Ignite Medical Resort Chesterton
Inspection history, citations, penalties and survey trends for this long-term care facility in Chesterton, Indiana.
- Location
- 2775 Village Point, Chesterton, Indiana 46304
- CMS Provider Number
- 155844
- Inspections on file
- 37
- Latest survey
- February 24, 2026
- Citations (last 12 mo.)
- 27
Citation history
Health deficiencies cited at Ignite Medical Resort Chesterton during CMS and state inspections, most recent first.
Surveyors identified that midodrine was administered to two residents outside of ordered blood pressure parameters and withheld once when within parameters, based on MAR entries showing doses given despite systolic BP readings above the ordered hold thresholds and one dose not given when BP was within range. In addition, a resident with diabetes, a tibia fracture, lower extremity impairment, edema, and anticoagulant therapy had compression leg wraps and a connected machine present and set up in the room without any corresponding physician order, and staff were initially unaware of the device’s presence or orders.
The facility did not complete or document required admission, skin, and accident assessments for multiple residents, including missing an admission assessment for a resident with a surgical wound, failing to document initial skin changes after a burn incident for another resident, and not performing or recording weekly skin evaluations for two residents with pressure ulcers, despite physician orders and care plans.
A resident with multiple medical conditions, including diabetes and fractures, developed a pressure injury and required wound care per physician orders. The wound nurse reported completing the required treatments but failed to document them on two occasions, attributing the omission to increased workload while covering alone.
A resident with multiple medical conditions and moderate cognitive impairment was left in her wheelchair without access to her call light while waiting to be put back to bed. The call light was found out of reach and not visible to the resident, delaying her ability to request assistance until staff were notified by other means.
The facility did not ensure that prescribed medications were administered as ordered for a resident with heart failure and two residents with infections. One resident did not receive an additional ordered dose of furosemide, while two others missed multiple doses of cephalexin due to documentation omissions and order changes. These deficiencies were confirmed through record review and staff interviews.
Two residents requiring dialysis did not receive proper pre- and post-dialysis assessments, and their medications were either scheduled incorrectly or not sent with them to dialysis as ordered. The facility failed to follow its own protocol for medication administration and documentation related to dialysis care.
The facility did not send required notifications of resident transfers or discharges to the State LTC Ombudsman, as confirmed by both record review and staff interview. The Administrator was unaware of the ongoing requirement, and the facility's policy states that such notifications must be provided.
The facility did not ensure that cognitively impaired residents received ongoing activities tailored to their preferences, as shown by missing or incomplete documentation of activity participation and offerings. For example, a resident with severe cognitive impairment and multiple health issues was not consistently engaged in preferred activities, and staff failed to document whether scheduled one-on-one visits or independent activities occurred. Similar gaps were found for two other residents, with staff confirming that some activities were provided but not recorded.
A resident with multiple health conditions, including COVID-19, did not receive a timely start of prescribed Paxlovid due to delays in pharmacy delivery and lack of floor stock. The medication, ordered for the resident, was not administered until three days later, despite its arrival at the facility the previous day. The delay was attributed to the facility's reliance on a non-local pharmacy and absence of a contract with a local provider.
A resident dependent on staff for toileting, with a history of falls and impaired cognition, activated her call light and requested bathroom assistance. Despite informing an LPN of her urgent need, there was a significant delay before two CNAs arrived to help, resulting in the resident waiting for assistance while expressing concern about being forgotten. The delay in response failed to honor the resident's right to be treated with respect and dignity.
The facility failed to consistently document and monitor bladder training, post void residuals, and urinary output for three residents with urinary catheters. Orders for catheter clamping, bladder scans, and output monitoring were not followed or recorded as required, and care plans for monitoring signs of UTI were not adhered to. The DON confirmed gaps in documentation and compliance with physician orders and facility policy.
Certified Nursing Assistants failed to don gowns, as required by Enhanced Barrier Precautions, when providing high-contact care to a resident with a wound. Despite clear signage and care plan instructions, staff only wore gloves while assisting the resident with toileting and incontinence care, contrary to physician orders and facility policy.
A resident experienced a delay in receiving assistance to get out of bed, despite requesting help and being assured by an RN that staff would assist her. The resident remained in bed for over two hours, impacting her planned activities. The care plan indicated the need for a mechanical lift and two staff for transfers due to the resident's medical condition, including congestive heart failure.
A facility failed to notify a resident's POA about falls, as required by policy. The resident, with severe cognitive impairment and multiple diagnoses, had a POA listed as the first contact for emergencies. However, the second contact was notified instead on three occasions, with no documentation explaining the oversight. The Clinical President and DON were unable to provide a reason for this failure.
A resident dependent on staff for daily living activities was found with a saturated incontinent brief and wet bedding, indicating a failure in timely incontinence care. Despite being assigned to the resident, a CNA had not checked on him since starting her shift. The resident's care plan required checks every 2-3 hours, but the resident reported not being changed since the previous day.
The facility failed to conduct required skin assessments for two residents with braces and immobilizers, as ordered by physicians. One resident with a right arm fracture did not receive weekly skin checks or monitoring of a surgical splint on multiple occasions. Another resident with a left humerus fracture did not receive weekly skin checks, and the Director of Nursing acknowledged the oversight. This deficiency was linked to a specific complaint.
A facility failed to implement care plan interventions for a resident at high risk for falls. Observations showed the absence of a stop sign and floor mat in the resident's room, despite these being specified in the care plan. The resident, with a history of falls and conditions like dementia, required maximum assistance. A nurse confirmed the lack of these safety measures, and the resident's record indicated multiple falls.
A resident's feeding tube was infusing at 55 cc/hr instead of the physician-ordered 20 cc/hr. Despite a dietician's recommendation to increase the rate, there were no physician orders to authorize this change. The facility's policy required a physician or nurse practitioner order for the feeding rate, which was not followed.
A facility failed to provide proper care for a midline catheter for a resident with severe cognitive impairment and multiple diagnoses, including pneumonia and a hand infection. The facility did not document the catheter placement, lacked physician's orders for flushing and care, and failed to perform necessary flushes, dressing changes, and site monitoring. Despite instructions from a Vascular Access Specialist, the facility did not adhere to its policy for IV fluid administration and monitoring.
A resident with diagnoses including pneumonia and dementia did not receive oxygen therapy as ordered by the physician. Observations revealed the resident's portable oxygen unit was turned off despite a nasal cannula being in place. The Assistant DON later turned on the oxygen to the prescribed two liters per minute. The facility's policy required oxygen to be administered per physician's orders, which was not followed.
A facility failed to ensure correct PPE use by a CNA for a resident on Enhanced Barrier Precautions (EBP). The CNA did not wear a protective gown during care, despite the resident's care plan and facility policy requiring it due to wounds and a central line. The CNA was unaware of the EBP requirement, even though a sign and PPE supplies were present.
The facility failed to maintain cleanliness and proper labeling in the kitchen and resident refrigerator, potentially affecting all residents. Observations included food debris, sticky residues, and incorrect sanitation test strips in the kitchen, as well as improperly labeled and dated food in the D Wing refrigerator. Interviews confirmed that dietary staff should have labeled the items according to facility policy.
The facility's kitchen was found to be unsanitary, with food debris on the freezer floor, an orange substance on the garbage disposal, and dust and dead insects inside light covers. The Executive Chef acknowledged the need for cleaning.
The facility failed to ensure residents had physician's orders and assessments for self-administration of medications. Several residents were observed with medications at their bedside without the necessary orders or assessments, including a resident with a plastic medication cup containing a white powder, another with over-the-counter vitamins, and others with nasal spray, antacids, eye drops, Biofreeze, Venelex cream, and portocort cream. The facility's policy required a physician's order for medications at the bedside, which was not followed.
The facility failed to manage oxygen therapy properly for four residents, with issues including incomplete oxygen orders, incorrect flow rates, and lack of documentation. A resident used oxygen at 3 liters per minute without a specified flow rate in the order, while another had oxygen levels set higher than ordered. Another resident had varying oxygen levels despite a specific order, and a fourth resident's oxygen use was undocumented. The facility's policy required recording oxygen orders in the chart, which was not followed.
The facility failed to ensure proper medication management and storage. An LPN was observed pre-pouring medications, which is against policy, and treatment carts were found unlocked with unlabeled creams. The Chief Nursing Officer confirmed that treatment carts should be locked and creams labeled with resident names.
The facility failed to follow infection control guidelines during medication administration and equipment disinfection. Staff were observed handling medications with bare hands and not using enhanced barrier precautions for a resident with a PICC line. Additionally, a glucometer was improperly disinfected with alcohol wipes instead of bleach wipes. These actions were contrary to the facility's policies and infection prevention standards.
A resident with cognitive impairment and multiple diagnoses was repeatedly observed wearing a hospital gown during the day, both in bed and while seated in a Broda chair. The resident required substantial assistance with dressing, but the facility lacked a specific care plan to address appropriate daytime attire, leading to a deficiency in maintaining the resident's dignity.
Two residents in an LTC facility experienced deficiencies in personal hygiene care. One resident, who was cognitively intact, reported her hair had not been washed since admission, despite needing substantial assistance for bathing. Another resident, not cognitively intact, was observed with long, dirty fingernails and excessive facial hair, requiring partial assistance with personal hygiene. The facility failed to provide necessary care as outlined in their care plans.
The facility failed to administer treatments as ordered for residents with skin conditions and constipation. A resident with a history of opioid use and constipation did not receive necessary bowel relief medications, and refusals were not documented. Another resident with dry skin on her legs did not consistently receive prescribed lotion applications. A third resident with extremely dry skin on his legs and feet did not receive the ordered cream, as it was not available in the treatment cart.
A resident with dementia and a femur fracture was observed with cloudy urine and a urine odor in their room, indicating a lack of catheter care. Despite having an indwelling urinary catheter, there were no timely orders for catheter care upon admission, and no documentation of care was found in the records. The facility's President of Clinical Operations confirmed the oversight.
A facility failed to complete weekly weights for a resident who was underweight and at risk for malnutrition. Despite a physician's order for weekly weights, none were recorded after the resident's admission weight. The resident had multiple diagnoses, including heart failure and dementia, and was assessed as severely impaired in daily decision-making. The VP of clinical operations acknowledged the oversight.
A facility failed to maintain and monitor a peripheral IV catheter for a resident diagnosed with dehydration. The resident, with a complex medical history, received an IV infusion of normal saline, but there were no orders for saline flushes to maintain patency. Observations and interviews revealed a lack of daily assessments and documentation of the IV site condition, contrary to the facility's policy.
A facility failed to maintain ongoing communication with a dialysis center for a resident with end-stage renal disease. Despite having a care plan and physician's orders for dialysis-related interventions, the facility did not complete necessary communication sheets on multiple occasions. These sheets were meant to document vital information before and after dialysis sessions. Interviews confirmed the oversight, with staff acknowledging the requirement to fill out the dialysis binder.
The facility failed to monitor blood pressure as ordered for two residents, leading to deficiencies in medication management. One resident, with hypertension, had missing documentation for several days, while another, prescribed midodrine for low blood pressure, had incomplete monitoring records. Interviews confirmed the monitoring should have been more frequent.
The facility exceeded the acceptable medication error rate, with errors involving two residents. An LPN administered an antibiotic late to a resident due to being occupied with other tasks, while an RN failed to administer a prescribed supplement to another resident, despite documenting it as given. These incidents resulted in a medication error rate of 5.88%.
The facility failed to maintain accurate clinical records and document physician notifications for residents receiving tube feeding and insulin. A resident's tube feeding times were not consistently recorded, and two residents had blood sugar levels outside prescribed parameters without proper physician notification. The facility's VP of Clinical Operations and President of Clinical Operations acknowledged these documentation lapses.
A resident was inappropriately prescribed antibiotics for a UTI that was not confirmed by the McGeer Criteria. Despite urinalysis and culture results showing no significant infection, the physician ordered Keflex based on undocumented symptoms of confusion and urinary issues. The CNO confirmed the lack of documentation, indicating a failure in the facility's antibiotic stewardship program.
A resident with multiple health conditions did not receive medications as ordered, including antibiotics and blood pressure treatments, on several occasions. The facility also administered midodrine outside of prescribed parameters. The DON acknowledged the issue, particularly for residents attending dialysis, but there was no documentation of physician notification for missed doses.
A resident with an anxiety disorder was mistakenly given scheduled doses of alprazolam instead of PRN due to a transcription error, resulting in lethargy and hospitalization. The error was identified after the resident received four doses without documented need.
A facility failed to provide necessary wound care for a resident with a surgical knee wound, as ordered by a physician. The resident, who was cognitively intact and had a history of infection and inflammatory reaction of a knee prosthesis, did not receive documented dressing changes on several occasions. The DON confirmed the lack of documentation for these dressing changes.
A resident with a wound infection was prescribed meropenem intravenously every 8 hours. The medication administration record showed missed doses on multiple occasions, with no documentation explaining the omissions. The care plan required the medication to be administered as ordered. The DON reported that nurses claimed to have given the medication but did not document it.
Medication Parameter Errors and Unauthorized Compression Device Use
Penalty
Summary
The deficiency involves failures to follow physician orders and to ensure appropriate orders were in place for treatments and medications. For one resident with dependence on renal dialysis and heart failure, a physician’s order dated 2/16/26 directed administration of midodrine 10 mg three times daily for hypotension, to be held if blood pressure was greater than 130/90. The February 2026 MAR showed midodrine was administered on multiple occasions when the systolic blood pressure exceeded 130 (including readings of 150/86, 146/59, and 141/78), and on one date the medication was not given when the blood pressure was 119/64, with a note stating the blood pressure was outside parameters. The DON stated the midodrine parameters came from hospital discharge orders, acknowledged the order was not clear, and indicated staff education was needed. Another resident with heart failure had a physician’s order dated 1/31/26 for midodrine 2.5 mg by mouth three times a day, to be held if systolic blood pressure was greater than 110. The February 2026 MAR indicated midodrine was administered several times when systolic blood pressure was above 110, including readings of 123/75, 136/74, 135/87, 129/72, and 117/63. A separate deficiency involved the use of compression leg wraps without a corresponding physician order. One resident with diabetes mellitus, a left tibia fracture, bilateral lower extremity impairment, and care plans for diuretic therapy related to edema and anticoagulant therapy for DVT prevention was observed with compression leg wraps and a connected machine in his room. Initially, the wraps were folded in a bag on the bed, and the resident reported not knowing who brought them or whether he or staff were supposed to apply them. On a later observation, the wraps were opened and connected to the machine on the bed. Record review showed no physician orders for the compression leg wraps. An RN stated she was unaware the wraps were on the bed and confirmed there was no order, and the DON stated the resident was supposed to wear the leg wraps for leg swelling and that the company must have dropped them off without notifying staff, adding that there should have been an order in the computer.
Failure to Complete Required Admission, Skin, and Accident Assessments
Penalty
Summary
The facility failed to complete required admission, skin, and accident assessments as ordered and per policy for several residents. For one resident admitted after digestive surgery with multiple comorbidities, there was no documented admission assessment or assessment of the surgical wound upon arrival. Although the wound nurse and primary nurse attempted to assess the surgical site, the assessment was not completed due to the resident's transfer to the hospital, and only vital signs were documented. The resident and family had expressed concerns about care, but no further information was provided. Another resident with a history of femur fracture, stroke, and other significant diagnoses experienced a burn incident involving hot tea. The initial assessment failed to document the presence of reddened skin on the right arm and back immediately after the incident. Blistering was only documented in a subsequent assessment, and the President of Clinical Operations confirmed that the initial assessment should have included the redness observed prior to blistering. For two additional residents with pressure ulcers, the facility did not complete or document weekly skin evaluations as ordered by the physician. In both cases, the electronic medical record lacked required skin evaluations for multiple weeks, despite physician orders and care plans indicating the need for regular skin checks. The Treatment Administration Record also showed missed documentation of these evaluations. The President of Clinical Operations acknowledged the missing documentation and indicated an understanding of the concern.
Incomplete Documentation of Wound Care Treatments
Penalty
Summary
The facility failed to maintain complete and accurate clinical records regarding wound treatments for one resident with pressure ulcers. Specifically, a resident with diagnoses including diabetes and fractures was admitted with surgical wounds and later developed a pressure injury to the left heel. The care plan required following facility protocols and physician orders for wound care. However, review of the Treatment Administration Record (TAR) for the relevant month showed that wound care was not signed out on two specific dates. During interviews, the wound nurse acknowledged performing the treatments but admitted to forgetting to document them, citing increased workload due to being the only wound nurse available that week.
Resident Unable to Access Call Light While Awaiting Assistance
Penalty
Summary
A deficiency occurred when a resident who required substantial to maximum assistance with activities of daily living was left in her wheelchair, unable to access her call light. The resident, who was visibly fatigued and shaking, had been waiting to be put back to bed after her husband requested staff assistance. Staff informed the husband that it would take some time due to other tasks. The resident attempted to use her call light but was unable to locate it, as it was found by a nurse in the back corner of the room, out of the resident's reach and not visible to her. The resident was only assisted back to bed after staff were notified of her inability to access the call light. The resident's medical record indicated diagnoses including muscle weakness, encephalopathy, diabetes, and adult failure to thrive, with moderate impairment in daily decision making. She required significant assistance with transfers and other ADLs. Previous documentation showed that the resident had been lethargic and required hospital admission for a severe urinary tract infection. The Assistant Director of Nursing acknowledged the concern regarding the call light but did not provide additional information.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to ensure that residents received necessary care and treatment as ordered, specifically related to medication administration. For one resident with diagnoses including congestive heart failure, diabetes, and acute kidney failure, a physician ordered an additional dose of furosemide for worsening symptoms, but the dose was not administered. The medication administration record (MAR) showed the dose was scheduled but left blank, and a nursing note indicated it was considered a duplicate order, resulting in the resident only receiving the original dose. No further explanation was provided by facility leadership. Two other residents with infections also did not receive medications as ordered. One resident with acute polynephritis and diabetes did not have two scheduled doses of cephalexin signed out as given, with no documentation explaining the omission. Another resident with muscle weakness, encephalopathy, and acute cystitis missed three doses of cephalexin due to pharmacy time changes and discontinuation of the original order, as confirmed by the nurse consultant. These failures were identified through record review and staff interviews.
Failure to Provide Safe and Appropriate Dialysis Care and Medication Administration
Penalty
Summary
The facility failed to provide necessary care and treatment for residents requiring dialysis, specifically related to pre- and post-dialysis assessments, medication scheduling, and medication administration. For one resident with end stage renal failure, the facility did not complete or retain required pre- and post-dialysis assessments, and the resident's seizure medication was scheduled on incorrect days, not aligning with the updated dialysis schedule. The Assistant Director of Nursing (ADON) confirmed that the dialysis days had changed, but the medication order was not updated accordingly, and the required assessments could not be located in the resident's records. Another resident, also dependent on dialysis, did not have her dialysis binder sent to the dialysis center on two occasions, and her prescribed medications were not sent with her as ordered. The resident reported that staff failed to send both her binder and medications, and the ADON confirmed that the prepackaged medications were found in the medication cart rather than being sent with the resident. The facility's own dialysis protocol required that medications to be administered during or after dialysis be labeled and sent with the resident, which was not followed in these instances.
Failure to Notify Ombudsman of Resident Transfers and Discharges
Penalty
Summary
The facility failed to provide required notifications to the Office of the State Long Term Care Ombudsman prior to transferring or discharging residents. Record review and interviews revealed that since May 2024, the Ombudsman had not received any notifications of resident transfers or discharges from the facility. During an interview, the Administrator stated she was unaware that sending notifications to the Ombudsman was still a requirement and confirmed that the facility had not been sending them. The facility's own policy, updated in May 2024, specifies that a copy of the transfer or discharge notice must be sent to the Ombudsman before or as close as possible to the time of notifying the resident.
Failure to Provide and Document Activities for Cognitively Impaired Residents
Penalty
Summary
The facility failed to provide ongoing activities that met the preferences of cognitively impaired residents, as evidenced by the review of records and interviews for three residents. For one resident with severe cognitive impairment and multiple medical diagnoses, activity assessments indicated preferences for snacks, movies, game shows, outings, pet visits, and religious services. However, documentation was lacking regarding whether scheduled one-on-one visits occurred or what activities were provided, and the resident was observed not actively engaged or alone in her room on multiple occasions. The Activity Director acknowledged inconsistent documentation of participation and activity types. Another resident with severe cognitive impairment and a history of dementia and alcohol dependence had documented preferences for creative arts, crafts, music, outdoor activities, and spiritual activities. Despite this, records only showed sporadic participation in group events, with refusals noted but no details on the types of activities offered or independent activities provided. A third resident's record also lacked documentation of participation in or being offered preferred activities such as reading, music, pet interaction, and outdoor time, despite these being identified as important. Staff interviews confirmed that some activities, like word searches, were provided but not documented, and activity records were only maintained for certain activities like communion.
Delayed Initiation of Antiviral Medication for COVID-19
Penalty
Summary
The facility failed to initiate medication administration in a timely manner for a resident who was admitted with diagnoses including congestive heart failure, COVID-19, and pneumonia. The resident, who had moderate cognitive impairment and required moderate assistance with daily activities, tested positive for COVID-19 and was prescribed Paxlovid on the day of admission. However, the medication was not started until three days after it was ordered. The delay occurred because the facility was waiting for the medication to arrive from their contracted pharmacy, which was not local and did not provide Paxlovid as floor stock. Although the medication arrived on a Sunday, it was not administered until the following day.
Delay in Assisting Resident to Bathroom Compromises Dignity
Penalty
Summary
A resident with diagnoses including a right femur fracture, pressure wound, and history of falls, who was dependent on staff for toileting, activated her call light to request assistance to use the bathroom. The resident, who had severely impaired cognition but no impairment to her extremities, was observed waiting in her wheelchair with two family members present. Despite informing an LPN of her need to use the bathroom, the nurse left the room after stating she would return shortly. The resident continued to wait, expressing concern that staff had forgotten her request. The call light log indicated the call was activated at 4:38 p.m., and staff did not assist the resident to the bathroom until approximately 17 minutes later, when two CNAs entered and provided the necessary help. The resident was able to void on the toilet after the delay. The care plan and care card both indicated the resident required assistance for toileting and transfers, with one staff member needed for transfers. The delay in responding to the resident's request resulted in a failure to treat her with respect and dignity as required.
Failure to Document and Monitor Catheter Care and Bladder Training
Penalty
Summary
The facility failed to ensure proper bladder training, post void residual (PVR) monitoring, and documentation after urinary catheter removal for three residents. For one resident with a history of femur fracture, stroke, and UTI, there was a lack of documentation regarding catheter clamping, resident-reported urge to void, and completion of bladder scans as ordered. Orders for bladder training and scans were inconsistently followed, and there was no consistent record of urine output or clear documentation of catheter removal and related care in the medical record. Another resident with obstructive uropathy and dementia had a physician's order for urinary output monitoring every shift, but the output was not consistently documented. The care plan required monitoring for signs and symptoms of UTI, including urine output, but the monitoring log showed multiple days without any recorded output, and only sporadic entries were made. A third resident with a groin abscess and an indwelling catheter also had inconsistent documentation of urinary output, with several days missing entries and only a few outputs recorded. The facility's catheter care policy required drainage bag emptying and output documentation at the end of each shift, but this was not followed. The Director of Nursing confirmed the lack of documentation for catheter care, bladder training, and urine output, as well as inconsistencies in following physician orders and facility policies.
Failure to Use Required PPE During Enhanced Barrier Precautions
Penalty
Summary
Certified Nursing Assistants (CNA 2 and CNA 3) failed to use the required Personal Protective Equipment (PPE) when providing care to a resident who was under Enhanced Barrier Precautions (EBP) due to the presence of a wound. During an observation, both CNAs entered the resident's room, which was clearly marked with a sign indicating EBP requirements, and donned only gloves before assisting the resident with toileting and incontinence care. When questioned, both CNAs denied that EBP was necessary for the resident and continued care without donning gowns as required. Review of the resident's medical record confirmed diagnoses including a right femur fracture, pressure wound, and falls, with physician orders and care plan interventions specifying the need for EBP, including the use of gowns and gloves during high-contact care. The facility's current EBP policy also required staff to wear gowns and gloves for residents with wounds during such care activities.
Failure to Assist Resident in a Timely Manner
Penalty
Summary
The facility failed to ensure a resident was treated with respect and dignity, as evidenced by a delay in assisting a resident out of bed upon request. On the specified date, Resident J activated the call light and requested assistance to have her meal tray removed and to get out of bed. RN 1 responded and informed the resident that staff were currently assisting another resident and would help her once available. Despite this assurance, observations showed that the resident remained in bed for over two hours after the initial request. During an interview, the resident expressed that this delay in assistance was a frequent occurrence, impacting her ability to carry out planned activities. RN 1 acknowledged informing a CNA about the resident's need for assistance, noting that a mechanical lift and two staff members were required for the transfer. Resident J's care plan confirmed the need for such assistance due to her medical condition, which included congestive heart failure and a history of falls.
Failure to Notify POA of Resident Falls
Penalty
Summary
The facility failed to notify a resident's Power of Attorney (POA) about falls, as required by their policy, for one of the three residents reviewed for physician/responsible party notification. Resident E, who had diagnoses including pneumonia, a fracture of the right arm, an infection of the right hand, and dementia, was identified as having a severely impaired cognitive status. The resident's record indicated that the POA was the first contact person in case of changes or emergencies. However, during fall investigations on three separate occasions, the person listed as the second contact was notified instead of the POA. There was no documentation explaining why the POA was not informed. During an interview, the Clinical President and Director of Nursing were unable to provide a reason for this oversight. The facility's policy required that communication with the responsible party be documented in the resident's record, and the responsible party should be notified after the physician.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for a resident who was dependent on staff for assistance with activities of daily living. During an observation, it was noted that the resident's call light had been activated by a visitor, and upon response by RN 4 and CNA 5, the resident was found with a saturated incontinent brief, wet gown, top sheet, and abdominal binder. Additionally, the incontinent pad under the resident was soaked, and there were dried urine rings on the bed. The resident indicated that he had last been changed the previous day. Interviews revealed that CNA 2, who was assigned to the resident, had not checked on him since starting her shift at 6 a.m. The administrator mentioned that the resident's call light had been on at 2 a.m., suggesting a possible check at that time. The resident's care plan, dated 3/7/25, indicated he required assistance for hygiene and toileting and should be checked every 2-3 hours for incontinence. The resident had a history of a bloodstream infection due to a central venous catheter and dementia, with a mental status assessment indicating moderately impaired cognition.
Failure to Conduct Required Skin Assessments for Residents with Braces
Penalty
Summary
The facility failed to ensure that residents received necessary care and services as ordered by the physician, specifically related to skin assessments for residents with a brace and an immobilizer. Resident E, who had a brace on the right wrist/forearm due to a fracture, did not receive the required weekly skin checks on several specified dates in January and February 2025. Additionally, the non-removable surgical splint was not monitored on multiple shifts as required. The Clinical President was informed of these missed assessments, but no further information was provided by the facility. Resident H, who had a left humerus fracture and was at risk for skin integrity issues, also did not receive the mandated weekly skin checks on several dates in February and March 2025. The Treatment Administration Record indicated that these checks were not signed out, and the Director of Nursing acknowledged the concern regarding the incomplete skin evaluations. This deficiency was related to a specific complaint, highlighting the facility's failure to adhere to physician orders for skin assessments.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to implement care plan interventions to prevent falls for a resident identified as high risk for falls. Observations on two consecutive days revealed the absence of a stop sign and floor mat in the resident's room, which were specified interventions in the care plan. The resident, who had a history of falls and was diagnosed with conditions including dementia and a fracture, required maximum assistance with transfers and was dependent for toileting and wheelchair mobility. Despite the care plan's directives, these safety measures were not in place, as confirmed by a registered nurse during an interview. The resident's record indicated multiple falls, underscoring the need for the prescribed interventions to mitigate fall risks.
Feeding Tube Infusion Rate Discrepancy
Penalty
Summary
The facility failed to ensure that a resident's feeding tube was infusing at the correct flow rate. Resident F, who had a gastrostomy tube and required enteral nutrition, was observed with the tube feeding infusing at 55 cc/hr, contrary to the physician's order of 20 cc/hr. This discrepancy was noted during observations on two separate occasions. The resident's care plan indicated that the tube feeding should follow current physician orders, which specified a rate of 20 cc/hr. However, a Registered Dietician's Progress Note recommended an increase to 55 cc/hr, but there were no corresponding physician orders to authorize this change. The facility's tube feeding policy required an order by the physician or nurse practitioner for the type of formula and rate, which was not adhered to in this case.
Failure to Provide Proper Midline Catheter Care
Penalty
Summary
The facility failed to provide appropriate care for a midline catheter for Resident E, who had a severely impaired cognitive status and was diagnosed with pneumonia, a fracture of the right arm, an infection of the right hand, and dementia. A midline catheter was ordered for IV antibiotic administration, but there was no documentation of when the catheter was placed in the resident's clinical record. Additionally, there were no physician's orders for flushing the midline or for the care of the midline catheter. The Medication Administration Record and/or Treatment Administration Record for March 2025 lacked information indicating that flushes were completed, dressing changes to the site were performed, and that the arm circumference and insertion site were monitored. The Director of Nursing and the President of Operations were informed of the lack of care for the IV site and orders for the flushes, but no further information was provided. A form from the Vascular Access Specialist indicated that the midline was placed on March 6, 2025, with specific instructions for flushing and dressing changes. However, these instructions were not followed as per the facility's policy, which required documentation of IV fluid administration and monitoring of the IV site in the clinical record. This lack of adherence to professional standards of practice led to the deficiency in the care of Resident E's midline catheter.
Failure to Administer Oxygen as Ordered
Penalty
Summary
The facility failed to provide appropriate respiratory care to a resident, identified as Resident E, who required oxygen therapy. During multiple observations, Resident E was seen sitting in a wheelchair with a nasal cannula in place, but the portable oxygen unit was turned off. It was only after the Assistant Director of Nursing intervened that the oxygen was turned on to the prescribed two liters per minute. Resident E's medical record indicated diagnoses of pneumonia, a fracture of the right arm, an infection of the right hand, and dementia. A physician's order dated 3/8/25 specified that oxygen should be administered at two liters per minute every shift, and the care plan dated 3/9/25 confirmed the need for oxygen therapy as per the physician's orders. The facility's policy on oxygen usage, dated 11/2018, required that oxygen be administered according to the physician's orders, which was not adhered to in this instance.
Failure to Use Correct PPE for Resident on Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure correct Personal Protective Equipment (PPE) was used by a staff member when providing care to a resident who was in Enhanced Barrier Precautions (EBP). During two separate observations, a Certified Nursing Assistant (CNA) did not don a protective gown while providing care to a resident who was incontinent and required EBP due to wounds and a central line. On the first occasion, there was no sign on the door indicating the resident was on EBP, and the CNA only wore gloves while providing care. On the second occasion, although a sign and PPE supplies were present, the CNA still did not wear a gown, stating she was unaware of the EBP requirement. The resident involved had a medical history that included pneumonia, a fracture, an infection, and dementia. The resident's care plan required EBP due to wounds present upon admission, and a physician's order had been in place since January for EBP. The resident also had a midline catheter inserted for intravenous antibiotic therapy. The facility's EBP policy required staff to wear gowns and gloves during high-contact care for residents with central lines and wounds, which was not adhered to in this case.
Kitchen and Refrigerator Labeling and Cleanliness Deficiencies
Penalty
Summary
The facility failed to maintain cleanliness and proper labeling in the kitchen and resident refrigerator, which could potentially affect all 67 residents receiving food from the kitchen. During an initial kitchen sanitation tour, several issues were observed, including food debris under the salad bar lid, sticky residue on storage bin lids, and dust accumulation on the convection oven. Additionally, opened bags of food in the dry storage room and freezer were not dated, and lemon slices in the cooler were uncovered. The test strips used for sanitation buckets were incorrect, as bleach strips were used instead of quat testing strips. In the D Wing refrigerator, several items were not properly labeled or dated, including a fast food container, a plastic container of food, and a bag of fast food. Despite a sign indicating that resident food must be dated, these items were not compliant. Interviews with the Executive Chef and a CNA confirmed that the dietary staff should have labeled the items, and the facility's policy required labeling with product name, received date, use by date, and resident's name.
Kitchen Sanitation Deficiency
Penalty
Summary
The facility failed to maintain cleanliness in the kitchen area, as observed during a sanitation tour. In the walk-in freezer, there was an accumulation of food debris on the floor and underneath the shelf. Additionally, the garbage disposal next to the dishwasher had a thick accumulation of an orange substance on its exterior. Furthermore, five plastic light covers located above the steam table and food preparation area were found to have an accumulation of dust and dead insects inside. These observations were confirmed during interviews with the Executive Chef, who acknowledged that the areas either had been cleaned or were in need of cleaning.
Failure to Ensure Physician's Orders and Assessments for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that residents had physician's orders and assessments for self-administration of medications. During observations, several residents were found with medications at their bedside without the necessary physician's orders or assessments to self-administer. For instance, Resident C was observed with a plastic medication cup containing a white powder and a bottle of Ammonium Lactate lotion, neither of which had a physician's order for self-administration. Similarly, Resident E had over-the-counter vitamins on her over bed table without any orders or assessments for self-administration. In another instance, Resident F was found with a nasal spray on her over bed table, which she used frequently, but there was no physician's order for self-administration. Resident G had chewable antacids and nasal spray at his bedside without the necessary orders or assessments. Resident B had eye drops and pills left on her over bed table, and although her care plan indicated a need for reassessment of her ability to self-administer medications, no recent assessment had been completed. Additionally, Resident H had a bottle of Biofreeze on her over bed table, and Resident D had a tube of Venelex cream in his room, both without the required orders or assessments for self-administration. Resident J, who was cognitively impaired, had a tube of portocort cream on his nightstand without the necessary physician's order or assessment. The facility's policy required a physician's order for medications at the bedside, which was not adhered to in these cases.
Deficiencies in Oxygen Therapy Management
Penalty
Summary
The facility failed to ensure proper management of oxygen therapy for four residents, leading to deficiencies in the administration and documentation of oxygen orders. Resident 130 was observed using oxygen at 3 liters per minute via nasal cannula without a specified flow rate in the physician's order, and the oxygen was not documented as being applied in the medication and treatment records. Similarly, Resident C was observed with oxygen levels set higher than the physician's order of 2 liters per minute, with no checks performed by the LPN on the day of observation. Resident F was observed with varying oxygen levels, including 5 liters per minute, despite a physician's order for 3 liters per minute for shortness of breath. The LPN had not checked the oxygen settings on the day of observation. Resident 127 was observed using oxygen at 2 liters per minute without documentation in the medication administration record, and the resident had been wearing oxygen daily since a decline in health. The facility's policy required that oxygen orders be recorded in the resident's chart, which was not adhered to in these cases.
Medication Management and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper medication management and storage practices, as observed in two separate incidents. On the C Wing, an LPN was found pre-pouring medications into plastic cups labeled with room numbers, which is against the facility's policy. During an interview, the LPN initially admitted to always pre-pouring medications but then retracted the statement, citing a bad day. The President of Clinical Operations confirmed that there was no policy allowing pre-pouring of medications, and the LPN's actions were inappropriate. Additionally, the facility did not maintain secure and properly labeled treatment carts. A wound nurse was observed with an unlocked treatment cart containing multiple opened and unlabeled tubes of creams, which were used as house stock for residents. Another wound nurse's cart contained numerous opened creams without resident names, including some for a discharged resident. The Chief Nursing Officer acknowledged that the treatment carts should have been locked and creams labeled with specific resident names. The facility's Medication Labeling and Storage policy requires all medications to be labeled according to state and federal laws, and floor stock medications to be kept in their original containers.
Infection Control Deficiencies in Medication Handling and Equipment Disinfection
Penalty
Summary
The facility failed to adhere to infection control guidelines during medication administration for several residents. On multiple occasions, LPNs and RNs were observed handling medications with their bare hands, without performing hand hygiene or donning gloves. This occurred with at least three residents, where pills were popped from medication cards directly into the staff's bare hands before being placed into medication cups or mixed with applesauce for administration. The staff acknowledged the improper handling of medications, indicating a lack of practice or awareness of proper procedures. In another instance, a resident with a peripherally inserted central catheter (PICC) line did not have enhanced barrier precautions (EBP) in place. An LPN administered an antibiotic via the PICC line without wearing a gown, and there was no signage or personal protective equipment (PPE) available to indicate the need for EBP. The resident's physician's order summary did not include an order for EBP, and the infection preventionist confirmed that EBP should have been implemented due to the presence of the PICC line. Additionally, the facility failed to properly disinfect a glucometer after use. An LPN used alcohol wipes instead of the required germicidal bleach wipes to clean the glucometer after performing a blood glucose test on a resident. The LPN admitted to using alcohol wipes due to the unavailability of bleach wipes in the medication cart. The infection preventionist confirmed that bleach wipes were the expected method for cleaning glucometers, as per the facility's policy.
Resident Dignity Compromised by Inappropriate Attire
Penalty
Summary
The facility failed to maintain the dignity of a resident, identified as Resident 30, by allowing him to remain in a hospital gown while in bed during the day. This was observed on multiple occasions over several days, including when the resident was seated in a Broda chair by the nurses' station. The resident's medical record indicated diagnoses such as dementia without behavior disturbance, delusional disorder, anxiety, dysphagia, and gastrostomy status. The resident was noted to be cognitively impaired and required substantial assistance with dressing, as per the Quarterly Minimum Data Set (MDS) assessment. The resident's care plan, which was reviewed and dated earlier in the year, indicated self-care deficits requiring assistance with activities of daily living, including dressing. However, there was no specific care plan addressing the issue of wearing a hospital gown during the day. This oversight contributed to the deficiency in maintaining the resident's dignity, as the facility did not have a plan in place to ensure the resident was dressed appropriately during the day.
Deficiencies in Personal Hygiene Care for Two Residents
Penalty
Summary
The facility failed to ensure that activities of daily living (ADLs) were adequately completed for two residents, resulting in deficiencies related to personal hygiene. Resident F, who was cognitively intact and required substantial assistance for bathing due to physical mobility issues, reported that her hair had not been washed since her admission. Despite her refusal to shower on one occasion due to the chair being too high, there was no documentation of a bath or shower on another date, nor was there evidence of refusal. The resident's care plan indicated the need for assistance, but the facility did not consistently provide the necessary care. Resident 170, who was not cognitively intact and required partial to moderate assistance with personal hygiene, was observed with long, dirty fingernails and excessive facial hair. The resident's care plan also indicated a need for assistance, but there was no documentation of nail care or shaving. The resident had refused baths on two occasions, and the facility was waiting for an electric razor from the resident's home, which contributed to the lack of personal hygiene care. These observations and interviews with staff highlighted the facility's failure to meet the residents' ADL needs.
Failure to Administer Ordered Treatments for Skin Conditions and Constipation
Penalty
Summary
The facility failed to ensure that treatments were completed as ordered for residents with non-pressure skin conditions and constipation. Resident 31, who had a history of high blood pressure, anxiety disorder, panic disorder, PTSD, and COPD, was at risk for constipation due to opioid use. Despite having physician orders for various constipation medications, the resident's bowel movements were infrequent, and there was no documentation that the nursing staff offered as-needed bowel relief medications. The resident had refused scheduled medication, and there was no further documentation that the physician was notified of these refusals in October 2024. Resident F, who had diagnoses including heart failure, type 2 diabetes, and peripheral vascular disease, was observed with dry, flaky, and red skin on her lower legs. Although there was a physician's order for Ammonium Lactate Cream to be applied daily, the resident reported that nursing staff did not consistently apply lotion to her legs. The Treatment Administration Record indicated that the cream was signed out as completed, but observations suggested otherwise. Resident 170, with conditions such as a brain disorder, type 2 diabetes, and end-stage renal disease, was observed with extremely dry skin on his legs and feet. A physician's order required the application of a specific cream every evening, but the cream was not found in the treatment cart, and the Wound Nurse could not confirm if the treatment was completed as ordered. The Treatment Administration Record showed the treatment as completed, but the physical condition of the resident's skin indicated a lack of proper care.
Failure to Obtain Timely Catheter Orders and Care
Penalty
Summary
The facility failed to ensure timely orders for a Foley catheter and catheter care for a resident with an indwelling urinary catheter. Observations over several days revealed that the resident's Foley catheter was draining cloudy, yellow urine, and there was a persistent urine odor in the resident's room. Despite these observations, there was no documentation of catheter care being completed in the resident's records. The resident, who was cognitively impaired and had a history of dementia and a femur fracture, was admitted with an indwelling urinary catheter. The care plan included monitoring for signs of urinary tract infection, but there was no physician's order for catheter care upon admission. The President of Clinical Operations acknowledged that the resident should have had an order for the catheter and catheter care upon admission.
Failure to Monitor Weekly Weights for Underweight Resident
Penalty
Summary
The facility failed to complete weekly weights for a resident identified as underweight and at risk for malnutrition. Resident J, who was admitted with diagnoses including heart failure, dementia, hypertension, muscle weakness, and depression, was assessed as severely impaired in daily decision-making but had no impairment in upper and lower extremities and used a wheelchair. A Comprehensive Nutrition Assessment indicated the resident was underweight and not well-nourished, necessitating monitoring of weight, appetite, skin, labs, and fluid status. A physician's order required weekly weights to be taken every Sunday, but no weights were recorded after the admission weight on 10/7/2024. During an interview, the VP of clinical operations confirmed that the resident should have been weighed weekly.
Failure to Maintain and Monitor Peripheral IV Catheter
Penalty
Summary
The facility failed to ensure proper maintenance, monitoring, and assessment of a peripheral intravenous (IV) catheter for a resident, leading to a deficiency in hydration management. The resident, who had a history of major depressive disorder, heart disease, breast cancer, anemia, anxiety, and high blood pressure, was admitted with a diagnosis of dehydration. A physician ordered 0.9% normal saline to be administered via a peripheral IV, which was placed on the resident's right hand. However, there were no subsequent physician's orders to maintain the IV for saline flushes after the infusion was completed. Observations revealed that the IV was not monitored or assessed daily, and there was no documentation regarding the condition of the IV site after the infusion or when the IV was discontinued. The Chief Nursing Officer confirmed the lack of daily assessments and absence of orders for saline flushes. Additionally, the facility's Peripheral IV Management policy required monitoring for signs of infection and phlebitis, which was not adhered to in this case.
Failure in Dialysis Communication for a Resident
Penalty
Summary
The facility failed to ensure ongoing communication with the dialysis center for a resident requiring dialysis services. Resident 43, who was cognitively intact and had multiple diagnoses including diabetes, renal disease, and heart failure, was on a care plan that required dialysis due to end-stage renal disease. The care plan included interventions such as checking the permacath site daily and monitoring vital signs and labs. Physician's orders specified obtaining dialysis pre-weights and pre-vital signs on designated days and transporting the resident to dialysis sessions. However, the facility did not complete the necessary Dialysis Communication sheets for several dates, including 10/11, 10/14, 10/16, 10/18, 10/23, and 10/28/2024. These sheets were intended to document vital information such as the resident's last meal, medications given, and vital signs before and after dialysis sessions. Interviews with the General Manager and LPN 6 confirmed the oversight, with LPN 6 acknowledging that the dialysis binder should be filled out before the resident leaves for dialysis and upon their return.
Deficiency in Blood Pressure Monitoring for Two Residents
Penalty
Summary
The facility failed to ensure proper monitoring of medication regimens for two residents, leading to deficiencies in blood pressure monitoring. Resident H, who had diagnoses including surgical wound disruption, muscle weakness, and chronic respiratory failure, was prescribed Diltiazem HCl for hypertension. The care plan required blood pressure monitoring every shift, but documentation was missing for several dates in October 2024. The President of Clinical Operations confirmed the lack of documentation during an interview. Similarly, Resident D, with conditions such as anxiety, insomnia, hypertension, and atrial fibrillation, was prescribed midodrine for low blood pressure. The physician's orders required blood pressure monitoring every shift, but records showed incomplete documentation, with some days missing entirely and others only recorded once. Interviews with the DON and the President of Clinical Operations confirmed the monitoring should have been more frequent, and an LPN indicated that blood pressure should be checked with each midodrine dose.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, as evidenced by two errors observed during 34 opportunities for errors, resulting in a medication error rate of 5.88%. The first error involved Resident K, where an LPN administered an antibiotic, Unasyn, via a PICC line at 10:30 a.m., which was supposed to be administered at 8:00 a.m. according to the physician's order. The LPN acknowledged the delay, attributing it to being occupied with other tasks such as obtaining another resident's weight and administering pain medications. The second error involved Resident L, where an RN prepared and administered Vitamin C and Osteo Bi-flex but failed to administer Methylsulfonylmethane, despite documenting that it had been given. The RN admitted to the oversight, noting that the medication was not available in the drawer and that she needed to contact the pharmacy. These errors were identified during a complaint investigation related to Complaint IN00443841.
Deficiencies in Clinical Record Documentation and Physician Notification
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident receiving tube feeding. The resident, who had diagnoses including dementia, delusional disorder, and dysphagia, was on a care plan that required tube feeding due to resisting eating and malnutrition. However, the Medication Administration Record (MAR) for several months showed that the tube feeding start and stop times were not consistently documented as per the physician's orders. This lack of documentation was confirmed during an interview with the President of Clinical Operations. Additionally, the facility did not document physician notifications for blood sugar levels outside the prescribed parameters for two residents. One resident, who was cognitively intact and required assistance with daily activities, had a sliding insulin scale that was incorrectly documented, leading to missed physician notifications for blood sugar levels that were outside the specified range. The VP of Clinical Operations acknowledged that the incorrect sliding scale might have been transferred from hospital orders, and the nurses followed a different protocol that did not require notification for the recorded blood sugar levels. For another resident with multiple diagnoses including diabetes and heart failure, the facility failed to document physician notifications for blood sugar levels exceeding 400, as required by the physician's order. Despite the General Manager's acknowledgment of the issue, there was no documentation to confirm that the physician had been notified, although the President of Clinical Operations claimed that the physician was aware of the resident's condition. This lack of documentation highlights a failure in maintaining accurate medical records and ensuring proper communication with physicians regarding critical health parameters.
Inappropriate Antibiotic Use Due to Lack of Documentation
Penalty
Summary
The facility failed to promote antibiotic stewardship by ensuring the appropriate use of antibiotic therapy for a resident, leading to unnecessary medication administration. Resident 41, who was admitted with multiple diagnoses including major depressive disorder with severe psychotic symptoms, heart disease, and anxiety, was prescribed an antibiotic for a urinary tract infection (UTI) that was not confirmed by the McGeer Criteria. The resident's Minimum Data Set (MDS) assessment indicated moderate impairment in daily decision-making and frequent urinary incontinence. Despite the urinalysis and culture results showing no significant infection, the physician ordered Keflex, an antibiotic, based on symptoms of confusion and urinary frequency and urgency, which were not documented in the nursing notes. The Chief Nursing Officer (CNO) confirmed that the physician made a late entry justifying the continuation of the antibiotic due to the resident's symptoms, although there was no documentation supporting these symptoms in the nursing progress notes. The facility's failure to adhere to the McGeer Criteria for infections and the lack of documented symptoms led to the inappropriate use of antibiotics, highlighting a deficiency in the facility's antibiotic stewardship program.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to ensure that medications were administered as ordered for a resident, identified as Resident B, who was reviewed for unnecessary medications. Resident B had a range of diagnoses including pneumonia, sepsis, type 2 diabetes mellitus, end-stage renal disease, hypotension, heart failure, and dependence on renal dialysis. The resident's medication regimen included various medications such as pain relievers, anti-anxiety drugs, antidepressants, antibiotics, and medications for heart rhythm and blood pressure management. However, the Medication Administration Record (MAR) for July 2024 indicated that several medications were not administered on multiple dates and times, including essential medications like antibiotics and blood pressure treatments. Additionally, the facility did not adhere to the prescribed parameters for administering midodrine, a medication used to treat hypotension, as it was given when the resident's blood pressure readings were above the specified threshold. The Director of Nursing acknowledged that some medications were not administered as ordered, particularly for residents who went out for dialysis, and there was no documentation that the physician was notified of the missed medications for Resident B. This oversight was identified during the facility's preparation for an annual survey, and it was noted that there was no documentation to confirm that the medications were administered upon the resident's return from dialysis.
Medication Transcription Error Leads to Unnecessary Drug Administration
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was managed and monitored appropriately, leading to the administration of unnecessary medication. A resident, who was cognitively impaired and diagnosed with anxiety disorder, was readmitted to the facility with a hospital discharge medication list indicating alprazolam 0.5 mg to be given three times a day as needed for anxiety. However, due to a transcription error, the medication was entered as a scheduled order rather than PRN, resulting in the resident receiving alprazolam on a scheduled basis without documented evidence of anxiety or behaviors necessitating its use. The resident received four scheduled doses of alprazolam, which led to lethargy and a change in condition, prompting the family to request a hold on the medication and the resident's transfer to a hospital. The facility's investigation confirmed the error in the medication order entry, which contributed to the resident's lethargic state and altered mental status. The incident was reported to the Indiana Department of Health as a reportable incident.
Failure to Provide Ordered Wound Care
Penalty
Summary
The facility failed to provide necessary care and treatment for a resident with a non-pressure wound as ordered by a physician. The resident, who was cognitively intact and had a surgical wound on the right knee, was admitted with diagnoses including infection and inflammatory reaction of a right knee prosthesis, diabetes mellitus, and hypertension. A physician's order required daily cleansing of the right knee with normal saline, application of xeroform gauze, and a cover dressing. However, the treatment administration record lacked documentation of dressing changes on specific dates, and progress notes did not indicate whether the dressing was completed. The Director of Nursing confirmed the absence of documentation for the dressing changes on the specified dates.
Failure to Document Antibiotic Administration
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically related to missed doses of an antibiotic. Resident C, who was admitted with diagnoses including mechanical complication of vascular grafts, localized skin infection, and peripheral vascular disease, was prescribed meropenem intravenously every 8 hours for a wound infection. The medication administration record for May 2024 showed that the antibiotic was not documented as given on several occasions: twice on May 7, and once each on May 14, May 22, and May 28. There was no documentation in the progress notes explaining the missed doses. The care plan indicated that the resident was on antibiotic therapy and required the medication to be administered as ordered. During an interview, the Director of Nursing stated that four out of five nurses claimed to have administered the medication but failed to document it, which should have been done if the medication was given.
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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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