Aperion Care Tolleston Park
Inspection history, citations, penalties and survey trends for this long-term care facility in Gary, Indiana.
- Location
- 2350 Taft St, Gary, Indiana 46404
- CMS Provider Number
- 155580
- Inspections on file
- 41
- Latest survey
- February 24, 2026
- Citations (last 12 mo.)
- 31
Citation history
Health deficiencies cited at Aperion Care Tolleston Park during CMS and state inspections, most recent first.
Surveyors found that staff failed to consistently provide and document required ADL assistance, including oral care, shaving, nail care, bathing, personal hygiene, and incontinence care, for several dependent residents. One resident repeatedly had unshaven facial hair and no oral care supplies available despite care plan orders for assisted oral hygiene. Another resident was often observed with food and mucus on his face, greasy hair, and wet clothing from incontinence, while a CNA acknowledged checks and changes were not done at the expected two-hour intervals. Additional residents were seen over multiple days with persistent facial hair, dirty or long jagged fingernails, and inconsistent showers or bed baths, even though their MDS assessments and care plans required partial to total staff assistance with personal hygiene and bathing, and there was no documentation of refusals. A review of a discharged resident’s record also showed missed scheduled showers despite a need for substantial to maximum assistance with bathing.
Two residents were not adequately protected from accidents when one cognitively impaired, fully dependent resident was left alone on the toilet and sustained an unwitnessed fall while attempting to transfer, despite a care plan identifying her fall risk and need for staff assistance, and another cognitively intact resident with supervision needs injured his foot on a broken closet door that remained hanging off its track in his room for several days, causing pain, swelling, and difficulty ambulating.
A resident with end stage renal disease left the facility for dialysis with documentation indicating no acute distress at the time of departure, but no further progress notes were entered afterward. The resident coded and died while at dialysis and did not return, yet the death was not documented in the progress notes, as confirmed by the DON. Although the resident’s discharge was reflected in the census and a Death in Facility MDS entry was completed, the absence of a progress note documenting the death resulted in an incomplete and inaccurate medical record.
A facility failed to thoroughly investigate an abuse allegation after a resident with severe cognitive impairment and multiple disabilities was reported to have been inappropriately touched by staff. The investigation was limited to a physical assessment and did not include interviews with other staff or residents, nor was the incident documented in the resident's record or communicated to the family.
Two residents who required substantial to maximum assistance with ADLs, including bathing, did not have showers or bed baths documented over extended periods. The facility relied on weekly skin assessments for documentation, but these did not indicate whether bathing was performed.
Two residents did not receive necessary care and services as ordered, including missed doses of prescribed medications for one resident and incomplete neurological and post-fall assessments for another following an unwitnessed fall. The DON was unable to provide explanations for the missed medication administrations or the incomplete documentation.
A facility failed to follow updated physician orders for a resident's pressure ulcer treatment. The resident had a pressure ulcer on the coccyx, and the physician's order was changed from a duoderm dressing every three days to a daily calcium alginate and border gauze dressing. However, the updated treatment was not transcribed into the resident's record until several days later, and the DON was unaware of the change, leading to the application of incorrect dressings.
A facility failed to ensure correct PPE use by a staff member cleaning a COVID-19 positive resident's room. The staff member wore only a surgical mask instead of the required N95 mask and face shield, despite the room being marked as a Red Zone. The resident's record confirmed COVID-19 diagnosis and droplet precautions, aligning with the facility's policy for PPE in Red Zones.
A facility failed to perform required neurological assessments every four hours for a resident identified as a fall risk after an unwitnessed fall. The assessments were incomplete, with gaps in documentation, contrary to the facility's policy. The DON acknowledged the failure to adhere to the protocol.
The facility was found to have multiple environmental deficiencies across three units, including dirty and discolored floors, marred walls, and missing or broken fixtures. Observations revealed issues such as rusty toilet bolts, missing caulk, and broken mini blinds. The Maintenance Director and Housekeeping Supervisor acknowledged these issues and were working on addressing them.
Two residents reported that staff did not knock before entering their rooms, compromising their privacy. Observations confirmed that a CNA and a housekeeper entered without knocking. Both residents had cognitive impairments, and the DON acknowledged the oversight.
The facility failed to provide adequate personal hygiene for three residents who were dependent on staff for ADLs. One resident was observed with dirty and long fingernails, while another had long facial hair despite recent shaving. A third resident was observed with facial hair, and the family had to assist with shaving. The care plans indicated a need for assistance, but documentation in the EMR was lacking.
The facility failed to complete ordered treatments for a resident with a skin condition and did not obtain a psychiatric consult for another resident on psychiatric medications. A resident's leg treatment was not documented as completed on multiple occasions, and another resident did not receive a timely psychiatric evaluation despite being on several psychiatric medications.
A facility failed to apply a palm protector as ordered for a resident with hemiplegia, observed without the device during a survey. The resident's care plan required a palm protector due to limited range of motion from a stroke. Despite physician orders, documentation was lacking in the Medication and Treatment Administration Records and electronic medical records, with no record of refusal by the resident.
A resident with a Foley catheter was observed multiple times with the catheter bag and tubing on the floor, contrary to the facility's urinary catheter care policy. Despite staff awareness, the issue persisted during various observations, including when the resident was transported for therapy. The resident had multiple medical conditions and required substantial assistance with personal hygiene.
The facility failed to manage feeding tubes properly for two residents. One resident's tube feeding was not administered according to physician's orders, while another resident's PEG tube site was not cleaned as required, leading to inadequate care. Both residents had cognitive impairments and required specific feeding interventions, which were not properly executed.
The facility failed to maintain correct oxygen flow rates for two residents. One resident was observed with oxygen set at 2.5 liters per minute instead of the prescribed 3 liters, while another had oxygen set at 3 liters per minute instead of the prescribed 2 liters. These discrepancies were confirmed by the ADON during observations.
The facility exceeded the acceptable medication error rate with two errors during medication administration. An LPN failed to prime an insulin pen before administering insulin to a resident, contrary to facility policy. Another LPN administered Aldactone to a resident despite a physician's order discontinuing the medication. These errors contributed to a medication error rate of 6.06%.
A resident with missing teeth had not seen a dentist since 2022, despite expressing a desire for dentures. The resident's medical record showed multiple health issues and moderate impairment in decision-making, but lacked a dental care plan. A misunderstanding about insurance delayed dental services, and the resident was not included on the dental list for a recent dentist visit.
A facility failed to maintain accurate clinical records for a resident with a history of aggression who was placed on 15-minute checks after an altercation. The documentation of these checks was either time-stamped incorrectly or left incomplete, as confirmed by the ADON.
The facility failed to ensure proper infection control practices, including hand hygiene during a glucometer check, PPE use for a resident under enhanced barrier precautions, and proper positioning of a Foley catheter drainage bag. An LPN did not sanitize hands before donning gloves, a CNA did not wear a gown for a resident requiring enhanced precautions, and a resident's catheter bag was observed on the floor multiple times.
Failure to Provide Consistent ADL Assistance and Hygiene Care for Multiple Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide and document adequate assistance with activities of daily living (ADLs), including oral care, shaving, nail care, bathing, personal hygiene, and incontinence care, for multiple dependent residents. One resident reported that staff did not set him up to brush his teeth and that shaving with dull razors was "very brutal"; he stated he would like an electric razor but none had been offered. Over several days of observation, this resident repeatedly had a large amount of facial hair and there was no evidence that oral care had been provided, despite care plan interventions specifying oral hygiene in the morning, after meals, and at bedtime, with partial to moderate assistance. When a CNA searched his drawers, no toothbrush or toothpaste could be found, and the CNA acknowledged she had not completed or set up oral care, even though documentation in the CNA task section indicated oral hygiene and personal hygiene had been provided on nearly all days, with no refusals noted. Another resident was repeatedly observed with food on his clothes, crumbs in his beard, a dry face with peeling skin, greasy hair, and dried mucus hanging from his nose while staff were present but did not clean his face. On one occasion, he was returned to the dining room after being checked for incontinence with his nose cleaned, but later the same day he was observed with the front of his pants and between his legs wet. The CNA caring for him stated she was supposed to check and change residents at least every two hours and reported that she had last checked him before lunch when he was dry, and then after lunch when he would not let her check him, with no further checks until the time he was found wet. Documentation showed he required supervision with eating and personal hygiene and substantial to maximum assistance with toileting and toilet transfers, and that he was mostly incontinent. CNA task documentation showed personal hygiene signed out every shift for the last 14 days, with no documentation of refusals, despite repeated observations of unaddressed hygiene needs. Additional residents were observed with persistent facial hair, long or dirty fingernails, and inconsistent bathing. One resident with Alzheimer’s disease and dementia was seen multiple times over several days with a large amount of white facial hair on her chin and face, despite care plan interventions for partial to moderate assistance with personal hygiene and no documentation of refusals for personal hygiene during the review period. Another resident with depressive and psychotic disorders and dementia was observed with a growth of facial hair and dirty fingernails, reported it had been several days since he had been shaved and that he preferred to be clean shaven, and continued to have dirty fingernails even after being shaved; his care plan required substantial to total dependence on staff for personal hygiene, with no refusals documented. A further resident with type 2 diabetes and vascular dementia was repeatedly observed over several days with facial hair on her chin and face and long, jagged fingernails, despite care plan interventions for partial to moderate assistance with personal hygiene and no documentation that she refused shaving. A closed record review for another resident with non-traumatic subarachnoid hemorrhage and chronic respiratory failure showed that the resident, who required substantial to maximum assistance for bathing, did not consistently receive showers at least twice weekly. Facility shower documentation indicated missed showers on multiple scheduled days, with only intermittent showers and bed baths recorded during the admission period. Nurse’s notes referenced a shower and patient care on certain dates, but overall records showed gaps in providing the frequency of bathing consistent with the resident’s assessed needs and care plan interventions. Across these residents, the survey findings showed discrepancies between observed care and documented CNA task entries, as well as failures to carry out care plan interventions for ADLs, including shaving, nail care, showers, personal hygiene, and timely incontinence care, without documented refusals.
Failure to Provide Adequate Supervision and Remove Environmental Hazards
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision to prevent falls for one resident and to maintain a safe, hazard‑free environment for another resident. Resident B, who had diagnoses including subarachnoid hemorrhage and chronic respiratory failure, was not cognitively intact for daily decision making and was dependent on staff for toileting and transfers. Her care plan identified her as at risk for falls and required staff to anticipate and meet her needs, keep the call light within reach, respond promptly to requests for assistance, and ensure appropriate footwear. Despite this, she experienced multiple falls, including an unwitnessed fall in the bathroom. The North Unit Manager reported that on one occasion the resident was left alone on the toilet and fell while attempting to transfer herself, even though she should not have been left unattended. The deficiency also includes the presence of an accident hazard in another resident’s room and the resulting injury. Resident C, who was cognitively intact and required supervision with ADLs, was observed with visible swelling of the right foot, ankle, and lower leg and reported that he injured his foot when a broken closet door in his room hit him while he was trying to fix it. The closet door was observed hanging off its track and away from the closet on multiple days, and the resident stated that staff were aware of the issue. He reported difficulty walking due to pain and swelling, at times ambulating with a cane and at other times propelling himself in a wheelchair with only his left shoe on because the right shoe would not fit. A nurse practitioner note documented that the resident had previously reported right foot pain after hurting his foot on the closet in his room, and the closet door remained hanging off the track during subsequent observations.
Failure to Accurately Document Resident Death in Medical Record
Penalty
Summary
The facility failed to maintain a complete and accurate medical record related to a resident death when documentation of the death was missing from the progress notes. Resident J, who had diagnoses including end stage renal disease, had a Death in Facility MDS entry completed on 12/11/25. A progress note on that date at 9:39 a.m. documented that the resident left the facility to go to dialysis with no acute distress noted at that time, and there were no further progress notes entered afterward. During interview, the Director of Nursing stated that the resident went to dialysis, coded there, died that day, and did not return to the facility, and acknowledged that the resident’s death had not been documented in the progress notes, although the discharge would have been reflected in the midnight census. This deficiency was identified for 1 of 5 residents reviewed for accidents (Resident J) and relates to Intake 2712287 under 3.1-50(a)(1), which requires safeguarding resident-identifiable information and maintaining medical records in accordance with accepted professional standards.
Failure to Thoroughly Investigate Abuse Allegation Involving Non-Communicative Resident
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of abuse involving a resident with severe cognitive impairment and multiple disabilities. An incident was reported in which a resident claimed to have witnessed inappropriate sexual contact between a staff member and another resident who was non-communicative and dependent in all activities of daily living. The facility's investigation was limited to a head-to-toe assessment of the alleged victim, a brief interview in which the resident was unable to respond, and a review of staffing and camera footage. No interviews were conducted with other staff or residents, and there was no documentation of the incident in the resident's record. Additionally, the facility did not perform a psychosocial follow-up assessment or notify the family or responsible party of the abuse allegation or investigation. The resident's medical record lacked any mention of the reported incident, and the facility's own policy required more comprehensive investigative procedures, including interviews with all relevant parties and documentation of all incidents. The administrator confirmed that no further assessments or notifications were made regarding the alleged abuse.
Failure to Complete and Document Showers for Dependent Residents
Penalty
Summary
The facility failed to ensure that activities of daily living (ADLs), specifically showers and bathing, were completed and properly documented for dependent residents. For one resident with diagnoses including spinal cord disease, schizophrenia, gout, and depression, records showed the individual required substantial to maximum assistance for most ADLs and was dependent for showering. However, there was no documentation of showers or bed baths for a three-month period, and the weekly skin assessments used by the facility did not indicate whether bathing had occurred, only documenting skin observations. Similarly, another resident with diagnoses such as COPD, depression, adult failure to thrive, dementia, cerebral palsy, and schizophrenia, also required substantial to maximum assistance for showering. Review of this resident's records revealed no documentation of showers over a nearly one-month period. In both cases, the DON confirmed that the facility relied on weekly skin assessments to document showers, but these assessments did not specify if showers or bed baths were completed.
Failure to Complete Medication Administration and Post-Fall Assessments
Penalty
Summary
The facility failed to provide necessary care and services for two residents, resulting in deficiencies related to medication administration and post-fall assessments. For one resident with diagnoses including heart disease, COPD, sepsis, depression, dementia, and anxiety, the Medication Administration Records showed that prescribed medications (aspirin, Zoloft, and Norco) were not documented as administered on multiple occasions. Physician orders required these medications to be given via PEG-tube, but the records for October and November indicated several blank entries where medications were not signed out as completed. The Director of Nursing was unable to provide an explanation for the missed doses. Another resident, with diagnoses such as respiratory failure, COPD, diabetes, kidney disease, dialysis, and dementia, experienced an unwitnessed fall. Although initial neurological checks were started, the Neurological Assessment Form was not completed at several required intervals, and the 72-hour post-fall documentation was discontinued prematurely. The resident's care plan called for ongoing assessment and interventions following the fall, but documentation and follow-up assessments were not completed as required by facility policy. The Director of Nursing confirmed that the required neurological and post-fall assessments were not fully carried out.
Failure to Follow Updated Pressure Ulcer Treatment Orders
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care for a resident, identified as Resident C, who had a pressure ulcer on the coccyx. The deficiency was observed when the Director of Nursing (DON) and Unit Manager 1 were performing pressure ulcer treatments and found that the dressing applied was not as per the physician's updated orders. The physician had ordered a duoderm dressing to be applied every three days, which was later changed to a calcium alginate and border gauze dressing to be applied daily. However, the dressing observed was a border gauze dressing dated 1/22/25, indicating a failure to follow the updated treatment plan. The resident's medical record review revealed a significant change in the treatment order on 1/17/25, which was not transcribed into the resident's record until 1/22/25. The DON was unaware of the change in orders until the day of the observation. The Treatment Administration Record showed that the duoderm dressing was applied on 1/20/25, and the new treatment was supposed to start on 1/23/25. This oversight in updating and following the physician's orders led to the deficiency in providing necessary treatment and services to promote healing of the pressure ulcer.
Failure to Use Correct PPE in COVID-19 Red Zone
Penalty
Summary
The facility failed to ensure the correct use of Personal Protective Equipment (PPE) by a staff member when cleaning a room of a COVID-19 positive resident, identified as Resident F, who was under COVID-19 Transmission-Based Precautions. During an observation, Housekeeper 1 was seen mopping the floor in Resident F's room, which was marked as a Red Zone, indicating the need for specific PPE including a N95 mask, gown, gloves, and face shield. However, Housekeeper 1 was only wearing a surgical mask and no face shield. Upon interview, Housekeeper 1 expressed uncertainty about the requirement to wear a N95 mask and face shield. Resident F's medical record confirmed a diagnosis of COVID-19 and required droplet precautions. The facility's COVID-19 policy, dated 7/24/23, specified the necessary PPE for Red and Yellow Zones, which was not adhered to in this instance.
Inadequate Neurological Assessment Follow-Up After Resident Fall
Penalty
Summary
The facility failed to complete adequate follow-up for a fall incident involving Resident B, who was identified as a fall risk due to cancer and medications. Resident B experienced an unwitnessed fall and the facility's neurological assessment protocol required checks every four hours for 24 hours following such an event. However, the documentation showed that neurological assessments were not consistently completed as required. Specifically, assessments were recorded at three intervals on the day of the fall and only once the following day, leaving gaps in the required four-hourly checks. The Director of Nursing confirmed that the assessments should have been completed and documented every four hours, as per the facility's policy.
Environmental Deficiencies in Facility Units
Penalty
Summary
The facility failed to maintain a clean and well-repaired environment for residents across three units: North, South, and PCU. Observations during an environmental tour revealed multiple deficiencies, including dirty and discolored floor tiles, marred walls, and missing or broken fixtures. In the North Unit, several rooms had issues such as discolored floors with dirt and debris accumulation, marred doors, and broken towel racks. Bathrooms in these rooms were particularly problematic, with dirty floors, scuffed tiles, and missing toilet bolt covers. In the South Unit, broken and missing mini blinds were noted, along with marred walls and dirty floors. The PCU also exhibited significant environmental issues, including scuffed floors, rusty toilet bolts, and missing caulk around toilets. The bathroom ceiling vents were found to be dusty and dirty. During an interview, the Maintenance Director and Housekeeping Supervisor acknowledged awareness of these issues and indicated ongoing efforts to address them. These findings relate to a specific complaint, IN00436414.
Failure to Maintain Resident Privacy
Penalty
Summary
The facility failed to maintain the privacy of two residents, as staff members did not knock on their doors before entering their rooms. Resident 2 reported that staff did not always knock before entering her room. This was observed when a CNA opened the door without knocking and then closed it, and another staff member partially opened the door without knocking. Resident 2's medical record indicated diagnoses including bipolar disorder, type 2 diabetes, major depressive disorder, and schizophrenia, with a moderate impairment in daily decision-making as per the Quarterly MDS assessment. Similarly, Resident 9 also reported that staff did not always knock before entering her room. This was confirmed when a housekeeper entered the room to replace a trash bag without knocking. Resident 9's medical record showed diagnoses of major depressive disorder and anxiety, with cognitive impairment in daily decision-making according to the Quarterly MDS assessment. The Director of Nursing acknowledged that staff should have knocked before entering the residents' rooms.
Failure to Provide Adequate Personal Hygiene for Residents
Penalty
Summary
The facility failed to ensure that activities of daily living (ADLs) were adequately completed for three residents who were dependent on staff for personal hygiene. Resident 35 was observed multiple times with dirty and long fingernails on both hands. The resident had a history of stroke, aphasia, diabetes, hemiplegia, heart disease, and high blood pressure, and was not cognitively intact for daily decision-making. The care plan indicated a need for staff assistance with personal hygiene, but there was no documentation in the electronic medical record (EMR) that the resident's fingernails had been cleaned or trimmed. The Assistant Director of Nursing (ADON) confirmed the need for nail care. Resident 58 was observed with long facial hair under her chin and neck, despite being shaved two days prior. The resident had diagnoses including type 2 diabetes, stroke, hemiplegia, high blood pressure, UTI, obstructive uropathy, dementia, anxiety, and depressive disorder, and was cognitively impaired for daily decision-making. The care plan noted an ADL self-care performance deficit, but no shaving was documented in the EMR. Similarly, Resident 236 was observed with facial hair, and the resident's daughter indicated that her brother was shaving him. The resident had a care plan indicating an ADL self-care deficit related to mobility and weakness, but no shaving was documented in the EMR. The ADON was unaware of the resident's preference to be clean-shaven.
Failure to Complete Ordered Treatments and Obtain Psychiatric Consults
Penalty
Summary
The facility failed to ensure that non-pressure ulcer treatments were completed as ordered for three out of four residents reviewed for skin conditions. Specifically, Resident 94 was observed with a scaly, scabbed, and inflamed left lower leg without any bandages, despite having a physician's order for Hydrocortisone cream application and wrapping with Kerlix on specific days. The Treatment Administration Records (TAR) for Resident 94 showed multiple instances from April to August 2024 where the treatment was not documented as completed. The resident's care plan indicated resistance to care and refusal of wound care, but the treatments were still not signed out as completed, as confirmed by the Assistant Director of Nursing (ADON) during an interview. Additionally, the facility failed to obtain a psychiatric consult as ordered for Resident 107, who was reviewed for unnecessary medications. Resident 107, diagnosed with multiple conditions including Parkinson's disease and psychotic disorder, was prescribed several psychiatric medications. However, there was no documentation or consents obtained for the resident to seek outside behavior management, and the psychiatric consult was not obtained in a timely manner. The ADON and Nurse Consultant confirmed the oversight during interviews, indicating a lapse in ensuring the resident received the necessary psychiatric evaluation and management.
Failure to Apply Palm Protector as Ordered
Penalty
Summary
The facility failed to ensure that a palm protector was applied as ordered by the physician for a resident with limited range of motion. During an observation, the resident was seen without the required anti-contracture device in her right hand, which was clenched like a fist. The resident's medical history includes stroke, aphasia, diabetes, hemiplegia, heart disease, and high blood pressure. The care plan specified the use of a palm protector for the resident's right hand due to hemiplegia from a stroke. The physician's orders allowed for a palm protector or a rolled washcloth to be used, but there was no documentation in the Medication and Treatment Administration Records for several months to indicate whether the palm protector was applied or removed. The electronic medical record task section also showed that the palm protector was marked as not applicable, with no documentation of refusal by the resident. The Assistant Director of Nursing confirmed the lack of documentation regarding the use of the palm protector.
Improper Foley Catheter Care Observed in Resident
Penalty
Summary
The facility failed to ensure proper care for a resident with a Foley catheter, as the catheter bag and tubing were repeatedly observed on the floor. During multiple observations, the catheter bag and tubing were seen on the floor while the resident was in bed and in a wheelchair. Staff members, including CNAs and the Director of Rehabilitation, were aware that the catheter bag should not be on the floor, yet it remained there during various times, including when the resident was transported to and from therapy. The resident involved had a history of type 2 diabetes, stroke, hemiplegia, high blood pressure, urinary tract infection, obstructive uropathy, dementia, anxiety, and depressive disorder. The resident was cognitively impaired and required substantial assistance with personal hygiene. Despite the facility's urinary catheter care policy, which mandates that catheter bags and tubing should not touch the floor, the deficiency persisted. The Director of Nursing confirmed that the catheter bag and tubing should not be on the floor, indicating a lapse in adherence to the facility's policy.
Deficiencies in Feeding Tube Management and Care
Penalty
Summary
The facility failed to ensure proper management and care for residents with feeding tubes, as observed in two cases. Resident 10, who had a PEG tube due to an intestinal obstruction and was cognitively impaired, was found with his tube feeding pump turned off and not connected to his feeding tube during scheduled feeding times. The physician's order specified that the tube feeding should be administered from 7:00 p.m. to 9:00 a.m., but observations indicated non-compliance with these orders. The resident's care plan required dependency on tube feeding and water flushes, yet these interventions were not properly executed. In the case of Resident 107, who had a PEG tube and was not cognitively intact, there was a lack of appropriate stoma site care. The resident's PEG tube site was observed with dried crusty drainage and no bandage, and there were no physician's orders for cleaning the stoma site. Despite the facility's policy requiring stoma site cleaning, the staff did not perform this care, as confirmed by interviews with the RN and the DON. The resident's care plan indicated the need for tube feeding due to swallowing difficulties, but the absence of orders for stoma care led to inadequate management of the resident's condition.
Oxygen Flow Rate Discrepancies for Two Residents
Penalty
Summary
The facility failed to ensure that oxygen was set at the correct flow rate for two residents requiring respiratory care. Resident 236 was observed multiple times with oxygen set at 2.5 liters per minute, despite the physician's order and care plan indicating it should be set at 3 liters per minute. This discrepancy was confirmed by the Assistant Director of Nursing (ADON) during an observation. Resident 236 had been admitted with diagnoses including pneumonia and high blood pressure, and the care plan specifically required oxygen therapy at the prescribed rate. Similarly, Resident 55 was observed with oxygen set at 3 liters per minute, contrary to the physician's order of 2 liters per minute. The resident's medical history included anoxic brain damage, dysphagia, hypertension, and COPD, necessitating precise oxygen therapy. The Medication Administration Record indicated that oxygen was documented as being administered at the correct rate of 2 liters, yet observations showed otherwise. The ADON acknowledged the discrepancy and noted that staff had been auditing the oxygen settings.
Medication Error Rate Exceeds 5% Due to Insulin and Discontinued Medication Errors
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, as evidenced by two errors observed during medication administration for two residents. The first error involved an LPN who did not prime an insulin pen before administering 10 units of insulin to a resident. The facility's policy requires that insulin pens be primed to remove air bubbles and ensure proper dosage delivery. This step was omitted during the medication pass, as confirmed by the 200 Unit Manager. The second error occurred when another LPN administered a 25 mg tablet of Aldactone to a resident, despite a physician's order discontinuing the medication. The error was identified upon review of the resident's records, which showed the discontinuation order dated prior to the administration. The Nurse Consultant confirmed that the medication should not have been given, as it was no longer prescribed for the resident.
Failure to Provide Annual Dental Services
Penalty
Summary
The facility failed to ensure that a resident received dental services at least annually, as required. Resident 88, who was observed with missing upper and lower teeth, reported not having seen a dentist since arriving at the facility in 2022 and expressed a desire for dentures. The resident's medical record, reviewed on 9/18/24, included diagnoses such as hypotension, anemia, adult failure to thrive, respiratory failure, heart failure, kidney disease, and dependence on renal dialysis. The Quarterly MDS assessment indicated the resident was moderately impaired in daily decision-making, yet there was no dental care plan in place. A physician's order from 2/5/24 allowed for dental care as needed, but the resident had not been seen by a dentist due to an initial misunderstanding about insurance issues, which was later corrected. Despite signing a new dental agreement on 8/29/24, the resident was not included on the dental list for the dentist's visit on 9/11/24.
Inaccurate Documentation of 15-Minute Checks for Resident
Penalty
Summary
The facility failed to maintain accurate and complete clinical records for a resident who was involved in an abusive incident. Resident 94, who has a history of schizophrenia, morbid obesity, cellulitis, high blood pressure, major depressive disorder, anxiety, osteoarthritis, and bipolar disorder, was not cognitively intact for daily decision-making according to a recent assessment. The resident had a potential for physical aggression as noted in their care plan. An incident occurred where Resident 94 pushed another resident to the ground after a verbal altercation in the bathroom. Following this incident, Resident 94 was moved to a different room and placed on 15-minute checks. However, the documentation of these 15-minute checks was found to be inaccurate and incomplete. The records showed that the checks were either time-stamped before or significantly after the actual observation times. For instance, on one day, the checks were documented at times that did not align with the required 15-minute intervals, with some periods left blank. During an interview, the Assistant Director of Nursing (ADON) confirmed that the time stamps were not accurate, indicating a failure in maintaining proper clinical records as per professional standards.
Infection Control Deficiencies in Hand Hygiene, PPE Use, and Catheter Care
Penalty
Summary
The facility failed to ensure proper infection control practices during a glucometer blood sugar check for a resident. An LPN was observed entering the resident's room and donning gloves without washing or sanitizing her hands upon entry or before putting on the gloves. The facility's hand hygiene policy, which was identified as current, indicated that hand hygiene should be completed upon room entry. This oversight was confirmed during an interview with the Nurse Consultant, who stated that it would be expected for staff to sanitize their hands prior to donning gloves. Additionally, a CNA failed to don the required personal protective equipment (PPE) for a resident under enhanced barrier precautions (EBP) due to wounds and infection. The CNA provided incontinence care to the resident without wearing a gown, as required by the EBP sign above the resident's bed. The CNA mistakenly believed the EBP was for another resident. Furthermore, a resident with a Foley catheter was observed multiple times with the catheter drainage bag on the floor, contrary to the facility's urinary catheter care policy, which mandates that drainage bags and tubing should not touch the floor. The resident's medical history included stroke, chronic kidney disease, and other conditions, and the resident was not cognitively intact for daily decision-making.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
