Envive Of Muncie
Inspection history, citations, penalties and survey trends for this long-term care facility in Muncie, Indiana.
- Location
- 7524 E Jackson Street, Muncie, Indiana 47302
- CMS Provider Number
- 155549
- Inspections on file
- 24
- Latest survey
- March 31, 2026
- Citations (last 12 mo.)
- 21
Citation history
Health deficiencies cited at Envive Of Muncie during CMS and state inspections, most recent first.
The facility failed to provide and document required written notices of transfer/discharge rights and bed-hold policies for three residents who were transferred to the hospital for acute changes in condition, including stroke-related symptoms, severe respiratory distress, and suspected urosepsis. In each case, staff notified providers, obtained orders for ER evaluation, contacted EMS, and documented the transfers and subsequent hospital admissions, but the clinical records lacked evidence that the residents or their representatives received the mandated written notices. Interviews with the SSD, DON, and an RN showed that bed-hold and related paperwork were routinely placed in packets sent with EMTs to the ER rather than being given directly to residents or their representatives, and there was no documentation that these notices were received, contrary to facility policy requiring provision and documentation of such notices after emergency transfers.
A resident was admitted and did not receive a written or verbal summary of the baseline care plan, as required by facility policy. Record review showed no documentation that the resident or the resident’s representative was given baseline care plan information within the required timeframe. The SSD acknowledged that no baseline care plan conference note was completed, no care plan conference had occurred since admission, and no phone contact was made with the resident’s representative to convey baseline care plan details, despite the resident having generally intact cognition. This was inconsistent with the facility’s policy requiring development of a baseline plan of care within 48 hours of admission and provision and documentation of a written summary to the resident and/or representative.
Two residents were not appropriately offered or administered pneumococcal vaccinations per CDC guidance and facility policy. One resident with a history of tonsillar cancer, traumatic brain injury, and diabetes had only a historical PPSV23 documented prior to admission, with no consent/declination form and no record of being offered current PCV15, PCV20, or PCV21 vaccines. Another resident with cardiac conditions and muscle weakness had a signed pneumococcal vaccine consent on file but no documentation of any pneumococcal vaccine being offered or given, and no updated consent or declination. The DON reported difficulty locating current vaccination forms and noted that an off-site company provides vaccinations, but no clinic had yet been scheduled, resulting in missing documentation and incomplete pneumococcal vaccination offerings for these residents.
A resident with cardiac conditions and moderate cognitive impairment had signed consents for a COVID-19 vaccine and booster through a representative, but review of records showed the resident never received a COVID-19 vaccination and lacked an updated consent or declination. The DON could not locate current vaccination forms, reported that vaccines were administered by an off-site company, and acknowledged that another vaccine clinic had not yet been scheduled, despite stating vaccines were to be offered yearly. The Infection Preventionist stated residents were offered COVID-19 vaccinations, while CDC guidance cited by surveyors recommended updated COVID-19 vaccines for adults, including those in LTC, with two doses for those 65 and older and consent required.
Surveyors found unsecured disposable razors stored in unlocked mirrored vanities in two shared bathrooms on a dementia unit, including one bathroom accessible from the main dining room. The bathrooms were used by four cognitively impaired residents with dementia, some with severe cognitive impairment, hallucinations, agitation, anxiety, and cognitive communication deficits, who were able to toilet and stand at the sink independently. The Memory Care Director acknowledged razors should not be left in resident bathrooms and stated that some razors had been brought in by families, while a CNA reported she did not usually keep razors in bathrooms. The Administrator was unable to locate a policy governing disposable razor storage.
A resident with moderate cognitive impairment, COPD, and multiple respiratory diagnoses received a prescribed ipratropium-albuterol nebulizer treatment ordered to be administered by a clinician, but nursing staff did not remain in the room during the treatment as required by facility policy. The resident was observed alone in bed with the nebulizer running while an RN was at the nurses' station, and the RN later confirmed she typically did not stay with residents during nebulizer treatments. The resident had not been assessed as able to self-administer medications, and the care plan called for medications to be administered as ordered, including adherence to the policy requiring staff to remain with the resident throughout the nebulizer treatment.
Surveyors found that multiple shared bathrooms on a dementia unit contained unlocked vanities with partially used and unlabeled personal care items, such as wound cleanser, deodorant, toothpaste, lotions, toothbrushes, and incontinence briefs, used by several cognitively impaired residents. Staff, including the Memory Care Director and a CNA, acknowledged that these items should have resident identifiers and typically would be stored in shower rooms, drawers, or closets, and the Administrator was unable to produce a policy governing storage of residents’ personal care items.
The facility did not consistently complete shift-to-shift narcotic reconciliation for three medication carts, with missing signatures and counts on controlled substance records and unreported discrepancies. Nursing staff failed to follow policy requiring both incoming and outgoing staff to verify and document controlled medication counts, impacting residents receiving controlled medications from these carts.
The facility did not document that required bed hold policies and transfer/discharge notifications were provided to residents or their representatives during hospitalizations, and failed to ensure that appropriate transfer information was communicated to a receiving provider when a resident was discharged to another facility. Although forms and policies were attached in records, there was no evidence of who received them, and staff interviews confirmed the lack of documentation.
A resident with multiple medical conditions experienced a significant, unplanned weight loss while on a carbohydrate controlled diet. Despite the RD's recommendations to liberalize the diet to provide more calories and protein, the diet was not changed, and the physician was not notified of the weight loss or the recommendations. Documentation and staff interviews confirmed these failures, and the facility's policy for multidisciplinary nutritional assessment and intervention was not followed.
Staff failed to consistently use Enhanced Barrier Precautions (EBP), including gowns and gloves, during high-contact care for a resident with a stage 3 sacral pressure injury. Multiple staff members were observed not following EBP protocols, lacked knowledge about EBP, and did not receive documented education on EBP requirements, despite facility policy and physician orders mandating these precautions.
Two residents were not properly offered, educated about, or administered pneumococcal vaccines as required by CDC guidance. One resident did not receive the vaccine despite consent and education, while another lacked documentation of education and consent. The DON confirmed gaps in the facility's process for vaccine administration and documentation.
A resident with chronic pain, hypertension, and diabetes was admitted with a history of prior COVID-19 vaccinations, but the facility failed to provide education, offer the vaccine, or document consent/declination as required. The DON reported no recent vaccine clinics and was unable to locate necessary documentation, resulting in a deficiency related to immunization procedures.
An LPN failed to disinfect glucometers and the surfaces they contacted during blood glucose monitoring for multiple residents. The devices were placed on the medication cart and over-bed tables without cleaning, and were returned to storage without disinfection, contrary to facility policy and manufacturer guidelines.
The facility failed to secure potentially hazardous items on the dementia unit, impacting 11 mobile residents. An unlocked cabinet contained gel hand sanitizer, denture cleaning tablets, and razors, posing a risk to residents with dementia. The Dementia Unit Manager acknowledged the cabinet should have been locked, as per facility policy.
Failure to Provide Required Written Transfer/Discharge and Bed-Hold Notices
Penalty
Summary
The deficiency involves the facility’s failure to provide written notice of transfer/discharge rights and the facility’s bed-hold policy to residents and/or their representatives when residents were transferred to the hospital. For one resident with cerebral infarction, atrial fibrillation, and vascular dementia, progress notes documented a change in condition with lethargy, garbled speech, and intermittent responsiveness, leading to a family request for transfer to the ER and subsequent transport by EMTs. The clinical record did not contain documentation that a Notice of Transfer rights or bed-hold policy was provided to the resident or her representative at the time of this hospitalization. A second resident with diagnoses including hyperosmolality, hypernatremia, tonsillar cancer, and nontraumatic subarachnoid hemorrhage experienced respiratory distress with moist respirations, labored breathing, and low oxygen saturation, prompting provider notification, an order for ER transfer, and EMS transport. Later that same month, the same resident had an unresponsive episode in the dining room with low oxygen saturation and decreased responsiveness, again resulting in provider notification and ER transfer. For both hospitalizations, progress notes documented the transfers and subsequent hospital admissions, but the clinical record lacked documentation that the Notice of Transfer rights and bed-hold policy were provided to the resident or his representative. A third resident with anemia, hypertension, and dementia exhibited a change in condition characterized by abnormal urine appearance and odor, altered mental status compared to baseline, and a family request for ER evaluation. The provider was notified, an order for ER evaluation was obtained, 911 was called, and the resident was transported and later admitted for urosepsis. The record did not show that the Notice of Transfer rights and bed-hold policy were provided to the resident or his representative. Interviews with the Social Services Director, DON, and an RN revealed that bed-hold paperwork and related forms were routinely placed in a packet sent with EMTs to the hospital, with no direct provision of these notices to residents or their representatives and no documentation that such notices were received, despite facility policy requiring that bed-hold and return policies be provided to residents and representatives within 24 hours of emergency transfer and that provision of appropriate notice be documented in the medical record.
Failure to Provide and Document Baseline Care Plan Summary After Admission
Penalty
Summary
The facility failed to ensure that a resident and/or the resident’s representative received a copy of the resident’s baseline care plan following admission. Record review for Resident 8 showed that the resident was admitted on an identified date, but the clinical record did not contain documentation that a written summary of the baseline care plan was provided to the resident or the resident’s representative. The facility’s policy, dated 8/2024, required that a baseline plan of care to meet the resident’s immediate health and safety needs be developed within 48 hours of admission and that the resident and/or representative be provided a written summary of this baseline care plan, with documentation of this provision in the medical record. During interviews, the Social Services Director (SSD) stated that she had not completed a baseline care plan conference review note for Resident 8 because the resident had not yet had a care plan conference since admission, and therefore no baseline care plan information was provided to the resident or the resident’s representative. The SSD further indicated that baseline care plan information was to be conveyed to residents or their representatives within 72 hours after admission and could be relayed over the phone, but no phone contact was made with Resident 8’s representative. Although Resident 8’s cognitive status was intact, with some fluctuation in cognitive function, the SSD did not provide baseline care plan information verbally or in writing to the resident. This failure was contrary to the facility’s written policy and the requirement to document provision of the baseline care plan summary in the medical record.
Failure to Offer and Administer Pneumococcal Vaccines per CDC Guidance
Penalty
Summary
The facility failed to offer and administer pneumococcal vaccinations in accordance with CDC guidance and its own policy for two residents. Resident 27, who had diagnoses including tonsillar cancer, traumatic brain injury, and diabetes, had a historical PPSV23 (Pneumovax 23) documented from 12/19/11 prior to admission. The clinical record did not contain a Pneumococcal Vaccine Consent or Declination Form and lacked any documentation that the resident had been offered or received the currently recommended pneumococcal conjugate vaccines (PCV15, PCV20, or PCV21) as outlined by CDC recommendations for adults 50 years and older. This was inconsistent with the facility’s written policy requiring assessment of pneumococcal vaccination status upon or shortly after admission and administration of vaccines per current CDC recommendations. Resident 45, with diagnoses including aortic valve insufficiency, heart disease, and muscle weakness, had no record of receiving any pneumococcal vaccination. The record contained a Pneumococcal Vaccine Consent signed on 12/6/24, but there was no updated consent or declination and no documentation that any pneumococcal vaccine had been offered or administered. During interviews, the DON stated she could not locate current pneumococcal vaccination forms for these residents, explained that vaccinations were administered by an off-site company, and acknowledged that another vaccine clinic needed to be scheduled but had not yet been arranged. The DON and Infection Preventionist both stated that pneumonia vaccinations were offered per guidelines, but the clinical records for these two residents did not support that pneumococcal vaccines had been appropriately offered or administered in accordance with CDC guidance and the facility’s policy.
Failure to Ensure Appropriate COVID-19 Vaccination and Documentation
Penalty
Summary
The facility failed to administer appropriate COVID-19 vaccinations in accordance with CDC guidance for one resident. Resident 45 had diagnoses including aortic valve insufficiency, heart disease, and muscle weakness, and a quarterly MDS dated 3/9/26 documented moderately impaired cognition. A COVID-19 vaccine consent and a COVID-19 booster consent were signed by the resident’s representative on 12/6/24. However, a review of the vaccination record showed the resident had not received any COVID-19 vaccination, and the record also indicated that the family representative had refused the vaccination in December 2024. The clinical record lacked an updated or yearly COVID-19 vaccination consent or declination. During interviews, the DON stated she was unable to locate current COVID-19 vaccination forms for this resident and confirmed that the facility did not administer vaccinations directly, instead using an off-site company to provide vaccines. She acknowledged that another vaccine clinic needed to be scheduled but had not yet done so, and also stated that COVID-19 vaccinations were to be offered yearly. The Infection Preventionist reported that residents were offered COVID-19 vaccinations. CDC guidance reviewed by surveyors indicated that adults, including those in LTC settings, should receive an updated COVID-19 vaccine, and that individuals aged 65 and older should receive two doses of an updated vaccine six months apart, with consent required from LTC residents. The deficiency was cited under 410 IAC 16.2-3.1-18(b)(5).
Unsecured Disposable Razors in Dementia Unit Bathrooms
Penalty
Summary
The facility failed to ensure the environment was free from accident hazards and did not provide adequate supervision to prevent accidents by allowing disposable razors to be unsecured in shared bathrooms on a dementia unit. During an observation of one shared bathroom used by two cognitively impaired residents, an unlocked tri-fold mirrored vanity above the sink was found to contain a disposable razor. The Memory Care Director, present at the time of the observation, stated that razors should not be left in residents' bathrooms. Record review showed that one of these residents had diagnoses including hallucinations, cognitive communication deficit, and unspecified dementia with severe cognitive impairment per a quarterly MDS, while the other had unspecified dementia and moderate cognitive impairment per a quarterly MDS. In a second shared bathroom, also on the memory care unit and accessible from the unit’s main dining room, surveyors observed two disposable razors stored in an unlocked tri-fold mirrored vanity above the sink. The Memory Care Director reported that family members had brought in the razors and acknowledged they should not have been left in the bathroom. Record review for the two residents using this bathroom showed diagnoses of unspecified dementia with severe cognitive impairment and cognitive communication deficit for one resident, and moderate unspecified dementia with agitation and anxiety for the other, with both needing assistance or having needs related to personal care. A CNA reported that these residents could toilet themselves and stand at the sink independently and that she did not normally keep razors in residents’ bathrooms. During an interview, the Administrator stated he was unable to locate a facility policy for storage of disposable razors.
Failure to Supervise Nebulizer Treatment for Cognitively Impaired Resident
Penalty
Summary
The deficiency involves a resident receiving a nebulizer treatment without required staff supervision, despite not being assessed as able to self-administer medications. During an observation, the resident was found lying in bed with a nebulizer machine running while an RN was seated at the nurses' station. After approximately two minutes, the RN entered the room, turned off the nebulizer, assessed the resident's lung sounds, and then left. The RN stated she did not normally remain with residents during their nebulizer treatments. Another RN also reported that she did not stay with residents during nebulizer treatments, but would return to check on them during the treatment. The resident had diagnoses including cognitive communication deficit, vascular dementia with moderate cognitive impairment, schizophrenia, acute bronchitis, COPD with acute exacerbation, acute cough, dyspnea, and other respiratory and circulatory symptoms. The resident’s medication orders included ipratropium-albuterol inhalation solution to be inhaled four times daily for shortness of breath and wheezing, with the medication specifically ordered to be administered by a clinician. The care plan identified a potential for impaired gas exchange related to COPD, dyspnea, rhinitis, shortness of breath, and wheezing, with interventions to administer medications as ordered. The clinical record did not show that the resident had been assessed as able to self-administer medications, and the facility’s policy for administering medications via small volume nebulizer required staff to remain with the resident for the duration of the treatment, which did not occur in this case.
Unlabeled and Cohorted Personal Care Items in Shared Dementia Unit Bathrooms
Penalty
Summary
Surveyors identified a failure to implement an effective infection prevention and control program related to the storage and labeling of residents’ personal care items in shared bathrooms on a dementia unit. In one shared bathroom used by two cognitively impaired residents with dementia, an unlocked tri-fold mirrored vanity above the sink contained multiple personal care items with no resident identifiers, including an empty bottle of Vashe wound cleanser, after shave gel, shaving cream, perfumed body cream, two denture brushes, and a toothbrush. The Memory Care Director stated that no one currently had wounds and could not explain why the wound cleanser was present. Record review showed one resident had severe cognitive impairment and the other had moderate cognitive impairment and needed assistance with personal care. In another shared bathroom used by three residents, the unlocked vanity contained a roll-on deodorant, partially used toothpaste, lotion, and a toothbrush in a foam cup, all without resident identifiers. One of these residents had diagnoses including schizoaffective disorder, psychotic disorder with delusions, paranoid schizophrenia, dementia with behavioral disturbance, and Alzheimer’s disease with late onset, and was assessed as having moderate cognitive impairment. A third shared bathroom, accessible from the memory care unit’s main dining room and used by two residents with dementia and moderate to severe cognitive impairment, contained an unlocked vanity with unlabeled personal care items including skin repair cream, a toothbrush, baby lotion, cornstarch powder, and four incontinence briefs. During interviews, the Memory Care Director and a CNA confirmed that personal care items should have resident identifiers and were normally stored in shower rooms, residents’ drawers, or closets, and the Administrator reported he could not locate a policy for storage of residents’ personal care items.
Failure to Complete Shift-to-Shift Narcotic Reconciliation for Multiple Medication Carts
Penalty
Summary
The facility failed to ensure that shift-to-shift narcotic reconciliation was completed for three of four medication carts reviewed, specifically on the A Unit, Cottage Unit, and C Unit medication carts. During medication storage observations, it was found that required signatures and counts were missing from the Shift To Shift Narcotic Count records at the beginning of shifts. For example, an LPN did not sign or record her count when taking over the cart, and discrepancies in the number of controlled medication cards and sheets were not recognized or reported as required. Review of records revealed multiple instances in May and June where shift-to-shift reconciliation was not documented for these carts. Interviews with nursing staff confirmed that both the incoming and outgoing staff were required to count and verify controlled substances together, document the count, and sign the records. However, staff admitted to not completing these steps consistently, and in some cases, discrepancies in the controlled substance counts were not reported to the DON as required by facility policy. The DON confirmed that incomplete reconciliation records made it impossible to verify if the process had been completed and that any discrepancies should have been immediately reported and investigated. The facility's current policy required strict compliance with laws and regulations regarding the handling, storage, and documentation of controlled substances, including shift-to-shift inventory reconciliation and immediate reporting of discrepancies. Despite this, the observed and documented lapses in reconciliation and documentation created opportunities for unrecognized discrepancies in controlled medication counts, affecting a significant number of residents who received controlled medications from the affected medication carts.
Failure to Document Provision of Bed Hold Policy and Transfer/Discharge Notifications
Penalty
Summary
The facility failed to provide proper documentation and notification regarding bed hold policies and transfer/discharge notifications to residents and/or their representatives during hospitalizations. For three residents with varying cognitive statuses and medical conditions such as respiratory failure, COPD, hypertension, dementia, and post-stroke deficits, the clinical records showed that while the required forms and bed hold policies were attached, there was no documentation indicating to whom these documents were provided. In each case, the records lacked evidence that the resident or their representative received the necessary notifications at the time of transfer or discharge to the hospital, as required by facility policy. Additionally, for one resident discharged to another long-term care facility, the clinical record did not contain documentation that the resident's discharge information was communicated to the receiving provider. Although the resident's daughter was given a packet of information and medications, there was no record of the receiving facility being provided with the required transfer information, such as the basis for transfer, practitioner contact, care plan, and other essential details for continuity of care. Interviews with facility staff confirmed that while procedures were in place to print and distribute documentation, there was no evidence in the clinical records to verify that the required notifications and information were actually provided to the appropriate parties. Facility policies reviewed specified the need for written notification and documentation of attempts to notify representatives, as well as the communication of comprehensive transfer information to receiving providers, but these requirements were not met in the reviewed cases.
Failure to Follow Dietitian Recommendations and Notify Physician for Significant Weight Loss
Penalty
Summary
The facility failed to follow the registered dietitian's (RD) recommendations and did not notify the physician regarding a resident who experienced a significant, unplanned weight loss. The resident, who had diagnoses including schizoaffective disorder, muscle weakness, obesity, and type 2 diabetes mellitus, was on a consistent carbohydrate diet. Over a six-month period, the resident lost 10.29% of her body weight, with meal consumption records indicating she typically ate only 51-75% of her meals. Despite the RD's repeated recommendations in March and April to liberalize the resident's diet to a regular diet to provide more calories and protein, the resident continued to receive the carbohydrate controlled diet. The clinical record did not contain documentation that the physician was notified of the significant weight loss or the RD's recommendations, nor was there an order to change the resident's diet or any indication that the physician declined the recommendation. Interviews with facility staff confirmed that the RD communicated her recommendations to the interdisciplinary team (IDT) via email and documented them in the electronic medical record, but the DON was unaware that the resident's diet had not been changed. The facility's policy required a multidisciplinary approach to nutritional assessment and intervention, but this process was not followed in this case.
Failure to Implement and Educate Staff on Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The facility failed to ensure that staff were properly educated in and implemented Enhanced Barrier Precautions (EBP) during high-contact care for a resident with a stage 3 sacral pressure injury. Observations revealed that staff, including an RN and multiple CNAs, did not consistently wear gowns as required during wound care and other high-contact activities, despite gloves being used. During wound care, the RN did not don a gown and her clothing came into contact with the resident's bed linens. The resident's care plan and physician orders specifically required EBP, including the use of gowns and gloves during high-contact care, but these precautions were not followed. Interviews with staff indicated a lack of knowledge and awareness regarding EBP requirements. Several CNAs were unfamiliar with what EBP entailed, how to identify which residents required EBP, or what personal protective equipment (PPE) was necessary. Assignment sheets and signage were not consistently used or noticed, and staff did not always perform hand hygiene or change gloves appropriately during care. One CNA was observed providing incontinence care, changing clothing, and manipulating a feeding tube without wearing a gown, performing hand hygiene, or changing gloves, despite EBP signage being present in the resident's closet. The Director of Nursing (DON) confirmed that EBP was required for residents with wounds, invasive lines, or indwelling devices, and that gowns and gloves should be used during high-contact care. However, the DON was unable to provide documentation of when EBP education was provided to staff or which staff had received it. Agency staff also reported not receiving EBP education prior to providing care. Facility policy required EBP for residents with wounds or indwelling devices, specifying gown and glove use for high-contact activities, but this policy was not consistently implemented.
Failure to Offer, Educate, and Administer Pneumococcal Vaccines per CDC Guidance
Penalty
Summary
The facility failed to offer, educate, and/or administer pneumococcal vaccines according to CDC guidance for two of five residents reviewed for immunizations. For one resident with diagnoses including COPD, type 2 diabetes with neuropathy, and a stage 4 pressure ulcer, the clinical record did not contain an order for the pneumococcal vaccine. Although a consent form was completed and education was provided, the vaccine was not administered as required. Another resident with chronic pain syndrome, hypertension, and type 2 diabetes had historical documentation of receiving pneumococcal vaccines prior to admission. However, the clinical record lacked documentation of education and a signed consent or declination form for the pneumococcal vaccination. The DON confirmed that the facility had not held a vaccine clinic with the outside provider and was uncertain about the process for administering vaccines when due between clinics. The facility policy required education, consent, and documentation for immunizations, which was not followed in these cases.
Failure to Educate, Offer, and Document COVID-19 Vaccination for Resident
Penalty
Summary
The facility failed to provide education, offer, and document COVID-19 vaccination status in accordance with CDC guidance for one resident reviewed for immunizations. The resident, who had a history of chronic pain syndrome, hypertension, and type 2 diabetes mellitus, was admitted to the facility with a prior history of receiving multiple COVID-19 vaccinations before admission. Upon review of the clinical record, there was no documentation of education or a signed consent/declination form for the COVID-19 vaccination as required by facility policy. Interviews with the DON revealed that the facility had not conducted a vaccine clinic since the change in ownership, and the process for administering vaccines between clinics was unclear. The DON was unable to locate documentation or consents for the resident's COVID-19 vaccinations, despite the facility's policy requiring that information and consent forms be provided and retained in the medical record upon admission. The lack of documentation and unclear processes led to the deficiency identified during the survey.
Failure to Disinfect Glucometers and Surfaces During Blood Glucose Monitoring
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices during blood glucose monitoring for five residents. During medication administration, an LPN was observed removing each resident's glucometer from a plastic bag in the medication cart, placing it directly on the medication cart and then on the resident's over-bed table without cleaning or disinfecting these surfaces. After performing the blood sugar check, the LPN returned the glucometer to the medication cart and then to the plastic storage bag without disinfecting the device. This process was repeated for each resident observed, and at no point were the glucometers or the surfaces they contacted cleaned or disinfected. Interviews with facility staff confirmed that the expectation was for glucometers to be cleaned and allowed to dry before being stored, in accordance with manufacturer guidelines and facility policy. The policy specifically required cleaning and disinfecting reusable equipment between uses. The failure to follow these procedures was observed for all five residents reviewed for infection control during medication administration, as neither the glucometers nor the medication cart and over-bed tables were disinfected before or after use.
Failure to Secure Hazardous Items on Dementia Unit
Penalty
Summary
The facility failed to ensure that potentially hazardous items were securely stored on the dementia unit, which could have impacted 11 of the 13 mobile residents residing there. During an observation, it was noted that residents were moving freely within the unit, some using wheelchairs and others with assistance devices. Although employees were present and interacting with residents, not all residents were within their line of sight. A specific observation revealed an unlocked cabinet in the dining area, which was supposed to remain locked at all times according to a sign on its face. The cabinet contained hazardous items, including two bottles of gel hand sanitizer, an open box of denture cleaning tablets, and 13 disposable razors, all of which had warning labels indicating potential harm if ingested. The Dementia Unit Manager confirmed during an interview that the cabinet should have been locked. All residents on the unit had a diagnosis of dementia or a related disorder, with 11 of them capable of independent locomotion. The facility's policy on the storage and security of potentially hazardous items emphasized the importance of providing an environment free from hazards, including the safe storage of toxic chemicals and sharp items, especially for residents with cognitive impairments. The failure to secure the cabinet posed a risk to the residents, who could have accessed these hazardous items.
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.
