Hawthorne Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Indianapolis, Indiana.
- Location
- 7465 Madison Ave, Indianapolis, Indiana 46227
- CMS Provider Number
- 155780
- Inspections on file
- 45
- Latest survey
- December 5, 2025
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Hawthorne Healthcare Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a history of wandering exited the secured memory care unit without staff knowledge when the only CNA assigned to the unit left it unattended. The resident was found by police approximately 1.5 miles from the facility and returned safely. Documentation showed the resident was at risk for elopement and required supervision, but no staff were present on the unit at the time of the incident.
The facility failed to maintain sanitary conditions in food service as Dietary staff was observed with uncovered facial hair while working in the kitchen. Despite the facility's policy requiring hair and facial hair to be covered, staff was seen plating meals and taking temperatures without proper hair restraints, violating sanitation requirements.
A facility failed to create a comprehensive care plan for a resident with an indwelling urinary catheter, despite the resident being cognitively intact and having a diagnosis of neuromuscular dysfunction of the bladder. The absence of a care plan was confirmed through observations and interviews, and the facility's policy on personalized care was not followed.
The facility failed to properly dispose of garbage and refuse, as observed during a tour and follow-up inspection. A large cardboard box with debris was found outside the kitchen's rear door, and the sliding side panel door of a dumpster was left open. The Dietary Manager confirmed that dumpster lids and doors should be closed when not in use, and all debris should be placed in dumpsters. The facility's policy and sanitation requirements mandate proper disposal and covering of waste receptacles.
A resident with epilepsy, alcohol dependence, and vascular dementia was transferred to another facility without notifying their guardian, as required by the facility's policy. The clinical record lacked documentation of the notification, and staff interviews confirmed the oversight.
A facility failed to provide a written Notice of Transfer/Discharge to a resident's representative before discharge. The resident, with diagnoses including epilepsy and vascular dementia, was discharged to another facility without the required documentation. A corporate nurse confirmed the lack of additional discharge documentation, and the facility's policy was reviewed, highlighting the need to record reasons for transfer or discharge.
The facility failed to document medication administration for two residents, despite the Corporate Nurse's indication that the medications were given. Medications for conditions such as central nervous system disorders, pain relief, acid reflux, diabetes, and depression were not recorded as administered according to physician's orders. The facility's policy requires medications to be charted when given, which was not followed.
The facility restricted access to the courtyard for several cognitively intact residents, allowing them outside only during supervised smoking times. This policy was implemented after a resident altercation, despite residents expressing the importance of outdoor access for their well-being. Interviews and records showed that the restriction affected their psychosocial health and self-determination.
A resident with severe cognitive impairment was observed with a scrape, swelling, and bruising on the nose and left eye, but the facility failed to report this injury of unknown origin to the state health department. Despite multiple staff members noticing the injury and a physician's order for an x-ray, the injury was not documented in a timely manner, and the facility's policy requiring reporting of such injuries was not followed.
A resident with autism, intellectual disability, and epilepsy was found with a scrape, swelling, and bruising on his nose and left eye. Despite a physician's order for an x-ray and observations by staff, the facility failed to investigate the injury's origin. The DON observed the resident bump into a wall but did not document it promptly. The facility's policy mandates investigation of unknown origin injuries, but the source was not identified by survey exit.
The facility failed to provide the required written bed hold policy to two residents during their transfers to the hospital. One resident, with end-stage renal disease, called 911 due to nausea and pain, while another resident with thumb wounds requested hospital transfer due to pain and inflammation. In both cases, the facility did not document that the bed hold policy was provided, contrary to their policy.
The facility failed to secure and properly label medications, including Ativan and TPN. Ativan, a controlled substance, was not double locked in the medication room, and TPN was not labeled with the nurse's initials or date in a resident's room. The facility lacked a policy for medication labeling.
A facility failed to notify a physician when a large knife was found in a resident's drawer, who had a history of suicidal ideations and attempts. The CNA reported the knife to the LPN and DON, who instructed the CNA to place it in the medication room, but the physician was not informed. The resident had a history of major depressive disorder, suicidal ideation, and multiple suicide attempts, yet the facility's records lacked documentation of physician notification, contrary to facility policy.
A resident with a history of IV drug use alleged that a nurse supplied her with heroin, leading to an emergency requiring CPR and Narcan. The resident, who was moderately cognitively impaired, later identified the LPN involved to the Administrator. Despite the facility's policy requiring such incidents to be reported to state authorities, the Administrator did not report the allegation, believing it was unnecessary as the investigation was ongoing.
A facility failed to implement person-centered care plans for a resident with suicidal ideations and a history of trauma and suicide attempts. A CNA found a large knife in the resident's drawer, which was placed in the medication room. The resident's clinical record showed diagnoses of major depressive disorder, panic disorder, and PTSD, but lacked care plans for suicidal ideations and attempts. Despite the resident's history of suicide attempts and psychiatric hospitalizations, the facility did not adhere to its policy requiring care plans with specific interventions.
A resident required emergency medical intervention after an opioid overdose, allegedly receiving heroin from an LPN at the facility. The incident was not reported to the state health department or police as required by facility policy, leading to a deficiency finding.
The facility failed to provide necessary behavioral health services for two residents with a history of aggression and substance use disorder. Despite previous incidents, neither resident had documented interventions to address or prevent aggressive behaviors. Additionally, a resident with alcohol dependence was found intoxicated multiple times without a documented plan for prevention and treatment. The facility's behavior management policy requires updating care plans with changes or new behaviors, but this was not adhered to, leading to the deficiency.
A resident with C. diff received only 8 of 39 doses of prescribed vancomycin due to a failure in communication and action. The pharmacy delivered an oral solution instead of capsules, but the facility did not notify the physician or update the order. The medication was not administered as prescribed, and unopened bottles were found in the medication room.
The facility failed to maintain accurate and complete documentation on the MAR and TAR for five residents, leading to missing entries for various medications and treatments. Residents reported issues such as uncertainty about medication administration and unavailability of medications. The DON acknowledged the documentation should have been completed accurately.
A facility failed to notify hospice when a resident, on hospice care for Fournier's gangrene, received new orders for intravenous antibiotics. The resident was supposed to start oral doxycycline, but instead, a midline was placed, and intravenous levofloxacin was administered without hospice notification. The hospice VP confirmed the delay in notification, and the order for doxycycline was not transcribed to the electronic medical record. The DON acknowledged the oversight, which led to a deficiency in care coordination.
A facility failed to implement transmission-based precautions for a resident with C. diff. The resident's clinical record lacked a physician's order for precautions, and staff were unaware of the diagnosis, leading to inadequate infection control measures. The DON was not informed of the resident's condition upon admission, highlighting a communication breakdown.
Resident Elopement Due to Lack of Supervision on Secured Memory Care Unit
Penalty
Summary
A cognitively impaired resident with diagnoses including Alzheimer's disease and dementia, and a history of wandering, exit seeking, and elopement, was able to exit the secured memory care unit of the facility without staff knowledge. The resident was under guardianship and had been assessed as severely cognitively impaired, with care plans in place identifying the risk for elopement and interventions such as diversionary activities and redirection. Despite these interventions, the resident had demonstrated exit-seeking behaviors prior to the incident, including multiple attempts to leave and verbalizing a desire to go home. On the night of the incident, the only CNA assigned to the secured memory care unit left the unit unattended due to a personal emergency, leaving no staff present. During this time, the resident exited the facility through an emergency exit door, which triggered an alarm. Staff became aware of the resident's absence only after the alarm sounded and the resident was discovered missing. The resident was subsequently found by police approximately 1.5 miles from the facility, near a busy intersection, and was returned to the facility. Facility records, including staff witness statements and clinical documentation, confirmed that the resident had a documented history of wandering and exit-seeking, and that the care plan required supervision and specific interventions to prevent elopement. The facility's policy defined elopement as a resident leaving the premises or a safe area without authorization or necessary supervision, placing the resident at risk for harm. The lack of staff presence on the secured unit directly led to the resident's unsupervised exit from the facility.
Removal Plan
- audits of elopement evaluations and care plans
- inservicing staff on elopement procedures
- ongoing monitoring
Failure to Maintain Sanitary Conditions in Food Service
Penalty
Summary
The facility failed to ensure food was served in a sanitary manner during three of four kitchen observations. Dietary staff, identified as Dietary [NAME] 2, was observed on multiple occasions with uncovered facial hair while working in the kitchen. Specifically, on November 6, 2024, from 11:20 a.m. to 11:23 a.m., Dietary [NAME] 2 was seen near the steam table area with facial hair approximately one-half inch in length above and below the lips, which was not covered. This observation was repeated during a follow-up from 11:35 a.m. to 11:40 a.m., and again from 12:12 p.m. to 12:20 p.m., while Dietary [NAME] 2 was taking meal temperatures and plating meals. During an interview, the Regional Dietary Consultant confirmed that staff hair, including facial hair, should be covered while in the kitchen. The facility's Staff Attire policy, dated September 2017, was reviewed and indicated that all staff members must have their hair confined in a hair net and facial hair properly restrained. Additionally, the Retail Food Establishment Sanitation Requirements Title 410 IAC 7-24 mandates that food employees wear hair restraints, including beard restraints, to prevent hair from contacting exposed food.
Failure to Develop Care Plan for Catheter Care
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident who had an indwelling urinary catheter. The resident, who was cognitively intact and diagnosed with neuromuscular dysfunction of the bladder, had the catheter since October 1, 2024. Despite the presence of physician's orders for the catheter, the resident's clinical record did not include a care plan addressing the catheter care. Observations and interviews conducted over several days confirmed the absence of a care plan. The Corporate Clinical Nurse Consultant acknowledged that a care plan should have been developed for the resident's catheter care. The facility's Plan of Care Overview policy, which emphasizes resident-focused and personalized care, was not adhered to in this instance.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to maintain proper disposal of garbage and refuse, as observed during a facility tour and follow-up inspection. During the initial tour with the Dietary Manager, a large cardboard box containing unidentifiable debris was found on the ground outside the kitchen's rear door, along with used cups, rags, and other debris. Additionally, the dumpster area, located approximately 100 yards from the kitchen's rear door, was observed to have two large dumpster containers. The east dumpster container had two sliding side panel doors, one of which was not closed. No staff were present in the area during these observations. A follow-up observation confirmed that the sliding side panel door on the east dumpster container remained open, with no staff visible in the area. The Dietary Manager confirmed that the dumpster container lids and sliding side panel doors should be kept closed when not in use, and all debris should be placed into the dumpster containers. The facility's Environment policy, dated September 2017, requires all trash to be properly disposed of in external receptacles, and the surrounding area to be free of debris. Additionally, the Retail Food Establishment Sanitation Requirements mandate that receptacles and waste handling units for refuse, recyclables, and returnables be kept covered with tight-fitting lids or doors if kept outside.
Failure to Notify Guardian Before Resident Transfer
Penalty
Summary
The facility failed to notify a resident's guardian prior to a transfer, which was identified during a review of Resident D's clinical record. Resident D, who had diagnoses including epilepsy, alcohol dependence, and vascular dementia, was appointed a guardian on 2/22/23. A progress note from 7/18/24 indicated that Resident D was discharged to another facility, but the clinical record lacked documentation that the guardian was notified before the discharge. During interviews, Corporate Nurse 1 confirmed there was no additional documentation regarding the discharge, and LPN 1 acknowledged that the guardian should have been notified prior to the transfer. The facility's policy on Admission, Discharge, and Transfer requires notifying the resident and their representative of the transfer or discharge in writing and recording the reasons in the medical record, which was not adhered to in this case.
Failure to Provide Written Notice of Transfer/Discharge
Penalty
Summary
The facility failed to provide a written Notice of Transfer/Discharge to the representative of a resident, identified as Resident D, prior to their discharge. Resident D had diagnoses including epilepsy, alcohol dependence, and vascular dementia, and had a guardian appointed on a previous date. The clinical record review revealed that Resident D was discharged to another facility, with all belongings sent along, but lacked documentation of the required written notice to the resident's representative. During an interview, a corporate nurse confirmed the absence of additional documentation regarding the discharge. The facility's policy on admission, discharge, and transfer was reviewed, which indicated the need to record reasons for transfer or discharge in the medical record.
Incomplete and Inaccurate Medication Documentation
Penalty
Summary
The facility failed to ensure that the medical records for two residents were complete and accurate, as medications were not documented when administered. For Resident B, the clinical record review revealed that medications including Carbidopa-Levodopa, Hydrocodone/Acetaminophen, and Omeprazole were not documented as administered according to the physician's orders on specific dates and times in August 2024. Despite the Corporate Nurse's indication that the medications were administered, the staff did not document the administration as required. Similarly, for Resident C, the clinical record review showed that several medications, including Furosemide, Amlodipine, Doxepin, Clonazepam, Insulin glargine, Trulicity, Insulin lispro, and Oxycodone/Acetaminophen, were not documented as administered according to the physician's orders over several days in August 2024. The Corporate Nurse confirmed that the medications were administered, but the staff failed to document the administration. The facility's policy on medication administration requires that medications be charted when given, which was not adhered to in these cases.
Facility Restricts Resident Access to Courtyard
Penalty
Summary
The facility failed to uphold resident rights by restricting access to the courtyard for five residents, all of whom were cognitively intact and expressed a desire to go outside for fresh air. This restriction was implemented following a resident altercation in the gazebo, leading the Executive Director to mandate supervision for any resident wishing to go outside, even during non-smoking times. Residents expressed dissatisfaction with this policy, as it limited their ability to enjoy the outdoors, which they felt was important for their well-being. Interviews with the residents revealed that they were informed by facility staff that they could only access the courtyard during designated smoking times or with supervision. The residents' records, including Minimum Data Set (MDS) assessments and care plans, indicated that going outside was important for their psychosocial well-being and that they were at risk for social isolation. Despite these documented needs, the facility maintained its restrictive policy, impacting the residents' quality of life and their right to self-determination.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to notify the state health department of an injury of unknown origin for Resident M, who was severely cognitively impaired with diagnoses including autistic disorder, intellectual disability, and epilepsy. Staff observed a scrape with swelling and bruising to Resident M's nose and left eye but did not know how the injury occurred. A physician's order for an x-ray was made after the Director of Nursing (DON) observed Resident M bump into a wall, but the injury may have been present before this incident. The x-ray showed no fracture or acute traumatic osseous abnormality. The injury was not documented in a timely manner, as the progress note was entered into the electronic medical record seven days after the x-ray was ordered. Interviews with staff revealed that the injury was noticed by multiple staff members, including the Activity Director and CNA 10, who reported the injury to RN 9 but felt it was not taken seriously. The facility's policy required that all allegations involving injuries of unknown origin be reported to the state, but this was not done. The Administrator was aware of the injury during a clinical meeting but needed to follow up with the DON to determine the cause. The facility's failure to report the injury of unknown origin to the state health department constituted a deficiency.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to investigate an injury of unknown origin for Resident M, who was observed with a scrape on his nose, swelling, and bruising on his nose and left eye. Resident M's clinical record indicated diagnoses of autistic disorder, intellectual disability, and epilepsy, and a quarterly MDS assessment noted that Resident M was rarely or never understood. On a specific date, a physician's order was made for an x-ray of Resident M's nose due to swelling and a suspected mass, but the x-ray results showed no fracture or acute traumatic abnormality. However, the progress note documenting the Director of Nursing (DON) observing Resident M bump into a wall was entered into the medical record seven days after the x-ray was ordered. Interviews revealed that the Administrator was informed of the injury during a clinical meeting, but the source of the injury was not identified. The DON indicated she saw Resident M bump into a wall but may not have been aware of the injury prior to this incident. A CNA reported the injury to an RN, but felt it was not taken seriously. An observation noted a small scratch and discoloration on Resident M's nose. The facility's policy required all injuries of unknown origin to be investigated, but by the survey exit, the facility had not identified the source of Resident M's injuries.
Failure to Provide Bed Hold Policy During Resident Transfers
Penalty
Summary
The facility failed to provide the required written bed hold policy to two residents, Resident D and Resident E, during their transfers to the hospital. Resident D, who was moderately cognitively impaired and diagnosed with end-stage renal disease, among other conditions, called 911 due to nausea, vomiting, and pain at his port site. The clinical record did not document that the bed hold policy was provided to him at the time of transfer or afterward. The Director of Nursing acknowledged that the staff should have provided the policy before Resident D left the facility and documented the action in a progress note. Similarly, Resident E, who had wounds on both thumbs and was his own responsible party, requested to be sent to the hospital due to hand pain, inflammation, and redness. The facility's records also lacked documentation that the bed hold policy was given to Resident E at the time of transfer or afterward. The facility's Administrator provided a copy of the current transfer and discharge policy, which indicated that the bed hold policy should be presented to the resident prior to transfer, but this was not followed in these cases.
Medication Security and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure the security and proper labeling of medications in the medication room and during random observations. During an observation, an unlocked medication refrigerator was found in the South Medication Room containing a clear plastic bag with Ativan, a controlled substance, which was not double locked as required. The Ativan was found in a pink bin with other medications instead of being secured in a lock box inside the refrigerator, as per the facility's policy dated September 2018. Additionally, a clear plastic bag containing TPN was observed hanging in a resident's room without being labeled with the nurse's initials or the date it was hung. The Director of Nursing acknowledged that the TPN should have been labeled and removed when the resident was transferred to the hospital four days prior. The facility was unable to provide a policy regarding the labeling of medications.
Failure to Notify Physician of Dangerous Item Found in Resident's Room
Penalty
Summary
The facility failed to notify the physician when a large knife was found in the drawer of a resident with a history of suicidal ideations and attempts. On July 2, 2024, a CNA discovered the knife while assisting the resident with counting money. The CNA reported the finding to the LPN and the DON, who instructed the CNA to place the knife in the medication room, promising to address the issue. However, the physician was not informed of this significant incident, which was a breach of the facility's policy requiring physician notification for new or unusual behaviors. The resident involved had a documented history of major depressive disorder with psychotic symptoms, panic disorder, assaultive behavior, suicidal ideation, and PTSD. The resident's clinical records revealed multiple past suicide attempts and psychiatric hospitalizations, including a recent overdose attempt. Despite this history, the facility's records lacked documentation of physician notification regarding the knife discovery, which was acknowledged as necessary by the DON during an interview.
Failure to Report Allegation of Abuse Involving Drug Supply
Penalty
Summary
The facility failed to report an allegation of abuse to the state health department concerning a resident with a history of intravenous drug use. The resident alleged that a nurse supplied her with heroin, which led to an incident requiring emergency medical intervention, including CPR and administration of Narcan. The resident initially withheld the source of the drugs but later identified an LPN as the supplier to the Administrator and Director of Nursing. Despite this serious allegation, the Administrator did not report the incident to the state health department, believing it was unnecessary as the investigation was still ongoing. The resident involved was moderately cognitively impaired, as indicated by an Admission MDS assessment. The facility's policy on Occurrence Incident Reporting classified such incidents as level 2, which are considered more serious and should be reported to state authorities. However, the Administrator did not adhere to this policy, resulting in a failure to report the allegation of abuse. This deficiency was identified during a complaint investigation related to the incident.
Failure to Implement Person-Centered Care Plans for Resident with Suicidal Ideations
Penalty
Summary
The facility failed to implement care plans with person-centered interventions for a resident diagnosed with suicidal ideations and a history of trauma and suicide attempts. During an interview, a CNA reported finding a large butcher knife in the resident's drawer, which was then placed in the medication room by the CNA as instructed by the DON. The resident's clinical record indicated diagnoses including major depressive disorder with psychotic symptoms, panic disorder, assaultive behavior, suicidal ideation, and post-traumatic stress disorder. Despite these significant mental health concerns, the clinical record lacked care plans addressing suicidal ideations and suicide attempts. The resident had a history of multiple suicide attempts and psychiatric hospitalizations, including a recent suicide attempt by overdose. The facility's progress notes indicated the resident expressed dissatisfaction with her medication regimen and had a history of impulsive behavior and insomnia. Despite these documented concerns, the facility did not have a care plan with specific interventions for the resident's suicidal ideations and attempts, as confirmed by the DON during an interview. The facility's policy on behavior management required care plans to be completed and updated with specific interventions, which was not adhered to in this case.
Failure to Report Alleged Abuse and Drug Incident
Penalty
Summary
The facility administration failed to maintain the mental and physical wellbeing of a resident, identified as Resident C, due to an unreported allegation of abuse involving a nurse. Resident C was sent to the emergency department after requiring CPR and Narcan, indicating an opioid overdose. The resident admitted to snorting heroin, which she claimed to have obtained from someone within the facility. Although Resident C initially withheld the source of the drugs, she later disclosed to the Administrator and the Director of Nursing (DON) that the drugs were provided by LPN 1. Despite this serious allegation, the incident was not reported to the state health department or the police in a timely manner. The Administrator confirmed that Resident C required emergency medical intervention in early July and suspected illegal drug use. Upon learning from Resident C that LPN 1 was the source of the drugs, the LPN was suspended, and an investigation was initiated. However, the police report provided by the Administrator was related to property disposal rather than the drug-related incident. The facility's policy on incident reporting categorizes such events as level 2 incidents, which should be reported to state authorities, but this protocol was not followed. This deficiency was identified during the investigation of Complaint IN00438670.
Failure to Provide Behavioral Health Services
Penalty
Summary
The facility failed to provide necessary behavioral health services to maintain the highest practicable well-being for two residents with a history of aggressive behavior and substance use disorder. Resident B and Resident C, both with moderate cognitive impairments, were involved in a physical altercation in the courtyard. Despite previous incidents of aggression, neither resident had interventions documented in their clinical records to address or prevent such behaviors. Interviews with staff revealed that Resident B had previously been involved in a verbal disagreement with another resident, and Resident C had been verbally aggressive in a common area, yet no specific interventions were in place. Additionally, Resident B, who has a diagnosis of alcohol dependence and alcohol-induced persistent dementia, was found intoxicated on multiple occasions within the facility. The clinical record indicated incidents where Resident B was intoxicated, including hiding alcohol in the toilet tank and drinking mouthwash to the point of intoxication. Despite these occurrences, there was no documented plan for the prevention and treatment of Resident B's substance use disorder. The Director of Nursing acknowledged that a care plan should have been in place for Resident B's alcohol-related behaviors. The facility's policy on behavior management requires updating care plans with changes or new behaviors and including resident-specific interventions. However, the lack of documented interventions for both residents' aggressive behaviors and Resident B's substance use disorder indicates a failure to adhere to this policy, contributing to the deficiency in providing adequate behavioral health services.
Significant Medication Error Due to Miscommunication and Inaction
Penalty
Summary
The facility failed to prevent significant medication errors for a resident diagnosed with Clostridium difficile (C. diff), who only received 8 out of 39 prescribed doses of vancomycin. The resident was cognitively intact and had been discharged from the hospital with a prescription for vancomycin capsules to be taken four times daily for 12 days. However, the facility's Medication Administration Record showed multiple instances where the medication was either not documented, marked as awaiting pharmacy, or noted as not available. Despite the pharmacy delivering vancomycin oral solution instead of capsules, the medication was not administered as prescribed. The Director of Nursing and the Assistant Director of Nursing, who also served as the Infection Preventionist, acknowledged that the pharmacy delivered the oral solution because they did not carry the capsules. They admitted that the physician should have been notified about the change in medication form, and the order should have been clarified and updated in the medical record. The unopened bottles of vancomycin solution found in the medication room further indicated a lack of communication and follow-through in administering the medication as ordered. This deficiency was related to a complaint investigation.
Incomplete Documentation of Medication and Treatment Administration
Penalty
Summary
The facility failed to ensure accurate and complete documentation on the medication administration record (MAR) and the treatment administration record (TAR) for five residents. Resident B expressed uncertainty about receiving all prescribed medications, and a review of the MAR revealed multiple instances of missing documentation for various medications, including atorvastatin, cholecalciferol, ferrous sulfate, insulin glargine, and others. Additionally, the TAR lacked documentation for wound care treatments on several dates. Resident D reported not receiving baclofen for muscle spasms due to the facility running out of the medication. The MAR for Resident D also showed missing entries for several medications, such as duloxetine, insulin glargine, Jardiance, and others. The TAR was incomplete for treatments like floating heels for pressure prevention. Similarly, Resident E mentioned instances where medications were unavailable, and the MAR showed missing documentation for medications like atorvastatin, ferrous sulfate, and Lantus solostar pen-injector. The TAR also lacked entries for wound care and the use of prevalon boots. For Resident F, the MAR for April 2024 was missing documentation for medications like levothyroxine, metoprolol, and pantoprazole. The TAR was incomplete for wound care treatments. Resident G's MAR also showed missing entries for medications such as Basaglar Kwikpen and fluticasone suspension, and the TAR lacked documentation for wound care treatments. The Director of Nursing acknowledged that the MARs and TARs should have been completed accurately, and the facility's policy indicated that medication documentation should follow accepted nursing standards.
Failure to Notify Hospice of New Antibiotic Orders
Penalty
Summary
The facility failed to notify hospice when a resident received new physician orders for intravenous antibiotics. Resident C, who was on hospice services due to Fournier's gangrene, was supposed to start an oral antibiotic, doxycycline, on 5/24/24. However, a few days later, a family member was informed by a nurse that Resident C had a midline placed and was started on an intravenous antibiotic, levofloxacin, without prior notification to hospice. The hospice VP confirmed that hospice was not notified until several days after the midline was placed and the intravenous antibiotic was administered. Additionally, the order for doxycycline was never transcribed to the electronic medical record. The clinical record review indicated that Resident C had diagnoses including obstructive uropathy, diabetes, and polymyalgia rheumatica, and was cognitively intact as per a quarterly MDS assessment. The hospice service agreement required that any changes in the plan of care be discussed and approved by hospice before implementation. The Director of Nursing acknowledged that hospice should have been notified before starting the levofloxacin. The failure to notify hospice and the lack of transcription of the doxycycline order led to a deficiency in the coordination of care for Resident C.
Failure to Implement Transmission-Based Precautions for C. diff
Penalty
Summary
The facility failed to implement transmission-based precautions for a resident diagnosed with C. difficile, a highly contagious infection. Resident B, who was admitted with a diagnosis of C. diff, did not have a physician's order for transmission-based precautions in their clinical record. Despite being in contact precautions at the hospital, this information was not communicated to the facility staff. The resident's clinical record also lacked a specific order for the antibiotic Vancomycin to treat C. diff, which was part of the discharge instructions from the hospital. Interviews with facility staff revealed a lack of awareness regarding Resident B's C. diff diagnosis and the necessary precautions. A CNA who provided incontinence care to Resident B was not informed about the need for personal protective equipment and did not use any during care. Similarly, the housekeeping department was not notified of the need for transmission-based precautions. The Director of Nursing was unaware of the resident's C. diff status upon admission, indicating a breakdown in communication and adherence to the facility's infection prevention policy.
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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