Richland Bean Blossom Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Ellettsville, Indiana.
- Location
- 5911 State Road 46, Ellettsville, Indiana 47429
- CMS Provider Number
- 155523
- Inspections on file
- 33
- Latest survey
- April 10, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Richland Bean Blossom Health Care Center during CMS and state inspections, most recent first.
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.
The facility failed to ensure timely electronic transmission of MDS assessment data to CMS for a resident. Record review showed an annual MDS that was more than 120 days overdue for submission. The MDS coordinator reported that two care area assessments on the annual MDS had remained incomplete until just before surveyor review, at which time the MDS was finished and submitted. The Administrator acknowledged there was no facility policy in place governing MDS transmissions.
Surveyors found that MDS assessments were inaccurately coded for two residents. One resident with a prior Level II PASARR for serious mental illness was incorrectly coded on the Annual MDS as not having a serious mental illness or related condition. Another resident with generalized anxiety disorder, major depressive disorder, and dementia, who was receiving Lorazepam for anxiety, was not coded with an active anxiety disorder diagnosis on the Quarterly MDS, despite active orders documented on the MAR. The MDS coordinator acknowledged both coding errors, and leadership reported there was no facility-specific MDS policy, relying instead on the RAI manual.
A resident with dementia and pain disorder did not receive proper reconciliation of narcotic pain medication when an LPN failed to follow facility procedures for accepting and documenting the delivery of oxycodone-acetaminophen. The medication was never located, and the required documentation was not completed as per facility policy.
Multiple residents reported that their bread often became soggy when served with wet items like corn, an issue that had been ongoing and communicated to staff several times. Observation of a meal tray confirmed that corn was placed under a hamburger bun and onion rings, causing them to become soggy. The Administrator acknowledged the problem, and the Dietary Manager was not previously aware of these concerns.
Residents repeatedly reported that wet foods served on the same plate as bread or sandwiches caused their meals to become soggy and unappetizing. Despite raising this issue in multiple resident council meetings and requesting separate dishware for liquid foods, the concern was not addressed. Direct observation confirmed the ongoing problem, and the Dietary Manager was unaware of the residents' complaints.
All residents on the secure dementia unit were left without a structured activities program for several months, as no activities schedule was posted or implemented. Residents were observed without engagement in planned activities, and staff only provided unscheduled activities inconsistently. The Executive Director confirmed the absence of a regular activities program, despite facility policy requiring one.
Staffing on the secured dementia unit was inadequate, with only one nurse and one or two CNAs or QMAs present at times, leaving residents—many of whom required extensive or total assistance for transfers and toileting—unattended when staff were occupied elsewhere. This resulted in increased risk of falls and unmet care needs, particularly during late afternoon and overnight shifts when staffing was reduced and residents experienced more confusion and agitation. A review showed a high number of falls occurred during these lower-staffed hours, despite the facility's assessment tool indicating that resident care needs and negative outcomes should guide staffing decisions.
A resident with multiple diagnoses, including psychosis, was prescribed Olanzapine for ongoing hallucinations following recommendations from her primary care doctor and psychologist. The facility did not document that informed consent was obtained from the resident or her representative regarding the risks, benefits, and alternatives to the psychotropic medication. The DON confirmed there was no policy for obtaining informed consent or for initiating psychotropic medications.
A resident with a history of hemiplegia, hemiparesis, and moderately impaired cognition was not included in care planning conferences, and neither the resident nor their family was involved in the development of the care plan. Documentation showed the last care conference was nearly a year prior, and the required quarterly conferences and documentation of participation were not completed, contrary to facility policy.
A resident with mobility and cognitive impairments did not have access to her call light for an extended period after staff deep-cleaned her room, leaving the device under a plastic container and out of reach. Multiple observations confirmed the call light remained inaccessible, contrary to facility policy requiring call lights to be within reach.
A resident with multiple health issues experienced several significant changes in condition and received new treatments, but the facility did not notify the resident's representative of these changes as required by policy. Documentation showed that while the family was informed of initial dehydration treatment, they were not notified of subsequent health declines or new interventions, and staff interviews confirmed gaps in communication.
Two residents did not have accurate MDS assessments: one with serious mental illness was not identified as PASARR Level II on the MDS, and another receiving hospice care was not marked as such in the assessment. The Clinical Reimbursement Director confirmed these errors and noted the facility follows the RAI manual for MDS coding.
A resident with significant mobility deficits and incontinence developed a Stage 3 pressure ulcer after staff failed to consistently implement required interventions such as regular turning, repositioning, and floating of the heels, despite care plans and repeated recommendations. Observations confirmed the resident's heels were not floated, and staff interviews indicated the resident did not refuse care.
A resident with left-sided hemiplegia and limited ROM did not receive a prescribed hand splint or range of motion exercises as outlined in the care plan. Despite the resident's request and documented need, the splint order was not processed, and staff did not perform ROM interventions. The facility lacked restorative aides and did not implement a restorative program for the resident, resulting in a failure to provide necessary services to prevent further decline.
A resident with a stage 3 pressure ulcer did not receive proper infection control during a dressing change, as staff failed to change gloves, perform hand hygiene, or use gowns as required by facility policy. Enhanced barrier precautions were not implemented or documented in the care plan or physician orders, despite the resident's condition necessitating these measures.
Residents were not adequately informed about state and local advocacy organizations or how to file complaints. Advocacy information was posted in a location that was not easily identifiable or accessible, especially for wheelchair users, and was not discussed during resident council meetings. The facility lacked a specific policy for posting this information.
A facility failed to accurately account for controlled substances for a resident with end-stage renal disease and pain. Although 60 hydrocodone-acetaminophen tablets were delivered and signed for by an LPN, only 30 were documented in the facility's records. The Controlled Substance Acceptance Log was not filled out, and the facility could not locate the missing tablets.
A facility failed to inform a resident's representative of the baseline care plan within the required timeframe. The resident, admitted with Alzheimer's, anxiety, and insomnia, had an interim care plan started on admission day. However, there was no documentation of a care plan meeting with the family within 72 hours, as required by facility policy.
A facility failed to complete a discharge summary for a resident with multiple diagnoses, including COPD and bipolar II disorder, who required supervision for self-care. The resident planned to return to Missouri without home health services. The discharge note indicated no cognitive impairment, and medications were called into a local pharmacy. However, the discharge summary, including a recapitulation of the stay and a post-discharge care plan, was not completed due to a system transition.
A resident with a history of respiratory issues did not receive proper respiratory care as the facility failed to change the oxygen tubing weekly, as required by the care plan and physician's orders. Observations showed outdated nasal cannula and portable oxygen tubing, which were confirmed by the DON.
A vial of Tubersol in a medication room was found without an opened date, contrary to facility policy requiring such labeling. The DON confirmed the oversight, and the facility's policy indicated Tubersol should be used within 30 days once opened and refrigerated.
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 Timely Transmit MDS Assessment Data to CMS
Penalty
Summary
The facility failed to ensure timely electronic transmission of MDS (Minimum Data Set) assessment data to the CMS system for one resident. Review of the clinical record for Resident 36 on 4/9/26 showed an annual MDS assessment dated 2/23/26 that was more than 120 days overdue for submission to CMS. During an interview on 4/10/26 at 11:22 a.m., the MDS coordinator stated she still had two care area assessments left to complete on the annual MDS assessment and that she had just finished them and submitted the MDS to CMS, indicating the assessment had not been completed and transmitted within the required timeframe. In a separate interview on 4/10/26 at 12:05 p.m., the Administrator reported that the facility did not have a policy regarding MDS transmissions, further demonstrating the lack of an established process to ensure that MDS data were encoded and transmitted to the State and CMS within the required time limits.
Inaccurate MDS Coding for Mental Health and PASARR Status
Penalty
Summary
The deficiency involves the facility’s failure to ensure that MDS assessments accurately reflected residents’ clinical status for two residents. For one resident with diagnoses including bipolar disorder and anxiety, the Annual MDS dated 3/11/26 indicated the resident was not considered by the state Level II PASARR process to have a serious mental illness or intellectual disability/related condition, despite a Level II PASARR having been completed on 3/31/23. This discrepancy was identified through record review and confirmed in an interview with the MDS coordinator, who acknowledged that the MDS assessment did not accurately reflect the existing Level II PASARR information. For another resident with generalized anxiety disorder, major depressive disorder, and dementia, the Quarterly MDS dated 3/30/26 did not code anxiety as an active diagnosis. However, review of the MAR showed active orders as of 2/27/26 for Lorazepam, prescribed for generalized anxiety disorder, and the RAI manual specifies that active diagnoses should be identified using sources such as medication sheets and physician orders during the 7-day look-back period. In an interview, the MDS coordinator confirmed that the resident did have an active anxiety disorder diagnosis and that the MDS should have been coded “yes” for anxiety disorder but was incorrectly coded “no.” The Administrator and MDS coordinator also stated the facility did not have an MDS policy and relied on the RAI manual for completing assessments.
Failure to Reconcile Narcotic Medication Upon Delivery
Penalty
Summary
The facility failed to ensure that narcotic pain medication was properly reconciled upon delivery from the pharmacy for a resident diagnosed with dementia, pain disorder, and hypertension. On 9/21/25, an LPN signed for the delivery of 30 oxycodone-acetaminophen 7.5-325 mg tablets but did not follow the facility's procedure for reconciling the controlled medications with the delivery slip before signing. The LPN placed the medications in the locked drawer on the medication cart but did not immediately record them on the narcotic disposition record as required by facility policy. The medication for the resident was never located after delivery. The resident's clinical record indicated a physician's order for oxycodone-acetaminophen as needed for pain, which was active at the time of the incident. The LPN later provided a written statement acknowledging that she did not thoroughly review the medications listed on the delivery document and could not recall any medication delivered for the resident. The facility's policy required immediate recording of controlled medications on the appropriate drug disposition record by the nurse accepting the delivery, which was not followed in this instance.
Failure to Serve Palatable and Appealing Food
Penalty
Summary
The facility failed to ensure that food was served with a palatable texture and appearance, as evidenced by multiple residents reporting that bread became soggy when served with wet items such as corn. During a resident council meeting, several residents stated that this issue was ongoing and had been reported to staff multiple times without resolution. Direct observation of a test tray revealed that the corn was placed beneath the hamburger bun and some onion rings, resulting in the bottom of the bun and the onion rings becoming soggy. The Administrator acknowledged the issue during an interview, and another resident confirmed that the sogginess was due to the corn liquid. The Dietary Manager was unaware of these concerns prior to the survey.
Failure to Address Resident Grievances Regarding Meal Presentation
Penalty
Summary
The facility failed to promptly respond to grievances raised by residents during resident council meetings regarding the issue of soggy bread and food items when wet foods were served on the same plate. Five residents reported that when meals included wet items such as corn, their bread would become soggy and unappetizing, and they had communicated this concern to staff multiple times without resolution. Review of resident council meeting minutes over several months showed repeated requests for separate dishware or bowls for liquid foods, but the issue persisted. Direct observation of a meal confirmed that wet food was served on a flat plate, resulting in a soggy hamburger bun and onion rings. The Dietary Manager was interviewed and stated he was not aware of the residents' concerns about soggy food.
Failure to Provide Ongoing Resident-Centered Activities Program on Dementia Unit
Penalty
Summary
The facility failed to implement an ongoing, resident-centered activities program for all 13 residents residing on the secure dementia unit. Over multiple days and time periods, residents were observed walking in hallways or sitting in dining and common areas without any structured activities taking place. There was no activities schedule posted or available on the unit, and confidential interviews confirmed that no activities calendar or schedule had been posted for several months. Residents had not participated in scheduled activities for several months, and activities were only provided inconsistently and on an unscheduled basis, either by an activities assistant or by nursing staff when they were not engaged in direct care. The Executive Director acknowledged the lack of regularly scheduled activities on the secure dementia unit. A review of the facility's Admission Statement indicated that an activities program, including a planned schedule for recreational, motivational, social, and other activities, was to be provided under the daily basic rate for all residents. Despite this, the facility did not ensure that such a program was in place or consistently implemented for residents on the secure dementia unit.
Insufficient Nursing Staff on Secured Dementia Unit
Penalty
Summary
The facility failed to provide sufficient nursing staff on the secured dementia unit for all 13 residents residing there. Observations showed that at various times, only one nurse and one or two CNAs or QMAs were present on the unit, with staff often occupied in different areas, leaving residents unattended. Several residents required extensive or total assistance for transfers and toileting, and many were at risk of falling. During periods when staff were assisting one resident or were off the unit, other residents were left without supervision, increasing their risk of falls and unmet care needs. Staff interviews confirmed that staffing was reduced from three to two staff members during the late afternoon and overnight shifts, coinciding with times when residents were more likely to experience increased confusion and agitation due to sundowner's syndrome. A review of the staffing schedule and clinical records indicated that the unit was consistently staffed with three nursing staff from 7:00 a.m. to 3:00 p.m., but only two staff from 3:00 p.m. to 7:00 a.m., despite the high level of assistance required by residents. Between 5/1/24 and 5/7/25, there were 53 falls among the 13 residents, with 39 of those falls occurring during the lower-staffed hours. The facility's own assessment tool stated that resident care needs and negative outcomes should be considered in staffing decisions, but the observed staffing levels did not meet the needs of the residents on the secured dementia unit.
Failure to Obtain Informed Consent Prior to Initiating Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that informed consent was obtained prior to initiating an antipsychotic medication for a resident diagnosed with myotonic muscular dystrophy, psychosis, and senile degeneration of the brain. The resident experienced hallucinations and was subsequently prescribed Olanzapine 2.5 mg daily by her primary care doctor and psychologist. Although the clinical record indicated that the family was aware of the situation, there was no documentation that informed consent was provided to the resident or her representative regarding the treatment options, risks, and benefits of the psychotropic medication. Additionally, the facility did not have a policy in place for initiating psychotropic medications or for obtaining informed consent, as confirmed by the DON during interviews.
Resident Not Included in Care Plan Development
Penalty
Summary
A resident with a history of hemiplegia, hemiparesis following a cerebral infarction, dysphagia, and moderately impaired cognition was not involved in the development or implementation of their person-centered care plan. The resident reported that neither he nor his family had been included in care conferences, and he could not recall ever being involved in the care planning process. Review of the clinical record confirmed that the last documented care conference occurred nearly a year prior, despite the resident's need for assistance with personal care and ongoing medical conditions. Further review of the resident's record showed that the most recent care conference was not conducted in accordance with the facility's policy, which requires regular care plan conferences and documentation of resident or representative participation. The DON confirmed the absence of recent care conference documentation and acknowledged that such conferences should occur quarterly. The facility's policy also states that if resident participation is not practicable, an explanation must be documented, which was not present in this case.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure reasonable accommodation of needs for one resident, as evidenced by the lack of access to a call light. During a resident council meeting, a resident reported not having access to her call light after staff had deep-cleaned her room, stating that the call light had been inaccessible for 24 hours and was currently under a stack of plastic totes. Direct observation confirmed that the call light was on the floor, under a plastic storage container, and not within the resident's reach. The resident had diagnoses including unsteadiness on feet, difficulty walking, need for assistance with personal care, and glaucoma, and was assessed as having moderately impaired cognition. Despite these needs, the call light remained inaccessible during multiple observations, and the resident confirmed she could not reach it. Facility policy requires that call lights be within reach and accessible to residents, but this was not followed in this instance.
Failure to Notify Resident Representative of Significant Change in Condition and Treatment
Penalty
Summary
The facility failed to notify the resident's representative of significant changes in the resident's condition and treatments. The resident, who had diagnoses including dementia, muscle weakness, and stage 3 chronic kidney disease, experienced several notable changes in health status, such as fatigue, altered mental status, dark urine, congestion, fever, productive cough, lethargy, and abnormal vital signs. Although the family was notified when sodium chloride was ordered for dehydration, subsequent changes and new treatments, including the administration of D5W/NaCl and further sodium chloride infusions, were not communicated to the family as required by facility policy. Progress notes for these events did not indicate that the family had been informed. The deficiency was further highlighted by staff interviews and policy review. An LPN was unaware of the resident's death, and the DON confirmed the facility's policy required family notification for significant changes in condition or treatment. The lack of documentation and communication regarding the resident's deteriorating condition and new interventions directly led to the deficiency identified during the review.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure accurate completion of the Minimum Data Set (MDS) assessments for two residents. For one resident with diagnoses including bipolar disorder, dementia, and mood disorder, the clinical record showed a PASARR Level II determination for serious mental illness. However, the annual MDS assessment did not indicate the resident as PASARR Level II, as section A1500 was incorrectly marked 'no.' The Clinical Reimbursement Director confirmed this was an error and acknowledged the absence of a specific MDS assessment coding policy, relying instead on the Resident Assessment Instrument (RAI) manual. For another resident with diagnoses including heart disease, chronic respiratory failure with hypoxia, and dementia, the clinical record indicated the resident was receiving hospice services. Despite this, the quarterly MDS assessment did not reflect hospice care in section O0110. The Clinical Reimbursement Director confirmed that hospice services were being provided during the assessment period and that the MDS should have been marked accordingly. Both deficiencies were identified through record review and staff interview, with reference to the RAI manual for correct coding procedures.
Failure to Implement Pressure Ulcer Prevention Interventions
Penalty
Summary
A deficiency was identified when a resident with a history of dementia, diabetes mellitus, muscle weakness, and incontinence developed a Stage 3 pressure ulcer. The resident was assessed as being at moderate risk for pressure ulcers and was dependent on staff for mobility and repositioning. Despite care plans and wound management recommendations specifying the need for regular turning, repositioning, and floating of the heels to prevent further skin breakdown, these interventions were not consistently implemented. Multiple observations over several days showed the resident lying in bed on her back with her heels resting directly on the bed surface, rather than being floated on pillows as required. There was no documentation in the clinical record indicating that the resident refused these interventions. Staff interviews confirmed that the resident did not refuse care and was dependent on staff for activities of daily living, including repositioning and heel offloading. The facility's own policy required redistributing pressure, including offloading heels, as part of basic pressure injury prevention. However, the care plan lacked documentation of specific interventions such as turning, repositioning, or floating heels after the development of the pressure ulcer. Despite repeated discussions of preventive measures with staff, the necessary interventions were not observed to be in place, leading to the deficiency.
Failure to Provide Range of Motion Services and Splint for Resident with Limited Mobility
Penalty
Summary
A resident with a history of hemiplegia and hemiparesis following a cerebral infarction, resulting in limited range of motion on the left side, did not receive appropriate services to prevent further decline in mobility. The resident expressed that his left hand could not open and requested to try a splint to improve function. Observations over several days confirmed that the resident did not have a splint in place and reported that staff were not performing range of motion exercises with him. The care plan indicated the resident was to wear a left hand brace daily, and an occupational therapy discharge summary documented that a splint had been ordered, with plans for OT to assess fit and provide education once delivered. Interviews with facility staff revealed that the order for the splint may not have been placed, and there was confusion regarding its status. The Business Office Manager was unsure if the order had been submitted, and the Executive Director later confirmed the order had not gone through. Additionally, the facility did not have restorative aides at the time, and the resident was not on a restorative program, which would typically be implemented after therapy discharge. The facility's policy required staff to assist residents with range of motion exercises and use of assistive devices, but these interventions were not provided to the resident as outlined.
Failure to Implement Infection Control Practices During Wound Care
Penalty
Summary
During a pressure ulcer dressing change for one resident, infection control practices were not followed by facility staff. The Assistant Director of Nursing (ADON) and a Certified Nursing Assistant (CNA) failed to change gloves and perform hand hygiene at appropriate times. Specifically, the CNA did not wash hands or use hand sanitizer before donning new gloves after providing incontinent care, and the ADON did not change gloves after removing a soiled dressing before applying a new one. Additionally, both staff members were not observed wearing gowns during the dressing change, and treatment supplies were placed on the resident's bed and later returned to the treatment cart without proper infection control measures. The resident involved had a stage 3 pressure ulcer of the sacral region, along with other diagnoses including dementia, diabetes mellitus, and muscle weakness. The resident's care plan identified the risk for complications from the pressure ulcer but did not include interventions for enhanced barrier precautions. Physician orders also lacked documentation for enhanced barrier precautions, despite facility policy requiring gloves and gowns during high-contact care activities for residents with wounds. Staff interviews confirmed that enhanced barrier precautions should have been implemented during the dressing change.
Failure to Inform Residents of Advocacy and Complaint Procedures
Penalty
Summary
The facility failed to ensure that residents were adequately informed about the state and local advocacy organizations and how to file complaints. During a resident council meeting, residents reported not knowing where the State Survey Agency (SSA) or State Long-Term Care Ombudsman information was posted, nor how to file a complaint. Observation revealed that the advocacy information was posted by the front entrance, but it was among other papers, not easily identifiable, and not within the line of sight for residents using wheelchairs. Review of resident council meeting minutes showed that the SSA or ombudsman information was not discussed during meetings. An interview with the Clinical Nurse Consultant confirmed that while residents received a copy of the information at admission and staff were expected to review it during meetings, there was no specific facility policy regarding the posting of local advocacy agencies.
Failure to Accurately Account for Controlled Substances
Penalty
Summary
The facility failed to ensure accurate acquiring and accounting of controlled substances for Resident E, who was diagnosed with end-stage renal disease and pain. The physician orders indicated that Resident E was prescribed hydrocodone-acetaminophen, a Schedule II controlled substance, to be taken as needed for pain. On a specific date, 60 tablets of this medication were delivered to the facility, as confirmed by the pharmacy's packing slip, and were signed for by an LPN. However, the Controlled Substance Acceptance Log, which should have documented the receipt of these medications, was left blank. Further investigation revealed that only 30 tablets were accounted for in the facility's records, despite the packing slip indicating that 60 tablets were delivered. The facility's Controlled Drug Record also showed only 30 tablets, suggesting that one card of 30 tablets was missing. Interviews with the Administrator confirmed that the nurse responsible for accepting the delivery failed to complete the necessary documentation, and the facility was unable to locate the missing card of narcotics.
Failure to Inform Resident's Representative of Baseline Care Plan
Penalty
Summary
The facility failed to ensure that the representative of a resident, who was admitted with diagnoses including Alzheimer's disease, anxiety, and insomnia, was informed of the baseline care plan. The resident was admitted on 6/6/24, and an interim 48-hour baseline care plan was initiated on the same day. However, the clinical record did not contain documentation that the resident's representative was informed of this care plan. Interviews with the Social Service Designee (SSD) revealed that the facility's practice was to conduct a care plan meeting with the family within 72 hours of admission, but there was no documentation of such a meeting in the clinical record. The facility's policy, revised in 4/2017, also required a care conference with the resident or representative within 72 hours of admission, which was not documented in this case.
Failure to Complete Discharge Summary for Resident
Penalty
Summary
The facility failed to ensure the completion of a discharge summary for a resident, identified as Resident 58, who was reviewed for discharge. The resident had multiple diagnoses, including chronic obstructive pulmonary disease, bipolar II disorder, and cognitive communication deficit, among others. The discharge Minimum Data Set (MDS) assessment indicated the resident required supervision for self-care and ambulation. On the day of discharge, the resident informed the social worker of her plan to leave the facility and return to Missouri without home health care or services. The resident's discharge note indicated she was a DNR and had no cognitive impairment or behavioral issues. Her medications were called into a local pharmacy, and she left the facility with her family and belongings. However, the facility did not complete a discharge summary that included a recapitulation of the resident's stay, a final summary of her status, and a post-discharge plan of care developed with her participation. The Social Services Director (SSD) acknowledged the absence of the discharge summary in the resident's clinical record, attributing it to a transition between systems at the time of discharge. The facility's policy on discharge planning did not specify the need for documentation of a discharge summary or recapitulation of the resident's stay, which contributed to the oversight.
Failure to Change Oxygen Tubing Weekly
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, identified as Resident 18, by not changing the oxygen tubing as required. Observations on multiple occasions revealed that the nasal cannula used for oxygen administration was dated 6/8/24, and the portable oxygen tubing was dated 4/28, indicating that the tubing had not been changed weekly as per the care plan and physician's orders. The care plan specifically required the tubing to be changed, dated, and labeled weekly, but this was not adhered to. Resident 18 had a medical history that included altered respiratory status, sleep apnea, muscular dystrophy, pneumonia, and a history of pulmonary embolism. The resident was observed both with and without oxygen, despite having orders to maintain oxygen saturations above 90% with 2 liters of oxygen via nasal cannula. The Director of Nursing confirmed that the tubing was outdated and acknowledged that it should have been changed weekly on Saturdays, as per the facility's policy and physician's orders.
Failure to Label Opened Vial of Tubersol
Penalty
Summary
The facility failed to label a vial of Tubersol with the opened date in one of the two medication rooms observed. During an observation on July 12, 2024, at 9:20 a.m., a vial of Tubersol was found in the refrigerator of the medication room without an opened date on either the vial or its box. The Director of Nursing (DON) confirmed the absence of an opened date and acknowledged that all opened vials should have this information. The facility's policy, titled 'Determining Expiration Dates,' was reviewed and indicated that Tubersol should be used within 30 days once opened and refrigerated. However, the policy itself was undated.
Latest citations in Indiana
Surveyors observed that dietary staff repeatedly worked in kitchen and meal service areas with uncovered facial hair, despite facility policy and state sanitation requirements mandating effective hair restraints. Two dietary aides with short beards or mustaches were seen walking through food preparation areas, taking food temperatures, handling food, and plating meals at steamtables in dining rooms without any facial hair coverings, while the current policy required all hair, including facial hair, to be restrained to prevent contamination.
The facility failed to consistently provide and document required bed-hold policy notices when several residents were transferred to the hospital. In multiple cases, residents with dementia, psychotic disorders, COPD, chronic respiratory failure, altered mental status, and cerebral infarction were sent out for acute changes in condition, and while transfer notes reflected physician and family notifications, they lacked documentation that the bed-hold policy was discussed with the resident or responsible party. Notices of Transfer or Discharge often indicated a copy of the bed-hold policy was sent with the resident, but the records did not show signed and dated acknowledgment by the resident or appropriate representative, including in situations where a resident had moderate cognitive impairment, short-term memory issues, or a documented need for a proxy and a financial POA authorizing an agent for health care decisions.
Surveyors found that the facility failed to provide trauma‑informed and culturally competent care by not incorporating two residents’ extensive trauma histories and specific behavioral triggers into their care plans. One resident with documented homelessness, polysubstance abuse, severe accidents with multiple fractures, viral encephalitis with coma, physical and sexual abuse, loss of family contact, and a past suicide attempt had multiple behavior‑focused care plans that referenced identifying triggers but listed none and did not mention their physical, sexual, medical, or psychosocial trauma. Another resident with TBI from being struck by a truck, an 11‑month coma, long‑term state hospital residence, alleged shooting of a parent, and diagnoses including intermittent explosive disorder and borderline personality disorder had a PASRR identifying a specific trigger and notes of inappropriate sexual behavior, yet their care plans omitted these traumatic events, the identified trigger, and the sexual behavior. Staff interviews confirmed that residents were screened for trauma, but the trauma histories and triggers were not reflected in the individualized plans of care.
A resident with schizophrenia, post‑stroke hemiparesis, and mild cognitive impairment expressed feeling down and wanting to kill himself, but staff did not document asking about a specific plan, did not notify the physician or psychiatric NP as expected, and did not develop or update a care plan addressing depression or suicidal ideation. The SSD documented offering support and initiating 15‑minute checks once, but there was no further follow‑up or documentation of interventions after subsequent suicidal statements made in a care plan meeting with the resident’s father. The DON and Administrator reported that facility policy requires immediate notification of key staff, assessment for a plan and means of self‑harm, and thorough documentation, which were not carried out or reflected in the medical record for this resident.
A resident with schizophrenia, post-stroke hemiparesis, and mild cognitive impairment verbalized suicidal ideation, but the care plan did not address depression or suicidal thoughts, and required assessments and services were not accurately or timely documented. An SSD note recorded the resident saying he wanted to kill himself and referenced 15‑minute checks and a care plan update, yet the active care plan lacked depression/suicidal ideation interventions. Multiple late-entry Social Services notes were later added, describing follow-up visits and the resident denying suicidal ideation, but the SSD later reported she did not typically ask about a suicide plan and did not personally provide individual follow-up visits as described. These practices conflicted with the facility’s policy requiring factual, first-hand, and timely documentation of assessments and services.
A resident was observed with an Albuterol inhaler on an overbed table and later reported keeping the inhaler in a nightstand drawer, with no staff present during these observations. Record review showed the resident had no cognitive impairment on the admission MDS but lacked any documented self-medication administration assessment. The DON acknowledged that the required assessment had not been completed, despite facility policy requiring staff and the practitioner to evaluate each resident’s mental and physical abilities before allowing self-administration of medications.
Surveyors found that the facility submitted inaccurate direct care staffing data to CMS through the PBJ system over multiple days in a quarter. CASPER reports showed apparent gaps in 24-hour licensed nurse coverage, low weekend staffing, and a 1-star staffing rating, while internal staffing sheets documented that licensed nurses were present and the facility was fully staffed on those days. The Administrator reported that the discrepancies were due to PBJ data entry errors, despite a facility policy requiring all PBJ entries to be accurate, auditable, and verifiable against payroll, invoices, or contracts.
Surveyors found that the facility did not provide or document required written transfer/discharge notices and bed-hold policy information for four residents who were sent to the hospital, including individuals with conditions such as dementia, CHF, chronic respiratory failure, and CKD. In each case, progress notes showed that the resident was transferred for acute issues, but the clinical records lacked evidence that written notices were given to the residents or their representatives, and in one case lacked documentation that required information was sent to the receiving provider. Facility leadership, including the ADON, DON, and Administrator, acknowledged that the records did not contain the required documentation, despite a written policy requiring such notices and information exchange.
A resident with Alzheimer’s disease and depression, previously on an antidepressant, exhibited intermittent refusals of medications and care, occasional yelling at staff, and reports of unusual perceptions, such as believing men were in or near her room. Nursing notes over several months documented these refusals and complaints but did not show that the behaviors were evaluated or recorded as dangerous, non-redirectable, or causing significant distress, nor did they document specific non-pharmacological interventions attempted or their outcomes. Despite this, a psychiatric NP later added new diagnoses of schizoaffective disorder, borderline personality disorder, and delusional disorder and ordered an antipsychotic (Seroquel) without a comprehensive evaluation in the record to support these diagnoses. The facility’s psychotropic medication policy, which requires identification and documentation of target behaviors, use of nonpharmacological interventions, and ongoing behavior monitoring, was not followed for this resident.
The facility failed to keep PASARR Level I screenings accurate and current for three residents when new mental health diagnoses and psychoactive medications were initiated. One resident’s PASARR omitted a PTSD diagnosis and an added antidepressant, despite documentation of PTSD on the MDS and care plan and a physician order for Pristiq. Another resident’s PASARR listed only depression and dementia, even after additional diagnoses such as borderline personality disorder, delusional disorder, and schizoaffective disorder were added and an antipsychotic (quetiapine) was ordered, with the MDS later reflecting psychotic disorder, schizophrenia, and depression with antipsychotic and antidepressant use. A third resident’s PASARR did not include a depression diagnosis or newly ordered escitalopram and lorazepam, although the admission MDS documented depression with antianxiety and antidepressant use. These omissions occurred despite facility policy requiring a new Level I review after significant mental status changes, including new mental health diagnoses or new psychotropic medications.
Uncovered Facial Hair During Food Preparation and Meal Service
Penalty
Summary
The deficiency involves the facility’s failure to ensure that food was served in a sanitary and safe manner in accordance with professional standards and facility policy during multiple kitchen and meal service observations. During an initial kitchen observation, two dietary aides were seen walking through the kitchen food preparation area with uncovered facial hair. One aide had facial hair above and below the lip and along the jaw line, approximately one-fourth inch in length, and the other had a mustache of similar length; neither used any facial hair covering. These observations occurred while staff were present in the kitchen area where food was stored and prepared. During subsequent observations on the same day, the same two dietary aides were again observed with uncovered facial hair while directly involved in meal preparation and service. One aide walked through the kitchen while the noon meal was being prepared and placed into a transport cart for service in the south dining room, and later was observed plating the noon meal at the steamtable in that dining room, still without a facial hair covering. The other aide walked through the kitchen while the noon meal was being prepared and placed into the steamtable for the north dining room, took food temperatures, assisted with plating meals at the steamtable, and retrieved food items and supplies from the kitchen, all while having an uncovered mustache approximately one-fourth inch in length. The Dietary Manager stated that staff hair was to be covered when in the kitchen and during meal service, and the facility’s written policy and the cited Indiana Food Establishment Sanitation Requirements both required effective hair restraints, including for facial hair, to prevent contamination of food, equipment, and utensils.
Failure to Provide and Document Bed-Hold Policy at Time of Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure that required bed-hold policy information was provided and documented for four residents transferred to the hospital. For a resident with dementia, psychotic disorder, and autistic disorder who had a BIMS score of 0 indicating severe cognitive impairment, progress notes documented physician notification and guardian notification when the resident was sent to the hospital, but there was no documentation that the bed-hold policy was provided to the responsible party. A Notice of Transfer or Discharge later indicated a copy of the bed-hold policy was sent with the resident. Another resident with COPD and chronic respiratory failure, cognitively intact with a BIMS score of 13, experienced a decline in condition and was transferred to the hospital by ambulance; progress notes documented family notification but did not document any discussion of the bed-hold policy, although a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident. A third resident with altered mental status and cerebral infarction, with a BIMS score of 10 indicating moderate cognitive impairment and documented short-term memory impairment, experienced changes in condition and was transferred to the hospital. Progress notes stated the resident was their own responsible party and that no other notification was completed, and transfer documentation did not include the bed-hold policy, although an untimed Notice of Transfer or Discharge indicated a copy of the bed-hold policy was signed by the resident. A financial power of attorney document in the record showed the resident had designated an agent to act in consent or refusal of health care. For a fourth resident with dementia and osteomyelitis, transfer documentation and a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident, and the transfer form noted the resident required a proxy for decision making. The facility’s policy required that at the time of transfer to a hospital, written notice specifying the duration of the bed-hold policy and information on return to the next available bed be provided, and that a signed and dated copy of the bed-hold notice given to the resident or representative be kept in the resident file, which was not consistently documented for these residents.
Failure to Integrate Trauma Histories and Behavioral Triggers Into Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to identify and incorporate residents’ trauma histories and specific behavioral triggers into their care plans, despite documented histories of significant trauma and behavioral health issues. For one resident, extensive social service and progress notes documented homelessness, polysubstance abuse, major depressive and anxiety disorders, chronic pain, a history of severe car accidents with multiple fractures, viral encephalitis resulting in a three‑month coma, loss of child custody, multiple divorces, physical abuse by a spouse, the death of a fiancé who was struck by a car while in a wheelchair, lack of family contact, and a past suicide attempt by Valium overdose. Additional documentation noted a history of rape by a brother at age eight and prior placement under direct supervision and 15‑minute checks related to suicidal ideation. Despite these documented traumatic events and behavioral health concerns, the resident’s care plans did not identify a history of physical trauma, sexual trauma, homelessness, substance abuse, medical trauma, or attempted suicide. For this same resident, the MDS showed no cognitive deficit and identified behaviors such as verbal aggression and rejection of care, along with diagnoses including seizure disorder, depression, chronic pain syndrome, homelessness, and anxiety disorder. Multiple care plans addressed behaviors such as drug‑seeking, pretending to have seizures for attention or medication, making false allegations, verbal aggression when unable to smoke, and a desire for intimate relationships with consenting male residents. These care plans referenced goals such as effective coping skills, seeking staff support, and compliance with the smoking policy, and they called for identification and reduction of behavioral triggers. However, none of these care plans actually listed any specific triggers. The care plan addressing the resident’s right to consensual intimate relationships focused on assessment and education regarding consent but did not integrate the resident’s extensive trauma history. Staff interviews indicated the resident had displayed sexual behaviors since admission, including an incident where the resident expressed anger at another resident for not buying a soda after engaging in sexual acts. A second resident with a documented history of traumatic brain injury (TBI), dementia, seizure disorder, borderline personality disorder, anxiety, intermittent explosive disorder, tobacco use, and other behavioral/emotional disorders was also affected by the same deficiency. Social history and progress notes documented that this resident sustained a TBI after being hit by a semi‑truck while riding a bicycle at age 18, resulting in an 11‑month coma, followed by 13 years in a state hospital and subsequent residence in a group home. Additional documentation indicated the resident allegedly shot their father at age 26 after being sworn at and had a PASRR identifying TBI, intermittent explosive disorder, and borderline personality disorder, with a specific trigger of hearing the name of the current U.S. President. Progress notes also described inappropriate sexual behavior toward staff, including touching themselves intimately during personal care and refusing to stop when redirected. Despite this, the resident’s care plans, which addressed explosive disorder and history of altercations, risk for decreased psychosocial well‑being, and refusal to bathe or shower, did not list any specific behavioral triggers, did not reference the traumatic events such as being hit by a truck or shooting their father, and did not document the inappropriate sexual behavior. The Administrator and Social Service Director acknowledged that residents were to be screened for trauma and that trauma responses and PTSD should be added to care plans, but the specific trauma histories and triggers for these two residents were not incorporated into their plans of care.
Failure to Assess and Care Plan for Resident Suicidal Ideation
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess, investigate, and care plan for a resident’s suicidal ideation in accordance with its own policy and staff expectations. The resident had diagnoses including schizophrenia, cerebral edema, and hemiparesis/hemiplegia following a cerebral infarction, and a current MDS showed mild cognitive impairment (BIMS score 12). A progress note documented that the resident told the Social Services Director (SSD) he was feeling down and wanted to kill himself; the SSD offered assistance, activities, and initiated 15‑minute checks, and the note stated the care plan was updated. However, the note did not indicate that the SSD asked whether the resident had a plan to kill himself, and there were no additional notes regarding suicidal ideation or follow‑up. Review of the current care plan showed no problem, goal, or interventions addressing depression or suicidal ideation, and progress notes over the following month contained no documentation of physician notification related to the suicidal statement. Further record and interview evidence showed that the care plan conference summary did not document interventions for suicidal ideation, and the SSD acknowledged she did not normally ask residents expressing suicidal ideation if they had a plan. The SSD reported that the resident had admission paperwork mentioning suicidal ideation related to depression after a stroke and that the resident again vocalized suicidal ideation during a care plan meeting with his father, after which emotional support was offered and the father took the resident out on a leave of absence; no further visits or follow‑up were done. The DON stated that, upon notification of suicidal verbalization, staff should assess the resident, ask if there is a plan, remove potential means of self‑harm, immediately notify the psychiatric NP, and document the occurrence, and that a detailed progress note and updated care plan were expected but not present for this resident. The Administrator similarly stated that staff should ask about a plan, document interventions, notify the physician and family, and update the care plan, and indicated the resident should have had a care plan addressing depression with suicidal ideation. The facility’s written policy required immediate notification of the DON, SSD, and physician, an interview including asking about a plan and assessing mood and means for self‑harm, and thorough documentation of mood, behavior, and all actions taken, which were not reflected in the resident’s record.
Incomplete and Inaccurate Documentation of Suicidal Ideation and Follow-Up
Penalty
Summary
The facility failed to ensure accurate, complete, and timely documentation of assessments and services for a resident who verbalized suicidal ideation. Resident 6, who had schizophrenia, cerebral edema, and right-sided hemiparesis/hemiplegia following a cerebral infarction, had a BIMS score of 12 indicating mild cognitive impairment. The resident’s admission paperwork mentioned suicidal ideation related to depression after a stroke, and a Social Services note on 3/11/2026 documented that the resident was feeling down and said he wanted to kill himself. The Social Services Director (SSD) documented that she talked with the resident, coordinated with Activities, advised the resident to contact SSD or nursing if he wanted to talk, and that the resident was scheduled for 15-minute checks and the care plan was updated. However, the current care plan initiated on 2/26/2026 did not address depression or suicidal ideation. Multiple Social Services progress notes were later entered as late entries in April, with effective dates in March, stating that the resident had no plan and no longer had suicidal ideation, that he felt much better after 1:1 time, and that he continued his daily routine and therapy. These late entries described follow-up visits and reassessments of suicidal ideation on several consecutive days, but in interviews the SSD stated she did not normally ask residents about having a plan when they verbalized suicidal ideation and did not recall any other occurrences beyond the initial event. She further indicated she did not personally provide individual follow-up visits with this resident regarding suicidal ideation, despite the late-entry notes describing such visits. The DON acknowledged that late entries had been added to address concern about suicidal verbalization, and the Administrator stated that upon suicidal statements staff should ask about a plan, notify the physician and family, and update the care plan, and that this resident should have had a care plan addressing depression with suicidal ideation. The facility’s documentation policy required factual, first-hand, timely documentation, which was not followed in this case.
Failure to Complete Required Self-Administration Assessment for Inhaler Kept at Bedside
Penalty
Summary
Surveyors identified that a resident was allowed to keep and access an Albuterol inhaler without the facility completing the required self-administration medication assessment. During an initial tour, the resident was observed sitting in a wheelchair with a handheld Albuterol inhaler on the overbed table and no staff present in the room or hallway. On a subsequent observation, the resident again was in a wheelchair and reported that the Albuterol inhaler was stored in the top drawer of the nightstand, where it was found. Review of the clinical record showed an admission MDS indicating no cognitive impairment, but there was no documentation of a self-medication administration assessment. In an interview, the DON confirmed that the resident did not have the required self-medication assessment, despite the facility’s policy stating that staff and the practitioner must assess each resident’s mental and physical abilities to determine whether self-administering medications is clinically appropriate. This failure to complete and document a self-administration medication assessment for a resident who had an Albuterol inhaler kept at bedside constituted noncompliance with the facility’s own policy and with 410 IAC 16.2-3.1-11(a).
Inaccurate PBJ Staffing Data Submission to CMS
Penalty
Summary
The deficiency involves the facility’s failure to electronically submit complete and accurate direct care staffing information to CMS through the Payroll-Based Journal (PBJ) system for 22 days in a fiscal quarter. A CASPER report review on 4/6/26 showed that, according to PBJ data, the facility did not have licensed nursing coverage 24 hours per day on multiple specific dates across three months, had low weekend staffing, and held a 1-star staffing rating. However, review of the facility’s internal staffing sheets for that quarter indicated the facility was fully staffed and had licensed nurse coverage on all of the dates in question. During an interview, the Administrator stated that the PBJ information must have contained data entry errors, as she had verified licensed staff coverage on the timesheets. The facility’s PBJ policy in effect stated that all staffing data entered into the PBJ system would be auditable and verifiable through payroll, invoices, or contracts, but the submitted PBJ data did not accurately reflect the facility’s actual licensed nurse staffing as documented on internal records. No specific residents or clinical conditions were mentioned in the report, and the deficiency centers solely on inaccurate staffing data submission rather than direct resident care events.
Failure to Provide and Document Required Transfer/Discharge and Bed-Hold Notices
Penalty
Summary
The deficiency involves the facility’s failure to provide and document required written notices of transfer/discharge and bed-hold policies, as well as required information to receiving providers, for four residents who were transferred or discharged to the hospital. For a resident with generalized anxiety disorder, major depressive disorder, and dementia, progress notes showed that the resident was sent to the hospital via 911 for chest pain, lower back pain, and shortness of breath and later returned to the facility, but the clinical record lacked documentation that a written Notice of Transfer/Discharge and the bed-hold policy were provided to the resident or representative, and lacked documentation that required information was conveyed to the receiving facility. The ADON and the Administrator both confirmed there was no documentation that these written notices were provided. For a resident with congestive heart failure and muscle weakness who was sent to the emergency room for painful urination and bloody urine, the clinical record lacked documentation that a Notice of Transfer/Discharge or bed-hold policy was given to the resident or representative, which the DON confirmed. Another resident with chronic respiratory failure and diabetes was discharged to the hospital for respiratory failure, and a resident with chronic kidney disease and dementia was discharged to the hospital, but in both cases there was no documentation that a written notice of transfer/discharge or bed-hold policy was provided to the residents or their representatives. Review of the facility’s Transfer and Discharge policy, dated 1/15/26, showed that the policy required the facility to provide written transfer/discharge notices and bed-hold information to residents and representatives and to provide specified information to receiving providers, but the records for these four residents did not contain the required documentation.
Failure to Document Target Behaviors and Non-Pharmacological Interventions Before Initiating Antipsychotic
Penalty
Summary
The deficiency involves the facility’s failure to document how a resident’s behaviors presented danger or distress to self or others, and failure to document non-pharmacological interventions attempted prior to initiating an antipsychotic medication. Resident 6 had documented diagnoses of Alzheimer’s disease, depression, and severe cognitive impairment, and was receiving sertraline for depression. A PASSAR identified only depression and dementia, and the admission MDS listed Alzheimer’s disease and depression as active diagnoses. Over several months, nursing progress notes documented that the resident intermittently reported unusual perceptions, such as believing there were men causing trouble, a man in her room, or a man wanting to marry her and yelling through the walls, but there was no documentation that these episodes caused danger to the resident or others or that they resulted in unmanageable distress. From late April through mid-July, nursing notes primarily described the resident’s frequent refusals of evening and morning medications, blood sugar checks, blood pressure checks, insulin administration, hygiene care, and showers. Staff documented that the resident sometimes yelled at staff, said “Get out!”, was visibly upset by a room move, was leery of staff and asked to see name badges, and became upset about a pillow under her head until it was removed, after which she calmed down. The notes also recorded instances where the resident believed housekeeping had not cleaned her room or that she had not received medications when she had. However, there were no progress notes or assessments indicating that these behaviors were evaluated as dangerous, non-redirectable, or causing significant distress or functional impairment, and no detailed behavior monitoring logs were present as required by facility policy. On a psychiatric NP visit for initial psychotropic medication management, new mental health diagnoses of schizoaffective disorder, borderline personality disorder, and delusional disorder were added, and Seroquel 25 mg, an antipsychotic, was ordered. The clinical record did not contain a comprehensive evaluation to support these new diagnoses, and there was no documentation of target behaviors meeting the facility’s policy criteria for psychotropic use, such as behaviors representing danger to self or others, causing distress and impairment in functional abilities, or clearly attributable to psychosis or mania. The resident’s representative reported that the resident had no prior history of mental health disorders or psychiatric hospitalization and was unaware of the new diagnoses. The facility’s own psychotropic medication policy required identification and documentation of specific target behaviors, use and documentation of nonpharmacological interventions, and ongoing monitoring of behaviors and interventions, which were not reflected in the record for this resident.
Failure to Update PASARR Screens for New Mental Health Diagnoses and Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that Preadmission Screening and Resident Review (PASARR) Level I screenings were accurate and updated when new mental health diagnoses and psychoactive medications were initiated for multiple residents. For one resident with dementia, anxiety, depression, and post-traumatic stress disorder (PTSD), the PASARR completed on admission listed anxiety, depression, and dementia with sertraline and quetiapine, but did not include the PTSD diagnosis or the antidepressant Pristiq, despite the admission MDS and care plan documenting PTSD and a subsequent physician’s order for Pristiq. For another resident with Alzheimer’s disease, borderline personality disorder, delusional disorder, schizoaffective disorder, and depression, the PASARR only reflected depression and dementia with sertraline, even though additional mental health diagnoses were added later and an antipsychotic (quetiapine) was ordered for borderline personality disorder, and the quarterly MDS documented psychotic disorder, schizophrenia, and depression with antipsychotic and antidepressant use. A third resident had diagnoses including Alzheimer’s disease, depression, anxiety disorder, irritability and anger, and nonrheumatic aortic valve stenosis. The PASARR for this resident listed dementia and anxiety with Risperdal but omitted the diagnosis of depression and the medications escitalopram and lorazepam, although physician’s orders were in place for escitalopram for depression and lorazepam for anxiety, and the admission MDS documented depression with antianxiety and antidepressant use. Interviews with the Assistant Director of Nursing confirmed that new Level I PASARR screens should have been completed when new mental health diagnoses and psychoactive medications were added, and that the PASARR for one resident, completed prior to arrival, should have included all mental health diagnoses and medications. The facility’s own policy required notification of the state mental health authority within 14 days after a significant change in mental condition and specified that a new Level I screen is required for new mental health diagnoses or newly prescribed psychotropic medications, which was not followed in these cases.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
