Bethel Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Evansville, Indiana.
- Location
- 6015 Kratzville Rd, Evansville, Indiana 47710
- CMS Provider Number
- 155607
- Inspections on file
- 24
- Latest survey
- March 16, 2026
- Citations (last 12 mo.)
- 32
Citation history
Health deficiencies cited at Bethel Manor during CMS and state inspections, most recent first.
Staff failed to protect resident privacy and dignity when CNAs repeatedly entered multiple resident rooms to deliver meal trays without knocking or announcing themselves. During an observed supper meal service, CNAs entered several rooms in succession without prior notice to the occupants. A CNA later acknowledged that staff are expected to knock, announce themselves, identify their department, and request permission before entering a room, and the facility’s dignity policy states that residents are to be treated with respect and their rights protected.
Surveyors found that kitchen equipment and floors were soiled with grease, food buildup, and debris, including under sinks, tables, and around the hot water heater. Despite having cleaning schedules and policies, staff interviews confirmed that required cleaning tasks were not consistently performed, resulting in unsanitary conditions that did not meet professional food service standards.
The facility failed to provide adequate assistance with showering and bathing for four residents who required substantial assistance. Multiple residents expressed concerns about not receiving routine showers or complete bed baths. Clinical records revealed that residents received significantly fewer showers than scheduled, with no documented refusals in most cases. The DON confirmed the expectation for residents to receive at least two showers weekly, but a shower policy was not provided.
The facility failed to provide consistent restorative nursing therapy to residents with limited mobility, as evidenced by insufficient therapy sessions for four residents. A resident with Alzheimer's and polyosteoarthritis received only five days of therapy over 12 weeks, despite needing regular exercises. Another resident with diabetes and chronic kidney disease also received minimal therapy. A resident with hemiplegia had only one documented walking session in 30 days, and a resident with diabetes and vascular disease had no recorded restorative care minutes. The lack of a dedicated restorative aide contributed to these deficiencies.
The facility's Cottage kitchen failed to maintain proper dishwasher temperatures and chemical levels, with incomplete logs for June and July. A dietary aide was unsure of the required temperatures, and attempts to reach the necessary 120°F were unsuccessful. Additionally, refrigerator and freezer temperature logs were frequently incomplete, contrary to facility policy.
The facility failed to implement Enhanced Barrier Precautions for three residents requiring transmission-based precautions, as PPE carts lacked signage and clinical records were incomplete. Additionally, a fan in the laundry room was improperly positioned, blowing air from soiled to clean linen areas, contrary to infection control policies.
The facility failed to assess two residents for their capability to self-administer medications. One resident, who was severely cognitively impaired, had Desitin at their bedside without an assessment or care plan. Another resident, who was cognitively intact, had a pill at their bedside without an order or assessment for self-administration. The facility's policy requires an interdisciplinary team assessment for self-administration, which was not conducted.
The facility failed to maintain resident privacy during medication administration when an LPN left a medication cart unattended with resident information visible on the computer screen. This occurred on two separate occasions, involving two residents, while the LPN was away from the cart. The facility's policy on confidentiality was not followed, as staff were expected to hide and/or lock computer screens to protect resident privacy.
A resident with Alzheimer's and severe cognitive impairment was physically abused by a CNA during care, resulting in a laceration above the left eye. The resident became combative, and the CNA, who had a history of PTSD, reacted by striking the resident. The incident was witnessed by a QMA, who reported it to the nurse on call. The facility's abuse policy was reviewed, and the CNA expressed remorse, with the incident considered isolated.
The facility failed to implement person-centered care plans for two residents, leading to deficiencies in their care. One resident, with Alzheimer's and anxiety, lacked care plans for monitoring multiple medications. Another resident, also with Alzheimer's, had a care plan for managing behavior and communication needs, but staff failed to follow it during incontinence care, causing distress. The DON confirmed care plans should be updated with new issues.
A resident with anxiety, depression, and psychotic disorder was given the wrong nasal spray medication, leading to rebound congestion. The NP intended for the resident to receive saline nasal spray, but Oxymetazoline HCl was administered instead. The error was discovered after the resident experienced symptoms following the discontinuation of the medication. The facility's policy on medication orders was not adhered to, resulting in this significant medication error.
The facility failed to prevent and properly care for pressure ulcers in two residents. One resident had a sacral pressure ulcer that was not covered as ordered, with inconsistent wound assessments and care. Another resident with diabetes and peripheral vascular disease had an unstageable heel ulcer, but weekly assessments were not conducted. The facility did not adhere to its policies on pressure injury prevention and management, leading to deficiencies in care.
Three residents experienced multiple falls due to inadequate supervision and failure to update care plans. Despite being deemed unsafe for independent mobility, a resident continued to fall without new interventions. Another resident's fall interventions were not properly documented or implemented, and a third resident fell due to insufficient assistance during transfers.
A facility failed to manage oxygen equipment properly and adhere to physician orders for a resident with COPD and diabetes. The resident's oxygen tubing was not labeled correctly, and there was no oxygen warning sign on the door. The resident's care plan required weekly changes of oxygen supplies, which were not followed, as confirmed by an LPN. The facility's policy also required an oxygen warning sign, which was missing.
The facility failed to implement care plans for two residents with dementia, leading to inadequate monitoring of symptoms and behaviors. One resident, significantly cognitively impaired, lacked a dementia care plan despite being on multiple medications. Another resident with Alzheimer's exhibited exit-seeking and agitation, yet had no care plans addressing these behaviors, resulting in a fall. The facility's policies on dementia care and elopement were not followed.
A resident with severe cognitive impairment did not receive their prescribed Pravachol medication on three occasions due to it being on order, despite facility policies requiring timely reordering. The pharmacy confirmed the medication was not dispensed, and the DON was unsure how it was marked as given on certain days. Facility policies for medication reordering and documentation were not adhered to, leading to this deficiency.
A resident with Alzheimer's and Anxiety Disorder, receiving hospice care, was prescribed lorazepam PRN without an end date, contrary to the facility's policy requiring evaluation every 14 days. The DON confirmed the oversight in medication management.
The facility failed to administer medications according to professional standards, resulting in a 7.69% medication error rate. Two LPNs administered insulin using Humalog Kwikpens without priming them, as required. The DON confirmed the need for priming but was unsure of the procedure. The user manual and facility policy both indicated the necessity of priming to ensure correct insulin dosage.
The facility failed to obtain consent before administering influenza vaccines to two residents. One resident received the vaccine without a current signed consent, and another was vaccinated despite a prior refusal by the resident's wife. An LPN admitted to not seeking annual consent due to time constraints. The facility's policy required education and documentation for immunizations, which was not followed.
The facility failed to post accurate nurse staffing information daily, with discrepancies in the actual hours worked by staff. Observations showed fractional staffing numbers without specifying shift details, and interviews confirmed the inaccuracy. The Scheduler pre-filled weekend sheets and updated them later, contrary to the facility's policy.
Failure to Knock or Announce Before Entering Resident Rooms During Meal Delivery
Penalty
Summary
The facility failed to ensure resident privacy and dignity when staff entered resident rooms without knocking or announcing themselves during meal tray delivery. During supper meal service on 3/12/26, a surveyor observed multiple instances in which CNAs entered specific resident rooms while delivering trays without first knocking or identifying themselves: at 5:06 p.m. CNA 3 entered one room, at 5:07 p.m. CNA 2 entered another room, at 5:10 p.m. CNA 2 entered a third room, at 5:11 p.m. CNA 3 entered a fourth room, at 5:12 p.m. CNA 2 entered a fifth room, and at 5:13 p.m. CNA 3 entered a sixth room, all without knocking or announcing their presence. On 3/16/26 at 11:37 a.m., CNA 4 stated that staff are expected to knock, announce themselves, state their department, and ask permission before entering a resident’s room. On 3/16/26 at 11:44 a.m., the Assistant Administrator provided the facility’s current dignity policy, revised in 2025, which states it is the practice of the facility to protect and promote resident rights and to treat each resident with respect and dignity. This deficiency was cited under 410 IAC 16.2-3.1-3(a) and relates to Intake 2738912.
Unsanitary Kitchen Conditions and Inadequate Cleaning Practices
Penalty
Summary
Surveyors observed that the facility failed to maintain sanitary conditions in the kitchen during two separate inspections. Specifically, there was grease and food buildup on the stove burners, and debris was found on the floor under the two and three compartment sinks, under racks holding pots and pans, under stainless steel prep tables, in the dishwasher area, around the hot water heater, and under the stove and steam table. The hot water heater itself had visible dirt and dust on its top and pipes. Additionally, five food carts and the side of the steamer unit were noted to have debris on their surfaces. Interviews with dietary staff revealed that night staff are responsible for sweeping and mopping the floors, including under equipment, and that all staff follow a cleaning schedule. The Dietary Manager provided both the facility's food safety policy and the kitchen cleaning schedules, which included cleaning the areas and equipment that were found to be soiled. Despite these policies and schedules, the observed conditions did not meet professional standards for food service safety, as required by facility policy and regulatory guidelines.
Failure to Provide Scheduled Showers and Baths
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living, specifically showering and bathing, for four residents who required substantial assistance. During a Resident Council meeting, multiple residents expressed concerns about not receiving routine showers or complete bed baths as scheduled. The clinical records of four residents were reviewed, revealing significant deficiencies in the provision of scheduled showers. Resident 28, diagnosed with Alzheimer's Disease and polyosteoarthritis, was scheduled to receive showers twice weekly but only received 3 out of 25 scheduled showers over a nearly three-month period, with no documented refusals. Similarly, Resident 37, who also has Alzheimer's Disease and anxiety, was scheduled for twice-weekly showers but only received 8 out of 25 scheduled showers, with one documented refusal. Resident 57, with dysphagia and muscle weakness, was completely dependent on staff for showers and received only 3 showers in seven weeks. Resident 6, diagnosed with diabetes and chronic kidney disease, was scheduled for twice-weekly showers but only received them consistently for 5 out of 12 weeks. The Director of Nursing confirmed that residents should receive at least two showers weekly or a complete bed bath if preferred, and that staff should document showers given or refused. However, a shower policy was requested but not provided.
Inadequate Restorative Nursing Therapy for Residents
Penalty
Summary
The facility failed to provide adequate restorative nursing therapy to residents with limited range of motion or mobility, as evidenced by the lack of consistent therapy sessions for four residents. Resident 28, diagnosed with Alzheimer's Disease and polyosteoarthritis, was supposed to receive bilateral lower and upper extremity exercises multiple times a week. However, documentation showed that the resident only received five days of therapy over a 12-week period. Similarly, Resident 6, with diagnoses including diabetes and chronic kidney disease, was also documented to have received only five days of therapy in the same timeframe, despite needing substantial assistance and having a care plan that included specific exercise routines. Resident 52, who had hemiplegia and hemiparesis following a cerebral infarction, was supposed to walk with staff assistance multiple times a week. However, the resident only participated in one documented session in the last 30 days, with another session refused and the rest not completed. The Director of Nursing acknowledged the lack of a dedicated Certified Nurse Aide for restorative nursing, indicating that the responsibility fell on whichever CNA was available. This lack of dedicated staff contributed to the inconsistency in providing the necessary restorative care. Resident 55, with diagnoses including Type 2 diabetes mellitus and peripheral vascular disease, was observed multiple times sitting in a wheelchair and had no recorded restorative care minutes during a seven-day look-back period. The resident's care plan included active range of motion exercises and walking with assistance, but the medical record lacked current physician orders for restorative care. Interviews with staff revealed that there was no restorative aide in the facility, and the existing policy on restorative nursing was not being followed, as indicated by the lack of documented restorative nursing activities.
Dishwasher and Temperature Log Deficiencies in Cottage Kitchen
Penalty
Summary
The facility failed to ensure proper dishwasher temperatures and chemical levels in one of its kitchens, known as the Cottage kitchen. During an initial kitchen tour, a dietary aide was unsure of the required dishwasher temperature and noted water on the floor, indicating potential malfunction. The temperature logs for June and July were incomplete, with numerous entries missing. Another dietary aide attempted to run the dishwasher to reach the required temperature of 120 degrees Fahrenheit but was unsuccessful, with the highest temperature recorded being 116 degrees Fahrenheit. The dishwasher's instruction manual indicated a recommended temperature of 140 degrees Fahrenheit and a minimum of 120 degrees Fahrenheit. Additionally, the chemical concentration was not logged, and a test strip showed 0 parts per million of hypochlorite, indicating a lack of proper sanitization. The report also highlighted issues with the temperature logs for the Cottage kitchen's refrigerators and freezers, which were frequently not filled out. The logs showed numerous missing entries for both the morning and evening shifts in June and July. The facility's policies required that temperatures be checked and logged at least twice per day, and that dishwasher temperatures and chemical concentrations be recorded at least once per shift. The dietary manager confirmed that the dishwasher was a low-temperature model and that staff had been instructed not to use it if the required temperatures and chemical levels were not met, but these instructions were not consistently followed.
Failure to Implement Enhanced Barrier Precautions and Prevent Cross-Contamination
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for three residents who required transmission-based precautions. For Resident 57, a PPE cart was observed outside the room without any signage indicating specific PPE instructions or the need to consult a nurse before entering. The clinical record for Resident 57 lacked orders, care plans, and progress notes related to transmission-based precautions, despite the resident having a feeding tube. Similarly, Resident 60, who had an indwelling urinary catheter, did not have a PPE cart or signage outside the room. The clinical record also lacked necessary documentation for transmission-based precautions. Resident 17 had a PPE cart outside the room, but no signage was present. The facility used a bumblebee sticker on the nameplate to indicate precautions, but staff had to rely on reports or physician orders for specific instructions. Additionally, the facility failed to prevent cross-contamination in the laundry processing area. A fan was observed blowing air from the side of the room where soiled linen was stored to the side where clean linen was stored. The Environmental Services Manager acknowledged that the fan was supposed to remain on the clean side of the room. The facility's Enhanced Barrier Precautions Policy and Infection Prevention and Control Program required clear signage for precautions and proper handling of linens to prevent infection spread, but these protocols were not followed.
Failure to Assess Residents for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that residents who were self-administering medications were assessed for their capability to do so. Resident 49 was observed with Desitin on their bedside table, despite being severely cognitively impaired and requiring substantial assistance with daily activities. The clinical record for Resident 49 lacked any assessment or care plan for self-administration of medication, and the QMA indicated that Desitin should not be kept at the bedside. This indicates a lack of adherence to the facility's policy regarding medication management and assessment for self-administration. Similarly, Resident 23 was observed with a medicine cup containing a pill on their bedside table. Although Resident 23 was cognitively intact, the clinical record did not include an order, care plan, or assessment for self-administration of medications. The Administrative Support confirmed that medications should not be left at the bedside and that Resident 23 did not have a self-administration assessment. The facility's policy requires an interdisciplinary team assessment to be recorded in the resident's medical record, which was not done in these cases.
Resident Privacy Breach During Medication Administration
Penalty
Summary
The facility failed to ensure resident privacy during medication administration for two observed instances. On the first occasion, a Licensed Practical Nurse (LPN) left a medication cart unattended with a computer screen displaying Resident 13's personal information, including their picture, name, date of birth, and medication list. This occurred while the LPN walked away from the cart and entered a resident's room, during which time another resident walked by the cart. On the second occasion, the same LPN left the medication cart unattended between the nurses' station and elevator, with Resident 16's information visible on the computer screen. During this time, the LPN was in the Dining Room with a resident, and a Certified Nurse Aide (CNA) was observed pushing a resident past the cart. The facility's policy on confidentiality was not adhered to, as staff were expected to hide and/or lock computer screens to protect resident privacy.
Resident Abuse Incident Involving CNA
Penalty
Summary
The facility failed to protect a resident from physical abuse by a Certified Nurse Aide (CNA). The incident involved a resident with Alzheimer's Disease and severe cognitive impairment, who was dependent on staff for daily care activities. During a care routine, the resident became combative, and the CNA, who had a history of post-traumatic stress from childhood abuse, reacted by striking the resident, resulting in a laceration above the left eye. The incident was witnessed by a Qualified Medicine Aide (QMA) who heard the resident yelling and intervened. The resident's care plan included specific interventions to manage behavioral disturbances, such as allowing time for the resident to respond and approaching them slowly. However, these interventions were not effectively implemented during the incident. The CNA reported that the resident was kicking and scratching during the care process, and despite attempts to calm the resident, the situation escalated. The CNA admitted to striking the resident once in response to the resident's aggressive behavior. Following the incident, the QMA reported the event to the nurse on call, who then informed the Director of Nursing (DON), Administrator, and the resident's family. The facility's policy on abuse, neglect, and exploitation was reviewed, which mandates the protection of residents from abuse and outlines procedures for identifying and reporting such incidents. Despite the CNA's popularity among staff and residents, the incident was considered an isolated event, and the CNA expressed remorse for their actions.
Failure to Implement Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement person-centered care plans for two residents, leading to deficiencies in their care. Resident 37, who has Alzheimer's Disease and anxiety, was receiving multiple medications, including antianxiety, antidepressant, diuretic, and antiplatelet drugs. However, the clinical record lacked care plans related to the monitoring of these medications, which is essential given the resident's severe cognitive impairment and need for substantial assistance with daily activities. Resident 49, also diagnosed with Alzheimer's Disease, required significant assistance with daily activities and had specific care plan interventions to manage their behavior and communication needs. Despite these interventions, a CNA failed to implement the care plan during incontinence care, resulting in the resident resisting care and expressing distress. The staff did not follow the care plan's guidance to stop and reapproach the resident later, which was confirmed by a QMA and the DON, who acknowledged that care plans should be updated with new orders or issues.
Medication Error Due to Incorrect Nasal Spray Administration
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, as evidenced by the administration of the wrong medication. A resident, who had diagnoses including anxiety, depression, and psychotic disorder, was mistakenly given Oxymetazoline HCl nasal spray for allergies, which was not ordered by the Nurse Practitioner (NP). The NP had intended for the resident to receive saline nasal spray for nasal congestion. The error was discovered when the resident experienced rebound congestion after the Oxymetazoline HCl nasal spray was discontinued. The resident's clinical records indicated that the nasal spray was administered from 6/3/24 to 7/1/24, despite the NP's order for saline nasal spray. The Director of Nursing (DON) and the NP were unable to determine how the incorrect order was entered into the system. The facility's Medication Orders policy requires specific details when recording medication orders, but it appears this protocol was not followed, leading to the administration of the incorrect medication.
Deficiencies in Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to ensure proper prevention and care of pressure ulcers for two residents, leading to deficiencies in their treatment. Resident 54 was observed with a pressure ulcer on the sacrum that was not covered with a dressing as required by physician orders. The wound was slightly open, revealing subcutaneous tissue, and surrounded by dark pink skin, indicating a deeper wound. Despite the presence of granulation tissue, the Licensed Practical Nurse (LPN) did not address the missing dressing. The resident's clinical records showed a history of Alzheimer's disease, anxiety, and a Stage 3 pressure ulcer, with orders for specific wound care that were not consistently followed. Weekly wound assessments were not completed as scheduled, and there were gaps in skin assessments, contributing to the deterioration of the pressure ulcer. Resident 55, diagnosed with Type 2 diabetes mellitus, diabetic neuropathy, and peripheral vascular disease, had an unstageable pressure ulcer on the left heel. The resident's care plan included the use of heel lift boots and Betadine swabs for wound care, but the facility failed to conduct regular weekly skin and wound assessments as required. The Administrative Support Person confirmed that the wound assessments were not being performed, indicating a lapse in the facility's adherence to its own policies on pressure injury prevention and management. The facility's policies on pressure injury prevention and management, as well as wound dressing, were not followed, leading to inadequate care for the residents' pressure ulcers. The lack of consistent wound assessments and failure to adhere to physician orders for wound care contributed to the worsening of the residents' conditions. The facility's failure to implement its surveillance system for pressure injuries further exacerbated the issue, resulting in deficiencies in the care provided to the residents.
Inadequate Supervision and Care Plan Updates Lead to Resident Falls
Penalty
Summary
The facility failed to ensure adequate supervision and assistance to prevent accidents for three residents reviewed for falls. Resident 52 experienced multiple falls, with interventions not consistently updated following each incident. Despite being deemed unsafe to be up independently by therapy, Resident 52 continued to attempt self-toileting and other activities without assistance, leading to several unwitnessed falls. The care plan was not updated with new interventions after some of these falls, indicating a lack of proactive measures to address the resident's fall risk. Resident 28, who is severely cognitively impaired and requires substantial assistance, also experienced multiple falls. The interventions put in place following these falls were not always effective or properly documented. For instance, staff education was listed as an intervention for several falls, but the Director of Nursing later admitted that this education did not exist. This lack of follow-through on planned interventions contributed to the resident's continued fall risk. Resident 11, with a history of falls and mild cognitive impairment, also experienced falls due to inadequate supervision and assistance. The resident's care plan indicated a need for two-person assistance for transfers, but falls occurred when this protocol was not followed. The facility's failure to consistently update care plans and implement effective interventions after falls highlights a systemic issue in managing fall risks for residents.
Failure to Properly Manage Oxygen Equipment and Adhere to Physician Orders
Penalty
Summary
The facility failed to ensure proper respiratory care for a resident, specifically in the management of oxygen equipment and adherence to physician orders. During an observation, Resident 24 was found using an oxygen concentrator with tubing that was not labeled with the correct date, as it displayed a future date of 6/30/24. Additionally, there was no oxygen warning sign on the resident's door, which is a requirement according to the facility's policy. The resident, who has a history of COPD and Type 2 Diabetes Mellitus with Diabetic Polyneuropathy, was noted to be mildly cognitively impaired and required partial assistance with daily activities. The resident's clinical records indicated a physician's order to change oxygen tubing and supplies weekly, specifically on the night shift every Sunday, which was not followed. The care plan also highlighted the need for regular changes of oxygen tubing, water, and filter. An interview with an LPN confirmed that the oxygen tubing should be changed weekly and properly labeled. The facility's policy, provided by the Administrative Support Person, reiterated the need for oxygen to be administered under physician orders and for the placement of an oxygen warning sign on the resident's door, which was not adhered to in this case.
Failure to Implement Care Plans for Dementia and Behavioral Monitoring
Penalty
Summary
The facility failed to ensure proper interventions were in place for monitoring symptoms, side effects, and behaviors of medications for two residents diagnosed with dementia. Resident 46, who was significantly cognitively impaired and dependent on staff for daily activities, was prescribed multiple medications for mood disturbance and anxiety. However, there was no care plan designated for dementia care, despite the facility's policy requiring individualized care plans for residents with dementia. The Licensed Social Worker acknowledged the absence of a care plan related to dementia for Resident 46. Resident 37, diagnosed with Alzheimer's Disease and anxiety, exhibited behaviors such as exit-seeking and agitation, which were documented in progress notes. Despite these behaviors, the clinical record lacked care plans addressing anxiety or exit-seeking behaviors. An elopement evaluation indicated that Resident 37 had not expressed a desire to go home or wandered, yet the resident had a witnessed fall while attempting to exit. The facility's policy on elopement and wandering required a systematic approach to monitoring and managing residents at risk, which was not reflected in Resident 37's care plan.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure that routine medications were available and dispensed according to physician's orders for a resident with hyperlipidemia. The resident, who had severe cognitive impairment and required assistance with eating, was prescribed Pravachol to manage high cholesterol. However, the medication was not administered on three occasions because it was on order, despite being dispensed on two other days. The pharmacy confirmed that the medication had been reordered but not yet dispensed, and the Director of Nursing was uncertain how the medication was marked as given on the days it was unavailable. The facility's policies required medications to be reordered when a four-day supply remained, but the medication was not reordered in a timely manner, leading to the missed doses. The Licensed Practical Nurse indicated that medications should be reordered seven days before they run out, but this protocol was not followed. The facility's documentation policy emphasized the need for complete and accurate records, yet there was a discrepancy in the medication administration record, suggesting errors in documentation.
Failure to Evaluate PRN Anti-Anxiety Medication
Penalty
Summary
The facility failed to ensure a resident was free from unnecessary medications, specifically regarding the use of a PRN anti-anxiety medication. A resident, who was receiving hospice services and had a diagnosis of Alzheimer's Disease with late onset and Anxiety Disorder, was prescribed lorazepam 0.5 MG to be taken orally every 4 hours as needed for anxiety and agitation. This order, dated 6/28/24, did not include an end date and was not evaluated every 14 days as required by the facility's Use of Psychotropic Medication Policy. The Director of Nursing acknowledged that PRN antianxiety medications should have been evaluated every 14 days and that an end date should have been set when the order was initiated.
Failure to Prime Insulin Pens Leads to Medication Errors
Penalty
Summary
The facility failed to ensure medications were administered according to physician's orders and professional standards, resulting in a medication administration error rate of 7.69%. This deficiency was observed in two instances involving insulin administration. In the first instance, an LPN prepared a Humalog Kwikpen for insulin administration for a resident with a blood glucose reading of 313. The LPN administered 3 units of insulin Lispro without priming the insulin pen, which is a necessary step to ensure the pen is working correctly and to avoid administering an incorrect dose. In the second instance, another LPN prepared a Humalog Kwikpen for a different resident who was to receive 5 units of insulin Lispro with her lunch meal. Similarly, the LPN administered the insulin without priming the pen. The Director of Nursing later confirmed that insulin pens should be primed before administration but was unsure of the exact procedure. The Humalog Kwikpen user manual and the facility's insulin pen policy both indicated the need to prime the pen by selecting 2 units and ensuring insulin appears at the needle tip before administration.
Failure to Obtain Consent for Influenza Vaccinations
Penalty
Summary
The facility failed to obtain consent before administering influenza vaccines to two residents. Resident 37 received the influenza vaccine without a signed consent on record for the vaccination administered. The only consent form available was dated over two years prior. Similarly, Resident 36 was given the influenza vaccine without a signed consent, despite the resident's wife having declined all vaccines upon admission. An LPN admitted to not seeking annual consent due to the time it took to contact families each year. The facility's Infection Prevention and Control Program required education and documentation regarding immunizations, but this was not adhered to in these cases.
Inaccurate Nurse Staffing Information Posting
Penalty
Summary
The facility failed to post accurate nurse staffing information for licensed and unlicensed nursing staff responsible for resident care per shift on a daily basis during the annual survey period. Observations revealed discrepancies in the posted nurse staffing data sheets, which did not reflect the actual hours worked by the staff. For instance, on 7/21/24 and 7/22/24, the sheets indicated fractional staffing numbers, such as 0.5 RNs and 2.5 LPNs, without specifying which part of the shift these staff members worked. This lack of specificity made it difficult to determine the actual staffing levels during each shift. Interviews with facility staff, including the MDS Coordinator and the Scheduler, confirmed that the posted staffing sheets did not accurately represent the actual hours worked. The Scheduler admitted to pre-filling the staffing sheets for the weekend and updating them with correct information only upon returning to work on Monday. The facility's policy required the Nurse Staffing Sheet to be posted at the beginning of each shift with accurate information, but this was not adhered to, leading to the deficiency.
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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