Ignite Medical Resort Crown Point Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Crown Point, Indiana.
- Location
- 1555 S Main Street, Crown Point, Indiana 46307
- CMS Provider Number
- 155835
- Inspections on file
- 31
- Latest survey
- September 9, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Ignite Medical Resort Crown Point Llc during CMS and state inspections, most recent first.
The facility did not follow professional standards for midline catheter care for three residents, including failures to document required flushing, assessments, and medication administration. Orders for dressing changes and flushes were missing or not followed, and there was a lack of documentation regarding catheter insertion, removal, and site assessments. Missed doses of IV antibiotics were not explained, and available medications were not administered as ordered.
A resident with severe cognitive impairment and a wound infection did not receive several scheduled doses of IV antibiotics due to unavailability, and there was no documentation that the physician or POA were notified of the missed doses, as required by facility policy.
Two residents requiring assistance with ADLs were not provided timely incontinent care or adequate bathing after episodes of significant urinary incontinence. Both were left in saturated briefs and wet linens for extended periods, and care provided did not include full cleansing of all urine-soaked areas, despite care plans and facility policy requiring regular checks and assistance.
Two residents with midline and PICC catheters did not receive care in accordance with professional standards, including a non-sterile dressing change by an LPN and lack of documentation for required dressing changes, flushes, and site assessments. The facility's own policies for sterile technique and timely interventions were not followed.
A resident with osteomyelitis and dementia did not receive scheduled IV antibiotic doses as ordered because the medication was not available from the pharmacy. Despite repeated notifications and reliance on the Emergency Drug Kit for initial doses, subsequent doses were missed due to delayed pharmacy delivery, contrary to the facility's daily delivery policy.
A resident with a Stage IV pressure ulcer and multiple diagnoses did not receive physician-ordered pre-albumin and CBC lab tests. The tests were ordered and sent to the lab, but were not completed, and no results or documentation were found in the medical record. The lab was unable to provide a reason for the missed testing.
Staff did not consistently use required PPE when providing high-contact care to two residents on Enhanced Barrier Precautions. In both cases, staff initially wore only gloves instead of both gowns and gloves as required by facility policy and care plans for residents with wounds or invasive lines. Proper PPE was only used after staff were reminded or noticed signage indicating EBP requirements.
A resident was found with medication at their bedside without the necessary physician's orders and assessments for self-administration. The facility's policy requires such orders and assessments, which were not present, leading to a deficiency in medication management.
A resident with acute medical conditions was transferred to the hospital without the required State-approved transfer form. The facility's policy to inform the resident and responsible party and prepare a transfer form was not followed, as confirmed by interviews with the DON and Administrator.
A facility failed to provide a resident and their Responsible Party with the bed-hold policy upon hospital transfer. The resident, who was cognitively intact, was transferred due to acute respiratory issues, but there was no documentation of the policy being communicated at the time of transfer. The facility's practice was to provide this information only at admission, not during each transfer.
A resident with a history of UTIs and other medical conditions was observed with her Foley catheter collection bag lying on the floor on two occasions. The A Unit Manager confirmed that staff should have placed the bag in a bath basin to prevent it from touching the floor. The resident's care plan included monitoring for UTIs, and she was receiving an antibiotic for sepsis.
A facility failed to follow up on dietary recommendations for a resident with a feeding tube. The RD suggested holding tube feedings and adding oral supplements, but there was no documentation that the NP was informed or that orders were updated. The resident's meal tray lacked the recommended supplements, and the A Unit Manager did not ensure the recommendations were implemented, contrary to facility policy.
A resident with a gastrostomy was observed receiving incorrect tube feeding flow rates, deviating from the physician's order of 65 ml/hr. The resident, with severe cognitive impairment and dependence on renal dialysis, was found with flow rates of 75 ml/hr and 45 ml/hr on different occasions. The error was confirmed by the C Unit Manager.
A facility failed to maintain a PICC for a resident by not changing the dressing as ordered. The resident, with diagnoses including dementia and asthma, was observed with a PICC dressing dated over two weeks old, despite a physician's order to change it weekly. An RN confirmed the dressing had not been changed since admission.
A facility failed to ensure proper infection control measures in an isolation room for a resident under contact and droplet precautions. An LPN was observed in the resident's room wearing only personal glasses and a surgical mask, without the required N95 mask, goggles or face shield, gown, or gloves. The resident had tested positive for coronavirus OC 43, necessitating strict isolation measures, which were not followed by the LPN.
A facility failed to administer medications as ordered for a resident undergoing dialysis, did not hold medication for another resident with low blood pressure, and inadequately monitored and treated a third resident's abdominal hernia and leg swelling. These deficiencies involved missed doses of critical medications, improper administration of hydralazine, and lack of care planning for lymphedema and hernia management.
A facility failed to provide timely access to medical records for three residents, resulting in a deficiency. A resident's POA requested records through a law firm, but only partial records were provided, and follow-up communications were ignored. Two other residents experienced delays in receiving their records, which were sent two weeks after the request, contrary to the facility's policy requiring records to be provided with two working days' notice.
A resident with a history of cancer and cognitive impairment alleged rough care by staff, but the facility failed to report this to the Administrator and IDOH within the required timeframe. The allegation was initially reported to the DON, who was on vacation, and the Administrator was not informed until later, resulting in a delay in reporting to the IDOH.
A facility failed to follow standard care practices during a g-tube medication administration. An LPN administered medications and a protein supplement through a resident's g-tube without confirming its placement. The LPN was unsure of the facility's policy for checking g-tube placement, which required confirmation by drawing back on the syringe for gastric content.
The facility inaccurately posted Nurse Staffing Information by including administrative nursing staff who did not provide direct resident care. Observations revealed discrepancies between the actual number of nurses and CNAs working and the posted staffing information. The ADON confirmed that administrative staff hours were included in the postings, contrary to CMS requirements.
The facility failed to maintain a sanitary kitchen, with issues including unlabeled and undated food, a build-up of ice in the freezer, and spills in the refrigerator and dry storage room. Cook 1 acknowledged the labeling issue and recent spills.
A resident with Diabetes Mellitus and a foot ulcer was observed with a soiled dressing on a skin tear, but there was no documentation or treatment order in place. The responsible nurse forgot to document the wound, and an LPN was unaware of the incident.
The facility failed to obtain a Physician's Order for a urinary catheter, complete catheter care, and record urinary output for a resident with type 2 diabetes, anemia, and dementia. Despite the resident having a urinary catheter since admission, there were no orders or documentation for catheter care or urine output, even though the resident was being treated for a UTI. The Director of Nursing confirmed the absence of necessary orders and documentation.
The facility failed to provide correct respiratory treatment for two residents. One resident received oxygen without a Physician's Order, and another had an incorrect oxygen flow rate despite having a PRN order for a different rate.
Failure to Follow Midline Catheter Care Standards and Documentation
Penalty
Summary
The facility failed to provide care for midline catheters in accordance with professional standards for three residents who required intravenous (IV) treatments. For one resident with a history of urinary tract infection and bladder cancer, there was a lack of documentation regarding the flushing of the midline catheter before and after medication administration, as well as after discontinuation of IV antibiotics. The medication administration record (MAR) did not show that flushes were performed as ordered, and there was no assessment or documentation of the IV line’s length or the condition of the catheter tip during dressing changes or after removal. The Director of Nursing (DON) acknowledged the absence of required documentation and orders related to flushing and assessments. Another resident with a urinary tract infection had a midline IV inserted for antibiotic treatment, but there were no physician’s orders for weekly dressing changes, site assessments, or normal saline flushes at the time of insertion. The MAR indicated that several doses of the prescribed antibiotic were not administered, and there was no documentation explaining the missed doses. Additionally, there was no record of who inserted the heparin lock or when the midline was placed. The DON confirmed that the medication was available in the emergency drug kit but was not used, and the physician was not notified about the missed doses. A third resident with rhabdomyolysis and peripheral vascular disease also experienced deficiencies in midline care. The MAR showed missed doses of prescribed antibiotics, and there was no documentation of the midline’s length or its discontinuation, nor was there an assessment of the site and line after removal. The facility’s central line care policy required physician orders for all treatments, documentation of line removal, and measurement of the line, but these standards were not met for the residents reviewed.
Failure to Notify Physician and POA of Missed Antibiotic Doses
Penalty
Summary
A resident with diagnoses including osteomyelitis of the left ankle/foot and dementia, and who had a family member designated as Power of Attorney (POA), was prescribed IV ampicillin-sulbactam every six hours for a wound infection. The Medication Administration Record (MAR) showed that the antibiotic was unavailable and not administered at four scheduled times over two days. There was no documentation indicating that the resident's physician or POA had been notified about the missed doses. During an interview, the Director of Nursing confirmed that both the physician and POA should have been notified of the missed medication. Facility policy required that such notifications be made and documented in the medical record, but this was not done.
Failure to Provide Timely and Adequate Incontinent Care and Bathing
Penalty
Summary
The facility failed to provide timely and adequate incontinent care and bathing for two residents who required assistance with activities of daily living (ADLs). In one instance, a resident with dementia, osteomyelitis, and a PICC line was observed lying in bed with saturated incontinence pads, wet linens, and a wet gown. The resident had not been checked for urinary incontinence since the CNA's shift began at 6 a.m. The resident's peri and buttocks areas were cleansed, but other urine-soaked areas such as the abdomen, back, arms, and legs were not washed before the resident was dressed in clean clothing and linens. The care plan indicated the resident required maximum assistance for bathing and toileting and should be checked for incontinence every 2-3 hours. Another resident with dementia was found in a room with a strong urine odor, lying in bed with damp covers, wet clothing, and a saturated incontinence brief. The incontinence pad under the resident had a large ring of drying urine. The CNA had not checked the resident for incontinence since starting work at 6 a.m. and indicated it had been a while since the resident was last checked. The resident received incontinence care with wipes and was changed into clean clothing, but the care plan required moderate assistance with toileting and bathing and checks for incontinence every 2-3 hours. Facility policy stated that incontinent residents should be changed every two hours and more frequently if needed.
Failure to Maintain Sterile Technique and Documentation for IV Catheter Care
Penalty
Summary
The facility failed to provide safe and appropriate care for midline and PICC catheters in accordance with professional standards of practice for two residents. For one resident with a PICC line in the left upper extremity, an LPN performed a dressing change using a process that was not fully sterile. The LPN touched non-sterile surfaces, such as her own hair and the resident's arm, while wearing sterile gloves, and did not cleanse her hands between glove changes. The resident's care plan indicated weekly dressing changes, but the observed process did not maintain sterility as required. For another resident with a midline IV catheter, there was no documentation of required dressing changes within 24 hours of insertion, nor evidence of regular flushing or assessment of the catheter site for infection or placement. The care plan called for weekly dressing changes and regular site monitoring, but there were no physician's orders for these interventions, and no documentation that they were performed. The facility's own policy required physician orders for treatments and dressing changes, as well as sterile technique and timely dressing changes, but these standards were not met for the residents involved.
Failure to Provide Timely IV Antibiotic Due to Pharmacy Delay
Penalty
Summary
The facility failed to provide a resident with an intravenous (IV) antibiotic in a timely manner as ordered by the physician. The resident, who had diagnoses including osteomyelitis of the left ankle/foot and dementia, was prescribed IV ampicillin-sulbactam every six hours for a wound infection. According to the Medication Administration Record (MAR), the first three doses were administered as ordered, but subsequent doses were missed because the medication was not available. Documentation showed that the antibiotic was not present in the Emergency Drug Kit (EDK), and the pharmacy was notified multiple times regarding the need for delivery. Despite repeated notifications to the pharmacy, the antibiotic was not delivered in time to prevent missed doses on several occasions. Progress notes indicated ongoing communication with the pharmacy and continued unavailability of the medication, resulting in the resident not receiving the prescribed antibiotic at the scheduled times. The facility's pharmacy delivery policy stated that medications and supplies would be delivered daily, but this was not adhered to in this instance, leading to the deficiency.
Failure to Complete Physician-Ordered Laboratory Tests
Penalty
Summary
The facility failed to ensure that a resident received laboratory services as ordered by the physician. A resident with a history of stroke and dementia had a Stage IV pressure ulcer on the coccyx, and a physician ordered pre-albumin and complete blood count (CBC) laboratory tests. Review of the medical record showed that the results of these tests were not present, and there was no documentation that the laboratory testing had been completed. During an interview, the wound nurse confirmed that the tests had been ordered and sent to the lab, but the lab did not complete the tests as scheduled and could not provide a reason for the failure.
Failure to Ensure Proper PPE Use During Enhanced Barrier Precautions
Penalty
Summary
Staff failed to use correct Personal Protective Equipment (PPE) when providing care to residents on Enhanced Barrier Precautions (EBP) during two separate observations. In the first instance, a resident with a PICC line, open wound, and incontinence was being cared for by an LPN and a CNA who initially wore only gloves and were unsure if EBP was required, as there was no sign on the door. After discussion, they realized EBP was needed due to the resident's wound and PICC line, and then donned gowns and changed gloves before continuing care. The resident's care plan specified that gowns and gloves were to be worn during high-contact care activities. In the second instance, two CNAs were observed providing a bed bath to a resident with a PICC line and a care plan requiring EBP. Although a sign indicating EBP was present on the door, both CNAs initially wore only gloves and believed EBP was not required. After reading the sign, they donned gowns over their uniforms. The facility's EBP policy required staff to wear gowns and gloves during high-contact care for residents with wounds or invasive lines, but this was not initially followed in either case.
Failure to Ensure Proper Orders for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident had the necessary physician's orders and assessments to self-administer medications. During an observation, a medication tablet was found on a resident's bedside table, which the resident identified as extra strength Tylenol. The resident stated that the nurse routinely left medications at the bedside for self-administration before therapy sessions. However, upon reviewing the resident's records, it was found that there were no self-administration assessments or physician's orders for the self-administration of Tylenol, despite the care plan indicating an order for self-administration of all medications. Interviews with the LPN and the Director of Nursing revealed that the most recent self-administration assessment did not include all of the resident's medications, and there was no order for self-administration of all medications. The facility's policy requires a physician's order and an assessment to determine a resident's ability to self-administer medications, which was not followed in this case. The Director of Nursing suggested that the order might have been overlooked when the resident was hospitalized, indicating a lapse in maintaining accurate and complete records for medication self-administration.
Failure to Provide Proper Notification and Documentation for Hospital Transfer
Penalty
Summary
The facility failed to ensure proper notification and documentation during the transfer of a resident to the hospital. The resident, who was cognitively intact and had diagnoses including acute kidney failure, pressure ulcer, and acute respiratory failure, was observed with tremors and difficulty breathing. Despite these symptoms, there was no documentation indicating that the State-approved transfer form was completed and sent with the resident when she was transferred to the hospital for medical evaluation. Interviews with the Director of Nursing and the Administrator revealed that while residents received a bed hold policy and transfer form at admission, the facility did not provide updated forms for each transfer. The facility's policy required informing the resident and their responsible party of the transfer and preparing a transfer form with a face sheet and medication list, which was not adhered to in this instance.
Failure to Provide Bed-Hold Policy Upon Hospital Transfer
Penalty
Summary
The facility failed to ensure that a resident and/or their Responsible Party were provided with the facility's bed-hold and reserve bed payment policy before and upon transfer to the hospital. This deficiency was identified for one of the four residents reviewed for hospitalization. The resident in question, who was cognitively intact for daily decision-making, was transferred to the hospital due to acute respiratory issues. Despite the transfer, there was no documentation indicating that the bed-hold policy was communicated to the resident or their Responsible Party at the time of the transfer. Interviews with the Director of Nursing and the Administrator revealed that the facility's practice was to provide the bed-hold policy and transfer form only at the time of admission, and not at each subsequent transfer. This oversight resulted in the resident and their Responsible Party not being informed of the bed-hold policy during the hospital transfer, which is a requirement to ensure residents and their families are aware of their rights and responsibilities regarding bed reservation during absences.
Improper Foley Catheter Care for a Resident
Penalty
Summary
The facility failed to ensure proper care for a resident with an indwelling Foley catheter, as the catheter collection bag was observed lying on the floor on two separate occasions. Resident 160, who has a history of urinary tract infections and other medical conditions such as anxiety, cerebral palsy, chronic kidney disease, and hypertension, was seen with her catheter bag touching the floor while sitting in a wheelchair and a recliner. The A Unit Manager acknowledged that staff should have placed the catheter bag in a bath basin to prevent it from touching the floor. The resident's care plan included monitoring and reporting signs of a urinary tract infection, and the resident was receiving an antibiotic for sepsis as per the physician's order summary.
Failure to Implement Dietary Recommendations for Resident with Feeding Tube
Penalty
Summary
The facility failed to ensure timely follow-up on dietary recommendations for a resident with a feeding tube. Resident 46, who was moderately cognitively impaired and had a feeding tube, was observed to have a potential alteration in nutrition and hydration. The Registered Dietician (RD) recommended placing the tube feedings on hold and adding oral supplements, including Med Pass and Magic Cup, to ensure adequate intake. However, there was no documentation indicating that the Nurse Practitioner (NP) was notified of these recommendations, nor were there any progress notes or physician's orders addressing them. On observation, the resident's lunch tray did not include the recommended Magic Cup, and the meal ticket did not list it. The A Unit Manager acknowledged receiving the RD's recommendations and sending them to the physician's office but did not follow up in person with the NP or ensure the recommendations were implemented. The facility's policy required nurses to inform physicians of dietician consults and document them in resident records, which was not adhered to in this case.
Incorrect Tube Feeding Flow Rate for Resident with Gastrostomy
Penalty
Summary
The facility failed to ensure that a resident with a gastrostomy received the appropriate treatment related to the flow rate of tube feeding. The resident, who was admitted with diagnoses including dependence on renal dialysis, unspecified dementia, and gastrostomy, was observed on multiple occasions with incorrect tube feeding flow rates. On one occasion, the flow rate was set at 75 ml/hr, and on another, it was set at 45 ml/hr, both of which deviated from the physician's order of 65 ml/hr. The resident's Admission Minimum Data Set assessment indicated severe cognitive impairment and the need for tube feedings. The discrepancy in the flow rate was confirmed during an interview with the C Unit Manager, who acknowledged the error and indicated the correct rate should be 65 ml/hr.
Failure to Change PICC Dressing as Ordered
Penalty
Summary
The facility failed to maintain a peripheral inserted central catheter (PICC) for a resident, identified as Resident 116, by not changing the dressing as ordered. On January 6, 2025, Resident 116 was observed with a PICC in the right upper arm, with a dressing dated December 23, 2024. The resident's medical record indicated a physician's order from December 25, 2024, to change the PICC dressing every seven days on Saturday. However, the January 2025 Medication Administration Record showed the dressing was last changed on January 4, 2025, indicating a lapse in following the prescribed schedule. During an interview, RN 4 confirmed that the dressing had not been changed since the resident's admission, despite the order to do so weekly. Resident 116 had diagnoses including unspecified dementia, asthma, and gout, and was noted to have moderate cognitive impairment and dependency on staff for transfers.
Inadequate PPE Use in Isolation Room
Penalty
Summary
The facility failed to maintain proper infection control measures in an isolation room for a resident under contact and droplet precautions. On January 7, 2025, Resident 125 was observed in her room with isolation signs indicating the need for an N95 or approved KN95 respiratory mask, goggles or a face shield, gown, and gloves. However, on January 8, 2025, an LPN was seen in the resident's room wearing only personal glasses and a surgical mask, without the required N95 mask, goggles or face shield, gown, or gloves. The LPN was unaware that the resident had tested positive for a coronavirus, which necessitated strict isolation measures. Resident 125's medical record indicated diagnoses of heart failure, acute and chronic respiratory failure, and hypothyroidism. The resident was cognitively intact and required supervision for certain activities. A health status note from January 3, 2025, confirmed the resident tested positive for coronavirus OC 43, a virus transmitted via respiratory excretion, leading to the implementation of strict droplet isolation. Despite a negative COVID-19 test, the resident remained in isolation to prevent virus transmission. The facility's infection control policy required droplet and contact precautions, including wearing a mask, gloves, and gown when entering the room, which were not adhered to by the LPN.
Medication and Monitoring Deficiencies in Resident Care
Penalty
Summary
The facility failed to ensure that a resident received medications as ordered, particularly for a resident undergoing dialysis. Resident C, who was dependent on renal dialysis and had severe cognitive impairment, missed several doses of critical medications, including doxycycline, carvedilol, and eopetin alfa injection, on multiple occasions due to being out of the facility for dialysis. The C Unit Manager acknowledged the issue and indicated that medications should be rescheduled if they coincide with dialysis times. Resident B, who was cognitively intact and diagnosed with type 2 diabetes mellitus, high blood pressure, and chronic kidney disease, received hydralazine despite having a systolic blood pressure below the ordered threshold of 130. This occurred on several occasions, as documented in the Medication Administration Record, indicating a failure to adhere to the physician's order to hold the medication under certain conditions. Resident D, who had lymphedema and heart failure, was not properly assessed or monitored for an abdominal hernia, and there was a lack of treatment for leg swelling. The resident reported discomfort from the hernia and noted that her legs were not wrapped as required for her lymphedema. Observations confirmed the absence of wraps and the presence of swelling. The facility's records lacked a care plan for the hernia and orders for ace wraps, highlighting a gap in the resident's care management.
Delayed Provision of Medical Records to Residents
Penalty
Summary
The facility failed to provide timely access to medical records for three residents, leading to a deficiency. Resident B's medical records were requested by a law firm on behalf of the resident's Power of Attorney (POA) but were not fully provided. The facility's Administrator was unaware of the request until a letter from the law firm was received, which had been delayed in reaching the appropriate personnel. The former Medical Records Coordinator (MRC) did not recall receiving the request, and the Corporate MRC had not approved the release of the full record. The facility's process for handling medical record requests was disrupted due to a change in personnel, resulting in the law firm receiving only partial records with duplicates and no response to their follow-up communications. Residents C and D also experienced delays in receiving their requested medical records. Both residents requested their complete medical records on the same date, but the records were not sent until two weeks later. The facility's policy required that records be provided upon request with two working days' notice, which was not adhered to in these cases. The deficiency was related to a complaint, indicating a systemic issue in the facility's process for managing medical record requests.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident, identified as Resident E, to the Administrator and the Indiana Department of Health (IDOH) within the required two-hour timeframe. The incident involved Resident E alleging that staff were rough during care. This allegation was reported by an LPN to the Director of Nursing (DON), who was on vacation at the time. However, the Administrator was not informed of the allegation until a later date, and there was no documentation of the incident being reported to the IDOH until the Administrator became aware of it. Resident E, who had a medical history including malignant cancer of the breast and uterus, was assessed to have a moderately impaired cognitive status and required varying levels of assistance for daily activities. Despite the resident's allegation, there was no documentation in the Nurses' Progress notes indicating that the allegation was voiced. The facility's abuse policy mandates immediate reporting of such allegations to the Administrator and the IDOH, which was not adhered to in this case.
Failure to Confirm G-Tube Placement Before Medication Administration
Penalty
Summary
The facility failed to ensure standard practice of care during a gastrostomy (g-tube) medication administration for a resident. During an observation, an LPN administered medications and a protein supplement through the resident's g-tube without confirming the placement of the tube beforehand. The LPN was unsure of the facility's policy for confirming g-tube placement, despite having worked in other facilities. The facility's policy, dated March 2023, required that the placement of the g-tube be confirmed by gently drawing back on the piston of the syringe for gastric content before administering medications.
Inaccurate Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the posted Nurse Staffing Information accurately reflected only the staff providing direct resident care. During observations, it was noted that the number of nurses and CNAs working did not match the posted staffing information. Specifically, the posted hours included administrative nursing staff, such as the Director of Nursing, the Assistant Director of Nursing, and the MDS assessment nurse, who did not provide continual direct resident care. This discrepancy was confirmed during an interview with the ADON, who acknowledged that the administrative staff hours were included in the posted information, contrary to the CMS Staffing Data Report requirements, which only account for direct care providers. This issue was identified during a review of nursing schedules and posted hours for specific periods in May, June, and July 2024.
Sanitary Kitchen Deficiency
Penalty
Summary
The facility failed to maintain a sanitary kitchen, as observed during an initial kitchen tour. In the walk-in refrigerator, boxes of soda and pies were found sitting directly on the floor, and a package of raw meat, gravy in a plastic container, and mashed potatoes were unlabeled and undated. Additionally, a raw potato and a pink substance were spilled on the refrigerator floor. In the freezer, there was a heavy build-up of ice on the ceiling and on two boxes of food. The dry storage room had a large amount of dry oatmeal spilled on the shelves and floor. Cook 1 acknowledged that the items should be labeled and dated and indicated that the spills had occurred recently while staff were busy preparing breakfast.
Failure to Document and Treat Resident's Skin Tear
Penalty
Summary
The facility failed to ensure that a resident received the necessary care and treatment for a skin tear. On 4/1/24, Resident 31 was observed with a dressing on his right elbow that was coming loose and soiled with blood. The resident indicated he had bumped his elbow that morning, resulting in a skin tear. A review of Resident 31's record on 4/2/24 revealed no documentation or assessment of the skin tear and no Physician's Order for treatment. The resident's diagnoses included Diabetes Mellitus and a foot ulcer, and he required extensive staff assistance for transfers and toileting. During interviews, an LPN was unaware of the incident, and the Unit Manager confirmed that the nurse responsible had forgotten to document the wound and there was no treatment order in place.
Failure to Obtain Physician's Order and Document Catheter Care
Penalty
Summary
The facility failed to ensure a Physician's Order was obtained for a urinary catheter, catheter care was completed, and urinary output was recorded for Resident 105. The resident, who had diagnoses including type 2 diabetes mellitus, anemia, and dementia, was admitted to the facility with a urinary catheter. Despite the Care Plan and Admission Nursing Evaluation indicating the presence of a urinary catheter, the Physician's Order Summary lacked any orders for the urinary catheter, catheter care, or urine output recording. Additionally, the Medication Administration Records and Treatment Administration Records for March and April 2024 did not document any catheter care or urine output, even though the resident was receiving antibiotic treatment for a urinary tract infection (UTI). Observations on 4/1/24 and 4/3/24 confirmed the presence of the urinary catheter, and the Bladder Continence Task documentation showed that urine output had only been recorded once since the resident's admission. During an interview, the Director of Nursing acknowledged the absence of orders in the computer for the urinary catheter, catheter care, or urine output recording. This deficiency highlights the facility's failure to follow proper protocols for managing a resident with a urinary catheter, leading to inadequate care and monitoring of the resident's condition.
Failure to Ensure Correct Respiratory Treatment
Penalty
Summary
The facility failed to ensure residents received the correct and necessary respiratory treatment. Resident 258 was observed with a nasal cannula in place with oxygen flowing at 2.5 liters per minute, but there was no Physician's Order for the oxygen. The resident's record indicated diagnoses including acute kidney failure, Diabetes Mellitus, and congestive heart failure. The Unit Manager confirmed there was no Physician's Order for the oxygen during an interview. Resident 3 was observed multiple times with oxygen flowing at 2.5 liters per minute via a nasal cannula. The resident's record indicated diagnoses including depression, chronic obstructive pulmonary disease (COPD), and asthma. The Care Plan indicated the resident should have oxygen therapy at 3 liters per nasal cannula PRN, and the April 2024 Physician's Order Summary confirmed this. The Director of Nursing indicated the resident's oxygen was a PRN order and should have been set at 3 liters when required.
Latest citations in Indiana
Surveyors observed that dietary staff repeatedly worked in kitchen and meal service areas with uncovered facial hair, despite facility policy and state sanitation requirements mandating effective hair restraints. Two dietary aides with short beards or mustaches were seen walking through food preparation areas, taking food temperatures, handling food, and plating meals at steamtables in dining rooms without any facial hair coverings, while the current policy required all hair, including facial hair, to be restrained to prevent contamination.
The facility failed to consistently provide and document required bed-hold policy notices when several residents were transferred to the hospital. In multiple cases, residents with dementia, psychotic disorders, COPD, chronic respiratory failure, altered mental status, and cerebral infarction were sent out for acute changes in condition, and while transfer notes reflected physician and family notifications, they lacked documentation that the bed-hold policy was discussed with the resident or responsible party. Notices of Transfer or Discharge often indicated a copy of the bed-hold policy was sent with the resident, but the records did not show signed and dated acknowledgment by the resident or appropriate representative, including in situations where a resident had moderate cognitive impairment, short-term memory issues, or a documented need for a proxy and a financial POA authorizing an agent for health care decisions.
Surveyors found that the facility failed to provide trauma‑informed and culturally competent care by not incorporating two residents’ extensive trauma histories and specific behavioral triggers into their care plans. One resident with documented homelessness, polysubstance abuse, severe accidents with multiple fractures, viral encephalitis with coma, physical and sexual abuse, loss of family contact, and a past suicide attempt had multiple behavior‑focused care plans that referenced identifying triggers but listed none and did not mention their physical, sexual, medical, or psychosocial trauma. Another resident with TBI from being struck by a truck, an 11‑month coma, long‑term state hospital residence, alleged shooting of a parent, and diagnoses including intermittent explosive disorder and borderline personality disorder had a PASRR identifying a specific trigger and notes of inappropriate sexual behavior, yet their care plans omitted these traumatic events, the identified trigger, and the sexual behavior. Staff interviews confirmed that residents were screened for trauma, but the trauma histories and triggers were not reflected in the individualized plans of care.
A resident with schizophrenia, post‑stroke hemiparesis, and mild cognitive impairment expressed feeling down and wanting to kill himself, but staff did not document asking about a specific plan, did not notify the physician or psychiatric NP as expected, and did not develop or update a care plan addressing depression or suicidal ideation. The SSD documented offering support and initiating 15‑minute checks once, but there was no further follow‑up or documentation of interventions after subsequent suicidal statements made in a care plan meeting with the resident’s father. The DON and Administrator reported that facility policy requires immediate notification of key staff, assessment for a plan and means of self‑harm, and thorough documentation, which were not carried out or reflected in the medical record for this resident.
A resident with schizophrenia, post-stroke hemiparesis, and mild cognitive impairment verbalized suicidal ideation, but the care plan did not address depression or suicidal thoughts, and required assessments and services were not accurately or timely documented. An SSD note recorded the resident saying he wanted to kill himself and referenced 15‑minute checks and a care plan update, yet the active care plan lacked depression/suicidal ideation interventions. Multiple late-entry Social Services notes were later added, describing follow-up visits and the resident denying suicidal ideation, but the SSD later reported she did not typically ask about a suicide plan and did not personally provide individual follow-up visits as described. These practices conflicted with the facility’s policy requiring factual, first-hand, and timely documentation of assessments and services.
A resident was observed with an Albuterol inhaler on an overbed table and later reported keeping the inhaler in a nightstand drawer, with no staff present during these observations. Record review showed the resident had no cognitive impairment on the admission MDS but lacked any documented self-medication administration assessment. The DON acknowledged that the required assessment had not been completed, despite facility policy requiring staff and the practitioner to evaluate each resident’s mental and physical abilities before allowing self-administration of medications.
Surveyors found that the facility submitted inaccurate direct care staffing data to CMS through the PBJ system over multiple days in a quarter. CASPER reports showed apparent gaps in 24-hour licensed nurse coverage, low weekend staffing, and a 1-star staffing rating, while internal staffing sheets documented that licensed nurses were present and the facility was fully staffed on those days. The Administrator reported that the discrepancies were due to PBJ data entry errors, despite a facility policy requiring all PBJ entries to be accurate, auditable, and verifiable against payroll, invoices, or contracts.
Surveyors found that the facility did not provide or document required written transfer/discharge notices and bed-hold policy information for four residents who were sent to the hospital, including individuals with conditions such as dementia, CHF, chronic respiratory failure, and CKD. In each case, progress notes showed that the resident was transferred for acute issues, but the clinical records lacked evidence that written notices were given to the residents or their representatives, and in one case lacked documentation that required information was sent to the receiving provider. Facility leadership, including the ADON, DON, and Administrator, acknowledged that the records did not contain the required documentation, despite a written policy requiring such notices and information exchange.
A resident with Alzheimer’s disease and depression, previously on an antidepressant, exhibited intermittent refusals of medications and care, occasional yelling at staff, and reports of unusual perceptions, such as believing men were in or near her room. Nursing notes over several months documented these refusals and complaints but did not show that the behaviors were evaluated or recorded as dangerous, non-redirectable, or causing significant distress, nor did they document specific non-pharmacological interventions attempted or their outcomes. Despite this, a psychiatric NP later added new diagnoses of schizoaffective disorder, borderline personality disorder, and delusional disorder and ordered an antipsychotic (Seroquel) without a comprehensive evaluation in the record to support these diagnoses. The facility’s psychotropic medication policy, which requires identification and documentation of target behaviors, use of nonpharmacological interventions, and ongoing behavior monitoring, was not followed for this resident.
The facility failed to keep PASARR Level I screenings accurate and current for three residents when new mental health diagnoses and psychoactive medications were initiated. One resident’s PASARR omitted a PTSD diagnosis and an added antidepressant, despite documentation of PTSD on the MDS and care plan and a physician order for Pristiq. Another resident’s PASARR listed only depression and dementia, even after additional diagnoses such as borderline personality disorder, delusional disorder, and schizoaffective disorder were added and an antipsychotic (quetiapine) was ordered, with the MDS later reflecting psychotic disorder, schizophrenia, and depression with antipsychotic and antidepressant use. A third resident’s PASARR did not include a depression diagnosis or newly ordered escitalopram and lorazepam, although the admission MDS documented depression with antianxiety and antidepressant use. These omissions occurred despite facility policy requiring a new Level I review after significant mental status changes, including new mental health diagnoses or new psychotropic medications.
Uncovered Facial Hair During Food Preparation and Meal Service
Penalty
Summary
The deficiency involves the facility’s failure to ensure that food was served in a sanitary and safe manner in accordance with professional standards and facility policy during multiple kitchen and meal service observations. During an initial kitchen observation, two dietary aides were seen walking through the kitchen food preparation area with uncovered facial hair. One aide had facial hair above and below the lip and along the jaw line, approximately one-fourth inch in length, and the other had a mustache of similar length; neither used any facial hair covering. These observations occurred while staff were present in the kitchen area where food was stored and prepared. During subsequent observations on the same day, the same two dietary aides were again observed with uncovered facial hair while directly involved in meal preparation and service. One aide walked through the kitchen while the noon meal was being prepared and placed into a transport cart for service in the south dining room, and later was observed plating the noon meal at the steamtable in that dining room, still without a facial hair covering. The other aide walked through the kitchen while the noon meal was being prepared and placed into the steamtable for the north dining room, took food temperatures, assisted with plating meals at the steamtable, and retrieved food items and supplies from the kitchen, all while having an uncovered mustache approximately one-fourth inch in length. The Dietary Manager stated that staff hair was to be covered when in the kitchen and during meal service, and the facility’s written policy and the cited Indiana Food Establishment Sanitation Requirements both required effective hair restraints, including for facial hair, to prevent contamination of food, equipment, and utensils.
Failure to Provide and Document Bed-Hold Policy at Time of Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure that required bed-hold policy information was provided and documented for four residents transferred to the hospital. For a resident with dementia, psychotic disorder, and autistic disorder who had a BIMS score of 0 indicating severe cognitive impairment, progress notes documented physician notification and guardian notification when the resident was sent to the hospital, but there was no documentation that the bed-hold policy was provided to the responsible party. A Notice of Transfer or Discharge later indicated a copy of the bed-hold policy was sent with the resident. Another resident with COPD and chronic respiratory failure, cognitively intact with a BIMS score of 13, experienced a decline in condition and was transferred to the hospital by ambulance; progress notes documented family notification but did not document any discussion of the bed-hold policy, although a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident. A third resident with altered mental status and cerebral infarction, with a BIMS score of 10 indicating moderate cognitive impairment and documented short-term memory impairment, experienced changes in condition and was transferred to the hospital. Progress notes stated the resident was their own responsible party and that no other notification was completed, and transfer documentation did not include the bed-hold policy, although an untimed Notice of Transfer or Discharge indicated a copy of the bed-hold policy was signed by the resident. A financial power of attorney document in the record showed the resident had designated an agent to act in consent or refusal of health care. For a fourth resident with dementia and osteomyelitis, transfer documentation and a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident, and the transfer form noted the resident required a proxy for decision making. The facility’s policy required that at the time of transfer to a hospital, written notice specifying the duration of the bed-hold policy and information on return to the next available bed be provided, and that a signed and dated copy of the bed-hold notice given to the resident or representative be kept in the resident file, which was not consistently documented for these residents.
Failure to Integrate Trauma Histories and Behavioral Triggers Into Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to identify and incorporate residents’ trauma histories and specific behavioral triggers into their care plans, despite documented histories of significant trauma and behavioral health issues. For one resident, extensive social service and progress notes documented homelessness, polysubstance abuse, major depressive and anxiety disorders, chronic pain, a history of severe car accidents with multiple fractures, viral encephalitis resulting in a three‑month coma, loss of child custody, multiple divorces, physical abuse by a spouse, the death of a fiancé who was struck by a car while in a wheelchair, lack of family contact, and a past suicide attempt by Valium overdose. Additional documentation noted a history of rape by a brother at age eight and prior placement under direct supervision and 15‑minute checks related to suicidal ideation. Despite these documented traumatic events and behavioral health concerns, the resident’s care plans did not identify a history of physical trauma, sexual trauma, homelessness, substance abuse, medical trauma, or attempted suicide. For this same resident, the MDS showed no cognitive deficit and identified behaviors such as verbal aggression and rejection of care, along with diagnoses including seizure disorder, depression, chronic pain syndrome, homelessness, and anxiety disorder. Multiple care plans addressed behaviors such as drug‑seeking, pretending to have seizures for attention or medication, making false allegations, verbal aggression when unable to smoke, and a desire for intimate relationships with consenting male residents. These care plans referenced goals such as effective coping skills, seeking staff support, and compliance with the smoking policy, and they called for identification and reduction of behavioral triggers. However, none of these care plans actually listed any specific triggers. The care plan addressing the resident’s right to consensual intimate relationships focused on assessment and education regarding consent but did not integrate the resident’s extensive trauma history. Staff interviews indicated the resident had displayed sexual behaviors since admission, including an incident where the resident expressed anger at another resident for not buying a soda after engaging in sexual acts. A second resident with a documented history of traumatic brain injury (TBI), dementia, seizure disorder, borderline personality disorder, anxiety, intermittent explosive disorder, tobacco use, and other behavioral/emotional disorders was also affected by the same deficiency. Social history and progress notes documented that this resident sustained a TBI after being hit by a semi‑truck while riding a bicycle at age 18, resulting in an 11‑month coma, followed by 13 years in a state hospital and subsequent residence in a group home. Additional documentation indicated the resident allegedly shot their father at age 26 after being sworn at and had a PASRR identifying TBI, intermittent explosive disorder, and borderline personality disorder, with a specific trigger of hearing the name of the current U.S. President. Progress notes also described inappropriate sexual behavior toward staff, including touching themselves intimately during personal care and refusing to stop when redirected. Despite this, the resident’s care plans, which addressed explosive disorder and history of altercations, risk for decreased psychosocial well‑being, and refusal to bathe or shower, did not list any specific behavioral triggers, did not reference the traumatic events such as being hit by a truck or shooting their father, and did not document the inappropriate sexual behavior. The Administrator and Social Service Director acknowledged that residents were to be screened for trauma and that trauma responses and PTSD should be added to care plans, but the specific trauma histories and triggers for these two residents were not incorporated into their plans of care.
Failure to Assess and Care Plan for Resident Suicidal Ideation
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess, investigate, and care plan for a resident’s suicidal ideation in accordance with its own policy and staff expectations. The resident had diagnoses including schizophrenia, cerebral edema, and hemiparesis/hemiplegia following a cerebral infarction, and a current MDS showed mild cognitive impairment (BIMS score 12). A progress note documented that the resident told the Social Services Director (SSD) he was feeling down and wanted to kill himself; the SSD offered assistance, activities, and initiated 15‑minute checks, and the note stated the care plan was updated. However, the note did not indicate that the SSD asked whether the resident had a plan to kill himself, and there were no additional notes regarding suicidal ideation or follow‑up. Review of the current care plan showed no problem, goal, or interventions addressing depression or suicidal ideation, and progress notes over the following month contained no documentation of physician notification related to the suicidal statement. Further record and interview evidence showed that the care plan conference summary did not document interventions for suicidal ideation, and the SSD acknowledged she did not normally ask residents expressing suicidal ideation if they had a plan. The SSD reported that the resident had admission paperwork mentioning suicidal ideation related to depression after a stroke and that the resident again vocalized suicidal ideation during a care plan meeting with his father, after which emotional support was offered and the father took the resident out on a leave of absence; no further visits or follow‑up were done. The DON stated that, upon notification of suicidal verbalization, staff should assess the resident, ask if there is a plan, remove potential means of self‑harm, immediately notify the psychiatric NP, and document the occurrence, and that a detailed progress note and updated care plan were expected but not present for this resident. The Administrator similarly stated that staff should ask about a plan, document interventions, notify the physician and family, and update the care plan, and indicated the resident should have had a care plan addressing depression with suicidal ideation. The facility’s written policy required immediate notification of the DON, SSD, and physician, an interview including asking about a plan and assessing mood and means for self‑harm, and thorough documentation of mood, behavior, and all actions taken, which were not reflected in the resident’s record.
Incomplete and Inaccurate Documentation of Suicidal Ideation and Follow-Up
Penalty
Summary
The facility failed to ensure accurate, complete, and timely documentation of assessments and services for a resident who verbalized suicidal ideation. Resident 6, who had schizophrenia, cerebral edema, and right-sided hemiparesis/hemiplegia following a cerebral infarction, had a BIMS score of 12 indicating mild cognitive impairment. The resident’s admission paperwork mentioned suicidal ideation related to depression after a stroke, and a Social Services note on 3/11/2026 documented that the resident was feeling down and said he wanted to kill himself. The Social Services Director (SSD) documented that she talked with the resident, coordinated with Activities, advised the resident to contact SSD or nursing if he wanted to talk, and that the resident was scheduled for 15-minute checks and the care plan was updated. However, the current care plan initiated on 2/26/2026 did not address depression or suicidal ideation. Multiple Social Services progress notes were later entered as late entries in April, with effective dates in March, stating that the resident had no plan and no longer had suicidal ideation, that he felt much better after 1:1 time, and that he continued his daily routine and therapy. These late entries described follow-up visits and reassessments of suicidal ideation on several consecutive days, but in interviews the SSD stated she did not normally ask residents about having a plan when they verbalized suicidal ideation and did not recall any other occurrences beyond the initial event. She further indicated she did not personally provide individual follow-up visits with this resident regarding suicidal ideation, despite the late-entry notes describing such visits. The DON acknowledged that late entries had been added to address concern about suicidal verbalization, and the Administrator stated that upon suicidal statements staff should ask about a plan, notify the physician and family, and update the care plan, and that this resident should have had a care plan addressing depression with suicidal ideation. The facility’s documentation policy required factual, first-hand, timely documentation, which was not followed in this case.
Failure to Complete Required Self-Administration Assessment for Inhaler Kept at Bedside
Penalty
Summary
Surveyors identified that a resident was allowed to keep and access an Albuterol inhaler without the facility completing the required self-administration medication assessment. During an initial tour, the resident was observed sitting in a wheelchair with a handheld Albuterol inhaler on the overbed table and no staff present in the room or hallway. On a subsequent observation, the resident again was in a wheelchair and reported that the Albuterol inhaler was stored in the top drawer of the nightstand, where it was found. Review of the clinical record showed an admission MDS indicating no cognitive impairment, but there was no documentation of a self-medication administration assessment. In an interview, the DON confirmed that the resident did not have the required self-medication assessment, despite the facility’s policy stating that staff and the practitioner must assess each resident’s mental and physical abilities to determine whether self-administering medications is clinically appropriate. This failure to complete and document a self-administration medication assessment for a resident who had an Albuterol inhaler kept at bedside constituted noncompliance with the facility’s own policy and with 410 IAC 16.2-3.1-11(a).
Inaccurate PBJ Staffing Data Submission to CMS
Penalty
Summary
The deficiency involves the facility’s failure to electronically submit complete and accurate direct care staffing information to CMS through the Payroll-Based Journal (PBJ) system for 22 days in a fiscal quarter. A CASPER report review on 4/6/26 showed that, according to PBJ data, the facility did not have licensed nursing coverage 24 hours per day on multiple specific dates across three months, had low weekend staffing, and held a 1-star staffing rating. However, review of the facility’s internal staffing sheets for that quarter indicated the facility was fully staffed and had licensed nurse coverage on all of the dates in question. During an interview, the Administrator stated that the PBJ information must have contained data entry errors, as she had verified licensed staff coverage on the timesheets. The facility’s PBJ policy in effect stated that all staffing data entered into the PBJ system would be auditable and verifiable through payroll, invoices, or contracts, but the submitted PBJ data did not accurately reflect the facility’s actual licensed nurse staffing as documented on internal records. No specific residents or clinical conditions were mentioned in the report, and the deficiency centers solely on inaccurate staffing data submission rather than direct resident care events.
Failure to Provide and Document Required Transfer/Discharge and Bed-Hold Notices
Penalty
Summary
The deficiency involves the facility’s failure to provide and document required written notices of transfer/discharge and bed-hold policies, as well as required information to receiving providers, for four residents who were transferred or discharged to the hospital. For a resident with generalized anxiety disorder, major depressive disorder, and dementia, progress notes showed that the resident was sent to the hospital via 911 for chest pain, lower back pain, and shortness of breath and later returned to the facility, but the clinical record lacked documentation that a written Notice of Transfer/Discharge and the bed-hold policy were provided to the resident or representative, and lacked documentation that required information was conveyed to the receiving facility. The ADON and the Administrator both confirmed there was no documentation that these written notices were provided. For a resident with congestive heart failure and muscle weakness who was sent to the emergency room for painful urination and bloody urine, the clinical record lacked documentation that a Notice of Transfer/Discharge or bed-hold policy was given to the resident or representative, which the DON confirmed. Another resident with chronic respiratory failure and diabetes was discharged to the hospital for respiratory failure, and a resident with chronic kidney disease and dementia was discharged to the hospital, but in both cases there was no documentation that a written notice of transfer/discharge or bed-hold policy was provided to the residents or their representatives. Review of the facility’s Transfer and Discharge policy, dated 1/15/26, showed that the policy required the facility to provide written transfer/discharge notices and bed-hold information to residents and representatives and to provide specified information to receiving providers, but the records for these four residents did not contain the required documentation.
Failure to Document Target Behaviors and Non-Pharmacological Interventions Before Initiating Antipsychotic
Penalty
Summary
The deficiency involves the facility’s failure to document how a resident’s behaviors presented danger or distress to self or others, and failure to document non-pharmacological interventions attempted prior to initiating an antipsychotic medication. Resident 6 had documented diagnoses of Alzheimer’s disease, depression, and severe cognitive impairment, and was receiving sertraline for depression. A PASSAR identified only depression and dementia, and the admission MDS listed Alzheimer’s disease and depression as active diagnoses. Over several months, nursing progress notes documented that the resident intermittently reported unusual perceptions, such as believing there were men causing trouble, a man in her room, or a man wanting to marry her and yelling through the walls, but there was no documentation that these episodes caused danger to the resident or others or that they resulted in unmanageable distress. From late April through mid-July, nursing notes primarily described the resident’s frequent refusals of evening and morning medications, blood sugar checks, blood pressure checks, insulin administration, hygiene care, and showers. Staff documented that the resident sometimes yelled at staff, said “Get out!”, was visibly upset by a room move, was leery of staff and asked to see name badges, and became upset about a pillow under her head until it was removed, after which she calmed down. The notes also recorded instances where the resident believed housekeeping had not cleaned her room or that she had not received medications when she had. However, there were no progress notes or assessments indicating that these behaviors were evaluated as dangerous, non-redirectable, or causing significant distress or functional impairment, and no detailed behavior monitoring logs were present as required by facility policy. On a psychiatric NP visit for initial psychotropic medication management, new mental health diagnoses of schizoaffective disorder, borderline personality disorder, and delusional disorder were added, and Seroquel 25 mg, an antipsychotic, was ordered. The clinical record did not contain a comprehensive evaluation to support these new diagnoses, and there was no documentation of target behaviors meeting the facility’s policy criteria for psychotropic use, such as behaviors representing danger to self or others, causing distress and impairment in functional abilities, or clearly attributable to psychosis or mania. The resident’s representative reported that the resident had no prior history of mental health disorders or psychiatric hospitalization and was unaware of the new diagnoses. The facility’s own psychotropic medication policy required identification and documentation of specific target behaviors, use and documentation of nonpharmacological interventions, and ongoing monitoring of behaviors and interventions, which were not reflected in the record for this resident.
Failure to Update PASARR Screens for New Mental Health Diagnoses and Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that Preadmission Screening and Resident Review (PASARR) Level I screenings were accurate and updated when new mental health diagnoses and psychoactive medications were initiated for multiple residents. For one resident with dementia, anxiety, depression, and post-traumatic stress disorder (PTSD), the PASARR completed on admission listed anxiety, depression, and dementia with sertraline and quetiapine, but did not include the PTSD diagnosis or the antidepressant Pristiq, despite the admission MDS and care plan documenting PTSD and a subsequent physician’s order for Pristiq. For another resident with Alzheimer’s disease, borderline personality disorder, delusional disorder, schizoaffective disorder, and depression, the PASARR only reflected depression and dementia with sertraline, even though additional mental health diagnoses were added later and an antipsychotic (quetiapine) was ordered for borderline personality disorder, and the quarterly MDS documented psychotic disorder, schizophrenia, and depression with antipsychotic and antidepressant use. A third resident had diagnoses including Alzheimer’s disease, depression, anxiety disorder, irritability and anger, and nonrheumatic aortic valve stenosis. The PASARR for this resident listed dementia and anxiety with Risperdal but omitted the diagnosis of depression and the medications escitalopram and lorazepam, although physician’s orders were in place for escitalopram for depression and lorazepam for anxiety, and the admission MDS documented depression with antianxiety and antidepressant use. Interviews with the Assistant Director of Nursing confirmed that new Level I PASARR screens should have been completed when new mental health diagnoses and psychoactive medications were added, and that the PASARR for one resident, completed prior to arrival, should have included all mental health diagnoses and medications. The facility’s own policy required notification of the state mental health authority within 14 days after a significant change in mental condition and specified that a new Level I screen is required for new mental health diagnoses or newly prescribed psychotropic medications, which was not followed in these cases.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
