Hammond-whiting Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Whiting, Indiana.
- Location
- 1000 114th St, Whiting, Indiana 46394
- CMS Provider Number
- 155423
- Inspections on file
- 36
- Latest survey
- February 11, 2026
- Citations (last 12 mo.)
- 32
Citation history
Health deficiencies cited at Hammond-whiting Care Center during CMS and state inspections, most recent first.
Nursing staff did not inform a resident with multiple diagnoses about the name or purpose of her prescribed medication during administration on two occasions. The resident struggled to take the medication due to its taste and became upset, but staff only encouraged her to finish it without providing education or explanation, contrary to facility policy and staff expectations.
A resident requiring assistance with ADLs, including bathing, did not receive a bath or shower for multiple consecutive days, as evidenced by observation of poor hygiene and a lack of documented care or refusals, despite a care plan indicating the need for such assistance.
A resident with multiple medical conditions did not receive ordered doses of vancomycin and alprazolam due to missing hospital discharge paperwork, lack of timely verification of medication orders, and absence of a prescription for the antianxiety medication. The MAR reflected several missed administrations, and staff were unable to provide explanations for these omissions.
Two residents with pressure-related skin conditions did not receive ordered care, including off-loading of heels and proper wound dressing. One resident was found with her heels resting on the bed despite an order to off-load, and another was observed without a dressing on a sacral wound and with heels not off-loaded. In both cases, staff did not follow physician orders for pressure ulcer prevention and care.
A resident with pressure ulcers had two active, conflicting physician orders for wound care—one for Aquacel alginate and another for Xerofoam—both of which were documented as completed on the TAR. During wound care, a nurse prepared to use the incorrect treatment before clarifying the current order, but both orders remained in the record, resulting in incomplete and inaccurate clinical documentation.
A wound nurse failed to wear a gown while providing wound care to a resident on Enhanced Barrier Precautions, despite CDC guidance requiring both gown and gloves for such high-contact care activities. The resident had multiple medical conditions and required significant assistance, and the facility's infection prevention nurse indicated their policy allowed discretion in applying EBP, which did not align with current CDC recommendations.
The facility's main kitchen was found to have unsanitary conditions, including dried food spillage on storage bins, improper placement of scoops directly on food, and a bag of thawed chicken in the refrigerator that was not dated. These issues were observed during a kitchen sanitation tour with the Dietary Food Manager.
The facility's kitchen was found to be unsanitary during inspections, with dirty floor tiles, dried food spillage, and dust accumulation on pipes. The Dietary Food Manager acknowledged the need for cleaning.
The facility failed to label and store medications properly, with unlabeled acetaminophen found in a medication cart and a medication room. Staff identified these as house medications, which were later confirmed by a nurse consultant to be inappropriate.
The facility did not follow the prescribed menu for residents on pureed diets. Instead of serving pureed beef tips with mushrooms over parsley noodles, residents were given pureed ham, peas, mashed potatoes and gravy, and bread. The Dietary Food Manager confirmed the error, noting that the cook usually prepared a special meal for these residents, leading to the menu deviation.
A resident with cognitive impairment and mobility issues had their call light consistently placed out of reach, contrary to their care plan. Observations confirmed the call light was clipped above the bed, making it inaccessible. Staff interviews and the Interim Administrator acknowledged the oversight.
The facility failed to hold care plan meetings and invite families for two residents. One resident, who was cognitively intact, was not informed about his care plan meetings, and his daughter was not contacted. Another resident, who was cognitively impaired, was also not invited to his care plan meetings. The Social Service Director confirmed there was no documentation of attempts to reach out to the residents or their families.
The facility failed to provide timely assistance with ADLs for two residents who required meal assistance, leaving them without help for over 10 minutes. Additionally, a resident with hemiplegia and visual impairment was not shaved regularly despite her request, as observed on multiple occasions. The Interim Administrator acknowledged these deficiencies.
A facility failed to provide a personalized activity program for a cognitively impaired resident in isolation. Observations showed the resident was often awake and restless, with her television off, despite her care plan indicating she benefited from activities and one-to-one visits. The Activity Director noted staffing shortages affected the frequency of visits, leading to a deficiency in meeting the resident's needs.
The facility failed to administer insulin as ordered for two residents, leading to deficiencies in medication management. A resident with dementia and diabetes did not receive her prescribed insulin on multiple occasions, and it was administered when her blood sugar levels were below specified parameters. Another resident on anticoagulant therapy was observed with a discoloration on the wrist, which was not assessed or monitored. Additionally, a resident reported late insulin administration, confirmed by the Medication Administration Record.
A resident with hemiplegia, dementia, and Stage 4 pressure ulcers did not receive necessary pressure ulcer care as prescribed. Observations showed her pressure-reducing heel boots were not used while in bed, and her feet rested directly on the mattress, contrary to physician's orders. The Treatment Administration Record inaccurately indicated that interventions were completed, and the Wound Nurse confirmed the care was not provided as documented.
A facility failed to administer oxygen at the prescribed flow rate for a resident with COPD and other health conditions. Observations showed the flow rate was below the required 3 liters per minute, despite documentation indicating it was given correctly. The Interim DON acknowledged the issue without further information.
A facility failed to complete a post-dialysis assessment for a resident requiring dialysis services. The resident, with conditions including kidney disease and hemiplegia, had a care plan that included monitoring the dialysis access site. However, post-dialysis communication forms were not consistently filled out, and vital signs were not documented as required by the facility's policy.
A resident in prolonged isolation due to Candida auris did not receive ongoing psychosocial visits, despite being at risk for mood changes due to anxiety. The resident, with multiple health conditions, expressed distress over the isolation. The facility's Social Service Director acknowledged the lack of regular psychosocial checks, contributing to the deficiency.
A facility failed to implement proper infection control guidelines, leading to improper PPE use and staff confusion about a resident's isolation status. The resident, with multiple health conditions including Candida auris, was incorrectly placed under droplet precautions. Additionally, an antiseptic bath ordered for the resident was not administered or documented on one occasion.
The facility failed to implement gradual dose reductions (GDR) for psychotropic medications for two residents. One resident continued to receive a higher dose of Seroquel despite a GDR order, and another resident continued to receive a higher dose of Ativan despite a GDR recommendation. There was no documentation of physician declination for the GDRs, and the Nurse Consultant confirmed the medications were not reduced as ordered.
The facility did not have an RN on duty for 8 consecutive hours on one day, as required. This was discovered during a review of staffing schedules, and the Interim Administrator confirmed the absence of RN coverage, which could have impacted all 67 residents.
Two residents with non-pressure related skin conditions were not properly assessed or monitored. One resident had a bruise on their hand while on anticoagulant therapy, with no documentation or monitoring orders. Another resident had multiple bruises and a scab, but no documentation or monitoring orders were in place. The DON was unaware or mistakenly believed monitoring orders were entered.
A resident with a history of stroke-related hemiplegia and cognitive impairment was observed multiple times with their bed not in a low position, despite being at risk for falls. The care plan required the bed to be kept low, but this was not adhered to, as confirmed by the DON, who noted the resident's preference against it.
Failure to Inform Resident About Medication During Administration
Penalty
Summary
The facility failed to ensure that a resident was fully informed about her medication during administration. On two separate occasions, nursing staff prepared and administered the powdered medication Lokelma to a resident with diagnoses including high blood pressure, diabetes, and Bell's palsy. During both medication passes, the staff did not inform the resident about the name or purpose of the medication. The resident expressed difficulty consuming the medication due to its taste, gagged, and became visibly upset, but was only encouraged to finish the dose without any explanation or education provided. Record review showed that the resident was moderately impaired for daily decision making, and a physician's order was in place for daily Lokelma administration for high potassium. Interviews with staff confirmed that the expectation was for nurses and medication aides to inform residents about their medications prior to administration. The facility's medication administration policy also required staff to provide residents with information about the drugs they were receiving.
Failure to Provide Bathing Assistance for Dependent Resident
Penalty
Summary
A dependent resident with diagnoses including heart failure, kidney disease, anxiety, and diabetes, who was assessed as moderately impaired in daily decision-making and requiring assistance with activities of daily living (ADLs), did not receive proper assistance with bathing. Observation revealed the resident had greasy hair, and a review of shower records showed the resident had not received a bath or shower over a nine-day period, with no documented refusals for those dates. The care plan indicated the need for assistance with ADLs, but there was a lack of documentation and provision of bathing care as required.
Failure to Administer Antibiotic and Antianxiety Medications as Ordered
Penalty
Summary
A resident with diagnoses including paraplegia, osteomyelitis, anxiety, hypertension, muscle weakness, and ulcerative colitis was admitted to the facility and had physician orders for both an antibiotic (vancomycin) and an antianxiety medication (alprazolam). The Medication Administration Record (MAR) showed that vancomycin was not signed out as administered for four consecutive doses, and alprazolam was not signed out as given on multiple dates. The resident was cognitively intact and had reported to staff that she was supposed to be on antibiotics. The Assistant Director of Nursing (ADON) indicated that the facility did not receive the After Visit Summary (AVS) from the hospital at admission, which resulted in missing information about the vancomycin order. Despite attempts to obtain the AVS and follow up with the hospital, the facility did not verify the antibiotic order with the physician in a timely manner, leading to missed doses. Additionally, the pharmacy did not fill the alprazolam prescription because they never received a prescription, and nursing staff could not provide an explanation for the missed administration of the antianxiety medication.
Failure to Provide Ordered Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevention for two residents with pressure-related skin conditions. For one resident, observations revealed that her heels were not off-loaded as ordered while she was in bed, despite having wounds on her left foot. The wound nurse confirmed there was no current order for off-loading boots and stated she would contact the physician to obtain one. The resident's medical record indicated she was cognitively impaired, dependent for all activities of daily living, and at risk for developing pressure ulcers. A physician's order was in place to off-load heels while in bed and confirm every shift, but this was not followed. Another resident was observed without a dressing covering her sacral wound, which was open to air, and her heels were also not off-loaded as ordered. The wound nurse acknowledged the missing dressing and immediately applied one. During a subsequent wound treatment, the nurse failed to wear a gown despite the resident being on Enhanced Barrier Precautions, only realizing the omission after being prompted. The resident's record showed severe cognitive impairment, lower extremity impairment, and dependence on staff for care. Physician's orders required off-loading of heels and specific wound care, but these were not consistently implemented.
Conflicting Wound Care Orders and Incomplete Clinical Records
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident with pressure ulcers, resulting in conflicting physician orders for wound treatment. During a wound care observation, a nurse prepared to apply Aquacel alginate to the wound bed, despite the current physician's order specifying the use of Xerofoam. The nurse stated she had confirmed with the physician that the Xerofoam order was correct and would remove the Aquacel order to prevent further confusion. However, both treatment orders remained active in the resident's record, and both were documented as completed on the Treatment Administration Record (TAR) on different dates. The resident involved had diagnoses including anemia, dysphagia, and high blood pressure, and was assessed as moderately impaired for daily decision-making, requiring dependent care for several activities of daily living. The care plan indicated the presence of pressure ulcers and directed staff to administer treatments as ordered. Despite this, the presence of two active, conflicting wound care orders led to inconsistent documentation and treatment practices, as evidenced by the TAR and direct observation.
Failure to Use Required PPE During Wound Care Under Enhanced Barrier Precautions
Penalty
Summary
A deficiency occurred when a wound nurse failed to use the required personal protective equipment (PPE) while providing wound care to a resident who was under Enhanced Barrier Precautions (EBP). During the observed wound treatment, the nurse performed hand hygiene and donned gloves but did not wear a gown, despite an EBP sign being posted on the resident's door. The nurse acknowledged forgetting to put on the gown when questioned. The resident was in bed, covered with blankets, and was observed to be cold and crying at the time of care. The wound care involved opening the resident's brief, placing a new pad, and preparing a collagen dressing for application. The resident had significant medical conditions, including hemiplegia, dementia, and was at risk for pressure ulcers, requiring substantial assistance with daily activities and being dependent for toileting and lower body care. The facility's infection prevention nurse indicated that their policy allowed discretion regarding EBP, stating that if a wound could be covered and was not draining, EBP might not be necessary. However, current CDC guidance requires both gown and gloves for high-contact care activities, such as wound care, under EBP. The failure to follow these guidelines led to the cited deficiency.
Sanitation Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to maintain sanitary conditions in the main kitchen, as observed during a kitchen sanitation tour. There was an accumulation of dried food spillage on the outside and lids of the flour, sugar, and rice bins. Additionally, plastic scoops were found inside the flour and rice bins, positioned directly on the food, which is not in accordance with sanitary food handling practices. Furthermore, a bag of thawed chicken was found in a plastic bin in the walk-in refrigerator, which was twisted closed but not dated, indicating a lack of proper labeling and tracking of food items. These observations were made in the presence of the Dietary Food Manager, who acknowledged the issues.
Unsanitary Kitchen Conditions
Penalty
Summary
The facility failed to maintain the kitchen area in a functional and sanitary manner, as observed during two separate kitchen sanitation tours. On the first tour, the floor tile throughout the kitchen was found to have an accumulation of dirt and debris along the baseboards, with discolored and dirty grout. Additionally, there was dried spillage on top of and in front of the dishwasher, and an accumulation of dust on the metal pipes above it. During the second tour, dried liquid spillage was observed on the wall beneath the coffee and juice machines, and dried food spillage was found on the PVC pipes under the three-compartment sink. In both instances, the Dietary Food Manager acknowledged the need for cleaning.
Improper Labeling and Storage of Medications
Penalty
Summary
The facility failed to properly label and store medications in accordance with accepted professional principles. During an observation of the north medication cart, two bottles of acetaminophen were found unlabeled in the top drawer. A Qualified Medication Aide (QMA) indicated these were house medications. Similarly, in the south medication room, a box of Benadryl and two bottles of acetaminophen were found without labels in the top left cabinets. A Licensed Practical Nurse (LPN) also identified these as house medications. The nurse consultant later confirmed that house medications should not be present and indicated that these medications had been removed.
Failure to Follow Prescribed Menu for Pureed Diets
Penalty
Summary
The facility failed to adhere to the prescribed menu for residents on pureed diets, which was identified through observation, record review, and interview. On October 3, 2024, it was observed that residents receiving a pureed diet were served pureed ham, peas, mashed potatoes and gravy, and bread, instead of the scheduled pureed beef tips with mushrooms over parsley noodles. This discrepancy was confirmed during an interview with the Dietary Food Manager, who acknowledged that the residents should have been served pureed beef tips as per the menu. The manager noted that the cook typically prepared a special meal for residents on pureed diets, which led to the deviation from the planned menu.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a resident's call light was placed within reach, which is a deficiency in accommodating the needs of the resident. Observations on multiple occasions revealed that the call light was clipped to the cord above the head of the resident's bed, making it inaccessible. The resident, who was diagnosed with hemiplegia/hemiparesis following a stroke, dementia, and a history of falling, was cognitively impaired and required substantial to maximum assistance for mobility. Despite these needs, the call light was consistently out of reach, contrary to the care plan intervention that specified it should be within reach. Interviews with staff confirmed the oversight, and the Interim Administrator acknowledged that the call light should have been accessible to the resident.
Failure to Conduct and Communicate Care Plan Meetings
Penalty
Summary
The facility failed to ensure that care plan meetings were held and that families were invited to attend these meetings for two residents. Resident 35, who was cognitively intact, was not informed about his care plan meetings, and his daughter was not contacted by the staff as promised. Despite the resident's multiple diagnoses, including retention of urine, insomnia, chronic obstructive pulmonary disease, heart failure, gout, and type 2 diabetes mellitus, there was no documentation of any attempt to reach out to the resident or his family regarding the missed care plan meetings. Similarly, Resident 37, who was cognitively impaired, reported not being invited to his care plan meetings. The resident's diagnoses included psychotic disturbance, mood disturbance, anxiety, and atherosclerotic heart disease. The Social Service Director confirmed the lack of documentation showing any effort to contact the resident or his family about the care plan meetings. This oversight affected the facility's compliance with the requirement to develop and review care plans with the involvement of residents and their families.
Failure to Provide Timely ADL Assistance and Personal Hygiene Care
Penalty
Summary
The facility failed to provide timely assistance with activities of daily living (ADLs) for residents who were dependent on staff for meal assistance. Resident 28, diagnosed with dementia and diabetes, was observed seated in a broda chair with her lunch tray placed in front of her at 12:02 p.m., but she was not assisted with her meal until 12:15 p.m. Her care plan indicated she required supervision or touching assistance with eating due to cognitive impairment. Similarly, Resident 29, who had Alzheimer's, dementia, dysphagia, and severe protein calorie malnutrition, was left without assistance from 12:02 p.m. until 12:13 p.m. Her care plan required extensive assistance from staff for eating due to her cognitive impairment and dependency. Additionally, the facility did not adequately address the personal hygiene needs of Resident 27, who was observed with facial hair on her chin and above her lip on multiple occasions. Despite her expressed desire to be shaved, records indicated that her facial hair was not trimmed or shaved on scheduled bath days, and there was no shower sheet available for one of the dates. Resident 27 had multiple diagnoses, including hemiplegia, asthma, diabetes, and impaired visual function, which required assistance with personal hygiene. The Interim Administrator acknowledged that the resident should have been shaved at least weekly.
Failure to Provide Personalized Activity Program for Resident in Isolation
Penalty
Summary
The facility failed to provide a personalized activity program for a cognitively impaired and dependent resident, identified as Resident C, who was in isolation. Observations over several days revealed that Resident C was often awake and attempting to lift her head and feet off the mattress, with her television turned off. Despite her diagnoses, which included Alzheimer's disease, dementia with agitation, cognitive communication deficit, and delusional disorder, the resident's care plan indicated she benefited from small group activities and one-to-one visits. However, the September 2024 One to One Visit Log showed that her last one-to-one visit was on 9/20/24, consisting only of a hand massage. Interviews and record reviews indicated that the resident had expressed interest in listening to music and watching sports, such as baseball and football, but these preferences were not consistently met. The Activity Director acknowledged that the resident liked to watch television and should have had it turned on, but due to staffing shortages, one-to-one visits were not being completed as frequently as needed. This lack of personalized activity programming and stimulation for Resident C, especially while in isolation, contributed to the deficiency identified by the surveyors.
Insulin Administration and Monitoring Deficiencies
Penalty
Summary
The facility failed to administer insulin as ordered for two residents, leading to deficiencies in medication management. Resident 28, who has dementia and diabetes, did not receive her prescribed Lispro and Glargine insulin on multiple occasions in September 2024. The insulin was also administered when her blood sugar levels were below the specified parameters, contrary to the physician's orders. The Interim Administrator acknowledged that the insulin should have been administered as ordered. Resident 35, who is on anticoagulant therapy with Eliquis and Plavix, was observed with a discoloration on the right wrist, which was not assessed or monitored as required. Despite the care plan's directive to monitor for side effects of anticoagulant therapy, there was no documentation of a skin assessment for the discoloration. The MDS Coordinator confirmed the absence of a monitoring order for the discoloration. Resident 219, who has diabetes and uses insulin, reported that her insulin was administered late on several occasions. The Medication Administration Record confirmed that insulin was given late on 9/29/24, with delays of up to two hours. The Interim Administrator admitted that the insulin was not administered within the correct parameters, indicating a lapse in timely medication administration for this resident.
Failure to Provide Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment and services to promote the healing of pressure ulcers for a resident with a history of hemiplegia/hemiparesis following a stroke, dementia, and pressure ulcers on both heels. Observations on multiple occasions revealed that the resident's pressure-reducing heel boots were not in use while she was in bed, and her feet were resting directly on the mattress, contrary to the physician's orders for offloading and the use of Prevalon boots every shift. The resident was cognitively impaired and required substantial to maximum assistance for mobility, which further necessitated adherence to the prescribed interventions to prevent further deterioration of her condition. The resident's care plan and physician's orders clearly indicated the need for offloading her heels and using pressure-reducing boots to manage her Stage 4 pressure ulcers. However, the Treatment Administration Record for October 2024 inaccurately reflected that these interventions were completed, despite evidence to the contrary. During an interview, the Wound Nurse confirmed that the heel boots should have been applied, or at least the resident's heels should have been offloaded, and acknowledged that the documentation should not have been signed off if the care was not provided.
Failure to Administer Correct Oxygen Flow Rate
Penalty
Summary
The facility failed to ensure that a resident's oxygen was administered at the correct flow rate as prescribed. Observations on multiple occasions revealed that the resident's oxygen flow rate was set below the prescribed 3 liters per minute. Specifically, on several dates, the flow rate was observed to be under 3 liters, including a specific instance where it was at 2.5 liters. The resident, who has a medical history including hemiplegia, COPD, and heart failure, requires continuous supplemental oxygen at 3 liters per minute as per the care plan and physician's order. Despite this, the Medication Administration Record indicated that oxygen was documented as being administered at the correct rate of 3 liters every shift, which was inconsistent with the observed flow rates. The Interim Director of Nursing acknowledged the concern but did not provide additional information.
Failure to Complete Post-Dialysis Assessment
Penalty
Summary
The facility failed to complete a post-dialysis assessment for a resident who required dialysis services. Resident 217, who had diagnoses including kidney disease, hemiplegia, hypertension, and anemia, was dependent on renal dialysis and had an arteriovenous fistula for dialysis access. The resident's care plan included interventions such as observing for bleeding at the dialysis access site and assessing the shunt site for bruit and thrill. However, the facility did not consistently fill out the post-dialysis communication forms on several occasions, specifically on 10/4/24, 9/30/24, and 9/25/24, and the form for 9/23/24 was missing. Interviews with LPN 1 revealed that vital signs and assessments of the bruit/thrill were supposed to be documented on the pre/post dialysis communication sheet. However, the Nurse Consultant confirmed that the post-dialysis communication sheet was not filled out consistently. The facility's policy required obtaining vital signs upon the resident's return from dialysis and completing the Pre/Post Dialysis Communication Form, which was not adhered to in this case.
Failure to Provide Psychosocial Support for Isolated Resident
Penalty
Summary
The facility failed to provide ongoing psychosocial visits for a resident who was in indefinite isolation. Resident 21, who was observed to be tearful and expressing distress about her prolonged isolation, was diagnosed with multiple conditions including hemiplegia, candidiasis, hyperlipidemia, anxiety, depression, heart failure, diabetes, and COPD. Her care plan indicated a risk for mood changes due to anxiety, and she had expressed preferences for leisure activities such as bingo, arts and crafts, listening to music, and going outside. Despite these needs, the facility did not ensure regular psychosocial support during her isolation period. The resident was placed in contact isolation due to a wound and Candida auris, with a physician's order for enhanced barrier precautions. Although there were some psychosocial notes indicating interactions with psych services and the interdisciplinary team, there was a lack of consistent psychosocial visits. The Social Service Director admitted to not conducting regular psychosocial checks for residents in prolonged isolation, which contributed to the deficiency in care for Resident 21.
Infection Control Deficiency Due to Improper PPE Use and Missed Antiseptic Bath
Penalty
Summary
The facility failed to implement proper infection control guidelines, as evidenced by the improper use of personal protective equipment (PPE) and a lack of staff awareness regarding the reasons for a resident's isolation. Observations revealed that staff and family members were using PPE inconsistently and without understanding the specific precautions required for the resident's condition. Interviews with various staff members, including an LPN, QMA, and CNAs, indicated confusion about the resident's isolation status, with some staff incorrectly attributing the droplet precautions to a condition the resident did not have. The MDS Coordinator clarified that the resident was only under contact and enhanced barrier precautions for Candida auris, not droplet precautions. Additionally, the facility failed to administer an antiseptic bath as ordered for the resident. The resident, who had multiple diagnoses including hemiplegia, candidiasis, and COPD, was supposed to receive a Chlorhexidine Gluconate body wash every evening shift for seven days as part of their care plan for Candida auris. However, the Medication Administration Record (MAR) indicated that the antiseptic soap was not signed out as given on one of the days. The Interim Administrator confirmed that the antiseptic soap was not administered or documented as given on that day, and no further information was provided to explain this lapse.
Failure to Implement Gradual Dose Reductions for Psychotropic Medications
Penalty
Summary
The facility failed to implement gradual dose reductions (GDR) of psychotropic medications for two residents, leading to a deficiency. Resident B, diagnosed with conditions including hemiplegia, dementia, Alzheimer's disease, and major depressive disorder, was prescribed Seroquel for restlessness. Despite a GDR being ordered to reduce the dosage from 25 mg to 12.5 mg, the resident continued to receive the higher dose from mid-September to early October. There was no documentation indicating that the GDR had been declined by the resident's physician, and the Nurse Consultant confirmed the medication had not been reduced as ordered. Similarly, Resident C, who had Alzheimer's disease, dementia with agitation, and delusional disorder, was prescribed Ativan for anxiety. A GDR was recommended to decrease the dosage from 0.5 mg to 0.25 mg, with the Interdisciplinary Team in agreement. However, the resident continued to receive the original dosage from mid-September to early October, with no documentation of a physician's declination of the GDR. The Nurse Consultant acknowledged that the medication had not been reduced as ordered. The facility's policy on psychotropic medication management requires GDR and non-pharmacologic interventions unless contraindicated, which was not adhered to in these cases.
Failure to Ensure Daily RN Coverage
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for 8 consecutive hours on one of the 14 days reviewed. This deficiency was identified during a review of staffing schedules for the period from September 16 to September 29, 2024. It was found that there was no RN coverage on September 29, 2024. During an interview, the Interim Administrator acknowledged the absence of an RN on that day and was aware of the requirement for daily RN coverage. This lapse had the potential to affect all 67 residents residing in the facility.
Failure to Monitor and Document Skin Conditions
Penalty
Summary
The facility failed to properly assess and monitor skin discoloration and scabbing for two residents with non-pressure related skin conditions. Resident D was observed with a reddish/purple discoloration on the top of their right hand on two separate occasions. Despite being on anticoagulant therapy, which requires monitoring for bruising, there was no documentation in the nursing progress notes regarding the discoloration, nor was there a physician's order to monitor the area. The Director of Nursing was unaware of the bruise on Resident D's hand. Resident E was observed with several reddish/purple bruises on their hands and arms, and a dressing on the left forearm covering a purple scab. Although a Skin Integrity Assessment noted skin tears on the resident's legs, there was no documentation or orders to monitor the discoloration on the hands and arms. The Director of Nursing was aware of the bruises but mistakenly believed that monitoring orders had been entered into the system. The facility's policy on skin integrity and wound management was not followed, as evidenced by the lack of proper documentation and monitoring.
Failure to Implement Fall Prevention Measures for At-Risk Resident
Penalty
Summary
The facility failed to implement preventative fall measures for a resident at risk for falls. Resident B, who had a history of hemiplegia, hemiparesis following a stroke, seizures, and muscle weakness, was observed multiple times with their bed not in a low position, contrary to the care plan interventions. The resident had moderate cognitive impairment and was dependent on staff for bed mobility and transfers. The care plan, which was reviewed earlier, indicated that the resident was at risk for falls and had a history of putting themselves on the floor. Despite this, the bed was observed not in the low position on several occasions. The Director of Nursing acknowledged that the bed should have been in the low position and noted that the resident did not like the bed in that position, indicating a need for care plan updates.
Latest citations in Indiana
Surveyors observed that dietary staff repeatedly worked in kitchen and meal service areas with uncovered facial hair, despite facility policy and state sanitation requirements mandating effective hair restraints. Two dietary aides with short beards or mustaches were seen walking through food preparation areas, taking food temperatures, handling food, and plating meals at steamtables in dining rooms without any facial hair coverings, while the current policy required all hair, including facial hair, to be restrained to prevent contamination.
The facility failed to consistently provide and document required bed-hold policy notices when several residents were transferred to the hospital. In multiple cases, residents with dementia, psychotic disorders, COPD, chronic respiratory failure, altered mental status, and cerebral infarction were sent out for acute changes in condition, and while transfer notes reflected physician and family notifications, they lacked documentation that the bed-hold policy was discussed with the resident or responsible party. Notices of Transfer or Discharge often indicated a copy of the bed-hold policy was sent with the resident, but the records did not show signed and dated acknowledgment by the resident or appropriate representative, including in situations where a resident had moderate cognitive impairment, short-term memory issues, or a documented need for a proxy and a financial POA authorizing an agent for health care decisions.
Surveyors found that the facility failed to provide trauma‑informed and culturally competent care by not incorporating two residents’ extensive trauma histories and specific behavioral triggers into their care plans. One resident with documented homelessness, polysubstance abuse, severe accidents with multiple fractures, viral encephalitis with coma, physical and sexual abuse, loss of family contact, and a past suicide attempt had multiple behavior‑focused care plans that referenced identifying triggers but listed none and did not mention their physical, sexual, medical, or psychosocial trauma. Another resident with TBI from being struck by a truck, an 11‑month coma, long‑term state hospital residence, alleged shooting of a parent, and diagnoses including intermittent explosive disorder and borderline personality disorder had a PASRR identifying a specific trigger and notes of inappropriate sexual behavior, yet their care plans omitted these traumatic events, the identified trigger, and the sexual behavior. Staff interviews confirmed that residents were screened for trauma, but the trauma histories and triggers were not reflected in the individualized plans of care.
A resident with schizophrenia, post‑stroke hemiparesis, and mild cognitive impairment expressed feeling down and wanting to kill himself, but staff did not document asking about a specific plan, did not notify the physician or psychiatric NP as expected, and did not develop or update a care plan addressing depression or suicidal ideation. The SSD documented offering support and initiating 15‑minute checks once, but there was no further follow‑up or documentation of interventions after subsequent suicidal statements made in a care plan meeting with the resident’s father. The DON and Administrator reported that facility policy requires immediate notification of key staff, assessment for a plan and means of self‑harm, and thorough documentation, which were not carried out or reflected in the medical record for this resident.
A resident with schizophrenia, post-stroke hemiparesis, and mild cognitive impairment verbalized suicidal ideation, but the care plan did not address depression or suicidal thoughts, and required assessments and services were not accurately or timely documented. An SSD note recorded the resident saying he wanted to kill himself and referenced 15‑minute checks and a care plan update, yet the active care plan lacked depression/suicidal ideation interventions. Multiple late-entry Social Services notes were later added, describing follow-up visits and the resident denying suicidal ideation, but the SSD later reported she did not typically ask about a suicide plan and did not personally provide individual follow-up visits as described. These practices conflicted with the facility’s policy requiring factual, first-hand, and timely documentation of assessments and services.
A resident was observed with an Albuterol inhaler on an overbed table and later reported keeping the inhaler in a nightstand drawer, with no staff present during these observations. Record review showed the resident had no cognitive impairment on the admission MDS but lacked any documented self-medication administration assessment. The DON acknowledged that the required assessment had not been completed, despite facility policy requiring staff and the practitioner to evaluate each resident’s mental and physical abilities before allowing self-administration of medications.
Surveyors found that the facility submitted inaccurate direct care staffing data to CMS through the PBJ system over multiple days in a quarter. CASPER reports showed apparent gaps in 24-hour licensed nurse coverage, low weekend staffing, and a 1-star staffing rating, while internal staffing sheets documented that licensed nurses were present and the facility was fully staffed on those days. The Administrator reported that the discrepancies were due to PBJ data entry errors, despite a facility policy requiring all PBJ entries to be accurate, auditable, and verifiable against payroll, invoices, or contracts.
Surveyors found that the facility did not provide or document required written transfer/discharge notices and bed-hold policy information for four residents who were sent to the hospital, including individuals with conditions such as dementia, CHF, chronic respiratory failure, and CKD. In each case, progress notes showed that the resident was transferred for acute issues, but the clinical records lacked evidence that written notices were given to the residents or their representatives, and in one case lacked documentation that required information was sent to the receiving provider. Facility leadership, including the ADON, DON, and Administrator, acknowledged that the records did not contain the required documentation, despite a written policy requiring such notices and information exchange.
A resident with Alzheimer’s disease and depression, previously on an antidepressant, exhibited intermittent refusals of medications and care, occasional yelling at staff, and reports of unusual perceptions, such as believing men were in or near her room. Nursing notes over several months documented these refusals and complaints but did not show that the behaviors were evaluated or recorded as dangerous, non-redirectable, or causing significant distress, nor did they document specific non-pharmacological interventions attempted or their outcomes. Despite this, a psychiatric NP later added new diagnoses of schizoaffective disorder, borderline personality disorder, and delusional disorder and ordered an antipsychotic (Seroquel) without a comprehensive evaluation in the record to support these diagnoses. The facility’s psychotropic medication policy, which requires identification and documentation of target behaviors, use of nonpharmacological interventions, and ongoing behavior monitoring, was not followed for this resident.
The facility failed to keep PASARR Level I screenings accurate and current for three residents when new mental health diagnoses and psychoactive medications were initiated. One resident’s PASARR omitted a PTSD diagnosis and an added antidepressant, despite documentation of PTSD on the MDS and care plan and a physician order for Pristiq. Another resident’s PASARR listed only depression and dementia, even after additional diagnoses such as borderline personality disorder, delusional disorder, and schizoaffective disorder were added and an antipsychotic (quetiapine) was ordered, with the MDS later reflecting psychotic disorder, schizophrenia, and depression with antipsychotic and antidepressant use. A third resident’s PASARR did not include a depression diagnosis or newly ordered escitalopram and lorazepam, although the admission MDS documented depression with antianxiety and antidepressant use. These omissions occurred despite facility policy requiring a new Level I review after significant mental status changes, including new mental health diagnoses or new psychotropic medications.
Uncovered Facial Hair During Food Preparation and Meal Service
Penalty
Summary
The deficiency involves the facility’s failure to ensure that food was served in a sanitary and safe manner in accordance with professional standards and facility policy during multiple kitchen and meal service observations. During an initial kitchen observation, two dietary aides were seen walking through the kitchen food preparation area with uncovered facial hair. One aide had facial hair above and below the lip and along the jaw line, approximately one-fourth inch in length, and the other had a mustache of similar length; neither used any facial hair covering. These observations occurred while staff were present in the kitchen area where food was stored and prepared. During subsequent observations on the same day, the same two dietary aides were again observed with uncovered facial hair while directly involved in meal preparation and service. One aide walked through the kitchen while the noon meal was being prepared and placed into a transport cart for service in the south dining room, and later was observed plating the noon meal at the steamtable in that dining room, still without a facial hair covering. The other aide walked through the kitchen while the noon meal was being prepared and placed into the steamtable for the north dining room, took food temperatures, assisted with plating meals at the steamtable, and retrieved food items and supplies from the kitchen, all while having an uncovered mustache approximately one-fourth inch in length. The Dietary Manager stated that staff hair was to be covered when in the kitchen and during meal service, and the facility’s written policy and the cited Indiana Food Establishment Sanitation Requirements both required effective hair restraints, including for facial hair, to prevent contamination of food, equipment, and utensils.
Failure to Provide and Document Bed-Hold Policy at Time of Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure that required bed-hold policy information was provided and documented for four residents transferred to the hospital. For a resident with dementia, psychotic disorder, and autistic disorder who had a BIMS score of 0 indicating severe cognitive impairment, progress notes documented physician notification and guardian notification when the resident was sent to the hospital, but there was no documentation that the bed-hold policy was provided to the responsible party. A Notice of Transfer or Discharge later indicated a copy of the bed-hold policy was sent with the resident. Another resident with COPD and chronic respiratory failure, cognitively intact with a BIMS score of 13, experienced a decline in condition and was transferred to the hospital by ambulance; progress notes documented family notification but did not document any discussion of the bed-hold policy, although a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident. A third resident with altered mental status and cerebral infarction, with a BIMS score of 10 indicating moderate cognitive impairment and documented short-term memory impairment, experienced changes in condition and was transferred to the hospital. Progress notes stated the resident was their own responsible party and that no other notification was completed, and transfer documentation did not include the bed-hold policy, although an untimed Notice of Transfer or Discharge indicated a copy of the bed-hold policy was signed by the resident. A financial power of attorney document in the record showed the resident had designated an agent to act in consent or refusal of health care. For a fourth resident with dementia and osteomyelitis, transfer documentation and a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident, and the transfer form noted the resident required a proxy for decision making. The facility’s policy required that at the time of transfer to a hospital, written notice specifying the duration of the bed-hold policy and information on return to the next available bed be provided, and that a signed and dated copy of the bed-hold notice given to the resident or representative be kept in the resident file, which was not consistently documented for these residents.
Failure to Integrate Trauma Histories and Behavioral Triggers Into Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to identify and incorporate residents’ trauma histories and specific behavioral triggers into their care plans, despite documented histories of significant trauma and behavioral health issues. For one resident, extensive social service and progress notes documented homelessness, polysubstance abuse, major depressive and anxiety disorders, chronic pain, a history of severe car accidents with multiple fractures, viral encephalitis resulting in a three‑month coma, loss of child custody, multiple divorces, physical abuse by a spouse, the death of a fiancé who was struck by a car while in a wheelchair, lack of family contact, and a past suicide attempt by Valium overdose. Additional documentation noted a history of rape by a brother at age eight and prior placement under direct supervision and 15‑minute checks related to suicidal ideation. Despite these documented traumatic events and behavioral health concerns, the resident’s care plans did not identify a history of physical trauma, sexual trauma, homelessness, substance abuse, medical trauma, or attempted suicide. For this same resident, the MDS showed no cognitive deficit and identified behaviors such as verbal aggression and rejection of care, along with diagnoses including seizure disorder, depression, chronic pain syndrome, homelessness, and anxiety disorder. Multiple care plans addressed behaviors such as drug‑seeking, pretending to have seizures for attention or medication, making false allegations, verbal aggression when unable to smoke, and a desire for intimate relationships with consenting male residents. These care plans referenced goals such as effective coping skills, seeking staff support, and compliance with the smoking policy, and they called for identification and reduction of behavioral triggers. However, none of these care plans actually listed any specific triggers. The care plan addressing the resident’s right to consensual intimate relationships focused on assessment and education regarding consent but did not integrate the resident’s extensive trauma history. Staff interviews indicated the resident had displayed sexual behaviors since admission, including an incident where the resident expressed anger at another resident for not buying a soda after engaging in sexual acts. A second resident with a documented history of traumatic brain injury (TBI), dementia, seizure disorder, borderline personality disorder, anxiety, intermittent explosive disorder, tobacco use, and other behavioral/emotional disorders was also affected by the same deficiency. Social history and progress notes documented that this resident sustained a TBI after being hit by a semi‑truck while riding a bicycle at age 18, resulting in an 11‑month coma, followed by 13 years in a state hospital and subsequent residence in a group home. Additional documentation indicated the resident allegedly shot their father at age 26 after being sworn at and had a PASRR identifying TBI, intermittent explosive disorder, and borderline personality disorder, with a specific trigger of hearing the name of the current U.S. President. Progress notes also described inappropriate sexual behavior toward staff, including touching themselves intimately during personal care and refusing to stop when redirected. Despite this, the resident’s care plans, which addressed explosive disorder and history of altercations, risk for decreased psychosocial well‑being, and refusal to bathe or shower, did not list any specific behavioral triggers, did not reference the traumatic events such as being hit by a truck or shooting their father, and did not document the inappropriate sexual behavior. The Administrator and Social Service Director acknowledged that residents were to be screened for trauma and that trauma responses and PTSD should be added to care plans, but the specific trauma histories and triggers for these two residents were not incorporated into their plans of care.
Failure to Assess and Care Plan for Resident Suicidal Ideation
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess, investigate, and care plan for a resident’s suicidal ideation in accordance with its own policy and staff expectations. The resident had diagnoses including schizophrenia, cerebral edema, and hemiparesis/hemiplegia following a cerebral infarction, and a current MDS showed mild cognitive impairment (BIMS score 12). A progress note documented that the resident told the Social Services Director (SSD) he was feeling down and wanted to kill himself; the SSD offered assistance, activities, and initiated 15‑minute checks, and the note stated the care plan was updated. However, the note did not indicate that the SSD asked whether the resident had a plan to kill himself, and there were no additional notes regarding suicidal ideation or follow‑up. Review of the current care plan showed no problem, goal, or interventions addressing depression or suicidal ideation, and progress notes over the following month contained no documentation of physician notification related to the suicidal statement. Further record and interview evidence showed that the care plan conference summary did not document interventions for suicidal ideation, and the SSD acknowledged she did not normally ask residents expressing suicidal ideation if they had a plan. The SSD reported that the resident had admission paperwork mentioning suicidal ideation related to depression after a stroke and that the resident again vocalized suicidal ideation during a care plan meeting with his father, after which emotional support was offered and the father took the resident out on a leave of absence; no further visits or follow‑up were done. The DON stated that, upon notification of suicidal verbalization, staff should assess the resident, ask if there is a plan, remove potential means of self‑harm, immediately notify the psychiatric NP, and document the occurrence, and that a detailed progress note and updated care plan were expected but not present for this resident. The Administrator similarly stated that staff should ask about a plan, document interventions, notify the physician and family, and update the care plan, and indicated the resident should have had a care plan addressing depression with suicidal ideation. The facility’s written policy required immediate notification of the DON, SSD, and physician, an interview including asking about a plan and assessing mood and means for self‑harm, and thorough documentation of mood, behavior, and all actions taken, which were not reflected in the resident’s record.
Incomplete and Inaccurate Documentation of Suicidal Ideation and Follow-Up
Penalty
Summary
The facility failed to ensure accurate, complete, and timely documentation of assessments and services for a resident who verbalized suicidal ideation. Resident 6, who had schizophrenia, cerebral edema, and right-sided hemiparesis/hemiplegia following a cerebral infarction, had a BIMS score of 12 indicating mild cognitive impairment. The resident’s admission paperwork mentioned suicidal ideation related to depression after a stroke, and a Social Services note on 3/11/2026 documented that the resident was feeling down and said he wanted to kill himself. The Social Services Director (SSD) documented that she talked with the resident, coordinated with Activities, advised the resident to contact SSD or nursing if he wanted to talk, and that the resident was scheduled for 15-minute checks and the care plan was updated. However, the current care plan initiated on 2/26/2026 did not address depression or suicidal ideation. Multiple Social Services progress notes were later entered as late entries in April, with effective dates in March, stating that the resident had no plan and no longer had suicidal ideation, that he felt much better after 1:1 time, and that he continued his daily routine and therapy. These late entries described follow-up visits and reassessments of suicidal ideation on several consecutive days, but in interviews the SSD stated she did not normally ask residents about having a plan when they verbalized suicidal ideation and did not recall any other occurrences beyond the initial event. She further indicated she did not personally provide individual follow-up visits with this resident regarding suicidal ideation, despite the late-entry notes describing such visits. The DON acknowledged that late entries had been added to address concern about suicidal verbalization, and the Administrator stated that upon suicidal statements staff should ask about a plan, notify the physician and family, and update the care plan, and that this resident should have had a care plan addressing depression with suicidal ideation. The facility’s documentation policy required factual, first-hand, timely documentation, which was not followed in this case.
Failure to Complete Required Self-Administration Assessment for Inhaler Kept at Bedside
Penalty
Summary
Surveyors identified that a resident was allowed to keep and access an Albuterol inhaler without the facility completing the required self-administration medication assessment. During an initial tour, the resident was observed sitting in a wheelchair with a handheld Albuterol inhaler on the overbed table and no staff present in the room or hallway. On a subsequent observation, the resident again was in a wheelchair and reported that the Albuterol inhaler was stored in the top drawer of the nightstand, where it was found. Review of the clinical record showed an admission MDS indicating no cognitive impairment, but there was no documentation of a self-medication administration assessment. In an interview, the DON confirmed that the resident did not have the required self-medication assessment, despite the facility’s policy stating that staff and the practitioner must assess each resident’s mental and physical abilities to determine whether self-administering medications is clinically appropriate. This failure to complete and document a self-administration medication assessment for a resident who had an Albuterol inhaler kept at bedside constituted noncompliance with the facility’s own policy and with 410 IAC 16.2-3.1-11(a).
Inaccurate PBJ Staffing Data Submission to CMS
Penalty
Summary
The deficiency involves the facility’s failure to electronically submit complete and accurate direct care staffing information to CMS through the Payroll-Based Journal (PBJ) system for 22 days in a fiscal quarter. A CASPER report review on 4/6/26 showed that, according to PBJ data, the facility did not have licensed nursing coverage 24 hours per day on multiple specific dates across three months, had low weekend staffing, and held a 1-star staffing rating. However, review of the facility’s internal staffing sheets for that quarter indicated the facility was fully staffed and had licensed nurse coverage on all of the dates in question. During an interview, the Administrator stated that the PBJ information must have contained data entry errors, as she had verified licensed staff coverage on the timesheets. The facility’s PBJ policy in effect stated that all staffing data entered into the PBJ system would be auditable and verifiable through payroll, invoices, or contracts, but the submitted PBJ data did not accurately reflect the facility’s actual licensed nurse staffing as documented on internal records. No specific residents or clinical conditions were mentioned in the report, and the deficiency centers solely on inaccurate staffing data submission rather than direct resident care events.
Failure to Provide and Document Required Transfer/Discharge and Bed-Hold Notices
Penalty
Summary
The deficiency involves the facility’s failure to provide and document required written notices of transfer/discharge and bed-hold policies, as well as required information to receiving providers, for four residents who were transferred or discharged to the hospital. For a resident with generalized anxiety disorder, major depressive disorder, and dementia, progress notes showed that the resident was sent to the hospital via 911 for chest pain, lower back pain, and shortness of breath and later returned to the facility, but the clinical record lacked documentation that a written Notice of Transfer/Discharge and the bed-hold policy were provided to the resident or representative, and lacked documentation that required information was conveyed to the receiving facility. The ADON and the Administrator both confirmed there was no documentation that these written notices were provided. For a resident with congestive heart failure and muscle weakness who was sent to the emergency room for painful urination and bloody urine, the clinical record lacked documentation that a Notice of Transfer/Discharge or bed-hold policy was given to the resident or representative, which the DON confirmed. Another resident with chronic respiratory failure and diabetes was discharged to the hospital for respiratory failure, and a resident with chronic kidney disease and dementia was discharged to the hospital, but in both cases there was no documentation that a written notice of transfer/discharge or bed-hold policy was provided to the residents or their representatives. Review of the facility’s Transfer and Discharge policy, dated 1/15/26, showed that the policy required the facility to provide written transfer/discharge notices and bed-hold information to residents and representatives and to provide specified information to receiving providers, but the records for these four residents did not contain the required documentation.
Failure to Document Target Behaviors and Non-Pharmacological Interventions Before Initiating Antipsychotic
Penalty
Summary
The deficiency involves the facility’s failure to document how a resident’s behaviors presented danger or distress to self or others, and failure to document non-pharmacological interventions attempted prior to initiating an antipsychotic medication. Resident 6 had documented diagnoses of Alzheimer’s disease, depression, and severe cognitive impairment, and was receiving sertraline for depression. A PASSAR identified only depression and dementia, and the admission MDS listed Alzheimer’s disease and depression as active diagnoses. Over several months, nursing progress notes documented that the resident intermittently reported unusual perceptions, such as believing there were men causing trouble, a man in her room, or a man wanting to marry her and yelling through the walls, but there was no documentation that these episodes caused danger to the resident or others or that they resulted in unmanageable distress. From late April through mid-July, nursing notes primarily described the resident’s frequent refusals of evening and morning medications, blood sugar checks, blood pressure checks, insulin administration, hygiene care, and showers. Staff documented that the resident sometimes yelled at staff, said “Get out!”, was visibly upset by a room move, was leery of staff and asked to see name badges, and became upset about a pillow under her head until it was removed, after which she calmed down. The notes also recorded instances where the resident believed housekeeping had not cleaned her room or that she had not received medications when she had. However, there were no progress notes or assessments indicating that these behaviors were evaluated as dangerous, non-redirectable, or causing significant distress or functional impairment, and no detailed behavior monitoring logs were present as required by facility policy. On a psychiatric NP visit for initial psychotropic medication management, new mental health diagnoses of schizoaffective disorder, borderline personality disorder, and delusional disorder were added, and Seroquel 25 mg, an antipsychotic, was ordered. The clinical record did not contain a comprehensive evaluation to support these new diagnoses, and there was no documentation of target behaviors meeting the facility’s policy criteria for psychotropic use, such as behaviors representing danger to self or others, causing distress and impairment in functional abilities, or clearly attributable to psychosis or mania. The resident’s representative reported that the resident had no prior history of mental health disorders or psychiatric hospitalization and was unaware of the new diagnoses. The facility’s own psychotropic medication policy required identification and documentation of specific target behaviors, use and documentation of nonpharmacological interventions, and ongoing monitoring of behaviors and interventions, which were not reflected in the record for this resident.
Failure to Update PASARR Screens for New Mental Health Diagnoses and Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that Preadmission Screening and Resident Review (PASARR) Level I screenings were accurate and updated when new mental health diagnoses and psychoactive medications were initiated for multiple residents. For one resident with dementia, anxiety, depression, and post-traumatic stress disorder (PTSD), the PASARR completed on admission listed anxiety, depression, and dementia with sertraline and quetiapine, but did not include the PTSD diagnosis or the antidepressant Pristiq, despite the admission MDS and care plan documenting PTSD and a subsequent physician’s order for Pristiq. For another resident with Alzheimer’s disease, borderline personality disorder, delusional disorder, schizoaffective disorder, and depression, the PASARR only reflected depression and dementia with sertraline, even though additional mental health diagnoses were added later and an antipsychotic (quetiapine) was ordered for borderline personality disorder, and the quarterly MDS documented psychotic disorder, schizophrenia, and depression with antipsychotic and antidepressant use. A third resident had diagnoses including Alzheimer’s disease, depression, anxiety disorder, irritability and anger, and nonrheumatic aortic valve stenosis. The PASARR for this resident listed dementia and anxiety with Risperdal but omitted the diagnosis of depression and the medications escitalopram and lorazepam, although physician’s orders were in place for escitalopram for depression and lorazepam for anxiety, and the admission MDS documented depression with antianxiety and antidepressant use. Interviews with the Assistant Director of Nursing confirmed that new Level I PASARR screens should have been completed when new mental health diagnoses and psychoactive medications were added, and that the PASARR for one resident, completed prior to arrival, should have included all mental health diagnoses and medications. The facility’s own policy required notification of the state mental health authority within 14 days after a significant change in mental condition and specified that a new Level I screen is required for new mental health diagnoses or newly prescribed psychotropic medications, which was not followed in these cases.
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