Brickyard Healthcare - Richmond Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Richmond, Indiana.
- Location
- 1042 Oak Dr, Richmond, Indiana 47374
- CMS Provider Number
- 155157
- Inspections on file
- 37
- Latest survey
- December 8, 2025
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Brickyard Healthcare - Richmond Care Center during CMS and state inspections, most recent first.
A resident with multiple comorbidities and high fall risk, requiring substantial assistance for transfers, was injured when a CNA transferred her without a gait belt or mechanical lift, contrary to care plan instructions. The resident's leg was lacerated on exposed metal from a wheelchair, resulting in a wound requiring 18 sutures. The incident was attributed to inadequate supervision, improper transfer technique, and unsafe equipment.
A resident with multiple psychiatric and medical diagnoses was found deceased in his room, and staff verified his DNR status and lack of vital signs. However, the facility did not document the death, notifications to the physician or family, or the disposition of the resident's body and belongings in the clinical record, contrary to facility policy. Leadership stated this was a deliberate decision made with legal counsel due to the stressful circumstances.
The facility failed to date and identify open medication bottles in two medication carts, with several bottles lacking open dates and some medications being unidentified. Loose pills and an unlabeled inhaler were also found. Staff interviews revealed uncertainty about medication origins and confirmed that open dates should be marked. The DNS stated that nursing staff are responsible for labeling, with a binder available for discard time lengths.
A facility failed to ensure the interdisciplinary team (IDT) determined and documented the clinical appropriateness of self-administration of medications for a resident. The resident, who was cognitively intact, was found with a pill and Visine eye drops at her bedside, which she did not want or request. An LPN confirmed the resident should not have medications at the bedside, and the Director of Nursing Services confirmed there was no self-administration order or care plan in place.
The facility failed to ensure proper documentation of code status and care plans for two residents. One resident had conflicting information between the POST form and care plan, while another resident's code status was not documented at all. The DNS acknowledged these discrepancies, which were not in line with the facility's policy on code status communication.
The facility breached resident privacy by allowing staff to use personal cell phones to capture images and videos of residents' medical conditions. An LPN took a picture of a resident's wound, and another recorded a video of a resident's behavioral change, both sent to the DNS for further guidance. This action violated the facility's policy on resident privacy.
The facility failed to ensure resident safety by not enforcing the use of smoking aprons for residents identified as needing them. A resident with chronic respiratory issues and two others with mobility impairments were observed smoking without aprons, contrary to their care plans. Despite assessments indicating the need for aprons, residents admitted to not consistently wearing them, and the facility's policy was not adequately enforced.
The facility failed to obtain physician orders for crushing medications for three residents, despite the practice being carried out based on nursing judgment. Residents with conditions such as diabetes and chronic obstructive pulmonary disease were receiving crushed medications without proper orders, contrary to the facility's policy. A nurse reported the issue to the Director of Nursing and Executive Director, but no corrective actions were taken.
A resident experienced a severe change in condition, exhibiting unusual behaviors and was administered Ativan without proper documentation of its indication or follow-up on its effectiveness. Despite attempts by an LPN to alert the DNS, the resident's condition worsened, leading to hospitalization where toxic encephalopathy due to drug use was diagnosed.
A facility failed to ensure a hospice order and care plan for a resident with anxiety disorder, diabetes, and chronic pain syndrome. The resident was placed on hospice, but the EHR lacked a hospice order and care plan. The DNS noted a one-time hospice consult order was not followed up, and a recent care plan library switch caused old plans to disappear. A hospice care plan was created later to coordinate care and obtain necessary orders.
A resident with chronic respiratory issues was found to have two medicated nasal sprays at their bedside without a prior self-administration assessment. Despite being cognitively intact, the facility did not complete the required assessment before allowing the resident to self-administer medications, as per their policy.
A resident with multiple medical conditions, including dysphagia and a history of pressure ulcers, did not receive fresh water daily as required. Observations showed the resident only had thickened juice and coffee available, despite expressing a preference for water. The care plan included encouraging fluid intake due to risks of constipation and elimination issues, but the facility staff failed to provide fresh water, as confirmed by the DON.
A facility failed to use PPE for a resident in contact isolation due to suspected ringworm. Despite clear signage, two CNAs entered the resident's room without gowns or gloves, unaware of the isolation status. The unit manager confirmed the need for precautions, and the DNS noted unsuccessful treatments for the resident's condition. The nurse practitioner later discontinued isolation after observing improvement with OTC cream.
The facility failed to follow physician orders for obtaining weights for two residents and conducting accurate skin assessments for another. One resident was not weighed for four months, and another experienced significant weight gains without provider notification. Additionally, a resident with a history of pressure ulcers did not have heels floated as required, and a rash was not treated after the initial period. Interviews revealed a lack of adherence to care plans and physician orders by staff.
The facility failed to conduct regular care plan meetings for two residents, one with cerebral palsy and autism, and another with intellectual disabilities and depression. Despite the policy requiring quarterly meetings, documentation showed gaps in scheduling, indicating non-compliance with care planning protocols.
A facility failed to notify a resident's infectious disease physician of lab results and did not obtain a lab as ordered before continuing antibiotic administration. The resident, with a history of osteomyelitis, was to receive Vancomycin with weekly lab tests, but the results were not consistently communicated. A high Vancomycin trough result was not reported, and the facility relied on the pharmacy for dosing management, which was not always followed. The resident filed a grievance regarding medication issues, leading to the discontinuation of Vancomycin.
A facility failed to ensure a staff member followed policies for the safe use of a mechanical lift, requiring two staff members for operation. This resulted in a resident falling and fracturing her knee during a transfer. The CNA involved was suspended and terminated for not adhering to the policy.
The facility failed to develop and implement a care plan for a resident experiencing seizure-like activities, despite multiple documented incidents and a fall. The DON confirmed the absence of a care plan, which is required by the facility's policy on comprehensive care plans.
The facility failed to provide timely and consistent wound care for two residents, leading to the worsening of pressure ulcers and subsequent hospitalizations. One resident developed an unstageable pressure ulcer that became infected, while another progressed to a stage 3 pressure ulcer due to inadequate treatment and documentation.
Failure to Provide Safe Transfer and Supervision Results in Resident Injury
Penalty
Summary
A deficiency occurred when a resident who required more than limited assistance with transfers did not receive adequate assistance and supervision, resulting in a significant injury. The resident, who had multiple diagnoses including metabolic encephalopathy, chronic kidney disease, vascular dementia, and was at high risk for falls, required substantial to maximal assistance for transfers and used a wheelchair. Despite care plan interventions indicating the need for extensive assistance from one to two staff and the possible use of a sit-to-stand lift during periods of increased weakness, the resident was transferred by a single CNA without the use of a gait belt or mechanical lift. During the transfer, the CNA lifted the resident under the arms at the resident's request, rather than using the sit-to-stand lift as directed. The resident lost balance and struck her left lower leg on the bed frame or wheelchair, resulting in a large laceration that required emergency medical attention and 18 sutures. The resident reported significant pain following the incident. Interviews with staff and the resident confirmed that the transfer was not performed according to policy or the resident's care plan, and that the wheelchair had a sharp exposed metal edge due to a missing rubber/plastic piece. Further review revealed that the facility's safe resident handling and transfer policy required the use of appropriate assistive devices and adherence to the resident's individual care plan. However, the resident's care plan did not specify transfer instructions until after the incident. The lack of proper supervision, failure to use required equipment, and the presence of a hazardous wheelchair contributed directly to the resident's injury.
Failure to Document Resident Death and Related Notifications
Penalty
Summary
The facility failed to document the death of a resident in the clinical record, including the notification of the resident's death to the physician, family, or responsible party, as well as the disposition of the resident's body, personal possessions, medications, and a complete and accurate notation of the resident's condition preceding death. Interviews with staff revealed that the resident, who had diagnoses including dementia, psychotic disturbance, bipolar disorder, depression, suicidal ideations, and anxiety disorder, was found deceased in his room with a plastic bag over his head. Staff confirmed the resident's Do Not Resuscitate (DNR) status and verified the absence of pulse and respirations. Despite these events, there was no documentation in the clinical record regarding the circumstances of the resident's death or the actions taken afterward. The last entry in the resident's record was made earlier that day by the Social Service Director, noting the resident was asleep and the room was orderly. Facility leadership, including the DON and the facility president, indicated that the decision not to document the death was made in consultation with the legal department, citing concerns about accuracy in a high-stress situation. The facility's own policy requires timely, accurate, and complete documentation of resident experiences and care, which was not followed in this instance.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure that open medication bottles were properly dated and identified in two medication carts observed during a survey. Several medication bottles, including Guaifenesin, Enulose, Polyethylene Glycol, Milk of Magnesia, oral simethicone, Dermal Wound Cleanser, and Refresh Optive Advanced, were found without open dates marked on them. Additionally, a Fluticasone Propionate inhalation powder lacked a resident label or dates, and a loose orange oblong pill was found in the medication drawer. During an interview, a registered nurse indicated uncertainty about the origin of the open pill and acknowledged that open dates and expiration dates should be marked on new medication bottles. In another observation, a loose blue pill was found in a medication drawer, and an Albuterol inhaler with no resident label was discovered in the bottom drawer. The licensed practical nurse was unsure of the medication's ownership and confirmed that open medications should not be stored in the cart. Further inspection revealed additional medication bottles without open dates, including Enulose, Guaifenesin, Max Tussin, Milk of Magnesia, Polyethylene Glycol, and Potassium Chloride. The Director of Nursing Services confirmed that nursing staff are responsible for marking open and dispose dates on new medication bottles, and a binder at the nurses' stations provides discard time lengths for different medications.
Failure to Ensure IDT Approval for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that the interdisciplinary team (IDT) determined and documented the clinical appropriateness of self-administration of medications for Resident T. The resident, who was cognitively intact for daily decision-making as per the Annual Minimum Data Set (MDS) assessment, was observed with a blue oblong pill in a medicine cup at her bedside, which she did not want but did not communicate to the nurse. Additionally, a bottle of Visine eye drops was found on her bedside table, which the resident indicated was left by a nurse. Licensed Practical Nurse (LPN) 3 confirmed that Resident T should not have any medications at the bedside and was unaware of who left them there. The Director of Nursing Services (DNS) also confirmed that there was no self-administration of medication order or care plan in place for Resident T. The facility's policy requires that a resident may only self-administer medications after the IDT has determined it is safe, which was not followed in this case.
Failure to Document Code Status and Care Plans
Penalty
Summary
The facility failed to ensure proper code status orders and care plans for two residents, Resident EE and Resident GG. Resident EE's clinical record showed a discrepancy between the Physician Orders for Scope and Treatment (POST) form, which indicated a Do Not Resuscitate (DNR) status, and the care plan, which listed the resident as a full code. This inconsistency was acknowledged by the Director of Nursing Services (DNS), who admitted that the care plan had not been updated properly. For Resident GG, the facility did not have a POST form, code status order, or care plan documented in the clinical record. The DNS explained that Resident GG had not yet decided on her code status, and the facility's practice was to treat such residents as full code until documentation was completed. However, this practice was not in alignment with the facility's policy, which requires clear documentation of code status in the medical record. This lack of documentation was noted during the review, highlighting a failure to adhere to the facility's policy on communicating residents' code status.
Violation of Resident Privacy and Confidentiality
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of residents' medical conditions by allowing staff to take pictures and videos on personal cell phones. This deficiency was identified for two residents, referred to as Resident KK and Resident W. In the case of Resident KK, an LPN took a picture of the resident's leg wound on her personal cell phone and sent it to the Director of Nursing Services (DNS) for a second opinion, as she was uncomfortable with the response from the on-call Nurse Practitioner. The LPN later deleted the picture from her phone. Similarly, another LPN recorded a video of Resident W, who was experiencing a significant change in condition, including delusional behavior and self-harm. The LPN sent the video to the DNS after failing to reach her by phone, seeking assistance due to the ineffectiveness of the prescribed medication. The facility's policy, as provided by the Executive Director, explicitly prohibits taking photographs or videos of residents, citing it as a violation of their rights to privacy and confidentiality.
Failure to Utilize Smoking Aprons for Resident Safety
Penalty
Summary
The facility failed to ensure the safety of residents who smoke by not utilizing smoking aprons as required. During observations, it was noted that Resident J, Resident Z, and Resident BB were smoking without wearing smoking aprons, despite their care plans indicating the necessity of such protective measures. Resident J, who has chronic respiratory failure, COPD, and other health issues, was observed smoking without a smoking apron. His care plan, dated 7/9/24, identified him as at risk for smoking-related injury and included the intervention of providing a smoking apron. However, during an interview, Resident J indicated that he did not wear a smoking apron, believing it was only for residents who were unsafe during smoking. Similarly, Resident Z and Resident BB were observed smoking without aprons. Resident Z, who has flaccid hemiplegia and limited range of motion, was assessed to require a smoking apron, yet she admitted to only occasionally wearing one. Resident BB, with moderate cognitive impairment and COPD, also acknowledged wearing a smoking apron sporadically, despite his care plan indicating its necessity. The facility's Director of Nursing Services confirmed that residents who trigger for smoking aprons in their assessments are required to wear them, but this policy was not consistently followed. The facility's smoking policy mandates safety measures for residents who smoke, but these were not adequately implemented for the residents in question.
Failure to Obtain Physician Orders for Crushed Medications
Penalty
Summary
The facility failed to obtain physician orders to crush medications for three residents, identified as Resident L, Resident O, and Resident P, during a survey. Resident L, who has a medical diagnosis of diabetes, reported taking crushed medications since admission, yet there was no active physician order for this practice. Similarly, Resident O, also diagnosed with diabetes, and Resident P, diagnosed with chronic obstructive pulmonary disease, did not have physician orders to crush their medications. A staff member confirmed that medications were crushed based on nursing judgment without physician orders. Registered Nurse (RN) 1 acknowledged issues with medications that could not be crushed and noted that the pharmacy was unaware of the practice due to the lack of physician orders. Despite providing the Director of Nursing Services and the Executive Director with a list of residents receiving crushed medications, no orders were obtained. The facility's medication administration policy requires medications to be crushed only as ordered, highlighting a discrepancy between practice and policy. This deficiency was related to a specific complaint, IN00446364.
Failure to Monitor and Document Medication Use for Resident
Penalty
Summary
The facility failed to adequately monitor and document the use of Ativan, an antianxiety medication, for a resident experiencing an acute change in condition. The resident, who was previously cognitively intact and without hallucinations or delusions, exhibited severe behavioral changes, including making snoring sounds, hitting himself, and tearing up his room. Despite these alarming symptoms, the facility did not document the indication for the Ativan order or follow up on its effectiveness. The Licensed Practical Nurse (LPN) on duty attempted to contact the Director of Nursing Services (DNS) and sent a video of the resident's condition to emphasize the severity of the situation. The resident's condition did not improve after the administration of Ativan, and further symptoms suggested the possibility of unprescribed medication use. The resident was eventually sent to the emergency room, where it was determined that he was suffering from toxic encephalopathy due to cocaine and amphetamine use. The facility's failure to document the purpose and follow-up of the Ativan administration, as well as the lack of immediate and effective intervention, contributed to the deficiency noted in the report.
Failure to Ensure Hospice Order and Care Plan
Penalty
Summary
The facility failed to ensure that an order and care plan were in place for a resident receiving hospice services. Resident DD, who had diagnoses including anxiety disorder, diabetes mellitus, and chronic pain syndrome, was placed on hospice on September 15, 2024. However, the clinical record lacked an order for hospice and a hospice care plan in the Electronic Health Record (EHR). The Director of Nursing Services (DNS) indicated that the resident's physician had initially put in a one-time order for a hospice services consult, which was not followed up with a permanent order. Additionally, the facility had recently switched their care plan library, resulting in the disappearance of old care plans. A hospice care plan was eventually created on November 7, 2024, to coordinate care with hospice services and obtain the necessary physician order and referral.
Failure to Complete Self-Administration Assessment for Resident
Penalty
Summary
The facility failed to ensure that a self-administration of medications assessment was completed for a resident who was reviewed for self-administration of medications. The resident, who was cognitively intact and had no behaviors according to a recent MDS assessment, had chronic respiratory failure and chronic obstructive pulmonary disease. Despite having a care plan initiated to complete a self-administration assessment, the resident was observed with two medicated nasal sprays on their bedside table without an assessment being completed at that time. Interviews and observations revealed that the resident kept the nasal sprays at their bedside, and staff were aware of this arrangement. A QMA confirmed that the resident used over-the-counter nasal sprays provided by their family. It was only after these observations that a self-administration assessment was conducted, which confirmed the resident's capability to self-administer the nasal sprays. The facility's policy required an intradisciplinary team to determine the safety of self-administration before allowing residents to do so, which was not adhered to in this case.
Failure to Provide Fresh Water to Resident
Penalty
Summary
The facility failed to provide fresh water daily to a resident, identified as Resident C, who was reviewed for hydration. Observations and interviews conducted over several days revealed that Resident C consistently had thickened juice and coffee available but no water. The resident expressed a preference for having fresh water daily, which was not being met. On multiple occasions, Resident C indicated she had not received any water in the past five days. Resident C's clinical record indicated several medical conditions, including congestive heart failure, pneumonia, dementia, chronic obstructive pulmonary disease, hypertension, anxiety, dysphagia, and a history of pressure ulcers. The resident was on a regular diet with thickened liquids as per physician orders. The care plan highlighted the risk of constipation and alterations in bowel and bladder elimination, with interventions to encourage fluid intake. Despite these documented needs, the facility's staff did not ensure the provision of fresh water, as confirmed by the Director of Nursing Services.
Failure to Use PPE for Resident in Contact Isolation
Penalty
Summary
The facility failed to adhere to proper infection prevention and control protocols by not donning personal protective equipment (PPE) before entering the room of a resident who was under contact isolation. The resident, who had a history of hypertension, anxiety, and major depressive disorder, was placed under contact precautions due to a suspected case of ringworm. Despite a sign on the resident's door indicating the need for contact precautions, including the use of gowns and gloves, two certified nurse aides (CNAs) entered the room without the required PPE. CNA 11 entered the room without a gown or gloves, unaware of the resident's isolation status, and CNA 13 also entered without PPE, mistakenly believing the resident was not in isolation after returning from therapy. The unit manager confirmed the resident's isolation status and attempted to educate the staff on the necessary precautions. The Director of Nursing Services (DNS) later revealed that the resident had been treated unsuccessfully for ringworm with various creams since May, and a dermatology appointment was scheduled for December. The nurse practitioner discontinued the contact isolation after realizing the appointment was months away, as the resident's condition seemed to improve with over-the-counter cream. The facility's policy on transmission-based precautions was reviewed, emphasizing the need for PPE to prevent pathogen transmission through direct or indirect contact.
Failure to Follow Physician Orders and Conduct Accurate Assessments
Penalty
Summary
The facility failed to adhere to physician orders for obtaining daily and monthly weights for two residents. Resident 6, who has diagnoses including schizophrenia, muscle weakness, and diabetes mellitus, was not weighed for four months despite a physician order for monthly weights. An abnormal weight was recorded on one occasion, but a re-weigh was not conducted as recommended by the registered dietician. Similarly, Resident 44, who has chronic respiratory failure and uses diuretics, experienced multiple instances of significant weight gain without the provider being notified as required by the physician's order. The facility also failed to conduct accurate skin assessments and follow physician orders for Resident C, who has a history of pressure ulcers and other medical conditions. Observations revealed that Resident C's heels were not floated as required, and the resident was wearing a brief in bed against physician orders. Skin assessments were inconsistently documented, and a rash on the resident's buttocks was not treated with the prescribed cream after the initial treatment period ended. Interviews with the Director of Nursing Services (DNS) and other staff indicated a lack of adherence to physician orders and care plans. The DNS acknowledged the responsibility of direct care staff to obtain weights and notify providers of significant changes, as well as ensuring pressure-relieving devices were in place for Resident C. However, these actions were not consistently carried out, leading to deficiencies in the care provided to the residents.
Failure to Conduct Regular Care Plan Meetings
Penalty
Summary
The facility failed to conduct care plan meetings for residents and their representatives as required, affecting two out of three residents reviewed. Resident F, who has multiple diagnoses including cerebral palsy, autism, and intellectual disabilities, was admitted on an unspecified date and had only two care plan meetings documented on January 2, 2024, and June 13, 2024. This indicates a lack of regular care plan meetings, which are essential for addressing the resident's complex needs. Similarly, Resident D, with diagnoses including unspecified intellectual disabilities and depression, had a care plan meeting documented on December 12, 2023, with no further meetings recorded. The Executive Director stated that care plan meetings should occur as needed and quarterly, with social services responsible for ensuring their completion. However, the documentation and interviews revealed that these meetings were not held quarterly as required, leading to a deficiency in the facility's compliance with its Care Planning-Resident Participation policy.
Failure to Notify Physician of Lab Results and Manage Antibiotic Administration
Penalty
Summary
The facility failed to notify a resident's infectious disease physician of lab results and did not obtain a lab as ordered by the pharmacy before continuing the administration of an antibiotic for a resident with skin conditions. The resident, who had a history of osteomyelitis, type 1 diabetes mellitus, peripheral vascular disease, and peripheral neuropathy, was admitted to the facility after a hospitalization for osteomyelitis of the right foot. The hospital discharge instructions required the resident to receive Ceftriaxone and Vancomycin for six weeks, with weekly CBC, CMP, and Vancomycin trough tests, and the results were to be faxed to the infectious disease physician. During the resident's stay, the facility's records indicated that the Vancomycin was administered according to orders, but the required lab results were not consistently obtained or communicated to the infectious disease physician. The Vancomycin trough result on 7/2/24 was high, but the physician's office was not notified of this or any other lab results. The facility's Medical Director suggested that the high result might have been due to incorrect timing of the lab draw, and the facility relied on the pharmacy to manage Vancomycin dosing. However, the pharmacy's recommendations were not always followed promptly, and there was no documentation of a Vancomycin trough result for 7/3/24 as recommended by the pharmacy. The facility's policies required prompt notification of lab results outside the clinical reference range to the ordering physician, but this did not occur. The resident's last dose of Vancomycin was administered on 7/8/24, and a grievance was filed by the resident regarding a medication issue. The DON acknowledged the lack of a Vancomycin trough result from 7/3/24 and indicated that the Vancomycin was discontinued after the grievance was filed. The facility's failure to adhere to its policies and the physician's orders led to the deficiency in care for the resident.
Failure to Follow Mechanical Lift Policy Results in Resident Fall and Fracture
Penalty
Summary
The facility failed to ensure a staff member followed policies for the safe use of a mechanical lift, which requires the operation to be conducted by two staff members. This failure resulted in a fall and a fracture for a resident who was being transferred from her chair to bed by a single CNA. The CNA did not secure the resident properly and left the mechanical lift unattended to lower the bed, during which the resident fell and sustained a knee fracture. The resident was sent to the hospital for evaluation and returned to the facility with a knee immobilizer for comfort. The resident involved had multiple diagnoses, including cerebral infarction, diabetes with neuropathy, morbid obesity, and general muscle weakness. She was non-ambulatory, used a wheelchair for mobility, and was dependent on mechanical lifts for transfers. Her care plan indicated that she required two staff members for all transfers using a mechanical lift. The CNA involved had been employed since December 2023 and had completed the necessary training and skills checkoffs for mechanical lift use. The incident was reported to the Indiana Department of Health's Long-Term Care Division, and an immediate investigation was initiated. The facility identified that the root cause of the fall was the CNA attempting to transfer the resident alone, contrary to the facility's policy. The CNA was suspended and subsequently terminated for not following the policy, which contributed to the resident's fall and injury.
Failure to Develop and Implement Care Plan for Seizure-Like Activities
Penalty
Summary
The facility failed to develop and implement a care plan for a resident experiencing seizure-like activities. Resident C, who had diagnoses including unspecified tremor and unspecified convulsions, had documented seizure-like activities on multiple occasions, including at least three on one date and two more on another. One of these seizure-like activities was associated with a fall. Despite these incidents, a review of Resident C's clinical record showed no care plan addressing his seizure-like activities. This deficiency was brought to the attention of the Director of Nursing (DON), who confirmed the absence of a care plan for Resident C's seizures or seizure-like activities. The facility's policy on comprehensive care plans, which mandates the development and implementation of person-centered care plans with measurable objectives and timeframes, was not followed in this case. The lack of a care plan for Resident C's seizure-like activities was identified during a complaint investigation.
Failure to Provide Timely and Consistent Wound Care
Penalty
Summary
The facility failed to ensure timely treatment and services for a resident who was admitted with an identified skin concern, leading to the development of an unstageable pressure ulcer that worsened and became infected. Resident E, who had multiple diagnoses including bipolar disorder, major depressive disorder, and malnutrition, was admitted with a pressure ulcer to the coccyx and lower back. Despite being at risk for pressure ulcer development as indicated by a Braden Scale assessment, the facility did not provide consistent and appropriate wound care. The clinical records showed a lack of proper documentation, inconsistent treatment orders, and failure to follow physician orders, resulting in the worsening of Resident E's condition and eventual hospitalization for a severe infection and Fournier's gangrene extending from a decubitus ulcer and abscess. Another resident, Resident D, who had diagnoses including congestive heart failure and muscle weakness, also did not receive timely and appropriate treatment for incontinence-associated dermatitis (IAD). The resident's condition progressed to a stage 3 pressure ulcer due to the lack of proper wound care and documentation. Despite being identified at risk for pressure ulcer development, there were no physician orders for the treatment of Resident D's skin conditions, and the treatment plans were not consistently followed or documented in the electronic medical records. This neglect led to the deterioration of Resident D's skin integrity and subsequent hospitalization. Interviews with the Director of Nursing (DON) revealed that upon reviewing the residents' charts, significant gaps in wound assessments, treatment orders, and adherence to physician orders were identified. The facility's policy on pressure injury prevention and management was not effectively implemented, leading to the deficiencies observed. The lack of systematic and prompt assessment, treatment, and monitoring of pressure injuries contributed to the adverse outcomes for the residents involved.
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.
