facility on 9/13/24. Previous orders for dialysis services and catheter monitoring had been discontinued on 9/3/24 and were not reinstated upon readmission. The Medication Administration Record (MAR) and Treatment Administration Record (TAR) for September 2024 showed no documentation of monitoring the dialysis catheter from 9/13/24 to 9/17/24. The facility's policy on Dialysis Monitoring and Observation required nurses to assess the catheter site for signs of drainage and the condition of the dressing every shift, which was not adhered to in this case. During an interview, the Regional President of Operations acknowledged the oversight and indicated a review of the dialysis orders would be conducted.
Failure to Report Abnormal Lab Results
Penalty
Summary
The facility failed to ensure that abnormal lab results were promptly communicated to the Physician for a resident who was reviewed for hospitalization. On a specific date, the resident was observed receiving intravenous fluids and had a history of cerebral infarction, chronic kidney disease, and type 2 diabetes mellitus. The resident's care plan included monitoring lab values and reporting results to the Physician. However, lab results collected on another date, which showed elevated levels in several tests, were not communicated to the Physician or Nurse Practitioner as required. The Nurse Practitioner only became aware of the abnormal lab results the following day, which included elevated BUN, creatinine, potassium, alkaline phosphatase, and white blood cell count. Upon reviewing these results, the Nurse Practitioner ordered the resident to be sent to the emergency room for renal failure. The resident was subsequently admitted to the hospital for acute kidney injury, with the admission history indicating acute renal failure and electrolyte abnormalities. The facility's policy required notifying the Physician of significant changes in the resident's condition, which was not adhered to in this case.
Failure to Disinfect Multi-Use Equipment
Penalty
Summary
The facility failed to ensure that multiple-use equipment was disinfected after use on residents, as observed during a medication administration observation. Specifically, an LPN was seen preparing medications for a resident and needed to check the resident's blood pressure before administering the medications. The LPN used a blood pressure wrist cuff from the medication cart, applied it to the resident's wrist, and then returned it to the cart without cleaning it before or after use. During an interview, the LPN admitted that she normally would clean the cuff but did not do so in this instance. The Regional President of Operations confirmed that the LPN should have cleaned the cuff prior to using it on the resident. The facility's policy on cleaning and sanitizing medical equipment states that devices used for more than one resident should be cleaned between each use.
Failure to Initiate CPR for Resident with Full Code Status
Penalty
Summary
The facility failed to initiate cardiopulmonary resuscitation (CPR) for a resident, referred to as Resident B, who was admitted on hospice care with a full code status as requested by the resident's Health Care Representative (HCR). Resident B had multiple medical conditions, including diabetes mellitus, severe vascular dementia, and quadriplegia, and was dependent on all activities of daily living. Despite the HCR's explicit request for CPR to be performed if there was no pulse and the resident was not breathing, the facility did not initiate CPR when the resident showed signs of actively dying and eventually expired. The resident's care plan and physician's orders indicated a full code status, meaning CPR should have been performed if necessary. However, during the resident's decline, the hospice nurse and facility staff did not initiate CPR or transfer the resident to the hospital, even after the HCR was informed of the resident's condition. The HCR had refused to discontinue medications and tube feeding until she could see the resident herself, but the resident expired before her arrival. Interviews with facility staff, including the Director of Nursing and hospice personnel, revealed that CPR was not initiated, and the resident was not transferred to the hospital despite being actively dying. The facility did not provide a policy regarding CPR initiation prior to the survey exit, and the deficiency was related to a complaint investigation.
Latest citations in Indiana
Surveyors observed that dietary staff repeatedly worked in kitchen and meal service areas with uncovered facial hair, despite facility policy and state sanitation requirements mandating effective hair restraints. Two dietary aides with short beards or mustaches were seen walking through food preparation areas, taking food temperatures, handling food, and plating meals at steamtables in dining rooms without any facial hair coverings, while the current policy required all hair, including facial hair, to be restrained to prevent contamination.
The facility failed to consistently provide and document required bed-hold policy notices when several residents were transferred to the hospital. In multiple cases, residents with dementia, psychotic disorders, COPD, chronic respiratory failure, altered mental status, and cerebral infarction were sent out for acute changes in condition, and while transfer notes reflected physician and family notifications, they lacked documentation that the bed-hold policy was discussed with the resident or responsible party. Notices of Transfer or Discharge often indicated a copy of the bed-hold policy was sent with the resident, but the records did not show signed and dated acknowledgment by the resident or appropriate representative, including in situations where a resident had moderate cognitive impairment, short-term memory issues, or a documented need for a proxy and a financial POA authorizing an agent for health care decisions.
Surveyors found that the facility failed to provide trauma‑informed and culturally competent care by not incorporating two residents’ extensive trauma histories and specific behavioral triggers into their care plans. One resident with documented homelessness, polysubstance abuse, severe accidents with multiple fractures, viral encephalitis with coma, physical and sexual abuse, loss of family contact, and a past suicide attempt had multiple behavior‑focused care plans that referenced identifying triggers but listed none and did not mention their physical, sexual, medical, or psychosocial trauma. Another resident with TBI from being struck by a truck, an 11‑month coma, long‑term state hospital residence, alleged shooting of a parent, and diagnoses including intermittent explosive disorder and borderline personality disorder had a PASRR identifying a specific trigger and notes of inappropriate sexual behavior, yet their care plans omitted these traumatic events, the identified trigger, and the sexual behavior. Staff interviews confirmed that residents were screened for trauma, but the trauma histories and triggers were not reflected in the individualized plans of care.
A resident with schizophrenia, post‑stroke hemiparesis, and mild cognitive impairment expressed feeling down and wanting to kill himself, but staff did not document asking about a specific plan, did not notify the physician or psychiatric NP as expected, and did not develop or update a care plan addressing depression or suicidal ideation. The SSD documented offering support and initiating 15‑minute checks once, but there was no further follow‑up or documentation of interventions after subsequent suicidal statements made in a care plan meeting with the resident’s father. The DON and Administrator reported that facility policy requires immediate notification of key staff, assessment for a plan and means of self‑harm, and thorough documentation, which were not carried out or reflected in the medical record for this resident.
A resident with schizophrenia, post-stroke hemiparesis, and mild cognitive impairment verbalized suicidal ideation, but the care plan did not address depression or suicidal thoughts, and required assessments and services were not accurately or timely documented. An SSD note recorded the resident saying he wanted to kill himself and referenced 15‑minute checks and a care plan update, yet the active care plan lacked depression/suicidal ideation interventions. Multiple late-entry Social Services notes were later added, describing follow-up visits and the resident denying suicidal ideation, but the SSD later reported she did not typically ask about a suicide plan and did not personally provide individual follow-up visits as described. These practices conflicted with the facility’s policy requiring factual, first-hand, and timely documentation of assessments and services.
A resident was observed with an Albuterol inhaler on an overbed table and later reported keeping the inhaler in a nightstand drawer, with no staff present during these observations. Record review showed the resident had no cognitive impairment on the admission MDS but lacked any documented self-medication administration assessment. The DON acknowledged that the required assessment had not been completed, despite facility policy requiring staff and the practitioner to evaluate each resident’s mental and physical abilities before allowing self-administration of medications.
Surveyors found that the facility submitted inaccurate direct care staffing data to CMS through the PBJ system over multiple days in a quarter. CASPER reports showed apparent gaps in 24-hour licensed nurse coverage, low weekend staffing, and a 1-star staffing rating, while internal staffing sheets documented that licensed nurses were present and the facility was fully staffed on those days. The Administrator reported that the discrepancies were due to PBJ data entry errors, despite a facility policy requiring all PBJ entries to be accurate, auditable, and verifiable against payroll, invoices, or contracts.
Surveyors found that the facility did not provide or document required written transfer/discharge notices and bed-hold policy information for four residents who were sent to the hospital, including individuals with conditions such as dementia, CHF, chronic respiratory failure, and CKD. In each case, progress notes showed that the resident was transferred for acute issues, but the clinical records lacked evidence that written notices were given to the residents or their representatives, and in one case lacked documentation that required information was sent to the receiving provider. Facility leadership, including the ADON, DON, and Administrator, acknowledged that the records did not contain the required documentation, despite a written policy requiring such notices and information exchange.
A resident with Alzheimer’s disease and depression, previously on an antidepressant, exhibited intermittent refusals of medications and care, occasional yelling at staff, and reports of unusual perceptions, such as believing men were in or near her room. Nursing notes over several months documented these refusals and complaints but did not show that the behaviors were evaluated or recorded as dangerous, non-redirectable, or causing significant distress, nor did they document specific non-pharmacological interventions attempted or their outcomes. Despite this, a psychiatric NP later added new diagnoses of schizoaffective disorder, borderline personality disorder, and delusional disorder and ordered an antipsychotic (Seroquel) without a comprehensive evaluation in the record to support these diagnoses. The facility’s psychotropic medication policy, which requires identification and documentation of target behaviors, use of nonpharmacological interventions, and ongoing behavior monitoring, was not followed for this resident.
The facility failed to keep PASARR Level I screenings accurate and current for three residents when new mental health diagnoses and psychoactive medications were initiated. One resident’s PASARR omitted a PTSD diagnosis and an added antidepressant, despite documentation of PTSD on the MDS and care plan and a physician order for Pristiq. Another resident’s PASARR listed only depression and dementia, even after additional diagnoses such as borderline personality disorder, delusional disorder, and schizoaffective disorder were added and an antipsychotic (quetiapine) was ordered, with the MDS later reflecting psychotic disorder, schizophrenia, and depression with antipsychotic and antidepressant use. A third resident’s PASARR did not include a depression diagnosis or newly ordered escitalopram and lorazepam, although the admission MDS documented depression with antianxiety and antidepressant use. These omissions occurred despite facility policy requiring a new Level I review after significant mental status changes, including new mental health diagnoses or new psychotropic medications.
Uncovered Facial Hair During Food Preparation and Meal Service
Penalty
Summary
The deficiency involves the facility’s failure to ensure that food was served in a sanitary and safe manner in accordance with professional standards and facility policy during multiple kitchen and meal service observations. During an initial kitchen observation, two dietary aides were seen walking through the kitchen food preparation area with uncovered facial hair. One aide had facial hair above and below the lip and along the jaw line, approximately one-fourth inch in length, and the other had a mustache of similar length; neither used any facial hair covering. These observations occurred while staff were present in the kitchen area where food was stored and prepared. During subsequent observations on the same day, the same two dietary aides were again observed with uncovered facial hair while directly involved in meal preparation and service. One aide walked through the kitchen while the noon meal was being prepared and placed into a transport cart for service in the south dining room, and later was observed plating the noon meal at the steamtable in that dining room, still without a facial hair covering. The other aide walked through the kitchen while the noon meal was being prepared and placed into the steamtable for the north dining room, took food temperatures, assisted with plating meals at the steamtable, and retrieved food items and supplies from the kitchen, all while having an uncovered mustache approximately one-fourth inch in length. The Dietary Manager stated that staff hair was to be covered when in the kitchen and during meal service, and the facility’s written policy and the cited Indiana Food Establishment Sanitation Requirements both required effective hair restraints, including for facial hair, to prevent contamination of food, equipment, and utensils.
Failure to Provide and Document Bed-Hold Policy at Time of Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure that required bed-hold policy information was provided and documented for four residents transferred to the hospital. For a resident with dementia, psychotic disorder, and autistic disorder who had a BIMS score of 0 indicating severe cognitive impairment, progress notes documented physician notification and guardian notification when the resident was sent to the hospital, but there was no documentation that the bed-hold policy was provided to the responsible party. A Notice of Transfer or Discharge later indicated a copy of the bed-hold policy was sent with the resident. Another resident with COPD and chronic respiratory failure, cognitively intact with a BIMS score of 13, experienced a decline in condition and was transferred to the hospital by ambulance; progress notes documented family notification but did not document any discussion of the bed-hold policy, although a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident. A third resident with altered mental status and cerebral infarction, with a BIMS score of 10 indicating moderate cognitive impairment and documented short-term memory impairment, experienced changes in condition and was transferred to the hospital. Progress notes stated the resident was their own responsible party and that no other notification was completed, and transfer documentation did not include the bed-hold policy, although an untimed Notice of Transfer or Discharge indicated a copy of the bed-hold policy was signed by the resident. A financial power of attorney document in the record showed the resident had designated an agent to act in consent or refusal of health care. For a fourth resident with dementia and osteomyelitis, transfer documentation and a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident, and the transfer form noted the resident required a proxy for decision making. The facility’s policy required that at the time of transfer to a hospital, written notice specifying the duration of the bed-hold policy and information on return to the next available bed be provided, and that a signed and dated copy of the bed-hold notice given to the resident or representative be kept in the resident file, which was not consistently documented for these residents.
Failure to Integrate Trauma Histories and Behavioral Triggers Into Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to identify and incorporate residents’ trauma histories and specific behavioral triggers into their care plans, despite documented histories of significant trauma and behavioral health issues. For one resident, extensive social service and progress notes documented homelessness, polysubstance abuse, major depressive and anxiety disorders, chronic pain, a history of severe car accidents with multiple fractures, viral encephalitis resulting in a three‑month coma, loss of child custody, multiple divorces, physical abuse by a spouse, the death of a fiancé who was struck by a car while in a wheelchair, lack of family contact, and a past suicide attempt by Valium overdose. Additional documentation noted a history of rape by a brother at age eight and prior placement under direct supervision and 15‑minute checks related to suicidal ideation. Despite these documented traumatic events and behavioral health concerns, the resident’s care plans did not identify a history of physical trauma, sexual trauma, homelessness, substance abuse, medical trauma, or attempted suicide. For this same resident, the MDS showed no cognitive deficit and identified behaviors such as verbal aggression and rejection of care, along with diagnoses including seizure disorder, depression, chronic pain syndrome, homelessness, and anxiety disorder. Multiple care plans addressed behaviors such as drug‑seeking, pretending to have seizures for attention or medication, making false allegations, verbal aggression when unable to smoke, and a desire for intimate relationships with consenting male residents. These care plans referenced goals such as effective coping skills, seeking staff support, and compliance with the smoking policy, and they called for identification and reduction of behavioral triggers. However, none of these care plans actually listed any specific triggers. The care plan addressing the resident’s right to consensual intimate relationships focused on assessment and education regarding consent but did not integrate the resident’s extensive trauma history. Staff interviews indicated the resident had displayed sexual behaviors since admission, including an incident where the resident expressed anger at another resident for not buying a soda after engaging in sexual acts. A second resident with a documented history of traumatic brain injury (TBI), dementia, seizure disorder, borderline personality disorder, anxiety, intermittent explosive disorder, tobacco use, and other behavioral/emotional disorders was also affected by the same deficiency. Social history and progress notes documented that this resident sustained a TBI after being hit by a semi‑truck while riding a bicycle at age 18, resulting in an 11‑month coma, followed by 13 years in a state hospital and subsequent residence in a group home. Additional documentation indicated the resident allegedly shot their father at age 26 after being sworn at and had a PASRR identifying TBI, intermittent explosive disorder, and borderline personality disorder, with a specific trigger of hearing the name of the current U.S. President. Progress notes also described inappropriate sexual behavior toward staff, including touching themselves intimately during personal care and refusing to stop when redirected. Despite this, the resident’s care plans, which addressed explosive disorder and history of altercations, risk for decreased psychosocial well‑being, and refusal to bathe or shower, did not list any specific behavioral triggers, did not reference the traumatic events such as being hit by a truck or shooting their father, and did not document the inappropriate sexual behavior. The Administrator and Social Service Director acknowledged that residents were to be screened for trauma and that trauma responses and PTSD should be added to care plans, but the specific trauma histories and triggers for these two residents were not incorporated into their plans of care.
Failure to Assess and Care Plan for Resident Suicidal Ideation
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess, investigate, and care plan for a resident’s suicidal ideation in accordance with its own policy and staff expectations. The resident had diagnoses including schizophrenia, cerebral edema, and hemiparesis/hemiplegia following a cerebral infarction, and a current MDS showed mild cognitive impairment (BIMS score 12). A progress note documented that the resident told the Social Services Director (SSD) he was feeling down and wanted to kill himself; the SSD offered assistance, activities, and initiated 15‑minute checks, and the note stated the care plan was updated. However, the note did not indicate that the SSD asked whether the resident had a plan to kill himself, and there were no additional notes regarding suicidal ideation or follow‑up. Review of the current care plan showed no problem, goal, or interventions addressing depression or suicidal ideation, and progress notes over the following month contained no documentation of physician notification related to the suicidal statement. Further record and interview evidence showed that the care plan conference summary did not document interventions for suicidal ideation, and the SSD acknowledged she did not normally ask residents expressing suicidal ideation if they had a plan. The SSD reported that the resident had admission paperwork mentioning suicidal ideation related to depression after a stroke and that the resident again vocalized suicidal ideation during a care plan meeting with his father, after which emotional support was offered and the father took the resident out on a leave of absence; no further visits or follow‑up were done. The DON stated that, upon notification of suicidal verbalization, staff should assess the resident, ask if there is a plan, remove potential means of self‑harm, immediately notify the psychiatric NP, and document the occurrence, and that a detailed progress note and updated care plan were expected but not present for this resident. The Administrator similarly stated that staff should ask about a plan, document interventions, notify the physician and family, and update the care plan, and indicated the resident should have had a care plan addressing depression with suicidal ideation. The facility’s written policy required immediate notification of the DON, SSD, and physician, an interview including asking about a plan and assessing mood and means for self‑harm, and thorough documentation of mood, behavior, and all actions taken, which were not reflected in the resident’s record.
Incomplete and Inaccurate Documentation of Suicidal Ideation and Follow-Up
Penalty
Summary
The facility failed to ensure accurate, complete, and timely documentation of assessments and services for a resident who verbalized suicidal ideation. Resident 6, who had schizophrenia, cerebral edema, and right-sided hemiparesis/hemiplegia following a cerebral infarction, had a BIMS score of 12 indicating mild cognitive impairment. The resident’s admission paperwork mentioned suicidal ideation related to depression after a stroke, and a Social Services note on 3/11/2026 documented that the resident was feeling down and said he wanted to kill himself. The Social Services Director (SSD) documented that she talked with the resident, coordinated with Activities, advised the resident to contact SSD or nursing if he wanted to talk, and that the resident was scheduled for 15-minute checks and the care plan was updated. However, the current care plan initiated on 2/26/2026 did not address depression or suicidal ideation. Multiple Social Services progress notes were later entered as late entries in April, with effective dates in March, stating that the resident had no plan and no longer had suicidal ideation, that he felt much better after 1:1 time, and that he continued his daily routine and therapy. These late entries described follow-up visits and reassessments of suicidal ideation on several consecutive days, but in interviews the SSD stated she did not normally ask residents about having a plan when they verbalized suicidal ideation and did not recall any other occurrences beyond the initial event. She further indicated she did not personally provide individual follow-up visits with this resident regarding suicidal ideation, despite the late-entry notes describing such visits. The DON acknowledged that late entries had been added to address concern about suicidal verbalization, and the Administrator stated that upon suicidal statements staff should ask about a plan, notify the physician and family, and update the care plan, and that this resident should have had a care plan addressing depression with suicidal ideation. The facility’s documentation policy required factual, first-hand, timely documentation, which was not followed in this case.
Failure to Complete Required Self-Administration Assessment for Inhaler Kept at Bedside
Penalty
Summary
Surveyors identified that a resident was allowed to keep and access an Albuterol inhaler without the facility completing the required self-administration medication assessment. During an initial tour, the resident was observed sitting in a wheelchair with a handheld Albuterol inhaler on the overbed table and no staff present in the room or hallway. On a subsequent observation, the resident again was in a wheelchair and reported that the Albuterol inhaler was stored in the top drawer of the nightstand, where it was found. Review of the clinical record showed an admission MDS indicating no cognitive impairment, but there was no documentation of a self-medication administration assessment. In an interview, the DON confirmed that the resident did not have the required self-medication assessment, despite the facility’s policy stating that staff and the practitioner must assess each resident’s mental and physical abilities to determine whether self-administering medications is clinically appropriate. This failure to complete and document a self-administration medication assessment for a resident who had an Albuterol inhaler kept at bedside constituted noncompliance with the facility’s own policy and with 410 IAC 16.2-3.1-11(a).
Inaccurate PBJ Staffing Data Submission to CMS
Penalty
Summary
The deficiency involves the facility’s failure to electronically submit complete and accurate direct care staffing information to CMS through the Payroll-Based Journal (PBJ) system for 22 days in a fiscal quarter. A CASPER report review on 4/6/26 showed that, according to PBJ data, the facility did not have licensed nursing coverage 24 hours per day on multiple specific dates across three months, had low weekend staffing, and held a 1-star staffing rating. However, review of the facility’s internal staffing sheets for that quarter indicated the facility was fully staffed and had licensed nurse coverage on all of the dates in question. During an interview, the Administrator stated that the PBJ information must have contained data entry errors, as she had verified licensed staff coverage on the timesheets. The facility’s PBJ policy in effect stated that all staffing data entered into the PBJ system would be auditable and verifiable through payroll, invoices, or contracts, but the submitted PBJ data did not accurately reflect the facility’s actual licensed nurse staffing as documented on internal records. No specific residents or clinical conditions were mentioned in the report, and the deficiency centers solely on inaccurate staffing data submission rather than direct resident care events.
Failure to Provide and Document Required Transfer/Discharge and Bed-Hold Notices
Penalty
Summary
The deficiency involves the facility’s failure to provide and document required written notices of transfer/discharge and bed-hold policies, as well as required information to receiving providers, for four residents who were transferred or discharged to the hospital. For a resident with generalized anxiety disorder, major depressive disorder, and dementia, progress notes showed that the resident was sent to the hospital via 911 for chest pain, lower back pain, and shortness of breath and later returned to the facility, but the clinical record lacked documentation that a written Notice of Transfer/Discharge and the bed-hold policy were provided to the resident or representative, and lacked documentation that required information was conveyed to the receiving facility. The ADON and the Administrator both confirmed there was no documentation that these written notices were provided. For a resident with congestive heart failure and muscle weakness who was sent to the emergency room for painful urination and bloody urine, the clinical record lacked documentation that a Notice of Transfer/Discharge or bed-hold policy was given to the resident or representative, which the DON confirmed. Another resident with chronic respiratory failure and diabetes was discharged to the hospital for respiratory failure, and a resident with chronic kidney disease and dementia was discharged to the hospital, but in both cases there was no documentation that a written notice of transfer/discharge or bed-hold policy was provided to the residents or their representatives. Review of the facility’s Transfer and Discharge policy, dated 1/15/26, showed that the policy required the facility to provide written transfer/discharge notices and bed-hold information to residents and representatives and to provide specified information to receiving providers, but the records for these four residents did not contain the required documentation.
Failure to Document Target Behaviors and Non-Pharmacological Interventions Before Initiating Antipsychotic
Penalty
Summary
The deficiency involves the facility’s failure to document how a resident’s behaviors presented danger or distress to self or others, and failure to document non-pharmacological interventions attempted prior to initiating an antipsychotic medication. Resident 6 had documented diagnoses of Alzheimer’s disease, depression, and severe cognitive impairment, and was receiving sertraline for depression. A PASSAR identified only depression and dementia, and the admission MDS listed Alzheimer’s disease and depression as active diagnoses. Over several months, nursing progress notes documented that the resident intermittently reported unusual perceptions, such as believing there were men causing trouble, a man in her room, or a man wanting to marry her and yelling through the walls, but there was no documentation that these episodes caused danger to the resident or others or that they resulted in unmanageable distress. From late April through mid-July, nursing notes primarily described the resident’s frequent refusals of evening and morning medications, blood sugar checks, blood pressure checks, insulin administration, hygiene care, and showers. Staff documented that the resident sometimes yelled at staff, said “Get out!”, was visibly upset by a room move, was leery of staff and asked to see name badges, and became upset about a pillow under her head until it was removed, after which she calmed down. The notes also recorded instances where the resident believed housekeeping had not cleaned her room or that she had not received medications when she had. However, there were no progress notes or assessments indicating that these behaviors were evaluated as dangerous, non-redirectable, or causing significant distress or functional impairment, and no detailed behavior monitoring logs were present as required by facility policy. On a psychiatric NP visit for initial psychotropic medication management, new mental health diagnoses of schizoaffective disorder, borderline personality disorder, and delusional disorder were added, and Seroquel 25 mg, an antipsychotic, was ordered. The clinical record did not contain a comprehensive evaluation to support these new diagnoses, and there was no documentation of target behaviors meeting the facility’s policy criteria for psychotropic use, such as behaviors representing danger to self or others, causing distress and impairment in functional abilities, or clearly attributable to psychosis or mania. The resident’s representative reported that the resident had no prior history of mental health disorders or psychiatric hospitalization and was unaware of the new diagnoses. The facility’s own psychotropic medication policy required identification and documentation of specific target behaviors, use and documentation of nonpharmacological interventions, and ongoing monitoring of behaviors and interventions, which were not reflected in the record for this resident.
Failure to Update PASARR Screens for New Mental Health Diagnoses and Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that Preadmission Screening and Resident Review (PASARR) Level I screenings were accurate and updated when new mental health diagnoses and psychoactive medications were initiated for multiple residents. For one resident with dementia, anxiety, depression, and post-traumatic stress disorder (PTSD), the PASARR completed on admission listed anxiety, depression, and dementia with sertraline and quetiapine, but did not include the PTSD diagnosis or the antidepressant Pristiq, despite the admission MDS and care plan documenting PTSD and a subsequent physician’s order for Pristiq. For another resident with Alzheimer’s disease, borderline personality disorder, delusional disorder, schizoaffective disorder, and depression, the PASARR only reflected depression and dementia with sertraline, even though additional mental health diagnoses were added later and an antipsychotic (quetiapine) was ordered for borderline personality disorder, and the quarterly MDS documented psychotic disorder, schizophrenia, and depression with antipsychotic and antidepressant use. A third resident had diagnoses including Alzheimer’s disease, depression, anxiety disorder, irritability and anger, and nonrheumatic aortic valve stenosis. The PASARR for this resident listed dementia and anxiety with Risperdal but omitted the diagnosis of depression and the medications escitalopram and lorazepam, although physician’s orders were in place for escitalopram for depression and lorazepam for anxiety, and the admission MDS documented depression with antianxiety and antidepressant use. Interviews with the Assistant Director of Nursing confirmed that new Level I PASARR screens should have been completed when new mental health diagnoses and psychoactive medications were added, and that the PASARR for one resident, completed prior to arrival, should have included all mental health diagnoses and medications. The facility’s own policy required notification of the state mental health authority within 14 days after a significant change in mental condition and specified that a new Level I screen is required for new mental health diagnoses or newly prescribed psychotropic medications, which was not followed in these cases.
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