Majestic Care Of North Vernon
Inspection history, citations, penalties and survey trends for this long-term care facility in North Vernon, Indiana.
- Location
- 701 Henry Street, North Vernon, Indiana 47265
- CMS Provider Number
- 155665
- Inspections on file
- 49
- Latest survey
- March 24, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Majestic Care Of North Vernon during CMS and state inspections, most recent first.
A resident with non-Alzheimer’s dementia and moderate cognitive impairment alleged that another resident hit her shoulder and reported this to nursing and social services staff. An RN heard the resident yell that she had been hit, briefly checked her shoulder without a full skin assessment, and did not notify the Administrator or DON. The Social Services Director documented a soft file investigation after the resident reported being hit while holding her shoulder, but did not report the allegation to facility leadership or the Department of Health. The Administrator stated he was not informed until several days later, despite facility policy requiring care team members to immediately report all such allegations to the Administrator and the Department of Health.
Surveyors found that the facility failed to dispose of Ozempic pens for two residents after discharge, contrary to facility policy and pharmaceutical waste requirements. The DON stated refrigerated meds were kept in the Unit C med room and that Ozempic was no longer stored in her office, but surveyors observed three Ozempic pens in a small refrigerator in the DON’s office, labeled for two residents who were no longer in the facility. Record review showed both residents were cognitively intact, had DM and anxiety, and had Ozempic orders that had been discontinued, with pharmacy records indicating remaining doses and no documented disposal. The DON later acknowledged that these medications should have been discarded earlier.
Medications and vaccines, including Ozempic, Prevnar 20, and RSV vaccine, were found stored in a miniature refrigerator in the DON’s office together with personal food and drink items, contrary to facility policy requiring all medications to be stored in the pharmacy and/or medication rooms under appropriate conditions for sanitation, segregation, and security. The DON acknowledged forgetting the medications were in the refrigerator and stated that resident medications should not be stored with personal food.
Surveyors found that water temperatures in several resident and common area bathrooms exceeded safe limits, with some readings as high as 134.5°F. The Women's Visitor Restroom, accessible to residents and the public, had water that was hot to the touch. Temperature logs showed inconsistent monitoring, and interviews with the Administrator and DON revealed no prior reports of burns or concerns related to hot water.
A resident with a right arm contracture and multiple comorbidities suffered a fracture after a contracted x-ray technician attempted to reposition her arm without adequate staff assistance, despite the resident's pain and inability to move the limb. The technician did not follow required procedures for seeking help from facility staff, and the resident's pain increased following the incident, with later imaging confirming fractures that required orthopedic intervention.
A resident with moderate cognitive impairment was denied cornbread and milk by an LPN after being told not to stand up while the LPN retrieved the items. When the resident stood up, the LPN discarded the food and drink, failing to treat the resident with respect and dignity as required by facility policy. The incident was witnessed by a CNA and reported by the resident's relative.
A CNA failed to follow hand hygiene protocols while serving meals, including touching her face and handling food items without sanitizing hands between actions. In the kitchen, an aide prepared drinks without a beard net, and expired or unlabeled food items were found in the refrigerators, all in violation of facility policies.
Surveyors identified infection control deficiencies involving improper wound care technique by an LPN, who failed to change gloves after touching contaminated items and did not rinse a wound as ordered, as well as multiple instances where residents' indwelling urinary catheter bags were observed dragging on or resting directly on the floor. These lapses occurred despite facility policies requiring proper hand hygiene and catheter care, and were confirmed through staff interviews and resident record reviews.
Staff left medications unattended at the bedside for two residents who had not been assessed or approved for self-administration. Both residents were cognitively intact but had not been cleared to self-administer, and facility policy prohibits leaving medications unless a resident is assessed as safe. The DON confirmed that no residents were currently approved for self-administration, and both residents' records indicated they required assistance with medication administration.
A resident with multiple diagnoses, including a history of UTIs and an indwelling catheter, received daily prophylactic Cephalexin per physician order, but the care plan was not updated to reflect this ongoing antibiotic regimen. The DON confirmed the omission, which was not in accordance with facility policy requiring comprehensive care plans to include all services provided.
Three residents received cardiac medications despite physician orders specifying hold parameters based on blood pressure readings. In multiple instances, medications such as Midodrine and Losartan were administered when residents' systolic blood pressure readings were outside the prescribed limits. Documentation and staff interviews confirmed that these medications were given contrary to both physician orders and facility policy.
A resident with an indwelling urinary catheter and a history of stroke, diabetes, and renal insufficiency was observed on multiple occasions with the catheter drainage bag resting on the floor, contrary to facility policy and professional standards. The resident was receiving prophylactic antibiotics for recurrent UTIs, and staff confirmed that catheter components should not touch the floor.
A nurse crushed and administered a Potassium Chloride Extended-Release tablet to a resident despite a physician's order specifying the tablet should not be crushed, but instead placed in applesauce to dissolve. The DON confirmed that staff should not crush medications with 'do not crush' instructions, in accordance with facility policy.
Surveyors found that multiple medication carts contained undated or improperly labeled medications, including insulins and inhalers, for several residents. An LPN and the DON confirmed that medications such as insulin and inhalers should be dated upon opening and stored according to policy, but this was not consistently done, resulting in a deficiency in medication management.
A facility failed to notify a physician of a change in condition for a resident with severe cognitive impairment and multiple diagnoses. The resident was lethargic and later found unresponsive without a pulse, but there was no documentation of physician notification. The facility's policy required such notification, which was not followed.
A facility failed to report an allegation of verbal abuse in a timely manner. An LPN was reported to have been verbally abusive to a resident, but the incident was not reported to the Department of Health until several days later. The investigation was conducted over the phone and lacked interviews with the resident or other residents, leading to a deficiency.
A facility failed to properly investigate an abuse allegation involving a resident and an LPN. Staff reported the LPN was verbally abusive, but the DON did not conduct a thorough investigation, relying on phone communication and failing to interview the resident or other residents. The investigation did not adhere to the facility's policy, leading to a noted deficiency.
The facility failed to maintain proper storage in resident snack refrigerators, with an ice pack used by a resident found unlabeled in the C-Hall freezer, and another ice pack stored next to ice cream in the A-Hall freezer. Additionally, an opened, unlabeled pudding cup was found in the D-Hall refrigerator. The DON confirmed that these items should be labeled and stored according to facility policies.
The facility failed to maintain a homelike environment due to persistent strong urine odors in the B-Hall secured unit, affecting the hallway, dining room, and common areas. Staff interviews revealed challenges in managing the odor, with maintenance and housekeeping efforts proving insufficient. The facility's policy on resident rights emphasizes a clean and comfortable environment, which was not upheld.
Failure to Timely Report Resident Abuse Allegation to Required Authorities
Penalty
Summary
The deficiency involves the facility’s failure to timely report and properly document a resident’s allegation of abuse to required facility leadership and external authorities. A resident with non-Alzheimer’s dementia and moderate cognitive impairment (Resident C) reported that another resident (Resident F) hit her left shoulder. She stated she informed a nurse and another staff member at the front of the building, and the nurse told her she would be okay. An RN heard a resident yell, “He hit me,” and found Resident C in front of the nurse’s station. The RN took Resident C back to her room, visually checked her shoulder, found no marks, did not complete a full skin assessment, and did not notify the Administrator or DON of the allegation. An LPN reported that in situations where a resident claims to be hit by another resident, she would verbally report to the Administrator and DON, and that floor staff do not document such occurrences, leaving documentation to management. The Administrator stated he was not informed of the incident until several days after it occurred. The Social Services Director reported that Resident C came to her holding her left shoulder and stating she had been hit by Resident F. The Social Services Director interviewed staff and created a “soft file” investigation document dated 03/20/2026, but did not report the allegation to the Administrator or DON. Review of the facility’s abuse policy, revised 06/05/2025, showed that care team members are required to immediately report all such allegations to the Administrator and to the Department of Health in accordance with the policy’s procedures. Despite multiple staff being informed of the allegation, the required immediate reporting to facility leadership and the Department of Health did not occur, and the Administrator only became aware of the allegation days later, at which point he had just begun his own investigation.
Failure to Dispose of Discharged Residents’ Ozempic as Required
Penalty
Summary
Surveyors identified a deficiency in the facility’s pharmaceutical services when medications belonging to two discharged residents were found stored in the DON’s office refrigerator instead of being disposed of. During an interview and observation, the DON initially stated that refrigerated medications were kept in the Unit C medication room refrigerator and that Ozempic was no longer stored in her office. However, surveyors observed a miniature refrigerator in the DON’s office containing three Ozempic pens: two labeled for one resident and one for another, both of whom the DON confirmed had been discharged. Facility policy on medication storage required routine inspection by the consultant pharmacist for discontinued medications, and the hazardous waste policy required management of all pharmaceutical waste as hazardous in accordance with applicable regulations. Record review showed that one resident, cognitively intact and diagnosed with diabetes mellitus and anxiety, had Ozempic orders that were discontinued on two separate occasions, with documentation indicating remaining doses at the time of last administration and no documentation of disposal. This resident had a discharge-return not anticipated assessment completed, and the Ozempic order was discontinued on the date of discharge. The second resident, also cognitively intact with diabetes mellitus and anxiety, had an Ozempic order discontinued while still in the facility and later passed away; pharmacy records indicated remaining doses after the last administration. During a subsequent interview, the DON acknowledged that the Ozempic medications for both residents should have been discarded earlier, confirming that the medications were not disposed of after discharge as required by policy and regulatory expectations.
Improper Storage of Medications and Vaccines in DON Office Refrigerator
Penalty
Summary
Surveyors observed that medications and vaccines were improperly stored in the DON’s office in a miniature refrigerator that also contained personal food and drink items. During the observation, the refrigerator held Ozempic, two single-dose vials of Prevnar 20 (pneumococcal 20-valent vaccine), and two single-dose vials of RSV vaccine alongside an unopened individually wrapped sandwich, a half-full dressing bottle, four unopened 12-ounce cans of lemonade, a three-quarters full bottle of water, and a personal water bottle. In an interview, the DON stated she had forgotten that the medications were in her refrigerator and acknowledged that resident medications should never be stored with personal food items. Review of the facility’s Medication Storage policy, last reviewed on 12/12/2023, indicated that all medications housed on the premises were to be stored in the pharmacy and/or medication rooms to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security, which was not followed in this instance. This citation relates to Intake 2791258 and 410 IAC 16.2-3.1-25(o).
Unsafe Water Temperatures in Resident and Common Area Bathrooms
Penalty
Summary
The facility failed to maintain safe water temperatures in 5 out of 9 resident bathrooms and 1 out of 2 common area bathrooms. During observations, water temperatures in these areas were found to be significantly above the recommended maximum, with readings ranging from 122.5 to 134.5 degrees Fahrenheit. The Women's Visitor Restroom, accessible to residents and the public, had water that was hot to the touch and could not be held under the hand. The Maintenance Director confirmed that the restroom had its own on-demand water heater, which had been tampered with despite a warning tape placed over the temperature dial. The restroom was generally unlocked and accessible except when in use. Temperature logs for September and October showed that water temperatures were within the acceptable range on certain dates, but there were gaps in the logs and no other dated records were provided. Interviews with the Administrator and DON indicated that there had been no reported burns or concerns related to hot water temperatures prior to the survey. The facility's policy required water temperatures to be maintained within the state's allowable range, but this was not consistently achieved in the areas observed.
Failure to Ensure Safe X-Ray Positioning Results in Resident Arm Fracture
Penalty
Summary
A resident with a history of stroke, contracture of the right arm, diabetes, hypertension, neurogenic bladder, arthritis, aphasia, and osteoporosis experienced significant pain and ultimately a fracture following an x-ray procedure performed by a contracted x-ray technician. The resident was cognitively intact but had physical impairments and required complete assistance for activities of daily living. The x-ray was ordered due to redness, swelling, and pain in both elbows, and the resident was being treated for possible cellulitis at the time. During the x-ray procedure, the technician attempted to reposition the resident's contracted right arm without adequate assistance from facility staff, despite the resident's inability to move the arm due to the contracture. The resident cried out in pain during the procedure, which was heard by a registered nurse who intervened and stopped the technician from further manipulating the arm. The technician stated that she could not obtain the necessary images without straightening the arm, but did not request or wait for staff assistance as required by the x-ray company's own procedures. Facility staff were not present in the room during the initial attempt, and the technician did not seek help despite the resident's obvious physical limitations and pain. Following the incident, the resident continued to experience increased pain in the right arm, which was not relieved by Tylenol and later required stronger pain management. Subsequent x-rays revealed fractures in the right arm, and the resident was referred to an orthopedic physician for casting. Interviews with facility staff and review of the x-ray company's procedures confirmed that facility staff assistance was required for repositioning residents with significant physical limitations, but this protocol was not followed during the incident.
Resident Denied Food and Drink as Punishment by LPN
Penalty
Summary
A deficiency occurred when a resident, who was moderately cognitively impaired and had diagnoses including hypertension, arthritis, and gastroesophageal reflux disease, was not treated with respect and dignity by a staff member. The incident began when the resident requested her cornbread, which had been saved from lunch, to be microwaved. An LPN agreed to do so and instructed the resident not to stand up while she was gone. Upon returning, the LPN observed the resident standing and, as a result, refused to give her the cornbread and milk, discarding both items in the trash. This action was witnessed by a CNA, who reported the event to her superiors. The resident later recounted the same sequence of events to the Social Service Director, and a facility document corroborated the details of the incident. The facility's policy on dignity requires that all residents be treated with respect and that their rights be protected and promoted. However, in this case, the LPN's actions—specifically, withholding food and drink as a consequence for the resident's movement and discarding the items—demonstrated a failure to uphold these standards. The incident was reported by both staff and the resident's relative, and documentation confirmed the resident's account of being denied food and drink in a manner that did not maintain her dignity.
Deficiencies in Hand Hygiene, Food Storage, and Staff Attire
Penalty
Summary
A Certified Nurse Aide (CNA) was observed during meal service in the D-Hall Dining Room engaging in multiple lapses in hand hygiene. The CNA pushed a chair, touched her nose, face, and ear, and then proceeded to serve a meal tray to a resident without performing hand hygiene between these actions. She handled the resident's plate, napkin, silverware, and food items directly before the resident began eating. The CNA later used hand sanitizer before serving another tray, but facility policy required the use of hand sanitizer after each tray and prohibited staff from touching themselves before serving meals. The CNA confirmed during an interview that these procedures were not followed as required. In the kitchen, an Activity Aide was observed preparing drinks without a beard net, despite having a long beard that was not restrained, contrary to facility policy. Additionally, the kitchen refrigerators contained several food items that were either undated, expired, or not properly labeled, including tuna salad, Dijon pork, milk, and tomato juice. The Assistant Dietary Manager confirmed that these items should have been labeled and discarded according to facility policy, and that the staff member's beard should have been covered while in the kitchen.
Infection Control Failures in Wound Care and Catheter Management
Penalty
Summary
Surveyors observed multiple failures in infection prevention and control practices involving wound care and indwelling urinary catheter management for four residents. During a wound dressing change for a resident with a severe cognitive impairment and a history of stroke, hypertension, and neurogenic bladder, an LPN donned gloves and then touched potentially contaminated items, such as her pocket and treatment cart keys, before handling wound care supplies. The LPN did not change gloves after these contacts, failed to rinse the wound thoroughly after applying Hibiclens as ordered, and touched sterile gauze pads with contaminated gloves. The facility's hand hygiene policy required handwashing or use of alcohol-based hand rub after contact with objects in the resident's vicinity, which was not followed. For three other residents with indwelling urinary catheters, surveyors observed that the catheter drainage bags were either dragging on the floor or resting directly on the bare floor in multiple locations and at different times. One resident's catheter bag was seen dragging on the floor while she was in the dining room and being transported through hallways. Another resident's catheter bag was observed with two to three inches in direct contact with the floor while he was in bed, and a third resident's catheter bag was repeatedly seen with about one inch resting on the floor while she sat in her recliner. Staff interviews confirmed that catheter bags should not be in contact with the floor, and the facility's policy required appropriate care in accordance with professional standards. The clinical records for the affected residents indicated significant medical histories, including diabetes, acute neurological disorders, stroke, benign prostatic hyperplasia, and neurogenic bladder. Observations and interviews confirmed that staff did not adhere to established infection control protocols for both wound care and catheter management, as required by facility policy and professional standards.
Medications Left Unattended for Residents Not Assessed for Self-Administration
Penalty
Summary
Facility staff left medications unattended at the bedside of two residents who had not been assessed or approved for self-administration of medications. In one instance, a resident was observed sitting on her bed with three medication cups containing various pills left on her bedside table. The resident confirmed the medications were hers and that the nurse had left them for her to take, with no staff present in or near the room. Review of her clinical record showed she was cognitively intact but had diagnoses including hypertension, heart failure, dementia, anxiety, and depression. The DON confirmed that the resident did not have a self-administration assessment and was not considered safe to self-administer medications. Facility policy prohibits leaving medications unattended unless a resident has been assessed as safe to self-administer. In another case, a resident was found reclining on her bed with a medication cup containing a half tablet and a capsule on her overbed table. The resident stated that sometimes staff left medications at her bedside and sometimes supervised her taking them, depending on whether the staff member was familiar with her. No staff were present in the immediate area at the time. Her clinical record indicated she was cognitively intact with diagnoses including stroke, anxiety, depression, and respiratory failure. The DON stated that there were no residents in the facility currently approved to self-administer medications, and the resident's assessment indicated she required assistance with medication administration.
Failure to Update Care Plan for Prophylactic Antibiotic Use
Penalty
Summary
The facility failed to revise the care plan for a resident who was receiving a prophylactic antibiotic for recurrent urinary tract infections (UTIs). The resident, who was moderately cognitively impaired and had diagnoses including stroke, diabetes, renal insufficiency, and an indwelling urinary catheter, had a physician's order for daily Cephalexin starting from 02/13/25. Review of the resident's medication administration records confirmed that the antibiotic was administered daily over several months. Despite the ongoing use of the prophylactic antibiotic, the resident's comprehensive care plan did not include any information regarding this medication regimen. The Director of Nursing confirmed that the care plan should have been updated to reflect the prophylactic antibiotic use, as ordered by the resident's urologist. Facility policy requires that the comprehensive care plan describe all services provided to maintain the resident's highest practicable well-being, but this was not done in this case.
Failure to Follow Physician Orders for Cardiac Medication Hold Parameters
Penalty
Summary
The facility failed to follow physician's orders regarding hold parameters for cardiac medications for three residents. For one resident with a history of stroke, hypertension, and coronary artery disease, the physician's order specified that Midodrine should be held if the systolic blood pressure exceeded 120. However, the medication was administered multiple times when the resident's systolic blood pressure was above this threshold, as documented in the Electronic Medication Administration Record (EMAR). Another resident, diagnosed with diabetes, hypertension, neurogenic bladder, and aphasia, had a physician's order for Losartan to be held if the systolic blood pressure was less than 120 or the heart rate was less than 60. Despite this, the EMAR showed that the medication was given on several occasions when the resident's systolic blood pressure was below 120. This pattern was observed over several months, indicating a repeated failure to adhere to the specified hold parameters. A third resident, with multiple diagnoses including amputation, anemia, hypertension, and diabetes, also had a physician's order for Midodrine to be held if the systolic blood pressure was greater than 120. The EMAR revealed that the medication was administered on numerous occasions when the resident's systolic blood pressure exceeded the prescribed limit. During an interview, an LPN stated that medications with hold parameters should not be administered if vital signs are outside the specified range, and the facility's policy confirmed this requirement. Despite this, the records demonstrated that staff did not consistently follow these orders.
Improper Placement of Urinary Catheter Drainage Bag
Penalty
Summary
A deficiency was identified when a resident with an indwelling urinary catheter, who was receiving prophylactic antibiotics for recurrent urinary tract infections, was observed with improper catheter drainage bag placement on multiple occasions. On one occasion, the drainage bag was seen hanging on the side of the bed with about two inches of the bag resting on the bare floor. On another occasion, the drainage bag was observed hanging under the resident's wheelchair, with about an inch of the bag touching the floor. In both instances, the urine in the tubing was noted to be dark yellow with sediment. The resident involved had a history of stroke, diabetes, and renal insufficiency, and was assessed as moderately cognitively impaired. Facility staff, including the Corporate Clinical Support Nurse, confirmed that no part of an indwelling catheter should be in contact with the floor. The facility's policy on indwelling catheters also required adherence to professional standards of practice, which were not followed in these observed instances.
Failure to Follow 'Do Not Crush' Medication Order
Penalty
Summary
A registered nurse prepared and administered medications to a resident, including Potassium Chloride Extended-Release 10 MEQ, by crushing all the medications together and mixing them with applesauce before administration. The physician's order for the Potassium Chloride specifically instructed that the tablet was not to be crushed, but rather placed in applesauce and allowed to dissolve. The nurse did not follow these instructions and crushed the tablet. The Director of Nursing confirmed that medications with 'do not crush' instructions should not be crushed. Facility policy also required staff to administer medications as ordered and not to crush medications labeled with 'do not crush' instructions.
Failure to Properly Label and Store Medications on Medication Carts
Penalty
Summary
Surveyors observed that the facility failed to store and label medications in accordance with professional standards on three of four medication carts. Specifically, on the A-Hall medication cart, an unopened vial of insulin Lispro for one resident was found undated, and two inhalers (Symbicort and Albuterol) for another resident were opened but not dated. On the B-Hall medication cart, a Combivent inhaler for a resident was present and dated, but the report does not specify if the date was appropriate. On the C-Hall medication cart, an opened vial of Humalog insulin for a resident was found undated, with the nurse indicating it had just been labeled with the pharmacy delivery date at the time of observation. During interviews, the DON confirmed that all insulins in the medication cart should be dated, and unopened insulins should be stored in the refrigerator. The DON also stated that inhalers such as Albuterol, Symbicort, and Combivent have specific expiration periods after opening and should be dated accordingly, with undated inhalers being discarded after their expiration. The facility's policy on product expiration dates was provided, confirming these requirements. The failure to date and properly store these medications constituted a deficiency in medication management.
Failure to Notify Physician of Change in Resident's Condition
Penalty
Summary
The facility failed to notify the physician of a change in condition for a resident, identified as Resident B, who was severely cognitively impaired with diagnoses including non-Alzheimer's dementia, hypertension, anxiety, and depression. On January 30, 2024, Resident B was documented to have eaten less than a quarter of his meals at both 10:50 A.M. and 1:50 P.M. Later that day, at 4:30 P.M., a progress note by an RN indicated that Resident B was lethargic. However, there was no documentation of the physician being notified of this change in condition. Subsequently, at 7:19 P.M., an LPN documented that Resident B was found unresponsive and without a pulse at 6:05 P.M. During interviews, the RN could not recall the resident or provide additional information beyond her documentation. The Director of Nursing confirmed that there was no documentation of physician notification on January 30, 2024, and the last recorded notification of change for Resident B was on November 7, 2023. The facility's policy required nurses to notify the physician of significant changes in a resident's condition, which was not adhered to in this case.
Failure to Timely Report Allegation of Verbal Abuse
Penalty
Summary
The facility failed to report an allegation of verbal abuse in a timely manner for a resident. The incident involved a Licensed Practical Nurse (LPN) who was reported to have been verbally abusive to a resident by yelling and using inappropriate language. The incident was witnessed by other staff members who reported it to the Director of Nursing (DON). Despite the report, the DON did not immediately come to the facility and conducted the investigation over the phone. The investigation was deemed insufficient as it lacked interviews with the resident involved or any other residents in the facility. The facility's policy requires that any allegations of abuse be reported to the Department of Health immediately, but no later than two hours after the allegation is made. However, the incident was not reported to the Indiana Department of Health until several days later. The DON initially determined that abuse had not occurred and allowed the nurse to finish her shift. It was only after consulting with the new Executive Director and Clinical Support Nurse that the incident was reported. The delay in reporting and the inadequate investigation process led to the deficiency.
Failure to Investigate Allegation of Abuse
Penalty
Summary
The facility failed to appropriately investigate an allegation of abuse involving a resident, identified as Resident C, and a Licensed Practical Nurse (LPN). On the date of the incident, multiple staff members reported that the LPN was verbally abusive towards Resident C, yelling and using inappropriate language. Despite these reports, the Director of Nursing (DON) did not conduct a thorough investigation. The DON was informed of the incident and initiated an investigation via phone without coming to the facility. The investigation lacked interviews with Resident C and other residents, which is contrary to the facility's policy that requires interviewing the resident, the accused, and all witnesses. The DON relied on the Executive Director's assessment that the LPN was merely stern with the resident, and the LPN was allowed to finish her shift. The investigation report showed that only staff members were interviewed, and there was no documentation of interviews with Resident C or other residents who might have been affected. The facility's policy mandates a comprehensive investigation process, including interviews with all involved parties, which was not followed in this case. This failure to conduct a proper investigation led to the deficiency noted in the report.
Improper Storage Practices in Resident Snack Refrigerators
Penalty
Summary
The facility failed to maintain proper storage practices in residents' snack refrigerators, as observed during a survey. In the C-Hall snack refrigerator, an ice pack used by Resident 67 for shoulder pain was found lying in the bottom bin of the freezer, without a label or date. The nurse acknowledged that resident items should be labeled with a name and date. In the A-Hall snack refrigerator, six small tubs of ice cream were stored next to a large blue ice pack belonging to a discharged resident who had used it post-knee replacement surgery. This indicates a lack of adherence to proper storage protocols for resident-specific items. Additionally, the D-Hall snack refrigerator contained an opened, half-full pudding cup that was not labeled. During an interview, the DON confirmed that opened pudding used for medication administration should be labeled and stored correctly. The facility's current policies on refrigerator and freezer maintenance, as well as food brought in by family or visitors, emphasize the importance of safe food handling and proper labeling. However, these policies were not followed, leading to the observed deficiencies.
Persistent Urine Odor in B-Hall Secured Unit
Penalty
Summary
The facility failed to provide a homelike environment due to persistent strong urine odors in the B-Hall secured unit, as observed by surveyors on multiple occasions. The odor was noted in various areas, including the hallway, dining room, and common areas, and was particularly strong during mealtimes. A sticky substance with a foul urine odor was also found on the floor near the jukebox in the common area, causing resistance when walking. Additionally, a resident's room was noted to have a strong urine smell, with the bedding removed and the bed left bare. Interviews with staff revealed ongoing challenges in managing the urine odor. The Head of Maintenance acknowledged efforts to control the smell, including the installation of new ventilation systems, but noted that the system was less effective in the secured unit due to closed doors. A CNA reported issues with residents urinating on the floor, while the housekeeping supervisor indicated difficulties in maintaining cleanliness due to the frequency of urination by certain residents. Despite efforts to mop regularly, the odor persisted, and previous issues with dining room recliners retaining urine odor had been addressed by replacing them. The facility's policy on resident rights emphasizes the importance of a safe, clean, and comfortable environment, which was not upheld in this instance.
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Surveyors observed that dietary staff repeatedly worked in kitchen and meal service areas with uncovered facial hair, despite facility policy and state sanitation requirements mandating effective hair restraints. Two dietary aides with short beards or mustaches were seen walking through food preparation areas, taking food temperatures, handling food, and plating meals at steamtables in dining rooms without any facial hair coverings, while the current policy required all hair, including facial hair, to be restrained to prevent contamination.
The facility failed to consistently provide and document required bed-hold policy notices when several residents were transferred to the hospital. In multiple cases, residents with dementia, psychotic disorders, COPD, chronic respiratory failure, altered mental status, and cerebral infarction were sent out for acute changes in condition, and while transfer notes reflected physician and family notifications, they lacked documentation that the bed-hold policy was discussed with the resident or responsible party. Notices of Transfer or Discharge often indicated a copy of the bed-hold policy was sent with the resident, but the records did not show signed and dated acknowledgment by the resident or appropriate representative, including in situations where a resident had moderate cognitive impairment, short-term memory issues, or a documented need for a proxy and a financial POA authorizing an agent for health care decisions.
Surveyors found that the facility failed to provide trauma‑informed and culturally competent care by not incorporating two residents’ extensive trauma histories and specific behavioral triggers into their care plans. One resident with documented homelessness, polysubstance abuse, severe accidents with multiple fractures, viral encephalitis with coma, physical and sexual abuse, loss of family contact, and a past suicide attempt had multiple behavior‑focused care plans that referenced identifying triggers but listed none and did not mention their physical, sexual, medical, or psychosocial trauma. Another resident with TBI from being struck by a truck, an 11‑month coma, long‑term state hospital residence, alleged shooting of a parent, and diagnoses including intermittent explosive disorder and borderline personality disorder had a PASRR identifying a specific trigger and notes of inappropriate sexual behavior, yet their care plans omitted these traumatic events, the identified trigger, and the sexual behavior. Staff interviews confirmed that residents were screened for trauma, but the trauma histories and triggers were not reflected in the individualized plans of care.
A resident with schizophrenia, post‑stroke hemiparesis, and mild cognitive impairment expressed feeling down and wanting to kill himself, but staff did not document asking about a specific plan, did not notify the physician or psychiatric NP as expected, and did not develop or update a care plan addressing depression or suicidal ideation. The SSD documented offering support and initiating 15‑minute checks once, but there was no further follow‑up or documentation of interventions after subsequent suicidal statements made in a care plan meeting with the resident’s father. The DON and Administrator reported that facility policy requires immediate notification of key staff, assessment for a plan and means of self‑harm, and thorough documentation, which were not carried out or reflected in the medical record for this resident.
A resident with schizophrenia, post-stroke hemiparesis, and mild cognitive impairment verbalized suicidal ideation, but the care plan did not address depression or suicidal thoughts, and required assessments and services were not accurately or timely documented. An SSD note recorded the resident saying he wanted to kill himself and referenced 15‑minute checks and a care plan update, yet the active care plan lacked depression/suicidal ideation interventions. Multiple late-entry Social Services notes were later added, describing follow-up visits and the resident denying suicidal ideation, but the SSD later reported she did not typically ask about a suicide plan and did not personally provide individual follow-up visits as described. These practices conflicted with the facility’s policy requiring factual, first-hand, and timely documentation of assessments and services.
A resident was observed with an Albuterol inhaler on an overbed table and later reported keeping the inhaler in a nightstand drawer, with no staff present during these observations. Record review showed the resident had no cognitive impairment on the admission MDS but lacked any documented self-medication administration assessment. The DON acknowledged that the required assessment had not been completed, despite facility policy requiring staff and the practitioner to evaluate each resident’s mental and physical abilities before allowing self-administration of medications.
Surveyors found that the facility submitted inaccurate direct care staffing data to CMS through the PBJ system over multiple days in a quarter. CASPER reports showed apparent gaps in 24-hour licensed nurse coverage, low weekend staffing, and a 1-star staffing rating, while internal staffing sheets documented that licensed nurses were present and the facility was fully staffed on those days. The Administrator reported that the discrepancies were due to PBJ data entry errors, despite a facility policy requiring all PBJ entries to be accurate, auditable, and verifiable against payroll, invoices, or contracts.
Surveyors found that the facility did not provide or document required written transfer/discharge notices and bed-hold policy information for four residents who were sent to the hospital, including individuals with conditions such as dementia, CHF, chronic respiratory failure, and CKD. In each case, progress notes showed that the resident was transferred for acute issues, but the clinical records lacked evidence that written notices were given to the residents or their representatives, and in one case lacked documentation that required information was sent to the receiving provider. Facility leadership, including the ADON, DON, and Administrator, acknowledged that the records did not contain the required documentation, despite a written policy requiring such notices and information exchange.
A resident with Alzheimer’s disease and depression, previously on an antidepressant, exhibited intermittent refusals of medications and care, occasional yelling at staff, and reports of unusual perceptions, such as believing men were in or near her room. Nursing notes over several months documented these refusals and complaints but did not show that the behaviors were evaluated or recorded as dangerous, non-redirectable, or causing significant distress, nor did they document specific non-pharmacological interventions attempted or their outcomes. Despite this, a psychiatric NP later added new diagnoses of schizoaffective disorder, borderline personality disorder, and delusional disorder and ordered an antipsychotic (Seroquel) without a comprehensive evaluation in the record to support these diagnoses. The facility’s psychotropic medication policy, which requires identification and documentation of target behaviors, use of nonpharmacological interventions, and ongoing behavior monitoring, was not followed for this resident.
The facility failed to keep PASARR Level I screenings accurate and current for three residents when new mental health diagnoses and psychoactive medications were initiated. One resident’s PASARR omitted a PTSD diagnosis and an added antidepressant, despite documentation of PTSD on the MDS and care plan and a physician order for Pristiq. Another resident’s PASARR listed only depression and dementia, even after additional diagnoses such as borderline personality disorder, delusional disorder, and schizoaffective disorder were added and an antipsychotic (quetiapine) was ordered, with the MDS later reflecting psychotic disorder, schizophrenia, and depression with antipsychotic and antidepressant use. A third resident’s PASARR did not include a depression diagnosis or newly ordered escitalopram and lorazepam, although the admission MDS documented depression with antianxiety and antidepressant use. These omissions occurred despite facility policy requiring a new Level I review after significant mental status changes, including new mental health diagnoses or new psychotropic medications.
Uncovered Facial Hair During Food Preparation and Meal Service
Penalty
Summary
The deficiency involves the facility’s failure to ensure that food was served in a sanitary and safe manner in accordance with professional standards and facility policy during multiple kitchen and meal service observations. During an initial kitchen observation, two dietary aides were seen walking through the kitchen food preparation area with uncovered facial hair. One aide had facial hair above and below the lip and along the jaw line, approximately one-fourth inch in length, and the other had a mustache of similar length; neither used any facial hair covering. These observations occurred while staff were present in the kitchen area where food was stored and prepared. During subsequent observations on the same day, the same two dietary aides were again observed with uncovered facial hair while directly involved in meal preparation and service. One aide walked through the kitchen while the noon meal was being prepared and placed into a transport cart for service in the south dining room, and later was observed plating the noon meal at the steamtable in that dining room, still without a facial hair covering. The other aide walked through the kitchen while the noon meal was being prepared and placed into the steamtable for the north dining room, took food temperatures, assisted with plating meals at the steamtable, and retrieved food items and supplies from the kitchen, all while having an uncovered mustache approximately one-fourth inch in length. The Dietary Manager stated that staff hair was to be covered when in the kitchen and during meal service, and the facility’s written policy and the cited Indiana Food Establishment Sanitation Requirements both required effective hair restraints, including for facial hair, to prevent contamination of food, equipment, and utensils.
Failure to Provide and Document Bed-Hold Policy at Time of Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure that required bed-hold policy information was provided and documented for four residents transferred to the hospital. For a resident with dementia, psychotic disorder, and autistic disorder who had a BIMS score of 0 indicating severe cognitive impairment, progress notes documented physician notification and guardian notification when the resident was sent to the hospital, but there was no documentation that the bed-hold policy was provided to the responsible party. A Notice of Transfer or Discharge later indicated a copy of the bed-hold policy was sent with the resident. Another resident with COPD and chronic respiratory failure, cognitively intact with a BIMS score of 13, experienced a decline in condition and was transferred to the hospital by ambulance; progress notes documented family notification but did not document any discussion of the bed-hold policy, although a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident. A third resident with altered mental status and cerebral infarction, with a BIMS score of 10 indicating moderate cognitive impairment and documented short-term memory impairment, experienced changes in condition and was transferred to the hospital. Progress notes stated the resident was their own responsible party and that no other notification was completed, and transfer documentation did not include the bed-hold policy, although an untimed Notice of Transfer or Discharge indicated a copy of the bed-hold policy was signed by the resident. A financial power of attorney document in the record showed the resident had designated an agent to act in consent or refusal of health care. For a fourth resident with dementia and osteomyelitis, transfer documentation and a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident, and the transfer form noted the resident required a proxy for decision making. The facility’s policy required that at the time of transfer to a hospital, written notice specifying the duration of the bed-hold policy and information on return to the next available bed be provided, and that a signed and dated copy of the bed-hold notice given to the resident or representative be kept in the resident file, which was not consistently documented for these residents.
Failure to Integrate Trauma Histories and Behavioral Triggers Into Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to identify and incorporate residents’ trauma histories and specific behavioral triggers into their care plans, despite documented histories of significant trauma and behavioral health issues. For one resident, extensive social service and progress notes documented homelessness, polysubstance abuse, major depressive and anxiety disorders, chronic pain, a history of severe car accidents with multiple fractures, viral encephalitis resulting in a three‑month coma, loss of child custody, multiple divorces, physical abuse by a spouse, the death of a fiancé who was struck by a car while in a wheelchair, lack of family contact, and a past suicide attempt by Valium overdose. Additional documentation noted a history of rape by a brother at age eight and prior placement under direct supervision and 15‑minute checks related to suicidal ideation. Despite these documented traumatic events and behavioral health concerns, the resident’s care plans did not identify a history of physical trauma, sexual trauma, homelessness, substance abuse, medical trauma, or attempted suicide. For this same resident, the MDS showed no cognitive deficit and identified behaviors such as verbal aggression and rejection of care, along with diagnoses including seizure disorder, depression, chronic pain syndrome, homelessness, and anxiety disorder. Multiple care plans addressed behaviors such as drug‑seeking, pretending to have seizures for attention or medication, making false allegations, verbal aggression when unable to smoke, and a desire for intimate relationships with consenting male residents. These care plans referenced goals such as effective coping skills, seeking staff support, and compliance with the smoking policy, and they called for identification and reduction of behavioral triggers. However, none of these care plans actually listed any specific triggers. The care plan addressing the resident’s right to consensual intimate relationships focused on assessment and education regarding consent but did not integrate the resident’s extensive trauma history. Staff interviews indicated the resident had displayed sexual behaviors since admission, including an incident where the resident expressed anger at another resident for not buying a soda after engaging in sexual acts. A second resident with a documented history of traumatic brain injury (TBI), dementia, seizure disorder, borderline personality disorder, anxiety, intermittent explosive disorder, tobacco use, and other behavioral/emotional disorders was also affected by the same deficiency. Social history and progress notes documented that this resident sustained a TBI after being hit by a semi‑truck while riding a bicycle at age 18, resulting in an 11‑month coma, followed by 13 years in a state hospital and subsequent residence in a group home. Additional documentation indicated the resident allegedly shot their father at age 26 after being sworn at and had a PASRR identifying TBI, intermittent explosive disorder, and borderline personality disorder, with a specific trigger of hearing the name of the current U.S. President. Progress notes also described inappropriate sexual behavior toward staff, including touching themselves intimately during personal care and refusing to stop when redirected. Despite this, the resident’s care plans, which addressed explosive disorder and history of altercations, risk for decreased psychosocial well‑being, and refusal to bathe or shower, did not list any specific behavioral triggers, did not reference the traumatic events such as being hit by a truck or shooting their father, and did not document the inappropriate sexual behavior. The Administrator and Social Service Director acknowledged that residents were to be screened for trauma and that trauma responses and PTSD should be added to care plans, but the specific trauma histories and triggers for these two residents were not incorporated into their plans of care.
Failure to Assess and Care Plan for Resident Suicidal Ideation
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess, investigate, and care plan for a resident’s suicidal ideation in accordance with its own policy and staff expectations. The resident had diagnoses including schizophrenia, cerebral edema, and hemiparesis/hemiplegia following a cerebral infarction, and a current MDS showed mild cognitive impairment (BIMS score 12). A progress note documented that the resident told the Social Services Director (SSD) he was feeling down and wanted to kill himself; the SSD offered assistance, activities, and initiated 15‑minute checks, and the note stated the care plan was updated. However, the note did not indicate that the SSD asked whether the resident had a plan to kill himself, and there were no additional notes regarding suicidal ideation or follow‑up. Review of the current care plan showed no problem, goal, or interventions addressing depression or suicidal ideation, and progress notes over the following month contained no documentation of physician notification related to the suicidal statement. Further record and interview evidence showed that the care plan conference summary did not document interventions for suicidal ideation, and the SSD acknowledged she did not normally ask residents expressing suicidal ideation if they had a plan. The SSD reported that the resident had admission paperwork mentioning suicidal ideation related to depression after a stroke and that the resident again vocalized suicidal ideation during a care plan meeting with his father, after which emotional support was offered and the father took the resident out on a leave of absence; no further visits or follow‑up were done. The DON stated that, upon notification of suicidal verbalization, staff should assess the resident, ask if there is a plan, remove potential means of self‑harm, immediately notify the psychiatric NP, and document the occurrence, and that a detailed progress note and updated care plan were expected but not present for this resident. The Administrator similarly stated that staff should ask about a plan, document interventions, notify the physician and family, and update the care plan, and indicated the resident should have had a care plan addressing depression with suicidal ideation. The facility’s written policy required immediate notification of the DON, SSD, and physician, an interview including asking about a plan and assessing mood and means for self‑harm, and thorough documentation of mood, behavior, and all actions taken, which were not reflected in the resident’s record.
Incomplete and Inaccurate Documentation of Suicidal Ideation and Follow-Up
Penalty
Summary
The facility failed to ensure accurate, complete, and timely documentation of assessments and services for a resident who verbalized suicidal ideation. Resident 6, who had schizophrenia, cerebral edema, and right-sided hemiparesis/hemiplegia following a cerebral infarction, had a BIMS score of 12 indicating mild cognitive impairment. The resident’s admission paperwork mentioned suicidal ideation related to depression after a stroke, and a Social Services note on 3/11/2026 documented that the resident was feeling down and said he wanted to kill himself. The Social Services Director (SSD) documented that she talked with the resident, coordinated with Activities, advised the resident to contact SSD or nursing if he wanted to talk, and that the resident was scheduled for 15-minute checks and the care plan was updated. However, the current care plan initiated on 2/26/2026 did not address depression or suicidal ideation. Multiple Social Services progress notes were later entered as late entries in April, with effective dates in March, stating that the resident had no plan and no longer had suicidal ideation, that he felt much better after 1:1 time, and that he continued his daily routine and therapy. These late entries described follow-up visits and reassessments of suicidal ideation on several consecutive days, but in interviews the SSD stated she did not normally ask residents about having a plan when they verbalized suicidal ideation and did not recall any other occurrences beyond the initial event. She further indicated she did not personally provide individual follow-up visits with this resident regarding suicidal ideation, despite the late-entry notes describing such visits. The DON acknowledged that late entries had been added to address concern about suicidal verbalization, and the Administrator stated that upon suicidal statements staff should ask about a plan, notify the physician and family, and update the care plan, and that this resident should have had a care plan addressing depression with suicidal ideation. The facility’s documentation policy required factual, first-hand, timely documentation, which was not followed in this case.
Failure to Complete Required Self-Administration Assessment for Inhaler Kept at Bedside
Penalty
Summary
Surveyors identified that a resident was allowed to keep and access an Albuterol inhaler without the facility completing the required self-administration medication assessment. During an initial tour, the resident was observed sitting in a wheelchair with a handheld Albuterol inhaler on the overbed table and no staff present in the room or hallway. On a subsequent observation, the resident again was in a wheelchair and reported that the Albuterol inhaler was stored in the top drawer of the nightstand, where it was found. Review of the clinical record showed an admission MDS indicating no cognitive impairment, but there was no documentation of a self-medication administration assessment. In an interview, the DON confirmed that the resident did not have the required self-medication assessment, despite the facility’s policy stating that staff and the practitioner must assess each resident’s mental and physical abilities to determine whether self-administering medications is clinically appropriate. This failure to complete and document a self-administration medication assessment for a resident who had an Albuterol inhaler kept at bedside constituted noncompliance with the facility’s own policy and with 410 IAC 16.2-3.1-11(a).
Inaccurate PBJ Staffing Data Submission to CMS
Penalty
Summary
The deficiency involves the facility’s failure to electronically submit complete and accurate direct care staffing information to CMS through the Payroll-Based Journal (PBJ) system for 22 days in a fiscal quarter. A CASPER report review on 4/6/26 showed that, according to PBJ data, the facility did not have licensed nursing coverage 24 hours per day on multiple specific dates across three months, had low weekend staffing, and held a 1-star staffing rating. However, review of the facility’s internal staffing sheets for that quarter indicated the facility was fully staffed and had licensed nurse coverage on all of the dates in question. During an interview, the Administrator stated that the PBJ information must have contained data entry errors, as she had verified licensed staff coverage on the timesheets. The facility’s PBJ policy in effect stated that all staffing data entered into the PBJ system would be auditable and verifiable through payroll, invoices, or contracts, but the submitted PBJ data did not accurately reflect the facility’s actual licensed nurse staffing as documented on internal records. No specific residents or clinical conditions were mentioned in the report, and the deficiency centers solely on inaccurate staffing data submission rather than direct resident care events.
Failure to Provide and Document Required Transfer/Discharge and Bed-Hold Notices
Penalty
Summary
The deficiency involves the facility’s failure to provide and document required written notices of transfer/discharge and bed-hold policies, as well as required information to receiving providers, for four residents who were transferred or discharged to the hospital. For a resident with generalized anxiety disorder, major depressive disorder, and dementia, progress notes showed that the resident was sent to the hospital via 911 for chest pain, lower back pain, and shortness of breath and later returned to the facility, but the clinical record lacked documentation that a written Notice of Transfer/Discharge and the bed-hold policy were provided to the resident or representative, and lacked documentation that required information was conveyed to the receiving facility. The ADON and the Administrator both confirmed there was no documentation that these written notices were provided. For a resident with congestive heart failure and muscle weakness who was sent to the emergency room for painful urination and bloody urine, the clinical record lacked documentation that a Notice of Transfer/Discharge or bed-hold policy was given to the resident or representative, which the DON confirmed. Another resident with chronic respiratory failure and diabetes was discharged to the hospital for respiratory failure, and a resident with chronic kidney disease and dementia was discharged to the hospital, but in both cases there was no documentation that a written notice of transfer/discharge or bed-hold policy was provided to the residents or their representatives. Review of the facility’s Transfer and Discharge policy, dated 1/15/26, showed that the policy required the facility to provide written transfer/discharge notices and bed-hold information to residents and representatives and to provide specified information to receiving providers, but the records for these four residents did not contain the required documentation.
Failure to Document Target Behaviors and Non-Pharmacological Interventions Before Initiating Antipsychotic
Penalty
Summary
The deficiency involves the facility’s failure to document how a resident’s behaviors presented danger or distress to self or others, and failure to document non-pharmacological interventions attempted prior to initiating an antipsychotic medication. Resident 6 had documented diagnoses of Alzheimer’s disease, depression, and severe cognitive impairment, and was receiving sertraline for depression. A PASSAR identified only depression and dementia, and the admission MDS listed Alzheimer’s disease and depression as active diagnoses. Over several months, nursing progress notes documented that the resident intermittently reported unusual perceptions, such as believing there were men causing trouble, a man in her room, or a man wanting to marry her and yelling through the walls, but there was no documentation that these episodes caused danger to the resident or others or that they resulted in unmanageable distress. From late April through mid-July, nursing notes primarily described the resident’s frequent refusals of evening and morning medications, blood sugar checks, blood pressure checks, insulin administration, hygiene care, and showers. Staff documented that the resident sometimes yelled at staff, said “Get out!”, was visibly upset by a room move, was leery of staff and asked to see name badges, and became upset about a pillow under her head until it was removed, after which she calmed down. The notes also recorded instances where the resident believed housekeeping had not cleaned her room or that she had not received medications when she had. However, there were no progress notes or assessments indicating that these behaviors were evaluated as dangerous, non-redirectable, or causing significant distress or functional impairment, and no detailed behavior monitoring logs were present as required by facility policy. On a psychiatric NP visit for initial psychotropic medication management, new mental health diagnoses of schizoaffective disorder, borderline personality disorder, and delusional disorder were added, and Seroquel 25 mg, an antipsychotic, was ordered. The clinical record did not contain a comprehensive evaluation to support these new diagnoses, and there was no documentation of target behaviors meeting the facility’s policy criteria for psychotropic use, such as behaviors representing danger to self or others, causing distress and impairment in functional abilities, or clearly attributable to psychosis or mania. The resident’s representative reported that the resident had no prior history of mental health disorders or psychiatric hospitalization and was unaware of the new diagnoses. The facility’s own psychotropic medication policy required identification and documentation of specific target behaviors, use and documentation of nonpharmacological interventions, and ongoing monitoring of behaviors and interventions, which were not reflected in the record for this resident.
Failure to Update PASARR Screens for New Mental Health Diagnoses and Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that Preadmission Screening and Resident Review (PASARR) Level I screenings were accurate and updated when new mental health diagnoses and psychoactive medications were initiated for multiple residents. For one resident with dementia, anxiety, depression, and post-traumatic stress disorder (PTSD), the PASARR completed on admission listed anxiety, depression, and dementia with sertraline and quetiapine, but did not include the PTSD diagnosis or the antidepressant Pristiq, despite the admission MDS and care plan documenting PTSD and a subsequent physician’s order for Pristiq. For another resident with Alzheimer’s disease, borderline personality disorder, delusional disorder, schizoaffective disorder, and depression, the PASARR only reflected depression and dementia with sertraline, even though additional mental health diagnoses were added later and an antipsychotic (quetiapine) was ordered for borderline personality disorder, and the quarterly MDS documented psychotic disorder, schizophrenia, and depression with antipsychotic and antidepressant use. A third resident had diagnoses including Alzheimer’s disease, depression, anxiety disorder, irritability and anger, and nonrheumatic aortic valve stenosis. The PASARR for this resident listed dementia and anxiety with Risperdal but omitted the diagnosis of depression and the medications escitalopram and lorazepam, although physician’s orders were in place for escitalopram for depression and lorazepam for anxiety, and the admission MDS documented depression with antianxiety and antidepressant use. Interviews with the Assistant Director of Nursing confirmed that new Level I PASARR screens should have been completed when new mental health diagnoses and psychoactive medications were added, and that the PASARR for one resident, completed prior to arrival, should have included all mental health diagnoses and medications. The facility’s own policy required notification of the state mental health authority within 14 days after a significant change in mental condition and specified that a new Level I screen is required for new mental health diagnoses or newly prescribed psychotropic medications, which was not followed in these cases.
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