Aperion Care Hanover
Inspection history, citations, penalties and survey trends for this long-term care facility in Hanover, Indiana.
- Location
- 410 W Lagrange Rd, Hanover, Indiana 47243
- CMS Provider Number
- 155208
- Inspections on file
- 45
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Aperion Care Hanover during CMS and state inspections, most recent first.
A cognitively intact resident with ADHD, depression, and Huntington’s disease, whose MDS showed little interest or pleasure in activities, had a care plan calling for engagement in preferred activities such as sports-related groups, science lab, and table activities, along with encouragement of social interaction and food/fluid-promoting activities. Despite this, staff reported the resident had become bored, attention-seeking, tearful, and increasingly behaviorally dysregulated, with no person-centered activities that kept him engaged. Activity staff acknowledged they had not figured out how to involve him, noted his smoke break conflicted with the first scheduled activity, and described him walking away from activities he disliked. Observations showed the resident present but not participating during a scheduled cognitive activity and absent from other group sessions, while nursing documentation described escalating behaviors, all in contrast to the facility’s policy requiring individualized activity programs tailored to each resident’s interests and needs.
A resident with anxiety, depression, Huntington’s disease, and a history of aggressive behavior had a care plan identifying risk for physical aggression and an intervention to analyze and document triggers and de-escalation strategies. On one night and early morning, staff observed the resident pacing the hallway, repeatedly opening and shutting his door, and playing his TV at maximum volume, becoming upset when asked to close his door and refusing, with increased behaviors noted. Despite this escalation and prior assessments documenting aggressive tendencies, the resident later approached the nurses’ station and suddenly punched another resident in a wheelchair in the face, knocking him backward and kicking him, then cursed, threatened, and lunged at staff, attempting to hit an LPN. The DON reported the resident had strong behaviors and agitation with limited observable signs before negative behaviors, demonstrating a failure to ensure his emotional and mental well-being was closely monitored and supported during escalating behavior.
A resident with mild cognitive impairment and dementia was subjected to repeated yelling by a CNA during shower care, as reported by another cognitively intact resident and confirmed by an LPN who intervened. The incident involved the CNA telling the resident to be quiet and continued down the hallway, violating the facility's policy on resident dignity and respect.
The facility failed to maintain effective pest control, leading to gnats in resident areas, and did not address chipping concrete, resulting in a resident's fall. Observations showed inadequate cleaning and maintenance documentation, with pest control not treating resident rooms. A resident fell due to chipping concrete, previously reported but not addressed, causing minor injuries.
The facility did not make State survey results readily available for residents and visitors, as required. Observations showed that the results, meant to be in a white binder in the living room, were not visible. Instead, they were in the Administrator's office, inaccessible without staff assistance. The MDS Coordinator confirmed this issue, and the Administrator acknowledged the lack of a policy to ensure accessibility.
The facility failed to maintain a clean and safe environment in Wing 2 and the courtyard. Observations revealed dirty shower rooms, missing tiles, and a chipped concrete sidewalk. A resident fell in the courtyard due to the sidewalk issue, resulting in injuries. Housekeeping and maintenance practices were inadequate, with no documentation of completed tasks or inspections. Facility policies were not effectively implemented, compromising resident safety and comfort.
The facility failed to store medications appropriately in one medication storage room and on three medication carts. Unopened bags and boxes were found on the floor in the Wing 2 Medication Storage Room. Loose pills, including Tylenol, coenzyme, risperidone, baclofen, and trazodone, were found in the drawers of Wing 2 and Wing 3 Medication Carts. An LPN acknowledged the carts were dirty and stated they would be cleaned.
The facility failed to follow guidelines for hairnet use in the kitchen, with the Dietary Manager, two cooks, and the Corporate Dietary Consultant observed with exposed hair during food preparation. The DM acknowledged the requirement for hairnets to cover all hair, as per the facility's policy.
A resident with diabetes did not receive prescribed insulin on three consecutive evenings, as documented in the EMAR. The facility's policy required documentation and physician notification for missed doses, but records lacked explanations for the omissions. An RN confirmed that medication refusals or withholdings should be documented, indicating a failure to adhere to medication administration guidelines.
A facility failed to monitor a resident's meal consumption and provide prescribed nutritional supplements. The resident, with multiple health conditions, had incomplete meal records and missed doses of a prescribed mighty shake supplement. Despite facility policies requiring documentation and administration of prescribed nutrition, these were not followed, leading to deficiencies in care.
A resident with Huntington's disease did not receive their prescribed medication, Austedo, on multiple occasions due to unavailability from the pharmacy. The facility's records lacked documentation of notifying the physician or pharmacy about the issue, contrary to the facility's policy. An LPN stated the procedure for such situations, but the resident's clinical record did not reflect these actions.
The facility failed to address pharmacy recommendations for medication irregularities for three residents. A pharmacist's suggestions for reviewing duplicate orders, updating diagnoses, and considering dose reductions were not documented as being addressed by physicians. The DON confirmed that recommendations were not reviewed or acknowledged, contrary to facility policy.
The facility failed to follow infection control guidelines for enhanced barrier precautions during wound care for three residents. Despite signs indicating the need for gowns and gloves, an LPN and an RN provided wound care without donning gowns. The facility's policy requires such precautions to prevent the transmission of multidrug-resistant organisms.
A resident with Huntington's disease and a history of aggression had multiple incidents of physical and verbal aggression towards staff and other residents. Despite these behaviors, the care plans addressing the resident's aggression had not been updated since November, even after significant incidents in December and January. The MDS coordinator admitted to updating the wrong care plan, leading to a deficiency in maintaining current care plans.
A resident with psychosocial adjustment difficulties and a history of trauma did not receive appropriate psychiatric services despite exhibiting behaviors such as anger, threats, and refusal of dialysis. The resident, who was cognitively intact and had conditions like anxiety and depression, showed signs of needing psychiatric intervention, which was not provided, contrary to the facility's policy on Behavioral Health Services.
A facility failed to investigate an abuse allegation involving a resident who was allegedly cursed at by a CNA. An LPN witnessed the incident and instructed the CNA to leave, but the CNA returned to work the next day. The Administrator interviewed the resident, who denied the incident, and only provided customer service education to the CNA without further investigation. The facility's policy requires a thorough investigation, which was not conducted.
A resident was temporarily moved to a different room due to COVID-19 exposure, but several personal belongings were left behind, leading to the resident's distress. Despite being informed of the temporary nature of the move, the resident's behavior escalated, resulting in her transfer to a psychiatric facility. The facility's policy on resident rights was not fully adhered to, as the resident's right to retain personal possessions was compromised.
The facility failed to maintain an effective pest control program, resulting in the presence of rodents. Observations revealed multiple open doors, food debris, and mouse droppings in the kitchen and storage areas. Staff interviews indicated inconsistent pest control measures and a lack of awareness about the pest issues.
The facility failed to maintain a clean and sanitary kitchen, with open doors, food debris, and overflowing trash observed. Cleaning schedules were incomplete, and staff cited being short-staffed as the reason for not documenting cleaning. The Administrator was unable to find a kitchen policy.
The facility failed to report investigation outcomes to the IDOH within the required 5 working days for nine incidents involving multiple residents, including drug diversion, resident-to-resident incidents, falls with injuries, and a resident-to-visitor incident. The Administrator acknowledged the delay and the facility's policy was not followed.
The facility failed to administer medications and monitor residents with behavioral health concerns. A resident with Huntington's Disease did not receive prescribed Haldol on multiple occasions, and another resident with dementia was not adequately monitored after returning from a Neuropsychiatry Hospital. Facility policies on medication administration and behavioral health services were not followed.
Failure to Provide Person-Centered Activities to Meet a Resident’s Psychosocial Needs
Penalty
Summary
The deficiency involves the facility’s failure to provide person-centered activities that met a cognitively intact resident’s interests and supported his physical, mental, and psychosocial well-being. The resident had diagnoses including ADHD, depression, and Huntington’s disease, and his MDS mood assessment showed he had little interest or pleasure in doing things nearly every day. His care plan identified a potential for altered activity pattern related to preferences, with goals for him to attend group activities of interest such as sports-related groups, science lab, and table activities, and interventions including explaining the importance of social interaction and inviting him to activities that promote intake of food and fluids. Despite this, the resident’s activity participation declined steadily since November 2025, and he was noted to now participate only in church and singing activities. Staff interviews and observations showed that the facility did not effectively implement individualized, person-centered activities for this resident. A CNA reported that the resident had become obsessed with attention, bored easily, cried frequently, and became upset when family did not answer his calls, and that there were no person-centered activities that kept him engaged. An activities staff member stated they had not figured out how to get him more involved, that his scheduled smoke break conflicted with the first daily activity, and that he would get mad, say he was bored, and walk away if he did not like the activity. On observation, during a scheduled “Whole Brain” activity, the resident was present in the dining room but was only eating and not involved in the activity, and he was not present in the sunroom during later scheduled activities. A nurse’s note documented behavioral issues including unsteady gait, refusal to sit, yelling, attempting to hit staff, and demanding staff call his family. These findings contrasted with the facility’s policy requiring identification and involvement of each resident in an ongoing program of activities designed to appeal to their interests and needs, including specialized or extended programs.
Failure to Monitor and Manage Escalating Behavioral Symptoms Leading to Resident Assault
Penalty
Summary
The facility failed to adequately monitor and address a resident’s escalating behavioral health symptoms, resulting in an aggressive resident-to-resident altercation. The resident had an Annual MDS showing he was unable to complete the cognition interview and had diagnoses including anxiety, depression, and Huntington’s disease, with continual disorganized thinking. His care plan, initiated earlier, identified a potential for physical aggression such as hitting, kicking, punching, and choking staff and other residents related to an impulse control disorder, and included an intervention to analyze and document times of day, places, circumstances, triggers, and de-escalation strategies. An Aggressive Behavior Assessment documented a history or recent episodes of aggressive or agitated behavior and substantial non-compliance with medications, treatment, or care. On the night and early morning in question, nursing staff observed the resident pacing up and down the hallway, repeatedly opening and shutting his door, and playing his TV at maximum volume, which was disrupting other residents. He became upset when staff asked to close his door and refused to allow it to be closed, with increased behaviors noted afterward. Communication about his behavior was sent to the Assistant DON, and management voiced understanding. Later that morning, the resident exited his room, walked toward the nurses’ station with his hands behind his back, and, without prior verbal request, punched another resident sitting in a wheelchair near the nurses’ station in the face with a closed fist, knocking him backward out of the wheelchair and then kicking him. Staff separated the residents as the aggressive resident continued to curse, threaten, and lunge at staff, attempting to hit the on-duty nurse. The DON stated the resident had strong behaviors, became agitated, walked up and down the hallway, and did not show many signs before a negative behavior, indicating the facility did not ensure his whole emotional and mental well-being was closely monitored during his escalating behavior.
Failure to Maintain Resident Dignity During Shower Care
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to treat a resident with respect and dignity during the provision of care. According to interviews and observations, the CNA repeatedly yelled "Shut up" at a resident while attempting to provide a shower. This incident was witnessed by another resident, who reported hearing the yelling from her room next to the shower area, and by an LPN who observed the CNA getting loud and telling the resident to be quiet. The LPN intervened and instructed the CNA to calm down. The Director of Nursing (DON) confirmed receiving a report of the incident, which included the CNA yelling at the resident and telling her she did not need to go to the bathroom, with the yelling continuing down the hallway. The resident who was the subject of the incident was described as mildly cognitively impaired, dependent on staff for activities of daily living related to showers, and diagnosed with non-Alzheimer's dementia. Despite the incident, the resident later reported no concerns with care and stated that staff were always nice to her. Another resident who overheard the incident was cognitively intact and had diagnoses including depression and anxiety. The facility's policy on dignity requires staff to promote care in a manner that maintains or enhances each resident's dignity and respect, which was not followed in this instance.
Pest Control and Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of gnats or drain flies in residents' bathrooms and bedrooms. Observations over several days revealed sticky floors, strong urine odors, and black debris around toilet bases in the Wing 2 Shower Room. Multiple instances of gnats were observed flying in shared bathrooms and resident bedrooms, with residents indicating that the problem had persisted for some time. The pest control provider visited the facility bi-weekly but did not treat residents' bedrooms or bathrooms, focusing instead on common areas and the kitchen. Additionally, the facility's housekeeping practices were found lacking. Although there were check-off lists for cleaning tasks, the Housekeeping Supervisor could not provide completed checklists, and none included cleaning the walls of the shower rooms. The Maintenance Director conducted daily building inspections but did not document his observations. The pest control records showed only one documented service in the past three months, labeled as a 'One Shot' service, which was a one-time treatment for gnats and drain flies. In a separate incident, a resident fell in the courtyard while propelling himself in a wheelchair, which was attached to his back with a seat belt. The fall occurred due to chipping concrete, which had been reported in a maintenance request two weeks prior. The resident sustained a scrape on the forehead and a bump on the head. The facility's policies on housekeeping, preventative maintenance, and falls were not effectively implemented, contributing to the deficiencies observed.
Survey Results Not Accessible to Residents and Visitors
Penalty
Summary
The facility failed to make the State survey results readily available for viewing by residents and visitors for two out of six days during the survey period. Observations on multiple occasions revealed that the survey results, which were supposed to be in a white binder in the living room, were not visible in the designated areas. Instead, the survey results were found in a pile in the Administrator's office, inaccessible without asking staff for assistance. The Minimum Data Set (MDS) Coordinator confirmed that the results were not accessible as required, and the Administrator admitted that there was no specific policy in place to ensure the survey results were available for public viewing, relying instead on following the regulation.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a clean and safe environment in Wing 2 and the outside courtyard, as observed during a survey conducted from March 21 to March 27, 2025. In Wing 2, the shower room was found with sticky floors, a strong urine odor, and black debris around the toilet base and shower stall tiles. Additionally, a shared bathroom had a shallow pit in the floor where tiles were missing, posing a risk to residents, including one who was unsteady on his feet. The bathroom also had a strong urine odor, and a resident's bathroom door had brown stains and debris on the doorknob. Interviews revealed that the housekeeping staff had cleaning check-off lists, but no completed checklists were available, and the maintenance director did not document his daily observations. In the courtyard, Resident B fell while propelling himself in his wheelchair due to a chipped concrete sidewalk. The resident, who used a seat belt for positioning, fell forward with the wheelchair still attached, resulting in a scrape on his forehead and a bump on his head. A CNA had previously submitted a work order for the concrete issue two weeks prior, but no action had been taken. The facility's policies on housekeeping, preventative maintenance, and falls were not effectively implemented, as evidenced by the lack of documentation and the failure to address known hazards. The report highlights deficiencies related to the facility's failure to provide a safe, clean, and comfortable environment for its residents. The lack of proper maintenance and housekeeping practices contributed to unsafe conditions, such as the dirty shower room, missing tiles, and chipped concrete, which ultimately led to Resident B's fall. The facility's policies were not adequately followed, resulting in an environment that did not meet the residents' rights for safety and cleanliness.
Medication Storage Deficiency
Penalty
Summary
The facility failed to store medications appropriately in one of its medication storage rooms and on three of its medication carts. During an observation, it was noted that the Wing 2 Medication Storage Room had three unopened bags of g-tube feeding formula and six unopened boxes sitting directly on the bare floor. The Director of Nursing indicated that these boxes were supplies. Additionally, a Wing 2 Medication Cart was found to contain a loose round tan pill inside a drawer, which was removed and disposed of by an LPN. Further observations revealed that a Wing 3 Medication Cart contained several loose pills, including a white round pill identified as Tylenol, an oval pill identified as a coenzyme, a small white pill identified as risperidone, and a small yellow/tan pill identified as baclofen. These pills were removed by an LPN and placed in a medication cup. Another Wing 3 Medication Cart was found to contain a loose white round pill, small papers, and powdered pill substances in the corners of the drawers. An LPN indicated that the loose pill was trazodone and acknowledged that the cart was dirty, stating that nurses were responsible for cleaning the medication carts and that she would clean it that day.
Failure to Properly Use Hairnets in Kitchen
Penalty
Summary
The facility failed to adhere to appropriate guidelines regarding the use of hairnets in the kitchen, as observed during three separate kitchen inspections. The Dietary Manager (DM) was noted to have three inches of hair exposed outside her hairnet on multiple occasions while in the food preparation area. Additionally, during another observation, two cooks and the Corporate Dietary Consultant were also found with hair exposed outside their hairnets. The DM acknowledged in an interview that hairnets should cover all hair and suggested using two hairnets if necessary. The facility's Hair Restraints policy, dated 2020, mandates that staff wear hair restraints in all food production, dishwashing, and serving areas.
Failure to Administer Prescribed Insulin
Penalty
Summary
The facility failed to administer prescribed insulin to a resident, identified as Resident 12, who was moderately cognitively impaired and had diagnoses including diabetes, hypertension, dementia, and paranoid schizophrenia. The physician's order required Humalog insulin to be administered after meals, but the Electronic Medication Administration Record (EMAR) for January 2025 showed that the insulin was not documented as given on three consecutive evenings. The resident's blood glucose levels on these dates were notably high, indicating a potential impact from the missed doses. The facility's policy required documentation if a medication dose was withheld, refused, or not available, and mandated physician notification if three consecutive doses of a vital medication were missed. However, the records lacked any documentation explaining why the insulin was not administered, and there was no indication that the physician was notified. An interview with RN 6 confirmed that any refusal or withholding of medication should be documented, and the EMAR should not have blanks, highlighting a lapse in following the facility's medication administration guidelines.
Failure to Monitor Nutrition and Provide Supplements
Penalty
Summary
The facility failed to adequately monitor meal consumption and provide necessary nutritional supplements for a resident diagnosed with Huntington's disease, anemia, seizure disorder, anxiety, depression, and abnormal weight loss. The resident's meal consumption records were incomplete, lacking documentation for numerous dinner meals over a span of nearly three months. A Certified Nurse Aide (CNA) confirmed that meal consumptions should be documented electronically after each meal, including instances where a meal is refused. However, the facility's policy on caregiver documentation was not adhered to, as evidenced by the missing meal records. Additionally, the resident was prescribed a nutritional supplement, a mighty shake, to be administered with meals. The Electronic Medication Administration Record (EMAR) showed that the resident did not receive the supplement on several occasions in March 2025. Progress notes indicated that the mighty shakes were unavailable during these times. A Licensed Practical Nurse (LPN) stated that if the shakes were unavailable, an alternate supplement should be provided and documented, although she was unaware of any shortages. The facility's policy on medication administration requires that medications be administered as prescribed, which was not followed in this case.
Failure to Ensure Medication Availability for Resident
Penalty
Summary
The facility failed to ensure the availability of a prescribed medication for a resident diagnosed with Huntington's disease, chorea, hypertension, and depression. The resident was supposed to receive Austedo, a medication for chorea, but did not receive it on multiple occasions as documented in the Electronic Medication Administration Record (EMAR). Specifically, the medication was not administered on several dates in September, October, and November 2024 due to its unavailability from the pharmacy. The clinical record lacked documentation that the physician or pharmacy was notified about the medication's unavailability. During an interview, an LPN indicated that if a medication was unavailable, they would check the emergency drug kit, contact the pharmacy, and notify the physician, documenting these actions in a progress note. However, the resident's clinical record did not reflect these steps. The facility's policy on medication administration requires that if three consecutive doses of a vital medication are not available, the physician must be notified, and the notification documented. This policy was not adhered to in the case of the resident, leading to the deficiency.
Failure to Address Pharmacy Recommendations for Medication Irregularities
Penalty
Summary
The facility failed to address pharmacy recommendations for three residents regarding medication irregularities. For Resident 37, the pharmacist recommended reviewing duplicate orders for Loperamide and updating the diagnosis for Topamax, as well as considering a dose reduction for Duloxetine. However, there was no indication that the physician responded to these recommendations. The Director of Nursing (DON) confirmed that recommendations were usually followed up within a week, but there was no documentation of the physician's response in this case. For Resident 32, the pharmacist recommended adding a 14-day stop date to the Lorazepam order, but the clinical record lacked evidence that the physician was informed of this recommendation. The DON acknowledged that the pharmacy review was not reviewed or acknowledged. Similarly, for Resident 4, the pharmacist suggested a trial dose reduction for Mirtazapine, Sertraline, and Trazadone, but there was no indication of a response from the physician. The facility's policy required the DON to notify the physician of any irregularities, but this was not documented in the residents' records.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to adhere to infection control guidelines related to enhanced barrier precautions during wound care for three residents. Resident 75, who was cognitively intact and diagnosed with conditions including Parkinson's disease and metastasized bone cancer, was observed receiving wound care without the attending LPN donning a gown, despite a sign indicating the need for enhanced barrier precautions. Similarly, Resident 4, who was moderately cognitively impaired and had diagnoses such as Parkinson's disease and diabetes, also received wound care from the same LPN without the use of a gown, contrary to the posted precautions. Resident 31, who was moderately cognitively impaired and diagnosed with conditions including dementia and diabetes, was also observed receiving wound care without the attending RN donning a gown, despite the presence of a sign indicating enhanced barrier precautions. The facility's policy on enhanced barrier precautions, which was revised in May 2024, mandates the use of gowns and gloves during high-contact resident care activities to prevent the transmission of multidrug-resistant organisms. However, this policy was not followed during the observed wound care activities for these residents.
Failure to Update Care Plans for Aggressive Resident
Penalty
Summary
The facility failed to update care plan interventions for a resident, identified as Resident C, who exhibited aggressive behaviors. Resident C, who was cognitively intact and diagnosed with anxiety, depression, and Huntington's disease, was involved in multiple incidents of physical and verbal aggression. These incidents included a physical altercation with another resident and several instances of verbal aggression and physical threats towards staff members. Despite these behaviors, the care plans addressing Resident C's potential for aggression had not been updated since November 2024, even after significant incidents occurred in December 2024 and January 2025. The facility's policy requires comprehensive care plans to be developed and revised to incorporate the resident's goals and needs. However, the MDS coordinator admitted to updating the wrong care plan following an altercation on December 1, 2024. The Social Service Director confirmed that the care plans for Resident C's aggressive behaviors had not been revised since November 2024, despite the noted increase in aggressive behavior. This oversight led to a deficiency in ensuring that care plans were current and reflective of the resident's needs and behaviors.
Failure to Provide Psychiatric Services for Resident with Psychosocial Difficulties
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident, identified as Resident C, who displayed psychosocial adjustment difficulties and had a history of trauma. Resident C, who was cognitively intact and diagnosed with conditions including renal insufficiency, diabetes, anxiety, and depression, exhibited several behavioral issues. These included slamming doors, making threats towards a roommate, and expressing anger towards staff. Despite these behaviors and a care plan intervention indicating the need for psychiatric or psychological services, Resident C did not receive such services. The Social Services Director acknowledged that the resident's behavior indicated a need for psychiatric services, yet these services were not provided. The clinical record and interviews revealed multiple incidents where Resident C expressed frustration and anger, including refusing dialysis due to dissatisfaction with transportation services and using offensive language towards staff. The facility's policy on Behavioral Health Services aimed to ensure residents received appropriate treatment to attain the highest practicable mental and psychosocial well-being. However, the facility did not adhere to this policy, as evidenced by the lack of psychiatric services for Resident C, despite clear indications of need. This deficiency was identified during a complaint investigation related to Resident C's care.
Failure to Investigate Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an abuse allegation involving a resident who was cognitively intact and had diagnoses including diabetes, hypertension, depression, and bipolar disorder. The incident occurred when a CNA allegedly cursed at the resident during dinner time. An LPN witnessed the CNA cursing at the resident and instructed the CNA to clock out and go home. Despite this, the CNA returned to work the next evening. Another CNA corroborated the LPN's account, indicating she also heard the CNA curse at the resident. The Administrator was informed of the incident and interviewed the resident, who denied the allegations. The Administrator only provided customer service education to the CNA and did not conduct a further investigation. The facility's policy requires a thorough investigation of abuse allegations, including interviewing or assessing all residents on the affected hall and usually suspending the employee in question for three days. However, the facility did not follow these procedures, and the resident's clinical record lacked documentation related to the allegation.
Failure to Honor Resident's Rights During Room Change
Penalty
Summary
The facility failed to honor a resident's rights concerning personal possessions during a temporary room change due to a COVID-19 situation. Resident E, who was cognitively intact and had diagnoses including COPD, hypertension, diabetes, arthritis, and depression, was moved to a different room to accommodate a male resident exposed to COVID-19. During this move, several of Resident E's belongings were left behind in her previous room, including personal items such as wall hangings, clothes, snacks, and a memorial board. Although staff indicated that non-essential items were left behind and could be retrieved upon request, Resident E became upset about the room change and the handling of her possessions. The Director of Nursing explained that the move was temporary and necessary due to the COVID-19 exposure, and Resident E was informed it would last about a week. However, the resident's behavior escalated following the move, leading to her being sent to an inpatient psychiatric facility. The facility's policy on resident rights, which includes the right to retain and use personal possessions to the maximum extent that space and safety permit, was not fully adhered to in this situation. This incident was part of a complaint investigation, highlighting a deficiency in respecting resident rights.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to ensure an effective pest control program was maintained, resulting in the presence of rodents. During an observation and interview, a gray mouse was seen running in the Social Service Director's (SSD) office, and the SSD indicated that the pest control measures in place were ineffective. Further observations revealed multiple open doors in the service hallway and kitchen, which could facilitate rodent entry. In the dry storage room, mouse droppings and chewed food packages were found, indicating a significant rodent problem. Additionally, the kitchen area was observed to have overflowing trash, food debris, and mouse droppings, further evidencing the pest issue. Interviews with staff revealed a lack of awareness and inconsistent pest control measures. The Cook was unsure of any pest issues, and the Dietary Aide mentioned not seeing the pest control company for about a month. The Administrator confirmed that the pest control company visited monthly and had been called recently due to the mouse sighting in the SSD office. However, pest control logs were not provided during the survey. The facility's pest control policy indicated regular and as-needed pest control services, but the observations and staff interviews suggested that these measures were not effectively implemented.
Facility Fails to Maintain Clean and Sanitary Kitchen
Penalty
Summary
The facility failed to provide a clean and sanitary kitchen, as observed during a survey. The service hallway doors leading to the kitchen were open, and no staff were present in the dish room or main kitchen. The dry storage room had a cardboard box of cheerios on the floor, and the floor and baseboard were black with food debris. A trash can between a milk cooler and the ice machine was overflowing with trash, and the lid was lying on the floor. Behind the stove, there was an open and empty jelly container, dried cooked green beans, and other food debris. The serving room contained steam tables with food crumbs and insulation underneath them. Cleaning schedules were provided but lacked documentation of cleaning on several dates, and staff indicated they were unable to check off the cleaning schedules due to being short-staffed. During an interview, the Administrator indicated that she thought the cleaning schedules were ready when the Dietary Manager left for vacation. However, the cleaning schedules were not completed. Later observations showed that some corrective actions were taken, such as removing the cardboard box of cheerios from the floor and emptying the trash can. The Administrator was unable to find a kitchen policy and had contacted corporate support, but a policy was not provided upon exit.
Failure to Timely Report Investigation Outcomes to IDOH
Penalty
Summary
The facility failed to ensure all investigations and outcomes of the investigations were reported to the Indiana Department of Health (IDOH) within 5 working days of the incident for nine reported incidents involving multiple residents. Specific incidents included a possible drug diversion, several resident-to-resident incidents, resident falls with injuries, and a resident-to-visitor incident. The follow-up outcomes of these investigations were significantly delayed, with all being reported on 04/24/24, well beyond the required 5-day period. During an interview, the Administrator acknowledged being behind on completing the 5-day follow-ups and indicated an intention to comply with State and Federal regulations. The facility's policy on verbal/mental abuse allegations and the quality assurance checklist was reviewed, which mandates that final reports be submitted to the ISDH. However, this policy was not adhered to in the cases reviewed, leading to the identified deficiency.
Failure to Administer Medications and Monitor Residents with Behavioral Health Concerns
Penalty
Summary
The facility failed to administer medications and monitor residents with behavioral health concerns for two residents. Resident B, who has Huntington's Disease, anxiety, depression, and a psychotic disorder, did not receive his prescribed Haldol medication on multiple occasions in March. An incident occurred where Resident B bumped into another resident's wheelchair, leading to a verbal altercation. Despite the incident, neither resident was placed on increased monitoring. Additionally, after Resident B returned from a Neuropsychiatry Hospital, there were no follow-up visits from Social Services until several days later, and he was not placed on 15-minute checks immediately upon return. Resident D, who has dementia, anxiety, and depression, was also not adequately monitored after returning from a Neuropsychiatry Hospital. The clinical record lacked any Social Service visits since her return. Resident D had a history of physical altercations and expressed violent intentions towards another resident. Despite this, she was taken off 15-minute checks without the SSD's involvement in the decision. The psychologist later recommended restarting the 15-minute monitoring due to the resident's impulsivity and recent hospitalization. The facility's policies on medication administration and behavioral health services were not followed. Medications were not documented in the EMAR after administration, and appropriate interventions consistent with individualized care plans were not implemented. The facility's failure to adhere to these policies resulted in inadequate care and monitoring for residents with behavioral health concerns.
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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