Eagle Valley Meadows
Inspection history, citations, penalties and survey trends for this long-term care facility in Indianapolis, Indiana.
- Location
- 3017 Valley Farms Rd, Indianapolis, Indiana 46214
- CMS Provider Number
- 155291
- Inspections on file
- 35
- Latest survey
- December 9, 2025
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Eagle Valley Meadows during CMS and state inspections, most recent first.
Multiple hallways and resident rooms were found with persistent unsanitary conditions, including soiled floors, bedding, and bathrooms with feces and urine, due to inconsistent housekeeping presence and lack of cooperation between nursing and housekeeping staff. Residents with limited mobility and incontinence were particularly affected, and management was unaware of the extent of the problem due to lack of reporting and oversight.
Two residents who were dependent on staff for toileting and transfers experienced significant delays in call light response, with one waiting nearly an hour for incontinence care and another reporting frequent accidents due to slow staff response. Staff were observed turning off call lights without providing care, and both residents' care plans required timely assistance. Facility leadership acknowledged the delays were unacceptable, but there was no specific policy on call light response times.
The facility did not provide adequate nursing staff to meet all residents' needs and failed to have a licensed nurse in charge on every shift, as required by regulations.
The facility failed to properly store and label medications, affecting all 78 residents. The medication storage room was disorganized, with medications scattered and improperly mixed. The B Hall medication cart had several residents' medications without open dates. The DON acknowledged the issues, citing the absence of a full-time MRC as a contributing factor.
A facility failed to ensure medication was not left at the bedside without a self-medication assessment for a resident. Ventolin and Symbicort inhalers were observed on a resident's over-the-bed table, although the resident was only approved to self-administer bacitracin. The facility's policy requires verification of medication details each time it is administered.
A facility failed to provide a comprehensive nutritional assessment and implement person-centered interventions for a resident on a low sodium diet. The resident, with conditions like congestive heart failure and diabetes, was dissatisfied with limited food options, mainly hamburgers, and had not been assessed by the RD since admission. The facility's records lacked necessary documentation, and care plans did not address specific dietary needs, contrary to facility policy.
An LPN in a facility failed to follow proper medication administration protocols for two residents. One resident received inhaler medications without appropriate intervals, and another was nearly given an incorrect dose of Robitussin due to the LPN's inability to accurately read the medication cup. The facility's policy on medication handling and verification was not adhered to.
A resident in the facility did not receive several scheduled medications, including clonazepam, dicyclomine, dorzolamide-timolol, hydrocodone-acetaminophen, symbicort, trazodone, and albuterol inhaler, as per the physician's orders. The facility's policy on medication administration was not followed, leading to multiple missed doses over several days.
Staff at the facility failed to follow infection control protocols by not performing hand hygiene or wearing PPE when entering a COVID-19 positive isolation room. A resident with vascular dementia and a history of cancer was in isolation, yet staff ignored clear signage requiring PPE, and there was no waste basket for PPE disposal in the room.
A resident with multiple medical conditions experienced a failure in dignity and respect when an LPN refused to leave her room after a confrontation over oxygen assistance. Despite the resident's request, the LPN remained, leading to an escalation where the resident threw water at the LPN. The facility's care plan noted behavioral issues, but there was no documentation of a care plan meeting, and the incident was not reported to the Administrator. Staff interviews indicated they were trained to handle such situations, but the resident's rights were not upheld.
The facility failed to maintain a clean and safe environment, with flying insects observed in the kitchen and residents' rooms. Despite pest control visits, structural and sanitation issues persisted, contributing to the infestation. Residents, including those with significant medical conditions, were affected by the presence of pests, indicating a widespread problem.
The facility failed to label and date medications when opened and did not remove expired medications from use. This was observed in two medication carts and a refrigerator. A resident's Haldol vial and another's Breo lacked opening dates. Systane eye drops were found without labels or opening dates. In the refrigerator, lorazepam bottles for two residents were undated or expired. The facility's guidance required Ativan to be dated and discarded after 90 days.
The facility failed to prevent linen contamination during dining service for four residents, as the SSD handled linens improperly and did not perform hand hygiene after picking up trash. Additionally, kitchen temperature logs were incomplete, violating the facility's food storage policy.
The facility failed to designate a qualified IP available for at least 20 hours a week without sharing duties with other departments. The IP role was filled by an LPN who also served as the full-time MDS Coordinator, with the RIPC visiting only 1-2 times a month. The facility assessment indicated a full-time IP was required, but the MDS Coordinator continued to manage her primary responsibilities, affecting the infection control program's effectiveness for all 75 residents.
A resident with multiple health conditions, including obesity and respiratory issues, was not provided with a bariatric bed or accessible call light. Observations showed the resident's mattress was askew and the call light was on the floor, contrary to care plan requirements. The facility lacked policies for call light accessibility and appropriate mattress use.
A facility failed to assess a resident for a level II PASARR despite the resident's medical diagnoses and use of Haldol, a psychotropic medication. The resident had conditions such as metabolic encephalopathy and psychotic disorder, which should have triggered a level II assessment. The level I assessment lacked necessary information, leading to the omission of the required referral, contrary to the facility's PASRR policy.
A resident with multiple health conditions, including cancer and hypertension, was observed over several days with long and dirty nails, indicating a failure in providing necessary nail care. Despite having a care plan that required assistance with ADLs, the resident's nails remained untrimmed, and the issue was only acknowledged after being reported to the DNS.
Two residents in the facility were not provided with necessary respiratory equipment, leading to deficiencies in their care. One resident, requiring a BIPAP machine for conditions like sleep apnea and COPD, was without a mask for several nights due to staff oversight. Another resident's nebulizer and CPAP mask were improperly stored, and the facility lacked a clear policy for respiratory equipment care.
A facility failed to ensure proper PPE use during high-contact care for a resident with an open wound and recurrent infections. A CNA was observed providing a shower without wearing an isolation gown or gloves, despite the presence of stool incontinence and an open wound. The resident was under enhanced barrier precautions due to a wound infection, and facility policy required PPE use during such care activities.
The facility failed to implement personalized fall interventions for a resident with dementia and a history of falls, resulting in multiple falls and significant injuries, including a clavicle fracture and a broken nose. Despite being identified as high risk, effective measures were not put in place, and the care plan was not adequately updated.
A resident with severe protein-calorie malnutrition and other health issues experienced significant weight loss due to the facility's failure to provide appropriate dietary management and assistance with eating. Despite being on a mechanical soft diet, the resident received regular food that she struggled to eat, and staff did not consistently assist her. Her weight dropped from 70.4 pounds to 57.4 pounds over 74 days.
Failure to Maintain Clean and Sanitary Environment in Resident Areas
Penalty
Summary
The facility failed to maintain a clean and sanitary environment across three of four hallways observed, specifically Hallways A, B, and D. Multiple resident rooms and shared bathrooms were found with significant cleanliness issues, including soiled floors, walls, handrails, and bedding. Observations included dried dark substances on walls, dirty and sticky floors, soiled sheets, and personal items mixed with debris. Bathrooms shared by residents were repeatedly found with feces, urine, and other waste on toilets, floors, and sinks, as well as stagnant urine and strong odors. In several cases, these unsanitary conditions persisted over consecutive days without being addressed, despite being reported by residents or their families. Housekeeping staff were inconsistently present or absent from the hallways during observations, and cleaning tasks were not completed as required. The Housekeeping Supervisor and other staff interviews revealed that there was confusion and lack of cooperation between nursing and housekeeping departments regarding responsibility for cleaning up messes, particularly those involving bodily waste. Housekeeping schedules showed limited staffing, with only two or three housekeepers assigned to cover all areas, and no check-off lists were used to verify completion of cleaning tasks. Management staff were expected to perform daily rounds and report issues, but the Executive Director was unaware of the extent of the cleanliness problems due to lack of reporting and personal verification. Residents affected by these deficiencies included individuals with limited mobility, incontinence, and those requiring assistance with activities of daily living. Some residents reported that their rooms had not been cleaned for extended periods, and family members expressed concerns about the unsanitary conditions. The facility's cleaning policies outlined specific procedures for daily and restroom cleaning, but these were not consistently followed, resulting in persistent unsanitary conditions in resident rooms, shared bathrooms, and common areas.
Failure to Respond Timely to Call Lights for Dependent Residents
Penalty
Summary
The facility failed to respond to call lights in a timely manner for two dependent residents. One resident, who had hemiplegia, hemiparesis, and Parkinson's disease, was observed waiting in her wheelchair for over 55 minutes for staff to change her wet brief. Despite activating her call light multiple times, staff either turned off the call light and left without providing care or informed her that care could not be provided during lunch due to contamination concerns. Staff, including CNAs and an LPN, were observed in the hallway and at the nurse's station but did not respond to the resident's repeated requests for assistance. The resident's care plan required assistance with toileting and incontinence care, and staff were expected to check her every two hours for incontinence. Another resident, who had a recent below-the-knee amputation and was dependent for toileting and transfers, reported that staff were often slow to respond to his call light, resulting in accidents and the need to wear an adult brief. This resident was also assessed as being cognitively intact and required assistance with elimination and incontinence care as needed. Both residents' care plans included keeping call lights within reach and providing timely assistance. The Director of Nursing Services stated that call light response times should not exceed five minutes, and the Executive Director acknowledged that it was unacceptable for call lights to go unanswered for extended periods. However, the facility did not have a specific policy regarding call light response times.
Insufficient Nursing Staff and Lack of Licensed Nurse in Charge
Penalty
Summary
The facility failed to provide enough nursing staff each day to meet the needs of every resident and did not ensure that a licensed nurse was in charge on each shift. This deficiency was identified through surveyor observation and review of facility staffing practices. The report specifically notes the lack of adequate staffing and the absence of a licensed nurse in charge during certain shifts, which did not meet regulatory requirements.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications and treatments in both the medication storage room and the medication cart, potentially affecting all 78 residents who received medications. During an observation, the medication storage room was found to be disorganized, with a large quantity of medications and treatments scattered throughout the room, including two full bins overflowing onto the counter and floor, and a sink filled with medications. The Director of Nursing (DON) acknowledged that these medications were removed from the medication carts that week and that a bag of medication was incorrectly mixed with those to be returned to the pharmacy. Additionally, the medication refrigerator contained Aplisol without an open date, which the DON indicated would be disposed of. Further review of the B Hall medication cart revealed that several residents' medications, including eye drops, lacked open dates, contrary to facility policy. The DON explained that the Medical Records Coordinator (MRC) had left the position, and a Float MRC, who only visited the facility bi-weekly, was not responsible for medication storage or returns. The facility's policy required medications to be stored orderly and labeled with open dates, but these procedures were not followed, leading to the observed deficiencies.
Medication Left at Bedside Without Assessment
Penalty
Summary
The facility failed to ensure that medication was not left at the bedside without a self-medication assessment for a resident. During an observation, Ventolin (albuterol) and Symbicort inhalers were found on the over-the-bed table of a resident. Upon reviewing the resident's self-administration assessment, it was noted that she was only approved to self-administer bacitracin to her nose, with no other medications listed for self-administration. The facility's policy on medication administration requires verification of the correct medication, dose, route, rate, time, and resident each time a medication is administered. This deficiency was identified in relation to a specific complaint.
Failure to Provide Comprehensive Nutritional Assessment and Interventions
Penalty
Summary
The facility failed to comprehensively assess and implement person-centered nutritional interventions for Resident B, who was on a low sodium diet due to her medical conditions, including acute on chronic congestive heart failure and type II diabetes mellitus. Resident B expressed dissatisfaction with the limited food options provided, specifically noting that hamburgers were the only alternative offered, which contradicted her dietary needs. Despite her request for a consultation with the Registered Dietician (RD) to review her diet and provide more suitable options, Resident B had not been visited by the RD since her admission. The facility's records showed a lack of documentation for a Nutrition Focused Physical Exam (NFPE) and an Estimated Nutrient Needs Assessment for Resident B. Her care plans did not include specific goals or interventions for her low sodium diet, and her weight had not been monitored since admission. The Regional Registered Dietician Consultant confirmed that the RD had not assessed Resident B, which should have triggered necessary care plan revisions. The facility's policy required a comprehensive nutrition assessment and resident-centered care plan, which were not adequately followed in Resident B's case.
Medication Administration Competency Deficiency
Penalty
Summary
The facility failed to ensure that staff were competent in medication administration for two residents. During a medication administration for one resident, an LPN provided a Symbicort inhaler, followed immediately by albuterol and Spirva, without any delay between puffs. The resident was given water to rinse her mouth, which she swallowed. This sequence of medication administration did not adhere to proper protocols for inhaler use. In another instance, the same LPN was observed preparing medication for a second resident. The LPN poured 15 mL of Robitussin into a medication cup, despite the physician's order indicating a dose of 10 mL. The LPN initially insisted the dose was correct until using a cell phone flashlight to verify the markings on the medication cup. The LPN acknowledged the need for magnifying glasses to read the measurements accurately. The facility's policy on medication administration was not followed, as medications should not be touched with bare hands, and doses must be verified against the medication order.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure medications were administered according to the physician's orders for a resident, identified as Resident B, who expressed concerns about missing medications. Upon review of Resident B's October Medication Administration Record (MAR), it was found that several medications were not administered as scheduled. These included clonazepam, dicyclomine, dorzolamide-timolol, hydrocodone-acetaminophen, symbicort, trazodone, and albuterol inhaler. The missed doses occurred on multiple occasions, indicating a pattern of non-compliance with the prescribed medication regimen. The facility's policy on medication administration, dated April 30, 2024, requires verification of the correct medication, dose, route, rate, time, and resident each time a medication is administered. However, this policy was not adhered to, as evidenced by the missed doses documented in the MAR. This deficiency was identified during an observation, interview, and record review process, and it relates to a specific complaint, IN00443579, highlighting the facility's failure to meet the pharmaceutical needs of the resident as per the physician's orders.
Failure to Adhere to Infection Control Protocols in COVID-19 Isolation Room
Penalty
Summary
The facility failed to prevent the potential spread of a highly contagious virus, specifically COVID-19, due to staff not adhering to proper infection control protocols. During observations, it was noted that staff members, including Certified Nursing Assistants (CNAs), entered a COVID-19 positive isolation room without performing hand hygiene or donning the required personal protective equipment (PPE) such as gowns, gloves, N-95 masks, or eye protection. This occurred over two consecutive days, and the staff were seen exiting the room and continuing their duties without performing hand hygiene, thereby increasing the risk of virus transmission. Resident C, a long-term care resident with vascular dementia and a history of cancer, was in isolation after testing positive for COVID-19. Despite clear signage indicating the need for PPE due to droplet isolation precautions, staff failed to comply with these requirements. Additionally, there was no waste basket for discarded PPE inside Resident C's room, further complicating proper infection control practices. The facility's policy on standard and transmission-based precautions was not followed, as evidenced by the staff's actions, which contradicted the guidelines for handling COVID-19 positive residents.
Failure to Respect Resident's Rights and Dignity
Penalty
Summary
The facility failed to maintain the dignity and respect of a resident, identified as Resident S, who was cognitively intact and had several medical conditions including COPD, morbid obesity, type 2 diabetes, hypertensive heart disease, chronic systolic heart failure, and anxiety disorder. On a specific date, Resident S was in the lobby with her daughter and removed her oxygen tubing due to a lack of airflow. She requested assistance from LPN 5, who was at the nurse's desk, but was reportedly yelled at and told that LPN 5 was not her nurse. Another nurse eventually assisted with the oxygen tank. Later, when LPN 5 entered Resident S's room with RN 6 to administer medication, Resident S asked LPN 5 to leave due to the earlier incident. LPN 5 refused, leading to a confrontation where Resident S threw water at LPN 5, who then threatened to call the police. The facility's care plan for Resident S, dated the same day as the incident, noted behavioral expressions such as yelling, cursing, and throwing objects at staff. The care plan included strategies like providing care in pairs, ensuring safety, and using a calm approach. However, there was no documentation of a care plan meeting on the date specified by the Administrator, who was unaware of any reports of verbal abuse or the incident until later. The Director of Nursing (DON) acknowledged that LPN 5 should have left the room when asked by the resident and had not reported the incident to the Administrator or conducted any employee education. Interviews with other staff members, including CNA 8 and RN 9, indicated they had received education on handling residents with behaviors and would leave a room if requested by a resident. The facility's policy on resident rights emphasized the right to be treated with dignity and respect and to be free from verbal abuse. Despite this, the incident with Resident S highlighted a failure to uphold these rights, as the resident's request for LPN 5 to leave was not honored, and the situation escalated unnecessarily.
Pest Infestation and Sanitation Issues in LTC Facility
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment, as evidenced by the presence of flying insects throughout the facility, including the kitchen and residents' rooms. During a kitchen tour, several dozen flying insects were observed on clean dishes, and the Dietary Manager confirmed the presence of these insects. The kitchen had multiple sanitation issues, such as standing water under the sink and a leaking ice machine, which contributed to the pest problem. The pest control company had previously identified structural and sanitation concerns, including loose floor tiles, gaps in doors, and biofilm buildup in drains, but these issues were not adequately addressed. Residents were directly affected by the pest infestation. Resident 7's room had a stained mattress with over 50 flying insects observed on it, and despite cleaning efforts, the insects persisted. Other residents, including Residents 65, 12, 53, and 124, reported and were observed with flying insects in their rooms. Resident 25, who had significant medical conditions, was found unarousable in her room with flying insects present. These observations indicate a widespread issue affecting the living conditions of all residents in the facility. The facility's pest control efforts were insufficient, as evidenced by the recurring presence of pests despite regular visits from a pest control company. The pest control documentation revealed ongoing issues with small flies, mice, and cockroaches, and repeated recommendations for structural and sanitation improvements were not fully implemented. The facility's policy on pest control was not effectively executed, leading to a failure in providing an environment free of pests and rodents.
Medication Labeling and Expiration Deficiencies
Penalty
Summary
The facility failed to properly label and date medications when opened and did not remove expired medications from use. This deficiency was observed in two of four medication carts and one refrigerator. On the A hall medication cart, a vial of Haldol for a resident was found without a date indicating when it was opened, despite being a one-time-use vial. Another resident's Breo medication also lacked an opening date. On the B hall medication cart, a bottle of Systane eye drops was found without a label, and another resident's Systane eye drops lacked an opening date. In the refrigerator, two bottles of lorazepam for a resident were found, one without an opening date and the other expired. Another resident's lorazepam bottle also lacked an opening date, and an additional bottle of lorazepam was found without a label. The facility's medication storage guidance, provided by the Director of Nursing Services, indicated that Ativan oral solution should be dated when opened and discarded 90 days after opening, and should be protected from light.
Deficiencies in Linen Handling and Kitchen Temperature Logging
Penalty
Summary
The facility failed to ensure that linens were not contaminated during dining service for four residents. The Social Services Director (SSD) was observed bringing tablecloths and clothing protectors into the dining room while holding them against her body and sleeve, which is against the facility's policy for handling clean linen. Additionally, the SSD did not perform hand hygiene after picking up trash from the dining room floor before handling linens for the residents. This action was contrary to the facility's hand hygiene policy, which aims to minimize the transmission of infection. The facility also failed to complete kitchen temperature logs as required. During a kitchen tour, it was observed that the temperature logs for the Prep Cooler and the High Temperature Dish Machine were incomplete for specific dates. The facility's policy mandates that thermometers should be checked and recorded at least twice daily, prior to breakfast preparation and again before dinner service. The lack of recorded temperatures indicates non-compliance with the facility's food storage policy.
Inadequate Infection Preventionist Staffing
Penalty
Summary
The facility failed to designate a qualified Infection Preventionist (IP) who was available for a minimum of 20 hours a week and did not share duties with other departments, as required for effective infection control and prevention. The Executive Director (ED) identified the facility's IP as an LPN who also served as the full-time Minimum Data Set (MDS) Coordinator. The Regional IP Consultant (RIPC) confirmed that the facility had been without a full-time IP for several months, and he only visited the facility 1-2 times a month to update infection tracking and reports, spending less than 20 hours per week on-site. In the absence of a full-time IP, the MDS Coordinator was responsible for daily implementation and oversight of the infection control program, despite her primary focus being on MDS tracking and assessment submission. The facility assessment, dated January 23, 2024, indicated that a full-time IP was required and should not share other duties. However, the MDS Coordinator, who temporarily filled the IP role, continued to manage her MDS responsibilities and assist with weekly wound rounds. During a review of the IP program and position vacancy, the ED acknowledged that another staff member should have been appointed to fill the MDSC role to ensure the IP did not share duties, thereby maintaining a comprehensive and effective daily program implementation. This deficiency had the potential to affect all 75 residents residing in the facility.
Failure to Provide Bariatric Bed and Accessible Call Light
Penalty
Summary
The facility failed to accommodate the needs and preferences of a resident by not providing a bariatric bed with mobility bars and ensuring the call light was within reach. The resident, who weighed 382 pounds and had multiple health conditions including obesity, sleep apnea, congestive heart disease, COPD, acute respiratory failure, diabetes mellitus, and schizophrenia, was observed multiple times with her mattress askew and the call light on the floor. Despite the care plan indicating the need for assistance with bed mobility and keeping the call light in reach, these measures were not implemented. The Director of Nursing Services was unaware of whether the resident had a bariatric bed and acknowledged the absence of policies for call lights and appropriate mattress use. The Executive Director confirmed that the call light should have been within reach, but there was no policy in place to ensure this. The lack of appropriate equipment and policies contributed to the deficiency in accommodating the resident's needs.
Failure to Conduct Level II PASARR Assessment
Penalty
Summary
The facility failed to properly assess a resident for coordination of preadmission screening and resident review (PASARR). Specifically, the facility did not refer one of four residents for a level II assessment, despite the resident's medical diagnoses and medication usage indicating the need for such an assessment. The resident in question had diagnoses including metabolic encephalopathy, psychotic disorder with delusions due to a known physiological condition, anxiety disorder, and depression. The resident was on Haldol, a psychotropic medication, which should have triggered a level II assessment. However, the level I assessment conducted lacked information about the resident's mental illness diagnosis and medication use, leading to the omission of the necessary level II assessment. The facility's PASRR policy, as provided by the Director of Nursing Services, mandates referral to the designated mental health or intellectual disability authority when there is a significant change in mental or physical status, which was not adhered to in this case.
Failure to Provide Nail Care for a Resident
Penalty
Summary
The facility failed to provide adequate nail care for a resident who was unable to manage his own nail hygiene. Over the course of three consecutive days, observations revealed that the resident's nails were long and dirty. The resident expressed that he had asked his daughter to cut his nails, but she was unavailable due to work commitments. The resident had a care plan indicating he required assistance with activities of daily living, including bathing and personal hygiene. Despite this, the necessary nail care was not provided, as evidenced by the repeated observations of the resident's unkempt nails. The Director of Nursing Services was informed of the situation and acknowledged the need for intervention.
Failure to Provide Adequate Respiratory Equipment
Penalty
Summary
The facility failed to provide necessary respiratory equipment for two residents, leading to deficiencies in their care. Resident 43, who required a BIPAP machine for conditions including obesity, sleep apnea, and COPD, was without a BIPAP mask for several nights. Despite having physician orders to use the BIPAP machine nightly, the mask was missing, and the Director of Nursing Services (DNS) was unaware of the issue until it was brought to her attention. The resident reported that a CNA had discarded the mask, and the DNS admitted that she had not ordered a replacement, leaving the resident unable to use the BIPAP machine as required. Similarly, Resident 53's respiratory equipment, including a nebulizer and CPAP mask, was observed uncovered and improperly stored on his bedside table. This resident, diagnosed with COPD, obstructive sleep apnea, and morbid obesity, had physician orders for CPAP use at bedtime and nebulizer treatments as needed. Despite requests, the facility failed to provide a respiratory equipment policy, and the procedures provided did not include instructions for the care of the equipment when not in use. These oversights indicate a lack of adherence to proper respiratory care protocols for residents requiring such equipment.
Failure to Use PPE During High-Contact Care
Penalty
Summary
The facility failed to ensure appropriate personal protective equipment (PPE) was utilized during high-contact resident care, specifically for a resident with an open wound and recurrent infections. During an observation, a certified nursing assistant (CNA) was seen providing a shower to a resident without wearing an isolation gown or gloves, despite the presence of stool incontinence and an open wound on the resident's right buttock. The CNA admitted to not wearing PPE because it was too hot in the shower room. The resident's wound was in direct contact with the shower chair, and the wound edges appeared macerated with green drainage present. The resident, who had a history of dementia, cellulitis, lymphedema, and reduced mobility, was placed under enhanced barrier precautions due to a wound infection. The facility's policy required the use of gown and gloves during high-contact care activities, such as bathing or showering, to prevent the transfer of multi-drug-resistant organisms (MDROs). Despite this, the CNA did not adhere to the policy, leading to a deficiency in infection prevention and control practices.
Failure to Implement Personalized Fall Interventions
Penalty
Summary
The facility failed to ensure fall interventions were personalized, implemented, and care planned for Resident B, who had a history of falls and dementia. Despite being identified as high risk for falls, the interventions put in place were not effective or personalized to her needs. Resident B experienced multiple falls within a short period, including an unwitnessed fall that resulted in a clavicle fracture and a broken nose. The interventions such as call light in reach and non-skid footwear were not suitable for her cognitive condition, and more effective measures like bed or chair alarms were not implemented. Resident B's medical history included dementia, repeated falls, and a recent subdural hematoma that required surgery. Despite this, the facility did not move her to a secured memory care unit as discussed, nor did they implement effective fall prevention measures. The family had requested additional interventions such as bed rails and fall mats, but these were not provided. The facility's documentation and follow-up on the falls were inconsistent, and there were discrepancies in the reported injuries and the observed condition of Resident B. The facility's policies on fall management and change of condition were not adequately followed. The interdisciplinary team did not update the care plan with effective interventions after each fall, and there was a lack of timely and appropriate communication with the physician and family regarding Resident B's condition. The facility's failure to provide adequate supervision and personalized fall interventions resulted in significant injuries to Resident B, highlighting deficiencies in their care planning and implementation processes.
Failure to Prevent Significant Weight Loss in Resident
Penalty
Summary
The facility failed to ensure that Resident L did not experience significant weight loss. Resident L, who had diagnoses including encephalopathy, Alzheimer's disease, and severe protein-calorie malnutrition, was observed struggling with her meals. Despite being on a mechanical soft diet, she received regular food that she had difficulty chewing. During an observation, Resident L was given a meal that she could not eat, and no staff assisted her with cutting the food or provided cues to help her eat. When she expressed difficulty and dislike for the food, she was eventually given a peanut butter and jelly sandwich and bananas, which she ate partially. However, this was not sufficient to meet her nutritional needs. Resident L's medical records indicated she was at risk for unintentional weight loss and required assistance with eating. Despite this, her care plan was not adequately followed. The records showed that she frequently refused Ensure Plus, a nutritional supplement, and her meal consumption was often very low. Her weight dropped from 70.4 pounds at admission to 57.4 pounds over 74 days, a loss of 18.5% of her body weight. The facility did not consistently provide the necessary assistance with eating, and her dietary needs were not adequately addressed. The facility's documentation and staff interviews revealed inconsistencies in Resident L's care. The diet prescribed by the hospital was not clearly communicated or followed, leading to confusion about her dietary needs. The Registered Dietitian noted that the facility should have contacted her if there were changes in Resident L's weight, but this did not happen. Additionally, a CNA reported that Resident L often did not eat unless encouraged and assisted, which was not consistently provided. The facility's failure to ensure proper dietary management and assistance contributed to Resident L's significant weight loss.
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.
