St Mary Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Lafayette, Indiana.
- Location
- 2201 Cason St, Lafayette, Indiana 47904
- CMS Provider Number
- 155094
- Inspections on file
- 25
- Latest survey
- March 31, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at St Mary Healthcare Center during CMS and state inspections, most recent first.
Surveyors found staff personal beverages stored on a food preparation counter next to food items and improperly stored frozen chicken in the walk-in freezer, including an opened bag containing a single chicken breast with ice buildup and a large box of chicken left in an untied bag with the lid wide open. The Dietary Manager and dietary staff acknowledged that staff drinks should not be kept in the kitchen and that opened chicken should be properly sealed, contrary to the facility’s Culinary Services policy requiring proper storage and moisture-proof wrapping of frozen foods.
The deficiency involves failure to follow physician orders for medication administration and to obtain required admission weights for three residents. A resident with hypotension and other conditions had midodrine ordered with specific systolic BP hold parameters, but MAR review showed the drug was both given when BP exceeded the hold threshold and withheld when BP was within the ordered range. Two other residents with multiple comorbidities did not have admission weights obtained as ordered or upon admission, with one resident’s first weight documented several days after arrival. Staff interviews revealed that medications should not be given or held outside parameters and that admission weights were expected at or near the time of admission, while facility policies required medications to be administered as prescribed and weights to be taken upon admission to establish a baseline.
A resident was discharged to a group home with paperwork indicating she required extensive assistance with daily activities, despite being independent in these areas. The DON later confirmed the discharge assessment was incorrect and was unaware that the inaccurate information had been sent.
Staff did not consistently serve meals to residents at the same table together, with plates distributed randomly rather than by table, and a staff member was observed eating while standing instead of sitting with residents. Additionally, a resident was removed from the dining room before finishing his meal to receive a shower, requiring his meal to be retrieved later. These actions did not align with facility policies on resident dignity and family-style dining.
A resident with multiple chronic conditions had a DNR form completed and signed, but the physician's order in the electronic chart was not promptly updated to reflect the new DNR status. Staff interviews confirmed that while the DNR form was uploaded, the order remained as full code for a period, resulting in a failure to ensure the resident's wishes were accurately documented.
Two residents were not provided with required SNF ABN and NOMNC forms when their Medicare Part A services were discontinued before benefit days were exhausted. The DON confirmed that beneficiary notices were not being completed as required prior to a recent policy change.
A resident with a history of schizophrenia, bipolar disorder, and cognitive communication deficit had conflicting information in their clinical record, with mental health diagnoses incorrectly entered into the MDS assessment. The DON and MDS Coordinator confirmed these diagnoses were inputted in error, and the facility lacked a specific MDS policy, relying instead on RAI guidelines.
A resident with multiple chronic conditions experienced unwitnessed falls, and staff failed to document the required 72-hour follow-up vital signs and neurological assessments as outlined in facility policy. Interviews confirmed that neurological checks were not initiated and documentation was not completed by a new nurse, resulting in incomplete post-fall monitoring records.
A resident's medical record contained incorrect diagnoses of schizophrenia and bipolar disorder, which were also reflected on the resident information sheet. The DON confirmed these diagnoses were inaccurate and should not have been listed, and the facility could not provide an accurate records policy.
The facility did not document the time when TB skin tests were read for four employees, as required by its infection control policy. Forms showed the dates of administration and reading, but the time was missing, despite policy and staff interview confirming this information should be recorded.
A resident with severe cognitive deficits and under hospice care did not receive prescribed Morphine concentrate due to unavailability, and there was no pain assessment documented. The facility staff failed to notify the physician, family, or hospice, and did not use the Emergency Drug Kit. Two staff members were terminated for not following facility policies.
The facility failed to ensure proper documentation and handling of medications, particularly narcotics, with missing signatures and discrepancies in records. The narcotic sign-in and sign-out record book lacked 66 nursing staff signatures, and the medication destruction logbook had 24 errors, including missing dates and resident names. Additionally, there were discrepancies between narcotic logbook entries and resident MARs for 14 residents, with 61 errors noted. The Regional Clinical Support nurse acknowledged staff errors, leading to the termination of two staff members for policy violations.
The facility failed to administer medications within the ordered time frame for multiple residents, did not accurately assess and document a resident's dental status, and did not provide appropriate positioning equipment for a resident, leading to inadequate care and support.
The facility failed to include a seizure disorder diagnosis or monitoring for seizure medication side effects in the care plan for a resident with epilepsy. Despite a physician's order for lamotrigine, the care plan did not address the risk for seizures, monitoring seizure activity, or safety measures. Interviews confirmed the omission, which contradicted the facility's policy on comprehensive care plans.
The facility failed to evaluate and document the effectiveness of post-fall interventions before removing them from the care plans of two residents. One resident experienced multiple falls, and interventions were not included in the care plan or documented for resolution. Another resident's intervention to offer activities after lunch was also not included in the care plan, with no documentation of its effectiveness.
The facility failed to monitor a resident on a fluid restriction related to dialysis, resulting in the resident exceeding the daily fluid limit on multiple occasions. Staff were unaware of the restriction, and the resident did not have a care plan for noncompliance with fluids.
The facility failed to monitor seizure medication side effects and seizure activity for a resident prescribed lamotrigine. The care plan lacked safety measures for seizures, and the facility did not confirm the seizure disorder diagnosis. Additionally, there was no attempt at a gradual dose reduction for the medication when given for mood disorder.
The facility failed to ensure timely AIMS assessments for a resident prescribed antipsychotic medications, with initial and subsequent assessments not completed according to policy. The resident had multiple diagnoses, including dementia and anxiety, and was at risk for adverse reactions.
The facility failed to maintain a clean and odor-free environment, with strong odors in hallways and rooms, damaged walls and doors, and wet carpets posing risks to residents. Ongoing sewage system issues contributed to the odors, and the facility's wall maintenance policy was not effectively implemented.
Improper Food Storage and Staff Beverages in Kitchen Preparation Area
Penalty
Summary
The deficiency involves improper food storage and the presence of employee beverages in the food preparation area, affecting the kitchen that serves all 65 residents. During a kitchen observation with the Dietary Manager, surveyors observed two unopened cans of energy drinks and a white cup with a lid and straw stored on a food preparation counter next to a jar of peanut butter and a loaf of bread. The Dietary Manager stated these drinks belonged to staff and acknowledged that staff were not supposed to store any personal food or drinks in the food preparation area. Dietary Staff later confirmed that staff should never leave their personal drinks or food in the kitchen. Additional observations in the walk-in freezer showed improper storage of frozen chicken. On the second shelf, there was a large opened plastic bag containing one skinless chicken breast with a small amount of ice buildup on the upper left corner, and a large cardboard box of skinless chicken breasts with the plastic bag left untied and the cardboard lid wide open. The Dietary Manager confirmed that the clear package containing the single chicken breast was open with ice on the edges and that the box of opened chicken should have been tied and not left open to air. These practices were inconsistent with the facility’s Culinary Services policy, which requires that food and supplies be properly stored and that all foods in the freezer be wrapped in moisture-proof wrapping or placed in suitable containers, labeled and dated, to keep foods safe and preserve quality.
Failure to Follow Medication Parameters and Obtain Timely Admission Weights
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders for medication administration and to obtain required admission weights for multiple residents. For one resident with hypotension, vitamin deficiency, acute kidney failure, and iron deficiency anemia, a care plan dated 3/19/26 identified potential for cardiovascular distress and included an intervention to administer medications as ordered. A physician’s order dated 3/11/26 directed administration of midodrine 5 mg four times daily, to be held for systolic blood pressure greater than 110. Review of the MAR from 3/11/26 through 3/25/26 showed midodrine was administered despite systolic blood pressures above the ordered hold parameter on several occasions, including readings of 167, 129, 112, 114, 111, and 127. The MAR also showed midodrine was held when it should have been given on multiple occasions when systolic blood pressure was at or below 110, with readings ranging from 100 to 110. The DON and an LPN confirmed during interviews that medications should not be administered or held outside of ordered parameters and that the MAR would reflect when medications were not given and the reason. The deficiency also includes failure to obtain admission weights as ordered or per facility guidelines for two residents. For one resident with diastolic congestive heart failure, dementia, type 2 diabetes mellitus, and anxiety disorder, a physician’s admission order dated 7/31/25 required a one-time weight, but no admission weight was found in the clinical record, and the DON stated the first weight was not obtained until 8/5/25. For another resident with cellulitis of the right lower limb, pulmonary fibrosis, dementia, diabetes mellitus, and hypertension, the resident was admitted on a specified date, but the admission weight was not obtained until three days later. Staff interviews revealed inconsistent understanding of when admission weights should be obtained: the Clinical Support Nurse stated the policy did not specify timing, while an LPN, another LPN, and a QMA each indicated admission weights should be obtained at admission, by the end of the admission shift, or within 24 hours. The facility’s Medication Administration General Guidelines policy stated medications are to be administered as prescribed, and the Guidelines for Weight Tracking policy stated residents will have their weight taken and recorded upon admission to establish a baseline.
Inaccurate Discharge Paperwork Provided to Receiving Facility
Penalty
Summary
The facility failed to ensure that accurate discharge paperwork was provided to the receiving facility for a resident who was being transferred to a group home. The discharge assessment sent with the resident indicated that she required assistance with eating, hygiene, toileting, showers, lower body dressing, and putting on and taking off footwear. However, interviews and record review revealed that the resident was actually independent in these areas and did not require such assistance. The Director of Nursing confirmed that the discharge plan was incorrect and was not aware that the inaccurate assessment had been sent with the resident. The resident involved had diagnoses including asthma, tracheostomy status, and congenital malformation of the musculoskeletal system, but was cognitively intact and capable of making her own decisions. The clinical record and nursing progress notes documented the discharge planning process, including meetings with the resident and family, and the actual discharge to the group home. Despite this, the discharge narrative provided to the receiving facility did not accurately reflect the resident's functional status at the time of transfer.
Failure to Ensure Dignified Dining Experience and Resident Rights
Penalty
Summary
The facility failed to uphold residents' rights to dignity and a respectful dining experience in the legacy dining room. Staff did not serve meals to residents at the same table together, instead distributing plates randomly based on meal tickets, contrary to the usual practice of serving one table at a time. Interviews with staff confirmed confusion and inconsistency in meal service procedures, with some staff following instructions to serve by ticket order and others expressing that serving by table was the standard. Additionally, a staff member was observed eating while standing next to residents rather than sitting with them, which was acknowledged by both the staff member and the DON as inappropriate and not in line with facility policy, which encourages staff to sit and eat with residents to promote a dignified, family-style dining environment. A resident was also removed from the dining room by a hospice CNA before completing his meal to receive a shower, despite having only finished his soup and waiting for the main course. The resident was returned to the dining room after the shower, at which point his meal had to be retrieved from the kitchen as other residents had already been served. Staff interviews and facility policy indicated that showers should not be given during mealtimes except in extreme situations, such as incontinence. The facility's own policies emphasize serving residents together, respecting their dignity, and providing a fine dining experience, all of which were not consistently followed during the observed incidents.
Failure to Timely Update DNR Order in Resident Record
Penalty
Summary
The facility failed to ensure that a do not resuscitate (DNR) order was updated in a timely manner for a resident with multiple complex medical diagnoses, including heart failure, coronary artery disease, hypertension, Parkinson's disease, type 2 diabetes, obesity, schizophrenia, iron deficiency anemia, and hypothyroidism. The resident initially had a physician's order indicating full code status. Subsequently, a State of Indiana Out of Hospital Do Not Resuscitate Declaration and Order form was completed and signed by the resident's representative and a witness, and later by the physician. Despite the completion of the DNR form, there was a delay in updating the physician's order to reflect the resident's new DNR status. Interviews with staff revealed that while the signed DNR form was uploaded into the resident's electronic chart, the corresponding order was not immediately updated to match the form. The Director of Nursing acknowledged that there were instances where the form was uploaded but the orders were not updated accordingly, which led to the deficiency.
Failure to Issue Required Medicare Beneficiary Notices
Penalty
Summary
The facility failed to provide required Skilled Nursing Facility Advance Beneficiary Notices of Non-coverage (SNF ABN) and Notice of Medicare Non-Coverage (NOMNC) to two residents who were discharged from Medicare Part A services before exhausting their benefit days. For both residents, documentation showed that Medicare Part A services were discontinued, but there was no evidence that the appropriate beneficiary notices were issued at the time of discharge. The Director of Nursing confirmed during an interview that beneficiary notices were not being completed prior to February of the current year. Facility policy required that NOMNCs be issued prior to therapy discharge and, if Medicare days remained, that both SNF ABN and NOMNC forms be provided, but this was not followed for the residents in question.
Incorrect Coding of MDS Assessment for Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessment was accurately coded for a resident with a history of schizophrenia, bipolar disorder, and cognitive communication deficit. The resident's clinical record included conflicting information: a Preadmission Screening and Resident Review (PASARR) indicated no known mental health conditions, while a resident information sheet reviewed by a physician listed schizophrenia and bipolar disorder as diagnoses. The admission MDS assessment did not indicate a diagnosis of schizophrenia, but a subsequent significant change in status MDS assessment did. Physician's orders did not include any antipsychotic medications for these conditions. Interviews with the Director of Nursing (DON) and the MDS Coordinator revealed that the diagnoses of schizophrenia and bipolar disorder were incorrectly entered into the MDS assessment, and these errors were later identified and removed. The facility did not have a specific MDS policy and relied on RAI guidelines.
Failure to Document Post-Fall Vital Signs and Neurological Assessments
Penalty
Summary
The facility failed to ensure that vital signs and neurological assessments were documented for a resident following unwitnessed falls. The resident, who had diagnoses including hypertension, chronic kidney disease, type 2 diabetes mellitus, and urinary retention, experienced unwitnessed falls on two separate occasions. In both instances, the clinical records and incident reports did not include documentation of the required 72-hour follow-up vital signs or neurological assessments. Interviews with the DON confirmed that neurological assessments were not initiated after one of the falls, and documentation was not started for the other. A nurse involved was new and did not initiate the required records. Facility policies required that nursing staff monitor and document the resident's response and effectiveness of interventions for 72 hours following a fall, including completing and documenting neurological assessments and vital signs. Staff interviews confirmed that the expected practice was to assess for injuries and complete vital signs and neurological checks every shift for 72 hours, with documentation in the electronic health record. However, these procedures were not followed or documented as required for the resident after the unwitnessed falls.
Inaccurate Resident Diagnoses Documented in Medical Record
Penalty
Summary
The facility failed to ensure the accuracy of a resident's medical record by listing incorrect diagnoses. Review of the clinical record for one resident showed diagnoses of schizophrenia and bipolar disorder, as well as a cognitive communication deficit. The resident information sheet, last reviewed by the physician, also included schizophrenia and bipolar disorder. However, physician's orders did not include any antipsychotic medications for these conditions. During interviews, the DON confirmed that the resident did not have schizophrenia or bipolar disorder and acknowledged that these diagnoses were incorrectly listed. Additionally, the facility was unable to provide an accurate records policy upon request.
Failure to Document Time of TB Test Readings for Employees
Penalty
Summary
The facility failed to follow its policy and procedure for administering and documenting two-step Mantoux skin tests for tuberculosis for four out of five employees reviewed. Specifically, for each of the employees, the facility's forms indicated the dates the TB tests were administered and read, but there was no documentation of the time the tests were read, as required by facility policy. The policy states that both the date and time of administration and reading must be recorded. During an interview, an LPN confirmed that all information, including lot number, date, time, and initials, should be documented when administering and reading TB tests, and that the tests should be read within 48-72 hours. The facility's current policy, reviewed and provided by the DON, also specifies that the administration and reading of the Mantoux test must include the date and time. The lack of time documentation for both steps of the TB test for these employees constitutes a failure to follow established infection control procedures.
Failure to Administer Prescribed Medication
Penalty
Summary
The facility failed to ensure that a resident received medications as per the physician's order, specifically for a resident with Alzheimer's disease, dementia, chronic kidney disease, and anxiety who was under hospice care. The Medication Administration Record (MAR) showed that the resident did not receive the prescribed Morphine concentrate every 6 hours on multiple occasions over a three-day period. The medication was reportedly unavailable for administration, and there was no documentation of pain assessment during this time. Additionally, the physician, family, and hospice were not notified of the missed doses, and the Emergency Drug Kit was not utilized. Interviews revealed that the errors were attributed to facility staff, leading to the termination of two staff members for not adhering to the facility's policies and procedures. The facility's policies required that medication administration be recorded immediately after administration and that controlled drugs have a corresponding count sheet. However, there was no documentation of pain assessment for the resident during the days in question, and the resident was only given routine Tylenol. The lack of adherence to these policies contributed to the deficiency in care provided to the resident.
Medication Documentation and Handling Deficiencies
Penalty
Summary
The facility failed to ensure proper documentation and handling of medications, particularly narcotics, as evidenced by missing signatures and discrepancies in medication records. The narcotic sign-in and sign-out record book was missing 66 nursing staff signatures over a period of more than a month. Additionally, the medication destruction logbook contained 24 errors, including missing dates, resident names, quantity amounts, and nursing signatures. Furthermore, there were significant discrepancies between the narcotic logbook entries and the resident Medication Administration Records (MAR) for 14 residents, with 61 errors noted over a two-month period. The narcotic book indicated that 32 medications were withdrawn, but the MAR did not reflect their administration, while the MAR showed 29 medications were administered without corresponding withdrawals in the narcotic record logs. During an interview, the Regional Clinical Support nurse acknowledged that documentation errors were made by the staff, and two staff members were terminated for not adhering to the facility's policies and procedures. The facility's policies, which were revised in 2018 and 2016, respectively, outlined the requirements for medication destruction and narcotic count documentation. These policies required detailed entries in the controlled substance accountability record/book and the MAR immediately after medication administration. The deficiencies were identified during a survey related to a specific complaint, highlighting lapses in the facility's medication management practices.
Medication Administration and Care Plan Deficiencies
Penalty
Summary
The facility failed to administer medications within the ordered time frame for multiple residents. Resident 40, diagnosed with type 2 diabetes mellitus, heart failure, edema, and chronic kidney disease, had a physician's order for buspirone to be administered three times a day within specific time frames. However, the medication was repeatedly given outside the ordered times, often in the early morning hours, without notifying the physician. Similar issues were observed with Resident 47, who was prescribed Eliquis, and Resident 1, who was prescribed baclofen. Both residents received their medications outside the ordered times, and there was no documentation indicating that the physician was informed of these deviations. The DON and QMA were unable to provide a clear explanation for these early administrations. The facility also failed to accurately assess and document Resident 46's dental status. The resident's clinical record contained conflicting information about her dental condition. While some records indicated she was edentulous, other notes suggested she had upper and lower dentures. Observations revealed that the resident had no upper teeth and several natural lower teeth, but there was no clear documentation or follow-up on her dental needs. Interviews with staff indicated a lack of awareness and inconsistency in the resident's dental care, with some staff unsure about the presence of dentures and others noting that the resident had lost her dentures at a previous facility. Additionally, the facility did not provide appropriate positioning equipment for Resident 27, who was observed sitting in a Broda chair without leg rests or foot supports, making it difficult for her to eat comfortably. The resident's care plan did not include the use of a Broda chair, and there was no physician's order for it. Hospice staff noted that the resident's wheelchair was being used for another resident, and the Broda chair provided by the facility was broken. The facility failed to communicate effectively with hospice about the resident's needs and did not update the care plan to reflect the current situation, leading to inadequate positioning and support for the resident.
Failure to Include Seizure Disorder in Care Plan
Penalty
Summary
The facility failed to include a seizure disorder diagnosis or monitoring for seizure medication side effects in the care plan for a resident with epilepsy. The resident's clinical record indicated diagnoses including epilepsy, dementia with behavioral disturbance, delusional disorder, depression, anxiety disorder, and insomnia. A physician's order prescribed lamotrigine, an anticonvulsant, for epilepsy. However, the care plan did not address the risk for seizures, monitoring seizure activity, or safety measures for seizures. Additionally, the care plan did not include the resident's anticonvulsant medication or approaches for monitoring its side effects. Interviews with the Clinical Support Nurse and the Director of Nursing confirmed that the facility had not included monitoring for seizures in the care plan. The facility's policy on comprehensive care plans indicated that care plan interventions should reflect risk areas or disease processes impacting the resident and should be revised to reflect changes in the resident's condition. Despite this policy, the care plan for the resident remained incomplete and did not address the necessary monitoring and safety measures for the resident's seizure disorder and medication side effects.
Failure to Evaluate and Document Post-Fall Interventions
Penalty
Summary
The facility failed to ensure post-fall interventions were evaluated for effectiveness and documented before being removed from the care plans of two residents. Resident 23, diagnosed with malignant neoplasm of the pancreas, unspecified dementia with behavioral disturbance, and chronic kidney disease stage 3, experienced a fall while ambulating with a walker. An intervention for hospice to re-evaluate the use of the ambulatory device and weakness was noted but not included in the current care plan, nor was there documentation of its resolution. Another fall resulted in an acute metatarsal injury, and a new intervention for staff to toilet the resident in the morning was also not included in the current care plan. Resident 54, diagnosed with unspecified dementia with anxiety, heart failure, type 2 diabetes mellitus, chronic kidney disease stage 3, repeated falls, and difficulty in walking, was found on the floor in his room. An intervention to encourage and offer activities after lunch was noted but not included in the fall care plan. The Director of Nursing indicated that interventions would be removed if the root cause of the fall changed, but there was no documentation to indicate whether the interventions were effective or no longer applied. The facility's Fall Management Program Guidelines require thorough investigation, reassessment, and updating of care plans, which was not followed in these cases.
Failure to Monitor Fluid Restriction for Dialysis Resident
Penalty
Summary
The facility failed to ensure proper monitoring of a resident on a fluid restriction related to dialysis. Resident 47, who had diagnoses including dependence on renal dialysis, diabetes mellitus, depression, and end-stage renal disease, had a care plan indicating a potential for weight fluctuations and alterations in labs due to dialysis treatments. The care plan included interventions such as limiting fluid intake if a fluid restriction was ordered. A physician's order dated 12/28/23 specified a daily fluid restriction of 1200 milliliters, with specific amounts to be given during meals and different shifts. However, a facility vitals report indicated that the resident exceeded the daily fluid restriction on 17 out of 25 days between 4/1/24 and 4/25/24. Interviews revealed that CNA 4 was unaware of the resident's fluid restriction and had not recently reviewed the care plan. The Director of Nursing (DON) confirmed the resident was on a fluid restriction and acknowledged that the resident did not have a care plan for being noncompliant with fluids. The resident herself indicated awareness of the need to limit fluid intake due to dialysis. The facility's policy on fluid restrictions, revised on 12/1/21, outlined procedures for monitoring and documenting fluid intake, but these were not effectively implemented for Resident 47.
Failure to Monitor Seizure Medication and Activity
Penalty
Summary
The facility failed to include monitoring for seizure medication side effects and seizure activity for Resident 29, who was prescribed lamotrigine. The resident's clinical record did not include a care plan for monitoring seizure activity or side effects of the anticonvulsant medication. The care plan also lacked safety measures for seizures, despite the resident having a diagnosis of epilepsy. Interviews with the Clinical Support Nurse and the DON revealed that the facility did not have a clear reason for the lamotrigine prescription and had not confirmed the seizure disorder diagnosis. The DON later concluded that Resident 29 did not have a seizure disorder after reviewing all records and attempting to contact the family for confirmation. Additionally, the facility did not attempt a gradual dose reduction for the lamotrigine when it was given for mood disorder rather than seizure disorder. The facility's policy on psychotropic medication usage and gradual dose reductions emphasized the need for appropriate use, evaluation, and monitoring by the interdisciplinary team. However, the facility failed to adhere to this policy, as there was no regular monthly review of the antipsychotic medication for continued need, appropriate dosage, side effects, risks, and benefits for Resident 29.
Failure to Conduct Timely AIMS Assessments for Antipsychotic Medications
Penalty
Summary
The facility failed to ensure timely assessments for side effects of antipsychotic medications for one resident. Resident 54, who had diagnoses including unspecified dementia with anxiety, major depressive disorder, anxiety disorder, and a cognitive communication deficit, was prescribed olanzapine and Risperdal without timely completion of the Abnormal Involuntary Movement Scale (AIMS) assessments. The initial AIMS assessment for olanzapine was completed 27 days after the medication was ordered, and the subsequent AIMS assessment was completed 7 months and 4 days after the initial assessment. Additionally, there was no diagnosis provided with the physician's orders for these medications. The facility's policy required AIMS assessments to be completed prior to or at the earliest possible time after the medication was prescribed and every six months thereafter. However, the Director of Nursing (DON) confirmed that the AIMS assessments were not completed according to the facility's policy. The failure to conduct timely AIMS assessments for Resident 54, who was at risk for adverse reactions related to antipsychotic medications, was a significant oversight in monitoring and managing the resident's medication regimen.
Facility Fails to Maintain Clean and Odor-Free Environment
Penalty
Summary
The facility failed to ensure a safe, clean, and comfortable environment for residents, staff, and the public. Observations revealed strong odors in various hallways and rooms, with the back hallway near the riser room and the chapel being particularly affected. The dementia unit dining room had walls with gouges and black marks on the doors, while the carpet in the hallways was faded and stained. Additionally, a urine-soaked brief was found in the trash can of a bathroom, contributing to a strong urine odor. Another room had very wet and slick carpet, posing a risk to residents walking on it with non-skid socks that became wet. The front hallway also had a foul, unidentifiable odor that was neither urine nor bowel movement-related. The Maintenance Director confirmed ongoing issues with the sewage system, which contributed to the odors, and noted that repairs were needed but had not yet been completed. The Executive Director acknowledged the wet carpet issue and the sewer smells, especially in the back hall, which were exacerbated by rain. The facility's current policy on wall maintenance was not effectively implemented, as evidenced by the damaged and poorly maintained walls and doors in several rooms and common areas.
Latest citations in Indiana
Surveyors observed that dietary staff repeatedly worked in kitchen and meal service areas with uncovered facial hair, despite facility policy and state sanitation requirements mandating effective hair restraints. Two dietary aides with short beards or mustaches were seen walking through food preparation areas, taking food temperatures, handling food, and plating meals at steamtables in dining rooms without any facial hair coverings, while the current policy required all hair, including facial hair, to be restrained to prevent contamination.
The facility failed to consistently provide and document required bed-hold policy notices when several residents were transferred to the hospital. In multiple cases, residents with dementia, psychotic disorders, COPD, chronic respiratory failure, altered mental status, and cerebral infarction were sent out for acute changes in condition, and while transfer notes reflected physician and family notifications, they lacked documentation that the bed-hold policy was discussed with the resident or responsible party. Notices of Transfer or Discharge often indicated a copy of the bed-hold policy was sent with the resident, but the records did not show signed and dated acknowledgment by the resident or appropriate representative, including in situations where a resident had moderate cognitive impairment, short-term memory issues, or a documented need for a proxy and a financial POA authorizing an agent for health care decisions.
Surveyors found that the facility failed to provide trauma‑informed and culturally competent care by not incorporating two residents’ extensive trauma histories and specific behavioral triggers into their care plans. One resident with documented homelessness, polysubstance abuse, severe accidents with multiple fractures, viral encephalitis with coma, physical and sexual abuse, loss of family contact, and a past suicide attempt had multiple behavior‑focused care plans that referenced identifying triggers but listed none and did not mention their physical, sexual, medical, or psychosocial trauma. Another resident with TBI from being struck by a truck, an 11‑month coma, long‑term state hospital residence, alleged shooting of a parent, and diagnoses including intermittent explosive disorder and borderline personality disorder had a PASRR identifying a specific trigger and notes of inappropriate sexual behavior, yet their care plans omitted these traumatic events, the identified trigger, and the sexual behavior. Staff interviews confirmed that residents were screened for trauma, but the trauma histories and triggers were not reflected in the individualized plans of care.
A resident with schizophrenia, post‑stroke hemiparesis, and mild cognitive impairment expressed feeling down and wanting to kill himself, but staff did not document asking about a specific plan, did not notify the physician or psychiatric NP as expected, and did not develop or update a care plan addressing depression or suicidal ideation. The SSD documented offering support and initiating 15‑minute checks once, but there was no further follow‑up or documentation of interventions after subsequent suicidal statements made in a care plan meeting with the resident’s father. The DON and Administrator reported that facility policy requires immediate notification of key staff, assessment for a plan and means of self‑harm, and thorough documentation, which were not carried out or reflected in the medical record for this resident.
A resident with schizophrenia, post-stroke hemiparesis, and mild cognitive impairment verbalized suicidal ideation, but the care plan did not address depression or suicidal thoughts, and required assessments and services were not accurately or timely documented. An SSD note recorded the resident saying he wanted to kill himself and referenced 15‑minute checks and a care plan update, yet the active care plan lacked depression/suicidal ideation interventions. Multiple late-entry Social Services notes were later added, describing follow-up visits and the resident denying suicidal ideation, but the SSD later reported she did not typically ask about a suicide plan and did not personally provide individual follow-up visits as described. These practices conflicted with the facility’s policy requiring factual, first-hand, and timely documentation of assessments and services.
A resident was observed with an Albuterol inhaler on an overbed table and later reported keeping the inhaler in a nightstand drawer, with no staff present during these observations. Record review showed the resident had no cognitive impairment on the admission MDS but lacked any documented self-medication administration assessment. The DON acknowledged that the required assessment had not been completed, despite facility policy requiring staff and the practitioner to evaluate each resident’s mental and physical abilities before allowing self-administration of medications.
Surveyors found that the facility submitted inaccurate direct care staffing data to CMS through the PBJ system over multiple days in a quarter. CASPER reports showed apparent gaps in 24-hour licensed nurse coverage, low weekend staffing, and a 1-star staffing rating, while internal staffing sheets documented that licensed nurses were present and the facility was fully staffed on those days. The Administrator reported that the discrepancies were due to PBJ data entry errors, despite a facility policy requiring all PBJ entries to be accurate, auditable, and verifiable against payroll, invoices, or contracts.
Surveyors found that the facility did not provide or document required written transfer/discharge notices and bed-hold policy information for four residents who were sent to the hospital, including individuals with conditions such as dementia, CHF, chronic respiratory failure, and CKD. In each case, progress notes showed that the resident was transferred for acute issues, but the clinical records lacked evidence that written notices were given to the residents or their representatives, and in one case lacked documentation that required information was sent to the receiving provider. Facility leadership, including the ADON, DON, and Administrator, acknowledged that the records did not contain the required documentation, despite a written policy requiring such notices and information exchange.
A resident with Alzheimer’s disease and depression, previously on an antidepressant, exhibited intermittent refusals of medications and care, occasional yelling at staff, and reports of unusual perceptions, such as believing men were in or near her room. Nursing notes over several months documented these refusals and complaints but did not show that the behaviors were evaluated or recorded as dangerous, non-redirectable, or causing significant distress, nor did they document specific non-pharmacological interventions attempted or their outcomes. Despite this, a psychiatric NP later added new diagnoses of schizoaffective disorder, borderline personality disorder, and delusional disorder and ordered an antipsychotic (Seroquel) without a comprehensive evaluation in the record to support these diagnoses. The facility’s psychotropic medication policy, which requires identification and documentation of target behaviors, use of nonpharmacological interventions, and ongoing behavior monitoring, was not followed for this resident.
The facility failed to keep PASARR Level I screenings accurate and current for three residents when new mental health diagnoses and psychoactive medications were initiated. One resident’s PASARR omitted a PTSD diagnosis and an added antidepressant, despite documentation of PTSD on the MDS and care plan and a physician order for Pristiq. Another resident’s PASARR listed only depression and dementia, even after additional diagnoses such as borderline personality disorder, delusional disorder, and schizoaffective disorder were added and an antipsychotic (quetiapine) was ordered, with the MDS later reflecting psychotic disorder, schizophrenia, and depression with antipsychotic and antidepressant use. A third resident’s PASARR did not include a depression diagnosis or newly ordered escitalopram and lorazepam, although the admission MDS documented depression with antianxiety and antidepressant use. These omissions occurred despite facility policy requiring a new Level I review after significant mental status changes, including new mental health diagnoses or new psychotropic medications.
Uncovered Facial Hair During Food Preparation and Meal Service
Penalty
Summary
The deficiency involves the facility’s failure to ensure that food was served in a sanitary and safe manner in accordance with professional standards and facility policy during multiple kitchen and meal service observations. During an initial kitchen observation, two dietary aides were seen walking through the kitchen food preparation area with uncovered facial hair. One aide had facial hair above and below the lip and along the jaw line, approximately one-fourth inch in length, and the other had a mustache of similar length; neither used any facial hair covering. These observations occurred while staff were present in the kitchen area where food was stored and prepared. During subsequent observations on the same day, the same two dietary aides were again observed with uncovered facial hair while directly involved in meal preparation and service. One aide walked through the kitchen while the noon meal was being prepared and placed into a transport cart for service in the south dining room, and later was observed plating the noon meal at the steamtable in that dining room, still without a facial hair covering. The other aide walked through the kitchen while the noon meal was being prepared and placed into the steamtable for the north dining room, took food temperatures, assisted with plating meals at the steamtable, and retrieved food items and supplies from the kitchen, all while having an uncovered mustache approximately one-fourth inch in length. The Dietary Manager stated that staff hair was to be covered when in the kitchen and during meal service, and the facility’s written policy and the cited Indiana Food Establishment Sanitation Requirements both required effective hair restraints, including for facial hair, to prevent contamination of food, equipment, and utensils.
Failure to Provide and Document Bed-Hold Policy at Time of Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure that required bed-hold policy information was provided and documented for four residents transferred to the hospital. For a resident with dementia, psychotic disorder, and autistic disorder who had a BIMS score of 0 indicating severe cognitive impairment, progress notes documented physician notification and guardian notification when the resident was sent to the hospital, but there was no documentation that the bed-hold policy was provided to the responsible party. A Notice of Transfer or Discharge later indicated a copy of the bed-hold policy was sent with the resident. Another resident with COPD and chronic respiratory failure, cognitively intact with a BIMS score of 13, experienced a decline in condition and was transferred to the hospital by ambulance; progress notes documented family notification but did not document any discussion of the bed-hold policy, although a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident. A third resident with altered mental status and cerebral infarction, with a BIMS score of 10 indicating moderate cognitive impairment and documented short-term memory impairment, experienced changes in condition and was transferred to the hospital. Progress notes stated the resident was their own responsible party and that no other notification was completed, and transfer documentation did not include the bed-hold policy, although an untimed Notice of Transfer or Discharge indicated a copy of the bed-hold policy was signed by the resident. A financial power of attorney document in the record showed the resident had designated an agent to act in consent or refusal of health care. For a fourth resident with dementia and osteomyelitis, transfer documentation and a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident, and the transfer form noted the resident required a proxy for decision making. The facility’s policy required that at the time of transfer to a hospital, written notice specifying the duration of the bed-hold policy and information on return to the next available bed be provided, and that a signed and dated copy of the bed-hold notice given to the resident or representative be kept in the resident file, which was not consistently documented for these residents.
Failure to Integrate Trauma Histories and Behavioral Triggers Into Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to identify and incorporate residents’ trauma histories and specific behavioral triggers into their care plans, despite documented histories of significant trauma and behavioral health issues. For one resident, extensive social service and progress notes documented homelessness, polysubstance abuse, major depressive and anxiety disorders, chronic pain, a history of severe car accidents with multiple fractures, viral encephalitis resulting in a three‑month coma, loss of child custody, multiple divorces, physical abuse by a spouse, the death of a fiancé who was struck by a car while in a wheelchair, lack of family contact, and a past suicide attempt by Valium overdose. Additional documentation noted a history of rape by a brother at age eight and prior placement under direct supervision and 15‑minute checks related to suicidal ideation. Despite these documented traumatic events and behavioral health concerns, the resident’s care plans did not identify a history of physical trauma, sexual trauma, homelessness, substance abuse, medical trauma, or attempted suicide. For this same resident, the MDS showed no cognitive deficit and identified behaviors such as verbal aggression and rejection of care, along with diagnoses including seizure disorder, depression, chronic pain syndrome, homelessness, and anxiety disorder. Multiple care plans addressed behaviors such as drug‑seeking, pretending to have seizures for attention or medication, making false allegations, verbal aggression when unable to smoke, and a desire for intimate relationships with consenting male residents. These care plans referenced goals such as effective coping skills, seeking staff support, and compliance with the smoking policy, and they called for identification and reduction of behavioral triggers. However, none of these care plans actually listed any specific triggers. The care plan addressing the resident’s right to consensual intimate relationships focused on assessment and education regarding consent but did not integrate the resident’s extensive trauma history. Staff interviews indicated the resident had displayed sexual behaviors since admission, including an incident where the resident expressed anger at another resident for not buying a soda after engaging in sexual acts. A second resident with a documented history of traumatic brain injury (TBI), dementia, seizure disorder, borderline personality disorder, anxiety, intermittent explosive disorder, tobacco use, and other behavioral/emotional disorders was also affected by the same deficiency. Social history and progress notes documented that this resident sustained a TBI after being hit by a semi‑truck while riding a bicycle at age 18, resulting in an 11‑month coma, followed by 13 years in a state hospital and subsequent residence in a group home. Additional documentation indicated the resident allegedly shot their father at age 26 after being sworn at and had a PASRR identifying TBI, intermittent explosive disorder, and borderline personality disorder, with a specific trigger of hearing the name of the current U.S. President. Progress notes also described inappropriate sexual behavior toward staff, including touching themselves intimately during personal care and refusing to stop when redirected. Despite this, the resident’s care plans, which addressed explosive disorder and history of altercations, risk for decreased psychosocial well‑being, and refusal to bathe or shower, did not list any specific behavioral triggers, did not reference the traumatic events such as being hit by a truck or shooting their father, and did not document the inappropriate sexual behavior. The Administrator and Social Service Director acknowledged that residents were to be screened for trauma and that trauma responses and PTSD should be added to care plans, but the specific trauma histories and triggers for these two residents were not incorporated into their plans of care.
Failure to Assess and Care Plan for Resident Suicidal Ideation
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess, investigate, and care plan for a resident’s suicidal ideation in accordance with its own policy and staff expectations. The resident had diagnoses including schizophrenia, cerebral edema, and hemiparesis/hemiplegia following a cerebral infarction, and a current MDS showed mild cognitive impairment (BIMS score 12). A progress note documented that the resident told the Social Services Director (SSD) he was feeling down and wanted to kill himself; the SSD offered assistance, activities, and initiated 15‑minute checks, and the note stated the care plan was updated. However, the note did not indicate that the SSD asked whether the resident had a plan to kill himself, and there were no additional notes regarding suicidal ideation or follow‑up. Review of the current care plan showed no problem, goal, or interventions addressing depression or suicidal ideation, and progress notes over the following month contained no documentation of physician notification related to the suicidal statement. Further record and interview evidence showed that the care plan conference summary did not document interventions for suicidal ideation, and the SSD acknowledged she did not normally ask residents expressing suicidal ideation if they had a plan. The SSD reported that the resident had admission paperwork mentioning suicidal ideation related to depression after a stroke and that the resident again vocalized suicidal ideation during a care plan meeting with his father, after which emotional support was offered and the father took the resident out on a leave of absence; no further visits or follow‑up were done. The DON stated that, upon notification of suicidal verbalization, staff should assess the resident, ask if there is a plan, remove potential means of self‑harm, immediately notify the psychiatric NP, and document the occurrence, and that a detailed progress note and updated care plan were expected but not present for this resident. The Administrator similarly stated that staff should ask about a plan, document interventions, notify the physician and family, and update the care plan, and indicated the resident should have had a care plan addressing depression with suicidal ideation. The facility’s written policy required immediate notification of the DON, SSD, and physician, an interview including asking about a plan and assessing mood and means for self‑harm, and thorough documentation of mood, behavior, and all actions taken, which were not reflected in the resident’s record.
Incomplete and Inaccurate Documentation of Suicidal Ideation and Follow-Up
Penalty
Summary
The facility failed to ensure accurate, complete, and timely documentation of assessments and services for a resident who verbalized suicidal ideation. Resident 6, who had schizophrenia, cerebral edema, and right-sided hemiparesis/hemiplegia following a cerebral infarction, had a BIMS score of 12 indicating mild cognitive impairment. The resident’s admission paperwork mentioned suicidal ideation related to depression after a stroke, and a Social Services note on 3/11/2026 documented that the resident was feeling down and said he wanted to kill himself. The Social Services Director (SSD) documented that she talked with the resident, coordinated with Activities, advised the resident to contact SSD or nursing if he wanted to talk, and that the resident was scheduled for 15-minute checks and the care plan was updated. However, the current care plan initiated on 2/26/2026 did not address depression or suicidal ideation. Multiple Social Services progress notes were later entered as late entries in April, with effective dates in March, stating that the resident had no plan and no longer had suicidal ideation, that he felt much better after 1:1 time, and that he continued his daily routine and therapy. These late entries described follow-up visits and reassessments of suicidal ideation on several consecutive days, but in interviews the SSD stated she did not normally ask residents about having a plan when they verbalized suicidal ideation and did not recall any other occurrences beyond the initial event. She further indicated she did not personally provide individual follow-up visits with this resident regarding suicidal ideation, despite the late-entry notes describing such visits. The DON acknowledged that late entries had been added to address concern about suicidal verbalization, and the Administrator stated that upon suicidal statements staff should ask about a plan, notify the physician and family, and update the care plan, and that this resident should have had a care plan addressing depression with suicidal ideation. The facility’s documentation policy required factual, first-hand, timely documentation, which was not followed in this case.
Failure to Complete Required Self-Administration Assessment for Inhaler Kept at Bedside
Penalty
Summary
Surveyors identified that a resident was allowed to keep and access an Albuterol inhaler without the facility completing the required self-administration medication assessment. During an initial tour, the resident was observed sitting in a wheelchair with a handheld Albuterol inhaler on the overbed table and no staff present in the room or hallway. On a subsequent observation, the resident again was in a wheelchair and reported that the Albuterol inhaler was stored in the top drawer of the nightstand, where it was found. Review of the clinical record showed an admission MDS indicating no cognitive impairment, but there was no documentation of a self-medication administration assessment. In an interview, the DON confirmed that the resident did not have the required self-medication assessment, despite the facility’s policy stating that staff and the practitioner must assess each resident’s mental and physical abilities to determine whether self-administering medications is clinically appropriate. This failure to complete and document a self-administration medication assessment for a resident who had an Albuterol inhaler kept at bedside constituted noncompliance with the facility’s own policy and with 410 IAC 16.2-3.1-11(a).
Inaccurate PBJ Staffing Data Submission to CMS
Penalty
Summary
The deficiency involves the facility’s failure to electronically submit complete and accurate direct care staffing information to CMS through the Payroll-Based Journal (PBJ) system for 22 days in a fiscal quarter. A CASPER report review on 4/6/26 showed that, according to PBJ data, the facility did not have licensed nursing coverage 24 hours per day on multiple specific dates across three months, had low weekend staffing, and held a 1-star staffing rating. However, review of the facility’s internal staffing sheets for that quarter indicated the facility was fully staffed and had licensed nurse coverage on all of the dates in question. During an interview, the Administrator stated that the PBJ information must have contained data entry errors, as she had verified licensed staff coverage on the timesheets. The facility’s PBJ policy in effect stated that all staffing data entered into the PBJ system would be auditable and verifiable through payroll, invoices, or contracts, but the submitted PBJ data did not accurately reflect the facility’s actual licensed nurse staffing as documented on internal records. No specific residents or clinical conditions were mentioned in the report, and the deficiency centers solely on inaccurate staffing data submission rather than direct resident care events.
Failure to Provide and Document Required Transfer/Discharge and Bed-Hold Notices
Penalty
Summary
The deficiency involves the facility’s failure to provide and document required written notices of transfer/discharge and bed-hold policies, as well as required information to receiving providers, for four residents who were transferred or discharged to the hospital. For a resident with generalized anxiety disorder, major depressive disorder, and dementia, progress notes showed that the resident was sent to the hospital via 911 for chest pain, lower back pain, and shortness of breath and later returned to the facility, but the clinical record lacked documentation that a written Notice of Transfer/Discharge and the bed-hold policy were provided to the resident or representative, and lacked documentation that required information was conveyed to the receiving facility. The ADON and the Administrator both confirmed there was no documentation that these written notices were provided. For a resident with congestive heart failure and muscle weakness who was sent to the emergency room for painful urination and bloody urine, the clinical record lacked documentation that a Notice of Transfer/Discharge or bed-hold policy was given to the resident or representative, which the DON confirmed. Another resident with chronic respiratory failure and diabetes was discharged to the hospital for respiratory failure, and a resident with chronic kidney disease and dementia was discharged to the hospital, but in both cases there was no documentation that a written notice of transfer/discharge or bed-hold policy was provided to the residents or their representatives. Review of the facility’s Transfer and Discharge policy, dated 1/15/26, showed that the policy required the facility to provide written transfer/discharge notices and bed-hold information to residents and representatives and to provide specified information to receiving providers, but the records for these four residents did not contain the required documentation.
Failure to Document Target Behaviors and Non-Pharmacological Interventions Before Initiating Antipsychotic
Penalty
Summary
The deficiency involves the facility’s failure to document how a resident’s behaviors presented danger or distress to self or others, and failure to document non-pharmacological interventions attempted prior to initiating an antipsychotic medication. Resident 6 had documented diagnoses of Alzheimer’s disease, depression, and severe cognitive impairment, and was receiving sertraline for depression. A PASSAR identified only depression and dementia, and the admission MDS listed Alzheimer’s disease and depression as active diagnoses. Over several months, nursing progress notes documented that the resident intermittently reported unusual perceptions, such as believing there were men causing trouble, a man in her room, or a man wanting to marry her and yelling through the walls, but there was no documentation that these episodes caused danger to the resident or others or that they resulted in unmanageable distress. From late April through mid-July, nursing notes primarily described the resident’s frequent refusals of evening and morning medications, blood sugar checks, blood pressure checks, insulin administration, hygiene care, and showers. Staff documented that the resident sometimes yelled at staff, said “Get out!”, was visibly upset by a room move, was leery of staff and asked to see name badges, and became upset about a pillow under her head until it was removed, after which she calmed down. The notes also recorded instances where the resident believed housekeeping had not cleaned her room or that she had not received medications when she had. However, there were no progress notes or assessments indicating that these behaviors were evaluated as dangerous, non-redirectable, or causing significant distress or functional impairment, and no detailed behavior monitoring logs were present as required by facility policy. On a psychiatric NP visit for initial psychotropic medication management, new mental health diagnoses of schizoaffective disorder, borderline personality disorder, and delusional disorder were added, and Seroquel 25 mg, an antipsychotic, was ordered. The clinical record did not contain a comprehensive evaluation to support these new diagnoses, and there was no documentation of target behaviors meeting the facility’s policy criteria for psychotropic use, such as behaviors representing danger to self or others, causing distress and impairment in functional abilities, or clearly attributable to psychosis or mania. The resident’s representative reported that the resident had no prior history of mental health disorders or psychiatric hospitalization and was unaware of the new diagnoses. The facility’s own psychotropic medication policy required identification and documentation of specific target behaviors, use and documentation of nonpharmacological interventions, and ongoing monitoring of behaviors and interventions, which were not reflected in the record for this resident.
Failure to Update PASARR Screens for New Mental Health Diagnoses and Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that Preadmission Screening and Resident Review (PASARR) Level I screenings were accurate and updated when new mental health diagnoses and psychoactive medications were initiated for multiple residents. For one resident with dementia, anxiety, depression, and post-traumatic stress disorder (PTSD), the PASARR completed on admission listed anxiety, depression, and dementia with sertraline and quetiapine, but did not include the PTSD diagnosis or the antidepressant Pristiq, despite the admission MDS and care plan documenting PTSD and a subsequent physician’s order for Pristiq. For another resident with Alzheimer’s disease, borderline personality disorder, delusional disorder, schizoaffective disorder, and depression, the PASARR only reflected depression and dementia with sertraline, even though additional mental health diagnoses were added later and an antipsychotic (quetiapine) was ordered for borderline personality disorder, and the quarterly MDS documented psychotic disorder, schizophrenia, and depression with antipsychotic and antidepressant use. A third resident had diagnoses including Alzheimer’s disease, depression, anxiety disorder, irritability and anger, and nonrheumatic aortic valve stenosis. The PASARR for this resident listed dementia and anxiety with Risperdal but omitted the diagnosis of depression and the medications escitalopram and lorazepam, although physician’s orders were in place for escitalopram for depression and lorazepam for anxiety, and the admission MDS documented depression with antianxiety and antidepressant use. Interviews with the Assistant Director of Nursing confirmed that new Level I PASARR screens should have been completed when new mental health diagnoses and psychoactive medications were added, and that the PASARR for one resident, completed prior to arrival, should have included all mental health diagnoses and medications. The facility’s own policy required notification of the state mental health authority within 14 days after a significant change in mental condition and specified that a new Level I screen is required for new mental health diagnoses or newly prescribed psychotropic medications, which was not followed in these cases.
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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.
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