Majestic Care Of Deming Park
Inspection history, citations, penalties and survey trends for this long-term care facility in Terre Haute, Indiana.
- Location
- 3300 Poplar St, Terre Haute, Indiana 47803
- CMS Provider Number
- 155358
- Inspections on file
- 28
- Latest survey
- January 15, 2026
- Citations (last 12 mo.)
- 26 (2 serious)
Citation history
Health deficiencies cited at Majestic Care Of Deming Park during CMS and state inspections, most recent first.
A cognitively impaired resident with dementia and a history of convulsions was found by a hospice CNA sitting on a male resident’s bed with her pants down and brief pulled aside, while the male resident, who had schizophrenia and a psychotic disorder with hallucinations, had his hands near her genital area. The encounter occurred behind a closed curtain in the male resident’s room. Prior to this, the female resident had been ambulating the halls as usual, and the facility had not yet identified or addressed her pattern of seeking out this male resident, whom she associated with her husband. Although both residents later denied that anything inappropriate occurred and staff had not previously observed sexual behaviors between them, surveyors determined that the facility failed to protect the cognitively impaired resident’s right to be free from sexual abuse, in violation of resident rights and abuse-prevention policies.
Staff did not report an allegation of resident-to-resident abuse to the state health department within the required timeframe after an incident involving two residents, despite facility policy mandating immediate notification. The delay occurred after the Social Services Director reported the event to the Administrator, who failed to ensure timely reporting.
A resident with severe cognitive impairment and a history of traumatic brain injury, identified as an elopement risk and wearing a WanderGuard, was able to leave the facility unsupervised after staff failed to visually check on her during their shift. The facility's alarm system did not alert staff to the exit, and the resident was later found outside with hypothermia and abnormal vital signs. Staff were not consistently aware of elopement risks, and required supervision protocols were not followed.
A resident with severe cognitive impairment and multiple comorbidities, identified as high risk for elopement, was able to leave the facility undetected overnight despite wearing a WanderGuard device. Staff failed to visually check on the resident during their shift, and the alarm system did not alert staff to the exit. The resident was found outside the facility with hypothermia and abnormal vital signs. Contributing factors included lack of staff awareness of elopement risk, inconsistent documentation and monitoring of safety devices, and a malfunctioning security system.
A resident with multiple sclerosis, moderate cognitive impairment, and dependence for ADLs was repeatedly observed with the call light out of reach, despite a care plan and facility policy requiring it to be accessible. The resident was unable to locate or use the call light on several occasions, and staff confirmed it should have been kept within reach.
Three residents did not receive showers and personal hygiene care according to their stated preferences and care plans. One resident received fewer showers than scheduled and was asked to sign off on care not provided, while another was observed with poor nail hygiene and had gaps in documentation for nail and hair care. A third resident's records showed conflicting information about bathing preferences and physician orders, resulting in missed showers. Staff interviews confirmed inconsistencies in documentation and a lack of clear policy for recording resident preferences.
A resident with multiple sclerosis and moderate cognitive impairment, dependent on staff for ADLs, was repeatedly observed with untrimmed fingernails and debris, indicating nail care was not consistently provided or documented as required by facility policy. An LPN confirmed nail care should have been done with each bath and as needed, but records showed missed or undocumented care.
A resident with a history of traumatic brain injury and multiple fractures was not safely transferred according to their care plan, which required two-person assistance and a Pivot Disk. Documentation showed inconsistent adherence to these requirements, and an incident occurred where the resident and a CNA fell during a transfer. Staff interviews revealed issues with bed locking mechanisms and non-use of the Pivot Disk, contributing to the unsafe conditions.
The facility failed to document and provide showers according to the personal preferences of three residents, leading to a deficiency in honoring resident choice and self-determination. One resident's wife reported he was not receiving the preferred two showers per week, often only receiving one. Another resident expressed not receiving showers as scheduled, with a significant gap in provision. A third resident reported receiving showers based on staff convenience rather than his preference. Resident Council meeting minutes highlighted ongoing concerns about shower provision.
A facility failed to conduct required respiratory assessments before nebulizer treatments, improperly stored respiratory equipment, and did not obtain a physician's order for oxygen supplementation for residents with COPD. Observations showed unbagged and undated nebulizer equipment, and interviews confirmed the lack of adherence to facility policies.
The facility failed to maintain accurate temperature logs and manage food expiration dates, as observed during kitchen inspections. Missing temperature entries for freezers and expired food items were found, with the Dietary Manager admitting to guessing temperatures and instructing staff to fill in logs inaccurately.
The facility failed to maintain proper catheter care for two residents, leading to potential infection risks. One resident's catheter bag and tubing were repeatedly observed in contact with the floor, and documentation of catheter care was inconsistent for both residents. Staff interviews confirmed an increase in UTIs, and the facility's policy on catheter care was not followed.
A resident requiring dialysis care did not receive meal trays for missed lunches while at dialysis, as the dietary staff was not informed of the resident's return. Additionally, the facility failed to consistently document the assessment of the resident's AV dialysis fistula, with missing entries in the Treatment Administration Records over several months.
The facility failed to properly administer inhaled medications, resulting in an 11.54% medication error rate. A nurse did not instruct two residents with COPD to rinse and spit after using corticosteroid inhalers and did not wait between administering different inhaled medications. This was against the facility's policy, as confirmed by LPNs.
The facility failed to properly label and dispose of medications in two storage rooms. An undated Aplisol vial was found, with staff unaware of its viability period, and an expired COVID vaccine was not disposed of as required. Facility policies on medication handling were not followed, resulting in these deficiencies.
A facility failed to assess and treat a resident's urinary catheter and follow up on continued hematuria, resulting in immediate jeopardy. The resident experienced a distended abdomen, low urine output, and bloody urine, but the physician was not notified, and no assessment or vital signs were obtained. The resident's condition worsened, leading to septic shock and respiratory failure, and the resident later expired.
A resident was left unattended in a mechanical lift pad by a CNA, contrary to the facility's policy requiring two-person assistance for transfers. The resident's records lacked documentation for the use of a mechanical lift and an appropriate care plan. Staff interviews confirmed the policy was not followed, leading to the deficiency.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse by Another Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s right to be free from sexual abuse. A hospice CNA entered a male resident’s room and found a female resident sitting on his bed with her pants down to her knees and her brief pulled to the side, while the male resident’s hands were near her vaginal area. The two residents were in the male resident’s room behind a pulled curtain when discovered. This incident was reported to the Indiana Department of Health as a reportable incident. The female resident, identified as having dementia, muscle weakness, and a history of convulsions, had a quarterly MDS indicating cognitive impairment. Her care plan later documented behavioral symptoms of seeking companionship with other residents. The DON indicated that the facility initially did not think there was a concern between this resident and other residents, and that it was later determined she was seeking the male resident because he resembled her husband. Prior to that determination, the resident had been observed walking around the hallways as usual, and there were no indications in the record that she had been restricted or more closely supervised to prevent such interactions. The male resident had diagnoses including schizophrenia, psychotic disorder with hallucinations, and adult failure to thrive, and his admission MDS indicated he was cognitively intact and receiving antipsychotic medication. His care plan, developed after the incident, noted a history of schizophrenia and psychotic disorder with hallucinations and that he could exhibit behaviors including inappropriate sexual interactions with others. Written statements from hospice CNAs described the scene in his room, with the female resident partially undressed and the male resident fully dressed with his hands near her genital area. Subsequent interviews and notes documented that both residents denied that anything inappropriate had occurred, and other staff present on the unit did not report observing inappropriate behaviors between the two residents prior to the incident. Nonetheless, the observed situation in the male resident’s room constituted a failure to protect the cognitively impaired female resident from sexual abuse. Facility policies provided by the DON indicated that when a resident is accused or suspected of abuse, the facility will ensure other residents are protected, which may include increased supervision, room changes, or transfer or discharge, and that residents have the right to a safe environment. In this case, the incident occurred despite these policies, and the surveyors determined that the facility failed to ensure the female resident’s right to be free from sexual abuse was protected.
Failure to Timely Report Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of resident-to-resident abuse to the Indiana Department of Health within the required timeframe for two residents. On the morning of the incident, one resident was observed yelling at another in a hallway, with staff intervening to separate them. The Social Services Director (SSD) witnessed the aftermath, spoke with those involved, and reported the incident to the former Administrator. The Administrator instructed the SSD to wait before documenting the event, indicating she wanted to consult someone first, but then left the facility without providing further direction. The SSD later entered progress notes about the incident, believing it had been reported to the state, as one resident had threatened another. However, the required notification to the Department of Health was not made within the mandated two-hour window after the allegation was made. Facility policy clearly required immediate reporting of any alleged abuse, but this protocol was not followed in this instance.
Failure to Prevent Elopement and Ensure Resident Supervision
Penalty
Summary
A resident with a history of traumatic brain injury, severe cognitive impairment, and identified as an elopement risk was able to leave the facility unsupervised during the night. The resident was wearing a WanderGuard bracelet, a device intended to prevent unsupervised exits, but the facility's alarm system failed to alert staff when the resident exited. Multiple staff members, including nurses and CNAs assigned to the resident's care, did not visually check on the resident during their shift, despite facility expectations and policies requiring residents to be checked at least every two hours. The last known observation of the resident was at approximately 9:40 p.m., after which no staff reported seeing or checking on her until the following morning. The resident was discovered missing during the day shift when a nurse went to check her blood sugar and found her room empty. A search was initiated, and the resident was found approximately 0.6 miles away from the facility, exhibiting signs of hypothermia and abnormal vital signs. Upon return, the resident was confused, had a low body temperature, and complained of pain. The WanderGuard device was found to be intact and functional when tested after the incident, but facility investigation revealed issues with the door's latch and mag-lock, which may have prevented the alarm from activating as intended. Staff interviews indicated a lack of awareness regarding which residents were at risk for elopement, and elopement risk was not included on assignment sheets. Documentation and staff statements confirmed that the resident had a care plan identifying her as an elopement risk, with interventions such as regular checks and use of the WanderGuard. However, these interventions were not consistently implemented, and staff did not follow the facility's policy for supervision and monitoring. The failure to provide adequate supervision and to ensure the effectiveness of the WanderGuard system resulted in the resident's unsupervised exit and exposure to harm.
Failure to Prevent Elopement and Provide Adequate Supervision
Penalty
Summary
A facility failed to provide adequate supervision and prevent an accident hazard when a resident with severe cognitive impairment, traumatic brain injury, Parkinson's disease, and type 2 diabetes eloped from the facility during the night. The resident, who was identified as being at high risk for elopement and falls, wore a WanderGuard bracelet intended to prevent unsupervised exits. Despite this, the resident was able to leave the facility undetected sometime after being last seen at 9:40 p.m. and was not discovered missing until the following morning at 7:11 a.m. when staff could not locate her. The resident was found approximately 0.6 miles away from the facility, exhibiting hypothermia and abnormal vital signs, and was returned to the facility for assessment and care. The investigation revealed that neither the night shift nurse nor the CNA assigned to the resident's hall visualized the resident during their entire 8-hour shift. Staff interviews indicated a lack of clarity regarding which residents were at risk for elopement, as this information was not included on CNA assignment sheets or point of care tasks. Additionally, staff were inconsistent in their understanding and documentation of required checks for the WanderGuard device, and some were unsure of their responsibilities regarding its function. The facility's alarm system failed to alert staff when the resident exited, and subsequent testing showed that the alarm was not audible in all areas of the building. There was also uncertainty about whether a vendor had access to the door alarm bypass code, which may have contributed to the resident's ability to exit undetected. Further contributing factors included a malfunctioning security camera system due to a power outage, which prevented review of surveillance footage, and a possible issue with the front door's magnetic lock, which may not have latched completely. The facility's policies required regular assessment and communication of elopement risk, as well as monitoring and documentation of interventions, but these were not consistently implemented. The lack of direct resident checks, insufficient staff awareness of elopement risk, and failure of the alarm system collectively led to the resident's unsupervised exit and subsequent exposure to harm.
Failure to Keep Call Light Within Reach for Dependent Resident
Penalty
Summary
The facility failed to ensure that a resident's call light was consistently kept within reach, as required by the resident's care plan and facility policy. On multiple occasions, the resident was observed lying in bed with the call light hanging off the side of the bed, nearly touching or halfway to the floor, making it inaccessible. During these times, the resident expressed uncertainty about the location of the call light and was unable to find it when attempting to do so. On one occasion, the call light was within reach and the resident was able to use it, but this was not consistently maintained. The resident involved had a diagnosis of multiple sclerosis, moderate cognitive impairment, and was dependent on staff for activities of daily living. The care plan identified the resident as being at risk for falls and specifically included an intervention to keep the call light within reach. Staff interviews confirmed that the call light should have been accessible to the resident at all times. Facility policy also required staff to ensure call lights were within reach and secured as needed.
Failure to Provide Showers and Personal Hygiene Care According to Resident Preferences
Penalty
Summary
The facility failed to ensure that showers and personal hygiene care were provided to residents according to their stated preferences and care plans. For one resident with hemiplegia and hemiparesis, documentation showed that he was scheduled for multiple showers but only received a portion of them, with some marked as refused or not applicable without proper justification. The resident reported not receiving the expected number of showers and being asked to sign off on shower sheets even when showers were not provided. The care plan and resident preference documents indicated a clear expectation for shower frequency and choice, but the facility's records and staff interviews revealed inconsistencies in both the provision and documentation of care. Another resident with paroxysmal atrial fibrillation and congestive heart failure was observed with poor personal hygiene, specifically debris under her fingernails, despite care plans indicating a need for assistance with ADLs, including bathing and nail care. Documentation showed gaps in the provision of nail care and hair washing, and there was a lack of refusal documentation for missed care. Staff interviews confirmed that shower sheets and point-of-care (POC) documentation should match, but discrepancies were found between the two, and some care activities were not consistently recorded. A third resident with multiple sclerosis and a recent patella fracture had conflicting documentation regarding bathing preferences and physician orders. While the care plan and task section of the electronic medical record indicated a preference for showers, a physician's order for bed baths only remained in the chart, and the resident did not receive showers as scheduled. Staff interviews revealed confusion about the resident's current preferences and orders, and the facility lacked a specific policy for documenting resident preferences, leading to inconsistencies in care delivery and record-keeping.
Failure to Provide and Document Required Nail Care for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident who required assistance with activities of daily living (ADLs) did not receive adequate nail care. Multiple observations over several days showed the resident lying in bed with untrimmed fingernails and dark debris underneath them. The resident reported that staff did not clean her nails very often. Review of the resident's care plan indicated a need for assistance with ADLs, including nail care on bath days and as necessary. The resident's diagnoses included multiple sclerosis, and the Minimum Data Set (MDS) assessment documented moderate cognitive impairment and dependence for ADLs. Documentation review revealed inconsistencies in recording nail care, with some shower sheets lacking evidence that nail care was provided or refused, and no progress notes indicating refusal. Facility policy required daily cleaning and regular trimming of nails, with documentation of care provided. An LPN confirmed that nail care should have been performed with each bath and as needed, but this was not consistently done or documented for the resident.
Failure to Ensure Safe Transfer Procedures
Penalty
Summary
The facility failed to ensure a safe transfer for a resident, identified as Resident C, who required extensive assistance due to a history of traumatic brain injury and multiple fractures from a motor vehicle accident. The resident's care plan specified the need for two-person assistance and the use of a Pivot Disk for transfers. However, documentation revealed that out of 69 transfer attempts, only 41 were conducted with two-person assistance, while three were done with only one person, and 25 transfers did not occur. Additionally, the Pivot Disk was not used during the transfer that resulted in an accident. An incident occurred when a CNA attempted to transfer Resident C from bed to wheelchair, during which the resident became unsteady, and both the CNA and the resident fell. The fall resulted in a skin tear for the resident. Interviews with staff revealed issues with bed locking mechanisms, which were not consistently reported or repaired, contributing to the unsafe transfer conditions. The CNAs admitted to not using the Pivot Disk, and the resident confirmed that the device was not used during her transfers. The Director of Nursing and the Administrator were unaware of the bed locking issues and the deviation from the prescribed transfer procedures. The facility's policy required adherence to individual transfer plans, but this was not followed, leading to the incident. The Certified Occupational Therapy Assistant noted that the resident only allowed therapy staff to use the Pivot Disk, indicating a lack of consistent practice among the nursing staff.
Failure to Honor Resident Shower Preferences
Penalty
Summary
The facility failed to document and provide showers according to the personal preferences of three residents, leading to a deficiency in honoring resident choice and self-determination. Resident 57's wife reported that he was not receiving the preferred two showers per week, often only receiving one. His care plan specified showers on Monday and Friday evenings, but records from April and May 2024 showed only bed baths without hair washing on several dates, with no documentation of refusals. The issue was raised in Resident Council meetings, and the Unit Manager acknowledged a lack of proper documentation and staff education. Resident 14 expressed that she was not receiving showers as scheduled, with her last shower recorded on May 27, 2024, despite her preference for showers on Tuesday and Saturday evenings. Her care plan, dated November 28, 2023, indicated these preferences, but there was a significant gap in shower provision. The MDS assessment showed moderate cognitive impairment, but no behaviors for rejecting care were documented. Resident 11 reported receiving showers based on staff convenience rather than his preference for Monday and Thursday evenings. His care plan, dated August 17, 2023, reflected these preferences, but the electronic records lacked documentation for specific dates. The Assistant Director of Nursing noted that missing entries could be due to missed charting rather than missed showers. Resident Council meeting minutes from March to May 2024 highlighted ongoing concerns about shower provision, with responses from management indicating audits and grievance processes were in place.
Deficiencies in Respiratory Care and Equipment Management
Penalty
Summary
The facility failed to conduct a respiratory assessment on a resident before administering a nebulizer treatment. During a medication administration observation, a registered nurse administered an albuterol nebulization solution to a resident with chronic obstructive pulmonary disease (COPD) without completing a respiratory assessment. The resident's medical records indicated a physician's order to document vital signs and perform a respiratory assessment before and after nebulizer treatments, but the Medication Administration Record lacked documentation of these assessments for May and June 2024. Interviews with nursing staff and the resident confirmed that assessments were not conducted as required by the facility's policy. The facility also failed to ensure proper storage of respiratory equipment for multiple residents. Observations revealed that nebulizer mouthpieces and tubing were left unbagged and undated on residents' beds or tables. This was noted for three residents, including one who was unable to reach the equipment without assistance. The facility's policy required that nebulizer equipment be disassembled, rinsed, air-dried, and stored in a zip-lock bag with a date label, but these procedures were not followed. Interviews with staff confirmed the expectation for proper storage and dating of equipment, which was not adhered to. Additionally, the facility did not obtain a physician's order for oxygen supplementation for a resident who was receiving oxygen via nasal cannula. The resident's record lacked documentation of a physician's order for oxygen administration, despite the resident indicating that she had been receiving oxygen since a recent hospital visit. The facility's policy stated that oxygen should be administered under a physician's order, except in emergencies, and orders should be obtained as soon as practicable. Interviews with staff highlighted the expectation for obtaining timely orders, which was not met in this case.
Deficiency in Food Storage and Temperature Logging
Penalty
Summary
The facility failed to maintain proper documentation and management of food storage temperatures and expiration dates, as observed during two kitchen inspections. During an initial kitchen tour, it was noted that temperature logs for the potato freezer, vegetable and meat freezer, and ice cream freezer were missing entries for two consecutive days. Additionally, outdated food items, including an opened gallon of milk and hard-boiled eggs, were found in the reach-in refrigerator. The Dietary Manager acknowledged the expired items and subsequently closed the refrigerator, preventing further inspection. In a follow-up interview, the Dietary Manager admitted to instructing a staff member to fill in the missing temperature logs with another staff member's initials, based on an 'educated guess' rather than actual recorded data. The facility's policy requires temperatures to be logged twice daily and for refrigerated food to be labeled, dated, and monitored to ensure timely use or disposal. However, these procedures were not followed, as evidenced by the missing temperature logs and expired food items found during the inspections.
Failure in Catheter Care Documentation and Maintenance
Penalty
Summary
The facility failed to ensure proper care and maintenance of indwelling urinary catheters for two residents, leading to potential risks of urinary tract infections. Resident 56 was observed multiple times with her catheter bag and tubing in contact with the floor, which is against the facility's policy for infection control. The resident had a history of obstructive and reflux uropathy and required extensive assistance with activities of daily living. Despite a care plan indicating the risk of infections related to the catheter, there were several instances where catheter care was not documented as completed. Resident 41, who had diagnoses including hemiplegia and neuromuscular dysfunction of the bladder, also had an indwelling urinary catheter. The care plan required catheter care every shift, but the Treatment Administration Record (TAR) showed missing documentation for several shifts in May 2024. This lack of documentation suggests that catheter care may not have been consistently performed, increasing the risk of infection for the resident. Interviews with staff, including the Infection Preventionist and Certified Nursing Assistants, revealed that there was an increase in UTIs in February and March 2024, but no specific root cause was identified. The staff acknowledged that catheter care should be documented in the medical record when completed. The facility's policy, revised in September 2014, emphasized keeping catheter tubing and drainage bags off the floor and documenting catheter care, which was not adhered to in these cases.
Failure to Provide Adequate Dialysis Care and Documentation
Penalty
Summary
The facility failed to provide adequate dialysis care for a resident, identified as Resident 27, who required dialysis services. The resident did not receive meal trays for lunches missed while attending dialysis sessions. Despite having a care plan that emphasized the need for adequate nutrition due to dialysis, the dietary staff was not informed of the resident's return from dialysis, resulting in missed meals. The Dietary Manager confirmed that the resident was not receiving lunch meals upon returning from dialysis, as the staff was unaware of the resident's schedule. Additionally, the facility did not consistently document the assessment of the resident's arteriovenous (AV) dialysis fistula, as required by the physician's order. The Treatment Administration Records (TARs) for March, April, and May 2024 showed missing documentation for the assessment of the AV fistula on several shifts. The Director of Nursing Services acknowledged the documentation gaps and indicated that the issue was being investigated through the facility's Quality Assurance and Performance Improvement (QAPI) program.
Improper Administration of Inhaled Medications
Penalty
Summary
The facility failed to ensure proper administration of inhaled medications, resulting in a medication error rate of 11.54 percent. During a medication administration observation, a registered nurse administered a Symbicort inhaler to a resident with chronic obstructive pulmonary disease (COPD) without allowing the resident to rinse and spit with water afterward. Additionally, the nurse did not wait before administering a second inhaled medication, Incruse Ellipta, to the same resident. The resident's care plan indicated a need for proper medication administration to manage respiratory distress related to COPD. In another instance, the same registered nurse administered Trelegy Ellipta to a different resident with COPD, again failing to instruct the resident to rinse and spit with water after use. Interviews with licensed practical nurses confirmed that the facility's policy required residents to rinse and gargle with water after using corticosteroid inhalers and to wait several minutes between administering different inhaled medications. The facility's policy was not followed, contributing to the observed medication errors.
Medication Labeling and Disposal Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and disposal of medications in two medication storage rooms. During an inspection, an undated and opened multi-use vial of Aplisol was found in the 200-hall medication storage room refrigerator. The label indicated it was for facility stock, but staff members, including an LPN, RN, and Unit Manager, were unaware of how long the Aplisol solution was viable once opened. It was later confirmed by the LPN that the Aplisol was good for 30 days once opened, as per facility policy, which was not adhered to in this instance. Additionally, in the 100-hall medication storage room refrigerator, a COVID vaccine labeled for a resident was found to be expired since March 27, 2024. The Unit Manager acknowledged the expiration and indicated that the Infection Preventionist nurse was responsible for handling vaccines and Aplisol solutions. The expired vaccine should have been disposed of according to the facility's policy, which mandates the removal and destruction of expired medications. The facility's policies on medication administration and Aplisol usage were not followed, leading to these deficiencies.
Failure to Assess and Treat Urinary Catheter Leading to Resident's Death
Penalty
Summary
The facility failed to assess and treat a resident's urinary catheter and follow up on continued hematuria, resulting in immediate jeopardy. Resident B, with a history of urinary catheter, severe sepsis with septic shock, and urinary tract infection (UTI), experienced a distended abdomen and low urine output. The catheter was changed, and bloody urine was returned, but the physician was not notified, and no assessment or vital signs were obtained. Several hours later, Resident B had black emesis, blood clots from the catheter, and bloody urine, leading to septic shock and respiratory failure. The resident was sent to the hospital and later expired. Resident B's medical record indicated multiple diagnoses, including chronic obstructive pulmonary disease (COPD), severe sepsis with septic shock, hematuria, and UTI. The resident had physician orders for various medications and catheter care, but the facility failed to notify the physician of abnormal findings and did not document communication with the urologist. The resident's condition worsened over several hours, with no follow-up assessments or vital signs recorded. The facility's documentation lacked evidence of timely communication with the physician or urologist regarding the resident's condition. Interviews with staff revealed that the nurse did not notify the physician because the issue was not considered a change in condition. The Director of Nursing Services (DNS) was not informed until the next morning, and the resident was sent to the hospital with significant delays. The facility's policies on change of condition and catheter care were not followed, leading to the resident's deteriorating condition and eventual death. The facility's failure to provide appropriate care and timely communication with medical professionals resulted in immediate jeopardy for Resident B.
Removal Plan
- The facility assessed all residents with urinary catheters for signs and symptoms of infection.
- Nursing staff were in-serviced on catheter care and urinary tract infections.
- Staff were educated on assessment and change of condition with urinary catheters.
Failure to Follow Mechanical Lift Transfer Policy
Penalty
Summary
The facility failed to follow its policy and procedure for safe mechanical lift transfers for Resident K. On the day of the incident, Resident K, who was alert and oriented, was placed in a lift pad by a CNA who then left the room without completing the transfer. The resident remained unattended in the lift pad, attached to the mechanical lift, until an occupational therapist and an LPN arrived to complete the transfer. The resident reported minor leg pain but no injuries were documented. The facility's policy requires two staff members to assist with mechanical lift transfers, which was not adhered to in this case. Resident K's clinical records revealed a lack of documentation for a physician's order to use a mechanical lift for transfers and an absence of a care plan addressing the use of the mechanical lift. The resident's quarterly MDS indicated she was cognitively intact, had an indwelling Foley catheter, and was dependent on staff for transfers. Interviews with various staff members, including the Director of Nursing Services, confirmed that the facility's policy mandates two persons to assist with mechanical lift transfers, and that the resident should not have been left unattended. The facility's policies on mechanical lift use and comprehensive care plans were reviewed and found to be consistent with the requirement for two-person assistance during transfers. However, the incident involving Resident K demonstrated a failure to adhere to these policies, resulting in the resident being left in a potentially hazardous situation. The deficiency was identified through observation, interviews, and record reviews, highlighting a lapse in following established safety protocols for resident transfers.
Latest citations in Indiana
Surveyors observed that dietary staff repeatedly worked in kitchen and meal service areas with uncovered facial hair, despite facility policy and state sanitation requirements mandating effective hair restraints. Two dietary aides with short beards or mustaches were seen walking through food preparation areas, taking food temperatures, handling food, and plating meals at steamtables in dining rooms without any facial hair coverings, while the current policy required all hair, including facial hair, to be restrained to prevent contamination.
The facility failed to consistently provide and document required bed-hold policy notices when several residents were transferred to the hospital. In multiple cases, residents with dementia, psychotic disorders, COPD, chronic respiratory failure, altered mental status, and cerebral infarction were sent out for acute changes in condition, and while transfer notes reflected physician and family notifications, they lacked documentation that the bed-hold policy was discussed with the resident or responsible party. Notices of Transfer or Discharge often indicated a copy of the bed-hold policy was sent with the resident, but the records did not show signed and dated acknowledgment by the resident or appropriate representative, including in situations where a resident had moderate cognitive impairment, short-term memory issues, or a documented need for a proxy and a financial POA authorizing an agent for health care decisions.
Surveyors found that the facility failed to provide trauma‑informed and culturally competent care by not incorporating two residents’ extensive trauma histories and specific behavioral triggers into their care plans. One resident with documented homelessness, polysubstance abuse, severe accidents with multiple fractures, viral encephalitis with coma, physical and sexual abuse, loss of family contact, and a past suicide attempt had multiple behavior‑focused care plans that referenced identifying triggers but listed none and did not mention their physical, sexual, medical, or psychosocial trauma. Another resident with TBI from being struck by a truck, an 11‑month coma, long‑term state hospital residence, alleged shooting of a parent, and diagnoses including intermittent explosive disorder and borderline personality disorder had a PASRR identifying a specific trigger and notes of inappropriate sexual behavior, yet their care plans omitted these traumatic events, the identified trigger, and the sexual behavior. Staff interviews confirmed that residents were screened for trauma, but the trauma histories and triggers were not reflected in the individualized plans of care.
A resident with schizophrenia, post‑stroke hemiparesis, and mild cognitive impairment expressed feeling down and wanting to kill himself, but staff did not document asking about a specific plan, did not notify the physician or psychiatric NP as expected, and did not develop or update a care plan addressing depression or suicidal ideation. The SSD documented offering support and initiating 15‑minute checks once, but there was no further follow‑up or documentation of interventions after subsequent suicidal statements made in a care plan meeting with the resident’s father. The DON and Administrator reported that facility policy requires immediate notification of key staff, assessment for a plan and means of self‑harm, and thorough documentation, which were not carried out or reflected in the medical record for this resident.
A resident with schizophrenia, post-stroke hemiparesis, and mild cognitive impairment verbalized suicidal ideation, but the care plan did not address depression or suicidal thoughts, and required assessments and services were not accurately or timely documented. An SSD note recorded the resident saying he wanted to kill himself and referenced 15‑minute checks and a care plan update, yet the active care plan lacked depression/suicidal ideation interventions. Multiple late-entry Social Services notes were later added, describing follow-up visits and the resident denying suicidal ideation, but the SSD later reported she did not typically ask about a suicide plan and did not personally provide individual follow-up visits as described. These practices conflicted with the facility’s policy requiring factual, first-hand, and timely documentation of assessments and services.
A resident was observed with an Albuterol inhaler on an overbed table and later reported keeping the inhaler in a nightstand drawer, with no staff present during these observations. Record review showed the resident had no cognitive impairment on the admission MDS but lacked any documented self-medication administration assessment. The DON acknowledged that the required assessment had not been completed, despite facility policy requiring staff and the practitioner to evaluate each resident’s mental and physical abilities before allowing self-administration of medications.
Surveyors found that the facility submitted inaccurate direct care staffing data to CMS through the PBJ system over multiple days in a quarter. CASPER reports showed apparent gaps in 24-hour licensed nurse coverage, low weekend staffing, and a 1-star staffing rating, while internal staffing sheets documented that licensed nurses were present and the facility was fully staffed on those days. The Administrator reported that the discrepancies were due to PBJ data entry errors, despite a facility policy requiring all PBJ entries to be accurate, auditable, and verifiable against payroll, invoices, or contracts.
Surveyors found that the facility did not provide or document required written transfer/discharge notices and bed-hold policy information for four residents who were sent to the hospital, including individuals with conditions such as dementia, CHF, chronic respiratory failure, and CKD. In each case, progress notes showed that the resident was transferred for acute issues, but the clinical records lacked evidence that written notices were given to the residents or their representatives, and in one case lacked documentation that required information was sent to the receiving provider. Facility leadership, including the ADON, DON, and Administrator, acknowledged that the records did not contain the required documentation, despite a written policy requiring such notices and information exchange.
A resident with Alzheimer’s disease and depression, previously on an antidepressant, exhibited intermittent refusals of medications and care, occasional yelling at staff, and reports of unusual perceptions, such as believing men were in or near her room. Nursing notes over several months documented these refusals and complaints but did not show that the behaviors were evaluated or recorded as dangerous, non-redirectable, or causing significant distress, nor did they document specific non-pharmacological interventions attempted or their outcomes. Despite this, a psychiatric NP later added new diagnoses of schizoaffective disorder, borderline personality disorder, and delusional disorder and ordered an antipsychotic (Seroquel) without a comprehensive evaluation in the record to support these diagnoses. The facility’s psychotropic medication policy, which requires identification and documentation of target behaviors, use of nonpharmacological interventions, and ongoing behavior monitoring, was not followed for this resident.
The facility failed to keep PASARR Level I screenings accurate and current for three residents when new mental health diagnoses and psychoactive medications were initiated. One resident’s PASARR omitted a PTSD diagnosis and an added antidepressant, despite documentation of PTSD on the MDS and care plan and a physician order for Pristiq. Another resident’s PASARR listed only depression and dementia, even after additional diagnoses such as borderline personality disorder, delusional disorder, and schizoaffective disorder were added and an antipsychotic (quetiapine) was ordered, with the MDS later reflecting psychotic disorder, schizophrenia, and depression with antipsychotic and antidepressant use. A third resident’s PASARR did not include a depression diagnosis or newly ordered escitalopram and lorazepam, although the admission MDS documented depression with antianxiety and antidepressant use. These omissions occurred despite facility policy requiring a new Level I review after significant mental status changes, including new mental health diagnoses or new psychotropic medications.
Uncovered Facial Hair During Food Preparation and Meal Service
Penalty
Summary
The deficiency involves the facility’s failure to ensure that food was served in a sanitary and safe manner in accordance with professional standards and facility policy during multiple kitchen and meal service observations. During an initial kitchen observation, two dietary aides were seen walking through the kitchen food preparation area with uncovered facial hair. One aide had facial hair above and below the lip and along the jaw line, approximately one-fourth inch in length, and the other had a mustache of similar length; neither used any facial hair covering. These observations occurred while staff were present in the kitchen area where food was stored and prepared. During subsequent observations on the same day, the same two dietary aides were again observed with uncovered facial hair while directly involved in meal preparation and service. One aide walked through the kitchen while the noon meal was being prepared and placed into a transport cart for service in the south dining room, and later was observed plating the noon meal at the steamtable in that dining room, still without a facial hair covering. The other aide walked through the kitchen while the noon meal was being prepared and placed into the steamtable for the north dining room, took food temperatures, assisted with plating meals at the steamtable, and retrieved food items and supplies from the kitchen, all while having an uncovered mustache approximately one-fourth inch in length. The Dietary Manager stated that staff hair was to be covered when in the kitchen and during meal service, and the facility’s written policy and the cited Indiana Food Establishment Sanitation Requirements both required effective hair restraints, including for facial hair, to prevent contamination of food, equipment, and utensils.
Failure to Provide and Document Bed-Hold Policy at Time of Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure that required bed-hold policy information was provided and documented for four residents transferred to the hospital. For a resident with dementia, psychotic disorder, and autistic disorder who had a BIMS score of 0 indicating severe cognitive impairment, progress notes documented physician notification and guardian notification when the resident was sent to the hospital, but there was no documentation that the bed-hold policy was provided to the responsible party. A Notice of Transfer or Discharge later indicated a copy of the bed-hold policy was sent with the resident. Another resident with COPD and chronic respiratory failure, cognitively intact with a BIMS score of 13, experienced a decline in condition and was transferred to the hospital by ambulance; progress notes documented family notification but did not document any discussion of the bed-hold policy, although a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident. A third resident with altered mental status and cerebral infarction, with a BIMS score of 10 indicating moderate cognitive impairment and documented short-term memory impairment, experienced changes in condition and was transferred to the hospital. Progress notes stated the resident was their own responsible party and that no other notification was completed, and transfer documentation did not include the bed-hold policy, although an untimed Notice of Transfer or Discharge indicated a copy of the bed-hold policy was signed by the resident. A financial power of attorney document in the record showed the resident had designated an agent to act in consent or refusal of health care. For a fourth resident with dementia and osteomyelitis, transfer documentation and a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident, and the transfer form noted the resident required a proxy for decision making. The facility’s policy required that at the time of transfer to a hospital, written notice specifying the duration of the bed-hold policy and information on return to the next available bed be provided, and that a signed and dated copy of the bed-hold notice given to the resident or representative be kept in the resident file, which was not consistently documented for these residents.
Failure to Integrate Trauma Histories and Behavioral Triggers Into Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to identify and incorporate residents’ trauma histories and specific behavioral triggers into their care plans, despite documented histories of significant trauma and behavioral health issues. For one resident, extensive social service and progress notes documented homelessness, polysubstance abuse, major depressive and anxiety disorders, chronic pain, a history of severe car accidents with multiple fractures, viral encephalitis resulting in a three‑month coma, loss of child custody, multiple divorces, physical abuse by a spouse, the death of a fiancé who was struck by a car while in a wheelchair, lack of family contact, and a past suicide attempt by Valium overdose. Additional documentation noted a history of rape by a brother at age eight and prior placement under direct supervision and 15‑minute checks related to suicidal ideation. Despite these documented traumatic events and behavioral health concerns, the resident’s care plans did not identify a history of physical trauma, sexual trauma, homelessness, substance abuse, medical trauma, or attempted suicide. For this same resident, the MDS showed no cognitive deficit and identified behaviors such as verbal aggression and rejection of care, along with diagnoses including seizure disorder, depression, chronic pain syndrome, homelessness, and anxiety disorder. Multiple care plans addressed behaviors such as drug‑seeking, pretending to have seizures for attention or medication, making false allegations, verbal aggression when unable to smoke, and a desire for intimate relationships with consenting male residents. These care plans referenced goals such as effective coping skills, seeking staff support, and compliance with the smoking policy, and they called for identification and reduction of behavioral triggers. However, none of these care plans actually listed any specific triggers. The care plan addressing the resident’s right to consensual intimate relationships focused on assessment and education regarding consent but did not integrate the resident’s extensive trauma history. Staff interviews indicated the resident had displayed sexual behaviors since admission, including an incident where the resident expressed anger at another resident for not buying a soda after engaging in sexual acts. A second resident with a documented history of traumatic brain injury (TBI), dementia, seizure disorder, borderline personality disorder, anxiety, intermittent explosive disorder, tobacco use, and other behavioral/emotional disorders was also affected by the same deficiency. Social history and progress notes documented that this resident sustained a TBI after being hit by a semi‑truck while riding a bicycle at age 18, resulting in an 11‑month coma, followed by 13 years in a state hospital and subsequent residence in a group home. Additional documentation indicated the resident allegedly shot their father at age 26 after being sworn at and had a PASRR identifying TBI, intermittent explosive disorder, and borderline personality disorder, with a specific trigger of hearing the name of the current U.S. President. Progress notes also described inappropriate sexual behavior toward staff, including touching themselves intimately during personal care and refusing to stop when redirected. Despite this, the resident’s care plans, which addressed explosive disorder and history of altercations, risk for decreased psychosocial well‑being, and refusal to bathe or shower, did not list any specific behavioral triggers, did not reference the traumatic events such as being hit by a truck or shooting their father, and did not document the inappropriate sexual behavior. The Administrator and Social Service Director acknowledged that residents were to be screened for trauma and that trauma responses and PTSD should be added to care plans, but the specific trauma histories and triggers for these two residents were not incorporated into their plans of care.
Failure to Assess and Care Plan for Resident Suicidal Ideation
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess, investigate, and care plan for a resident’s suicidal ideation in accordance with its own policy and staff expectations. The resident had diagnoses including schizophrenia, cerebral edema, and hemiparesis/hemiplegia following a cerebral infarction, and a current MDS showed mild cognitive impairment (BIMS score 12). A progress note documented that the resident told the Social Services Director (SSD) he was feeling down and wanted to kill himself; the SSD offered assistance, activities, and initiated 15‑minute checks, and the note stated the care plan was updated. However, the note did not indicate that the SSD asked whether the resident had a plan to kill himself, and there were no additional notes regarding suicidal ideation or follow‑up. Review of the current care plan showed no problem, goal, or interventions addressing depression or suicidal ideation, and progress notes over the following month contained no documentation of physician notification related to the suicidal statement. Further record and interview evidence showed that the care plan conference summary did not document interventions for suicidal ideation, and the SSD acknowledged she did not normally ask residents expressing suicidal ideation if they had a plan. The SSD reported that the resident had admission paperwork mentioning suicidal ideation related to depression after a stroke and that the resident again vocalized suicidal ideation during a care plan meeting with his father, after which emotional support was offered and the father took the resident out on a leave of absence; no further visits or follow‑up were done. The DON stated that, upon notification of suicidal verbalization, staff should assess the resident, ask if there is a plan, remove potential means of self‑harm, immediately notify the psychiatric NP, and document the occurrence, and that a detailed progress note and updated care plan were expected but not present for this resident. The Administrator similarly stated that staff should ask about a plan, document interventions, notify the physician and family, and update the care plan, and indicated the resident should have had a care plan addressing depression with suicidal ideation. The facility’s written policy required immediate notification of the DON, SSD, and physician, an interview including asking about a plan and assessing mood and means for self‑harm, and thorough documentation of mood, behavior, and all actions taken, which were not reflected in the resident’s record.
Incomplete and Inaccurate Documentation of Suicidal Ideation and Follow-Up
Penalty
Summary
The facility failed to ensure accurate, complete, and timely documentation of assessments and services for a resident who verbalized suicidal ideation. Resident 6, who had schizophrenia, cerebral edema, and right-sided hemiparesis/hemiplegia following a cerebral infarction, had a BIMS score of 12 indicating mild cognitive impairment. The resident’s admission paperwork mentioned suicidal ideation related to depression after a stroke, and a Social Services note on 3/11/2026 documented that the resident was feeling down and said he wanted to kill himself. The Social Services Director (SSD) documented that she talked with the resident, coordinated with Activities, advised the resident to contact SSD or nursing if he wanted to talk, and that the resident was scheduled for 15-minute checks and the care plan was updated. However, the current care plan initiated on 2/26/2026 did not address depression or suicidal ideation. Multiple Social Services progress notes were later entered as late entries in April, with effective dates in March, stating that the resident had no plan and no longer had suicidal ideation, that he felt much better after 1:1 time, and that he continued his daily routine and therapy. These late entries described follow-up visits and reassessments of suicidal ideation on several consecutive days, but in interviews the SSD stated she did not normally ask residents about having a plan when they verbalized suicidal ideation and did not recall any other occurrences beyond the initial event. She further indicated she did not personally provide individual follow-up visits with this resident regarding suicidal ideation, despite the late-entry notes describing such visits. The DON acknowledged that late entries had been added to address concern about suicidal verbalization, and the Administrator stated that upon suicidal statements staff should ask about a plan, notify the physician and family, and update the care plan, and that this resident should have had a care plan addressing depression with suicidal ideation. The facility’s documentation policy required factual, first-hand, timely documentation, which was not followed in this case.
Failure to Complete Required Self-Administration Assessment for Inhaler Kept at Bedside
Penalty
Summary
Surveyors identified that a resident was allowed to keep and access an Albuterol inhaler without the facility completing the required self-administration medication assessment. During an initial tour, the resident was observed sitting in a wheelchair with a handheld Albuterol inhaler on the overbed table and no staff present in the room or hallway. On a subsequent observation, the resident again was in a wheelchair and reported that the Albuterol inhaler was stored in the top drawer of the nightstand, where it was found. Review of the clinical record showed an admission MDS indicating no cognitive impairment, but there was no documentation of a self-medication administration assessment. In an interview, the DON confirmed that the resident did not have the required self-medication assessment, despite the facility’s policy stating that staff and the practitioner must assess each resident’s mental and physical abilities to determine whether self-administering medications is clinically appropriate. This failure to complete and document a self-administration medication assessment for a resident who had an Albuterol inhaler kept at bedside constituted noncompliance with the facility’s own policy and with 410 IAC 16.2-3.1-11(a).
Inaccurate PBJ Staffing Data Submission to CMS
Penalty
Summary
The deficiency involves the facility’s failure to electronically submit complete and accurate direct care staffing information to CMS through the Payroll-Based Journal (PBJ) system for 22 days in a fiscal quarter. A CASPER report review on 4/6/26 showed that, according to PBJ data, the facility did not have licensed nursing coverage 24 hours per day on multiple specific dates across three months, had low weekend staffing, and held a 1-star staffing rating. However, review of the facility’s internal staffing sheets for that quarter indicated the facility was fully staffed and had licensed nurse coverage on all of the dates in question. During an interview, the Administrator stated that the PBJ information must have contained data entry errors, as she had verified licensed staff coverage on the timesheets. The facility’s PBJ policy in effect stated that all staffing data entered into the PBJ system would be auditable and verifiable through payroll, invoices, or contracts, but the submitted PBJ data did not accurately reflect the facility’s actual licensed nurse staffing as documented on internal records. No specific residents or clinical conditions were mentioned in the report, and the deficiency centers solely on inaccurate staffing data submission rather than direct resident care events.
Failure to Provide and Document Required Transfer/Discharge and Bed-Hold Notices
Penalty
Summary
The deficiency involves the facility’s failure to provide and document required written notices of transfer/discharge and bed-hold policies, as well as required information to receiving providers, for four residents who were transferred or discharged to the hospital. For a resident with generalized anxiety disorder, major depressive disorder, and dementia, progress notes showed that the resident was sent to the hospital via 911 for chest pain, lower back pain, and shortness of breath and later returned to the facility, but the clinical record lacked documentation that a written Notice of Transfer/Discharge and the bed-hold policy were provided to the resident or representative, and lacked documentation that required information was conveyed to the receiving facility. The ADON and the Administrator both confirmed there was no documentation that these written notices were provided. For a resident with congestive heart failure and muscle weakness who was sent to the emergency room for painful urination and bloody urine, the clinical record lacked documentation that a Notice of Transfer/Discharge or bed-hold policy was given to the resident or representative, which the DON confirmed. Another resident with chronic respiratory failure and diabetes was discharged to the hospital for respiratory failure, and a resident with chronic kidney disease and dementia was discharged to the hospital, but in both cases there was no documentation that a written notice of transfer/discharge or bed-hold policy was provided to the residents or their representatives. Review of the facility’s Transfer and Discharge policy, dated 1/15/26, showed that the policy required the facility to provide written transfer/discharge notices and bed-hold information to residents and representatives and to provide specified information to receiving providers, but the records for these four residents did not contain the required documentation.
Failure to Document Target Behaviors and Non-Pharmacological Interventions Before Initiating Antipsychotic
Penalty
Summary
The deficiency involves the facility’s failure to document how a resident’s behaviors presented danger or distress to self or others, and failure to document non-pharmacological interventions attempted prior to initiating an antipsychotic medication. Resident 6 had documented diagnoses of Alzheimer’s disease, depression, and severe cognitive impairment, and was receiving sertraline for depression. A PASSAR identified only depression and dementia, and the admission MDS listed Alzheimer’s disease and depression as active diagnoses. Over several months, nursing progress notes documented that the resident intermittently reported unusual perceptions, such as believing there were men causing trouble, a man in her room, or a man wanting to marry her and yelling through the walls, but there was no documentation that these episodes caused danger to the resident or others or that they resulted in unmanageable distress. From late April through mid-July, nursing notes primarily described the resident’s frequent refusals of evening and morning medications, blood sugar checks, blood pressure checks, insulin administration, hygiene care, and showers. Staff documented that the resident sometimes yelled at staff, said “Get out!”, was visibly upset by a room move, was leery of staff and asked to see name badges, and became upset about a pillow under her head until it was removed, after which she calmed down. The notes also recorded instances where the resident believed housekeeping had not cleaned her room or that she had not received medications when she had. However, there were no progress notes or assessments indicating that these behaviors were evaluated as dangerous, non-redirectable, or causing significant distress or functional impairment, and no detailed behavior monitoring logs were present as required by facility policy. On a psychiatric NP visit for initial psychotropic medication management, new mental health diagnoses of schizoaffective disorder, borderline personality disorder, and delusional disorder were added, and Seroquel 25 mg, an antipsychotic, was ordered. The clinical record did not contain a comprehensive evaluation to support these new diagnoses, and there was no documentation of target behaviors meeting the facility’s policy criteria for psychotropic use, such as behaviors representing danger to self or others, causing distress and impairment in functional abilities, or clearly attributable to psychosis or mania. The resident’s representative reported that the resident had no prior history of mental health disorders or psychiatric hospitalization and was unaware of the new diagnoses. The facility’s own psychotropic medication policy required identification and documentation of specific target behaviors, use and documentation of nonpharmacological interventions, and ongoing monitoring of behaviors and interventions, which were not reflected in the record for this resident.
Failure to Update PASARR Screens for New Mental Health Diagnoses and Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that Preadmission Screening and Resident Review (PASARR) Level I screenings were accurate and updated when new mental health diagnoses and psychoactive medications were initiated for multiple residents. For one resident with dementia, anxiety, depression, and post-traumatic stress disorder (PTSD), the PASARR completed on admission listed anxiety, depression, and dementia with sertraline and quetiapine, but did not include the PTSD diagnosis or the antidepressant Pristiq, despite the admission MDS and care plan documenting PTSD and a subsequent physician’s order for Pristiq. For another resident with Alzheimer’s disease, borderline personality disorder, delusional disorder, schizoaffective disorder, and depression, the PASARR only reflected depression and dementia with sertraline, even though additional mental health diagnoses were added later and an antipsychotic (quetiapine) was ordered for borderline personality disorder, and the quarterly MDS documented psychotic disorder, schizophrenia, and depression with antipsychotic and antidepressant use. A third resident had diagnoses including Alzheimer’s disease, depression, anxiety disorder, irritability and anger, and nonrheumatic aortic valve stenosis. The PASARR for this resident listed dementia and anxiety with Risperdal but omitted the diagnosis of depression and the medications escitalopram and lorazepam, although physician’s orders were in place for escitalopram for depression and lorazepam for anxiety, and the admission MDS documented depression with antianxiety and antidepressant use. Interviews with the Assistant Director of Nursing confirmed that new Level I PASARR screens should have been completed when new mental health diagnoses and psychoactive medications were added, and that the PASARR for one resident, completed prior to arrival, should have included all mental health diagnoses and medications. The facility’s own policy required notification of the state mental health authority within 14 days after a significant change in mental condition and specified that a new Level I screen is required for new mental health diagnoses or newly prescribed psychotropic medications, which was not followed in these cases.
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