Waters Of Martinsville, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Martinsville, Indiana.
- Location
- 2055 Heritage Dr, Martinsville, Indiana 46151
- CMS Provider Number
- 155183
- Inspections on file
- 39
- Latest survey
- January 30, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Waters Of Martinsville, The during CMS and state inspections, most recent first.
Surveyors identified that food was not stored, prepared, and served in a safe and sanitary manner when staff prepared meal trays without hairnets, expired ranch dressing and milk were left in the walk-in refrigerator, and debris and food particles accumulated on and around the dishwasher area. These conditions occurred despite a facility policy requiring food to be stored and prepared in a clean, safe, and sanitary manner.
Surveyors found that two residents were living in unsanitary conditions, including stained or absent bed linens, strong urine odors, and urine-soiled briefs left in a shared bathroom garbage can. One resident reported discarding her own soiled briefs in the bathroom trash and not recalling when her sheets were last changed, while another resident sharing the bathroom noticed briefs in the trash that she had not placed there. In a separate room, a resident’s bed had no sheets on two consecutive days, and a fleece blanket and mattress were found saturated with urine, with the resident unable to recall when linens or the blanket were last cleaned. A CNA acknowledged that soiled briefs should not remain in the bathroom trash, and the facility could not provide a related policy.
Surveyors observed that food was not prepared or stored in a sanitary manner, with dietary staff lacking proper hair coverage, expired and unlabeled food items in storage, dirty floors and surfaces, improper storage of utensils, and incomplete temperature records. These deficiencies had the potential to affect nearly all residents in the facility.
A resident with multiple medical and psychiatric diagnoses, who was cognitively intact, was found to have ants both inside and outside her dresser drawer, and reported ongoing ant presence in her room, including in her bed. The facility's pest control policy was reviewed but was undated, indicating a failure to ensure an effective pest control program.
A resident with a history of falls and high fall risk experienced multiple falls, including one resulting in fractures and another leading to paralysis, without appropriate care plan updates or new interventions. Another resident with dementia and high elopement risk exited the facility through a malfunctioning door lock, which had been previously reported as faulty, and the incident was not documented in nursing notes. Staff interviews revealed lapses in communication, documentation, and adherence to facility policies regarding incident response and supervision.
A resident with multiple chronic conditions fell while attempting to get out of bed, resulting in left arm pain and an x-ray order. An LPN placed the abnormal x-ray results in the physician binder but did not directly notify the physician, contrary to facility policy requiring direct notification of abnormal results.
A resident with a history of fractures, osteoporosis, and high fall risk was admitted with fall precautions, but the facility failed to document the fall risk or history of falls in the baseline care plan. Despite fall risk reviews indicating high risk, the care plan lacked appropriate interventions, and the required documentation and resident signature were missing.
A resident with atherosclerotic heart disease and dementia developed a pressure ulcer, but the facility failed to notify the resident's representative in a timely manner. Despite a nursing note indicating an attempt to contact the family, no further attempts were documented, and the representative was only informed during a visit. The facility's policy required notification within 24 hours, which was not followed.
The facility did not resolve grievances related to meal service for five residents, who were observed not receiving fruit cocktail with their meals despite raising the issue in a Resident Council Meeting. The Dietary Manager confirmed the fruit was available but not served, and the DON provided meeting minutes documenting the unresolved complaints.
The facility failed to provide house shakes to nine residents with orders for them due to running out of stock over the weekend. The Dietary Manager confirmed the shortage, and the Director of Nursing presented an Order Listing Report detailing the residents' needs for the shakes, which were prescribed for purposes such as wound healing and weight loss. The Administrator acknowledged the shortage, which left residents without their supplements until Monday lunch, highlighting a lapse in meeting dietary needs.
The facility failed to follow approved dietary menus, impacting multiple residents who did not receive the correct meals, including desserts and fruits. Observations and interviews confirmed discrepancies between the served meals and the approved menus, which were not aligned with the facility's substitution policy.
A resident with bipolar disorder repeatedly refused medication and exhibited increased disruptive behaviors, but the facility failed to notify the physician as required by policy. The resident's condition included agitation and verbal aggression, leading to psychiatric hospitalization. The DON was unaware of the policy for notifying physicians after medication refusals.
A facility failed to implement treatment orders for a resident with a stage 3 pressure ulcer. Despite recommendations to cleanse the wound and apply dressings, orders were not entered into the MAR/TAR until weeks later. Interviews revealed that the orders were improperly entered and not activated, leading to a delay in care.
The facility failed to prevent and manage pressure ulcers for two residents, leading to the worsening of existing ulcers and the development of new ones. A resident with dementia developed an unstageable ulcer on the left heel and a new ulcer on the left buttock, with inadequate pressure relief interventions. Another resident developed a Stage III ulcer on the upper back, with delayed treatment and poor communication among staff.
The facility failed to maintain a safe and sanitary environment, with issues including a dark substance on a vent cover, unsecured biohazard room, loose electrical outlet, and unsanitary resident bathrooms. The biohazard room contained unsecured cleaners and biological specimens, while several bathrooms had strong odors and dark substances around toilets.
The facility failed to provide written transfer and discharge notices to two residents and their representatives. One resident with chronic obstructive pulmonary disease and another with multiple diagnoses, including schizophrenia, were transferred to the hospital without the necessary documentation. The facility's policy did not include sending written notices, and the Interim DON confirmed this practice.
The facility failed to provide written notification of its bed-hold policy to two residents transferred to the hospital. One resident had chronic obstructive pulmonary disease, and another had schizophrenia, dysphagia, and other conditions. The Interim DON acknowledged that the facility did not provide the notification forms in writing prior to transfer, contrary to the facility's policy.
The facility failed to ensure accurate MDS assessments for two residents. One resident's assessment incorrectly marked PASARR Level II status, and another resident's assessment inaccurately indicated IV feeding. These errors were acknowledged by the MDS Coordinator during interviews.
A resident with chronic respiratory issues was observed multiple times with unlabeled nasal cannula oxygen tubing, despite physician's orders and facility policy requiring labeling. An LPN indicated that the facility lacked a respiratory therapy department, leaving the responsibility to nursing staff, who were unaware of when the tubing was last changed.
A resident with multiple diagnoses, including schizophrenia and dementia, was mistakenly given another resident's medications, leading to hospitalization. The error occurred when an agency nurse administered the wrong medications, despite facility policies requiring proper identification and adherence to the MAR.
Failure to Maintain Safe and Sanitary Food Storage and Preparation Practices
Penalty
Summary
The deficiency involves failure to ensure food was stored, prepared, and served in a safe and sanitary manner during two kitchen observations. During a kitchen tour, the Activity Director and Social Service Director were observed preparing meal trays in the kitchen without wearing hairnets. In the walk-in refrigerator, surveyors observed a one-gallon jug of ranch dressing that had an expiration date of 12/12/25 but was opened on 12/29/25, indicating it was opened after its expiration date and remained stored there. Surveyors also observed a buildup of debris and food particles on top of the dishwasher and along the floor underneath the metal dishwasher tables, indicating the dishwashing area and floors were not thoroughly cleaned. On a subsequent observation in the walk-in refrigerator, surveyors found two full one-gallon jugs of 2% milk with an expiration date of 1/29/26 that remained in storage past that date. Facility staff, including the Dietary Manager and Regional Dietary Director, acknowledged that the expired ranch dressing and milk should have been removed from the refrigerator and that the dishwashing area should have been thoroughly cleaned. The facility’s Food Storage policy, dated 11/29/19, stated that food should be stored and prepared in a clean, safe, and sanitary manner, which was not followed in these instances.
Failure to Maintain Clean Linens and Sanitary, Odor-Free Resident Rooms and Bathrooms
Penalty
Summary
The deficiency involves the facility’s failure to maintain a sanitary and safe environment in resident rooms and shared bathrooms. In one shared bathroom between two rooms, surveyors observed a large orange/brown stain on the fitted sheet of one bed and a urine-soiled brief left in the bathroom garbage can, along with a strong urine odor. One resident using that bathroom stated she could not remember when her sheets were last changed and reported that when she changed her own briefs, she threw the soiled briefs into the bathroom garbage can. Another resident who shared the same bathroom reported that she also placed her own soiled briefs in the garbage can and had noticed soiled briefs in the garbage that she had not put there. A CNA confirmed that soiled briefs should not have been left in the bathroom garbage can and that staff should have checked and removed garbage bags and soiled briefs. In another room, surveyors noted a strong urine odor and found a resident lying on a bed without any sheets, covered only with a small fleece blanket. The resident was unsure of the source of the urine odor and could not remember when she last had sheets on her mattress. On the following day, the same bed still had no linens, and the fleece blanket thrown on top of the bed was saturated with urine, with the mattress also wet. The resident reported that staff had not put linens on her mattress on either day and could not recall when the blanket was last cleaned. When requested, the facility was unable to provide a policy related to these issues.
Food Safety and Sanitation Deficiencies in Dietary Services
Penalty
Summary
The facility failed to ensure food was prepared and stored in a sanitary manner, as observed during a kitchen inspection. Dietary staff were seen with hair not fully covered by hair nets, with hair hanging out and down the back and shoulders. Multiple food items in the refrigerators were either past their use-by dates, unlabeled, or undated, including milk, gelatin, bacon grease, ham, and ground beef. The walk-in refrigerator had a visibly dirty floor with food debris and a leaking juice container, while the walk-in freezer had visible mold-like substances on the door. Additionally, a scoop was stored inside a flour bin in the dry goods area, and dirty linens were found inappropriately stored in a trash bag on the floor. Food safety records for temperature checks were incomplete for the morning shift. Interviews with the Dietary Manager and Administrator confirmed that these practices were not in accordance with facility policy, which requires proper hair restraints, labeling and dating of food, clean storage areas, and regular temperature checks. The observed deficiencies had the potential to affect nearly all residents in the facility, as the unsanitary conditions and improper food handling could compromise food safety for 52 of 53 residents.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program as evidenced by the presence of ants in a resident's room. During an observation, several ants were seen crawling both inside and outside a dresser drawer that was partially open in the resident's room. The resident reported that ants were present in her room consistently and had previously been found in her bed. Review of the resident's clinical record showed diagnoses including chronic obstructive pulmonary disorder, personality disorder, and major depressive disorder, and the resident was noted to be cognitively intact. The facility's current pest control policy, which aims to ensure a pest-free environment, was provided but was undated.
Failure to Prevent Falls and Elopement Due to Inadequate Supervision and Hazard Control
Penalty
Summary
The facility failed to provide adequate supervision and implement effective interventions to prevent repeated falls for a resident assessed as high risk for falls. The resident, who had diagnoses including diabetes, osteoporosis, osteoarthritis, and a history of traumatic fracture, experienced multiple falls during her stay. Despite being identified as high fall risk on assessments and having a history of falls, the baseline care plan did not document the resident's fall risk or specific interventions to prevent falls. After a witnessed fall and subsequent unwitnessed fall resulting in fractures of the wrist and hand, there was no documentation of new orders or interventions following the x-ray results. Additionally, after another fall where the resident was unable to stand and later became paralyzed, there was no interdisciplinary team (IDT) note or root cause analysis completed, contrary to facility policy. The facility also failed to ensure adequate supervision and safety measures for a resident assessed as high risk for elopement due to wandering behaviors. The resident, diagnosed with Lewy Bodies dementia, was able to exit the facility through an unlocked door without staff knowledge. The care plan for this resident included interventions for wandering but did not address the malfunctioning door lock, which had been reported as faulty by staff prior to the incident. The resident was found outside by a physical therapist, and there was no documentation of the elopement event in the nursing progress notes, despite an incident report being completed. Interviews with staff revealed lapses in communication and documentation regarding both residents' incidents. For the resident with repeated falls, staff did not consistently notify providers of critical results or update care plans with new interventions. For the resident who eloped, staff had previously reported the faulty door lock, and the incident was not properly documented in the clinical record. Facility policies required immediate reporting, investigation, and care plan updates for incidents and accidents, but these procedures were not followed in these cases.
Failure to Notify Physician of Abnormal X-ray Results After Resident Fall
Penalty
Summary
The facility failed to ensure timely physician notification of abnormal x-ray results for a resident who experienced a fall. The resident, who had multiple diagnoses including diabetes mellitus, a history of healed traumatic fracture, unsteadiness on feet, abnormal gait, osteoarthritis, and osteoporosis, attempted to get out of bed and fell, resulting in left arm pain. The nurse practitioner was notified and ordered an x-ray, with instructions to notify the clinician of any change in condition. When the x-ray results became available later that day, the LPN placed the results in the physician binder but did not directly notify the physician, and there was no documentation of how or when the physician was informed. The facility's policy required direct physician notification for abnormal x-ray results, but this was not followed in this instance.
Failure to Implement Baseline Care Plan for High Fall Risk Resident
Penalty
Summary
The facility failed to implement a baseline care plan addressing fall risk for a resident with multiple diagnoses, including diabetes mellitus, a history of healed traumatic fracture, unsteadiness on feet, abnormal gait, osteoarthritis, and osteoporosis. Upon admission, the resident's hospital records indicated osteoporosis and compression fractures, and the resident was placed on fall precautions. Despite this, the baseline care plan created did not document the resident's history of falls, nor did it include the resident's signature. Additionally, the care plan did not address the resident's high risk for falls, as identified in fall risk reviews conducted on two separate occasions. During interviews and record reviews, it was confirmed that the Director of Nursing presented all care plans for the resident, but none included a plan for high fall risk. The facility's policy required the admitting nurse to initiate a baseline care plan assessment upon admission to identify potential problems and implement appropriate interventions, with further review and revision by the interdisciplinary team within 72 hours. However, this process was not followed for the resident in question, resulting in the omission of necessary fall risk interventions in the baseline care plan.
Failure to Notify Resident's Representative of Pressure Ulcer
Penalty
Summary
The facility failed to notify a resident's representative of a significant change in the resident's physical status. Resident B, who had diagnoses including atherosclerotic heart disease and dementia, developed a pressure ulcer on the coccyx, which was discovered on 9/5/24. A nursing progress note indicated that a call was made to inform the resident's family representative, but contact was not made, and no further attempts were documented. A wound assessment report later confirmed the presence of an unstageable pressure ulcer. The resident's representative was not informed of the wound until a visit on 9/14/24, when a staff member mentioned it. The Director of Nursing stated that family members were contacted via phone, and if not reached, a message was left without further follow-up unless the resident was transferred to a hospital. The facility's policy required notification within 24 hours of a significant change, but this was not adhered to in this case.
Failure to Address Resident Grievances Regarding Meal Service
Penalty
Summary
The facility failed to address and resolve grievances related to food concerns for five residents, as observed during a survey. On December 27, 2024, multiple residents, including Residents B, C, D, E, and F, were observed not receiving fruit cocktail with their meals, despite having previously raised this issue during a Resident Council Meeting on November 20, 2024. Resident D specifically mentioned not receiving desserts or any fruit, and this was corroborated by the absence of fruit cocktail on the meal trays of the residents observed in the dining room. The Dietary Manager confirmed that the fruit cocktail was available in the refrigerator but was not distributed with the lunch trays. The Director of Nursing provided the Resident Council Meeting Minutes, which documented the residents' complaints about not receiving fruit or desserts with meals. Despite these grievances being documented, the facility did not take prompt action to resolve the issue, as evidenced by the continued absence of fruit cocktail during meals on the day of the survey.
Failure to Provide Prescribed Nutritional Supplements
Penalty
Summary
The facility failed to provide house shakes to nine residents who had orders for them, resulting in a deficiency. The Dietary Manager (DM) confirmed during interviews that the facility ran out of house shakes over the weekend, affecting residents who required these nutritional supplements. The Director of Nursing (DON) presented an Order Listing Report, which detailed the specific orders for each resident, including the frequency and purpose of the shakes, such as wound healing and weight loss. The residents affected included those with orders dating back several months, indicating a prolonged need for these supplements. The Administrator (ADM) acknowledged that the facility ran out of health shakes on Saturday evening, leaving residents without their prescribed supplements until lunch on Monday. The facility's policy on fortified foods and supplements was reviewed, which indicated that the Dining Services Department was responsible for preparing and delivering these items to nursing for distribution. This deficiency was related to specific complaints and highlighted a lapse in the facility's ability to meet the dietary needs of its residents as per their care plans.
Failure to Follow Approved Dietary Menus
Penalty
Summary
The facility failed to adhere to the approved dietary menus for two observed meals, impacting multiple residents. During a kitchen tour, the Dietary Manager indicated that the lunch menu included fried chicken, mashed potatoes, baked beans, and fruit cocktail. However, observations revealed that several residents, including Residents D, B, C, E, and F, did not receive the fruit cocktail as part of their meal. Interviews with these residents confirmed that they were not offered the fruit cocktail, and the Dietary Manager admitted that the fruit cocktail was not served with the lunch tray. This issue was previously raised in a Resident Council Meeting, where residents complained about not receiving desserts or fruit with their meals. Further discrepancies were noted on another day when the posted menu indicated lunch items such as nachos, rice, and Dutch apple pie, but residents received different items, including baked beans and a dish with marshmallows instead of the apple pie. The cook provided a handwritten menu that did not match the approved dietician menu, which listed different meals for the observed dates. The facility's policy on menu substitutions was reviewed, indicating that staff could choose any food within the same list to substitute for unavailable items, but this policy was not followed as the approved menus were not adhered to.
Failure to Notify Physician of Resident's Medication Refusal and Behavioral Changes
Penalty
Summary
The facility failed to notify the physician of a resident's change in condition, specifically regarding the refusal of medication and increased behavioral issues. Resident C, diagnosed with schizoaffective disorder, paranoid personality disorder, bipolar disorder, and insomnia, was prescribed divalproex sodium for bipolar disorder. Despite multiple refusals to take the medication and exhibiting increased agitation and disruptive behaviors, the physician was not informed as per the facility's policy. The resident's clinical records indicated several instances of medication refusal and behavioral disturbances. From August to October 2024, the resident frequently refused the prescribed divalproex sodium, receiving only a fraction of the doses. The resident's behavior included agitation, verbal aggression, and threats towards staff, as well as disruptive actions that affected other residents. Despite these significant changes in behavior and medication adherence, the facility staff did not notify the physician in a timely manner. The Director of Nursing (DON) was unaware of the specific policy regarding medication refusal, which required notifying the physician after two consecutive refusals or three refusals within a week. This lack of adherence to policy resulted in a failure to address the resident's changing condition appropriately, as evidenced by the resident's eventual need for psychiatric hospitalization.
Failure to Implement Pressure Ulcer Treatment Orders
Penalty
Summary
The facility failed to provide care consistent with professional standards for a resident with a pressure ulcer. The resident, diagnosed with Alzheimer's Disease and depression, developed a stage 3 pressure wound on the coccyx, discovered during their stay. Initial treatment recommendations included cleansing the wound with normal saline, applying collagen particles, and covering with bordered gauze. Subsequent recommendations adjusted the dressing to a transparent film, to be applied three times a week and as needed. However, these treatment orders were not entered into the Medication Administration Record and Treatment Administration Record (MAR/TAR) for the initial assessments on 9/11/24 and 9/18/24. A physician's order was eventually entered on 9/26/24, but no treatment was documented until 10/1/24, indicating a significant delay in care. Interviews with the Director of Nursing and the Administrator revealed that the treatment orders may not have been properly entered by staff and were electronically placed in a queue without activation. This oversight resulted in a lack of documented treatment for the pressure wound from its discovery until nearly three weeks later.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to prevent the development and worsening of pressure ulcers for two residents, leading to significant deficiencies in care. Resident 34, who had diagnoses including dementia and diabetes mellitus, was identified as being at mild risk for pressure ulcers. Despite this, the resident developed a stage two pressure ulcer on the left heel, which deteriorated into an unstageable ulcer. The facility did not implement timely interventions for pressure relief, such as heel boots or a low air loss mattress, even after recommendations from the Nurse Practitioner. Observations showed that the resident often did not have pressure-relieving devices in place, and the care plan was not updated promptly to address the worsening condition. Additionally, Resident 34 developed a new pressure ulcer on the left buttock, which was also not addressed with adequate pressure relief interventions. The care plan for this injury was delayed, and the necessary pressure-relieving devices were not consistently used. Observations and interviews revealed that the resident spent significant time in bed without appropriate pressure relief, contributing to the deterioration of the pressure ulcers. Resident 5 developed a facility-acquired Stage III pressure ulcer on the left upper back, reportedly caused by tight bra straps. The facility failed to initiate the prescribed wound treatment promptly, and there was a lack of documentation and communication regarding the wound's care. Interviews with staff indicated confusion about the presence and treatment of the wound, and there was no evidence of an interdisciplinary team meeting or root cause analysis to address the development of the pressure ulcer.
Facility Fails to Maintain Safe and Sanitary Environment
Penalty
Summary
The facility was found to have multiple deficiencies related to maintaining a safe and sanitary environment over a six-day survey period. Observations revealed that the air conditioning vent cover in the nursing supply room was covered with a dark, moist, powder-like substance. Additionally, the biohazard room near the south nursing station was repeatedly found unsecured and unattended, containing multiple containers of liquid cleaners, an unlocked refrigerator with resident biological specimens, and a biohazard bin with full sharps containers. The Director of Nursing acknowledged the need for repair to secure the biohazard room door. Further deficiencies were noted in resident rooms and bathrooms. An electrical outlet in a resident's room was observed to be loose and pulling away from the wall. Several resident bathrooms were reported to have a strong odor of urine and feces, with a dark substance around the base of the toilets. These observations were consistent across multiple dates and times, affecting numerous residents. The facility administrator confirmed the presence of these issues, indicating the need for cleaning and repair of the toilet caulking and the electrical outlet.
Failure to Provide Written Transfer and Discharge Notices
Penalty
Summary
The facility failed to provide the required written notification for transfer and discharge to two residents and their representatives. Resident 1, diagnosed with chronic obstructive pulmonary disease, was sent to the hospital, but the clinical record lacked documentation of the written Notice of Transfer and Discharge forms being provided. Similarly, Resident 31, who had diagnoses including schizophrenia, dysphagia, cognitive communication deficit, and unspecified psychosis, was transferred to the hospital without the necessary written notification being documented in the clinical record. The facility's policy, as provided by the Interim Director of Nursing, did not include sending the Transfer and Discharge form in writing to the resident and the resident representative. Instead, the forms were sent with the resident when they were transferred to another facility. This practice was confirmed during an interview with the Interim Director of Nursing, who acknowledged that the facility did not provide the written notices as required.
Failure to Provide Written Bed-Hold Policy Notification
Penalty
Summary
The facility failed to provide written notification of its bed-hold policy to residents who were transferred to the hospital, as required. This deficiency was identified for two residents during a review of their clinical records. Resident 1, who had a diagnosis including chronic obstructive pulmonary disease, was sent to the hospital, but the clinical record lacked documentation of the facility's bed-hold policy being provided in writing. Similarly, Resident 31, with diagnoses including schizophrenia, dysphagia, cognitive communication deficit, and unspecified psychosis, was transferred to the hospital without documented written notification of the bed-hold policy. During an interview, the Interim Director of Nursing admitted that the facility did not provide the bed-hold notification forms in writing to the residents prior to their transfer. Instead, the forms were sent with the residents when they were transferred to another facility. The facility's policy, which was undated but currently in use, stated that the bed-hold notification should be provided in written form and/or by telephone conversation prior to hospital transfer. This discrepancy between policy and practice led to the deficiency noted by the surveyors.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure accurate assessments for two residents during their MDS evaluations. For Resident 31, the clinical record review revealed a discrepancy in the Annual MDS assessment dated 2/8/24. The assessment incorrectly marked section A1500 as 'NO' for PASARR Level II, despite a prior determination on 10/20/23 indicating a Level II outcome for long-term approval without specialized services. Additionally, section A1510 was left incomplete, which should have been filled out due to the resident's PASARR Level II status. The MDS Coordinator acknowledged the error during an interview, confirming that the sections were incorrectly marked and incomplete. For Resident 3, the Quarterly MDS assessment dated 7/3/24 inaccurately indicated that the resident received parenteral/IV feeding in section K0520. However, the MDS Coordinator confirmed that the resident had not received IV nutrition since being admitted to the facility. This error was identified during a review of the resident's clinical record and was acknowledged by the MDS Coordinator during an interview.
Failure to Label Oxygen Tubing for Resident
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for a resident who required oxygen therapy. The resident, diagnosed with chronic respiratory failure with hypoxia, COPD, cognitive communication deficit, and dementia, was observed multiple times with unlabeled nasal cannula oxygen tubing. The physician's orders specified that the resident was to receive oxygen at a rate of 2 liters per minute and that the oxygen tubing should be changed weekly on Sunday nights. However, during several observations over a period of days, the tubing was consistently found to be unlabeled, contrary to the facility's policy. An interview with an LPN revealed that the facility did not have a dedicated respiratory therapy department, suggesting that the responsibility for labeling the tubing fell to the nursing staff. The LPN admitted to not knowing when the tubing was last changed. The facility's policy on oxygen administration, provided by the Regional Nurse Consultant, clearly stated that tubing should be labeled with the date, time, and initials of the staff member completing the service. This lack of adherence to the policy resulted in a deficiency in the standard of care provided to the resident.
Significant Medication Error Involving Resident
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by an incident involving a resident who was administered another resident's medications. The resident, who had diagnoses including schizophrenia, dysphagia, cognitive communication deficit, unspecified dementia, and unspecified psychosis, was mistakenly given a combination of medications not prescribed to them. These medications included Lyrica, Hydralazine, Oxycontin, Cymbalta, Coreg, Calcium, Senna, and Eliquis. This error was identified during a hospital stay, where it was noted that the resident had been given these incorrect medications. Interviews with the Executive Director and the Director of Nursing confirmed that the medication error occurred when an agency nurse administered the wrong medications to the resident. The facility's policy and procedure for medication administration, as well as the guidelines from UnitedRx Long Term Care Pharmacy, were reviewed and indicated that licensed professional nurses are responsible for administering medications according to the Medication Administration Record (MAR) and must identify the resident before administering medication. Despite these guidelines, the error occurred, leading to the resident's hospitalization and subsequent readmission to the facility.
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Surveyors observed that dietary staff repeatedly worked in kitchen and meal service areas with uncovered facial hair, despite facility policy and state sanitation requirements mandating effective hair restraints. Two dietary aides with short beards or mustaches were seen walking through food preparation areas, taking food temperatures, handling food, and plating meals at steamtables in dining rooms without any facial hair coverings, while the current policy required all hair, including facial hair, to be restrained to prevent contamination.
The facility failed to consistently provide and document required bed-hold policy notices when several residents were transferred to the hospital. In multiple cases, residents with dementia, psychotic disorders, COPD, chronic respiratory failure, altered mental status, and cerebral infarction were sent out for acute changes in condition, and while transfer notes reflected physician and family notifications, they lacked documentation that the bed-hold policy was discussed with the resident or responsible party. Notices of Transfer or Discharge often indicated a copy of the bed-hold policy was sent with the resident, but the records did not show signed and dated acknowledgment by the resident or appropriate representative, including in situations where a resident had moderate cognitive impairment, short-term memory issues, or a documented need for a proxy and a financial POA authorizing an agent for health care decisions.
Surveyors found that the facility failed to provide trauma‑informed and culturally competent care by not incorporating two residents’ extensive trauma histories and specific behavioral triggers into their care plans. One resident with documented homelessness, polysubstance abuse, severe accidents with multiple fractures, viral encephalitis with coma, physical and sexual abuse, loss of family contact, and a past suicide attempt had multiple behavior‑focused care plans that referenced identifying triggers but listed none and did not mention their physical, sexual, medical, or psychosocial trauma. Another resident with TBI from being struck by a truck, an 11‑month coma, long‑term state hospital residence, alleged shooting of a parent, and diagnoses including intermittent explosive disorder and borderline personality disorder had a PASRR identifying a specific trigger and notes of inappropriate sexual behavior, yet their care plans omitted these traumatic events, the identified trigger, and the sexual behavior. Staff interviews confirmed that residents were screened for trauma, but the trauma histories and triggers were not reflected in the individualized plans of care.
A resident with schizophrenia, post‑stroke hemiparesis, and mild cognitive impairment expressed feeling down and wanting to kill himself, but staff did not document asking about a specific plan, did not notify the physician or psychiatric NP as expected, and did not develop or update a care plan addressing depression or suicidal ideation. The SSD documented offering support and initiating 15‑minute checks once, but there was no further follow‑up or documentation of interventions after subsequent suicidal statements made in a care plan meeting with the resident’s father. The DON and Administrator reported that facility policy requires immediate notification of key staff, assessment for a plan and means of self‑harm, and thorough documentation, which were not carried out or reflected in the medical record for this resident.
A resident with schizophrenia, post-stroke hemiparesis, and mild cognitive impairment verbalized suicidal ideation, but the care plan did not address depression or suicidal thoughts, and required assessments and services were not accurately or timely documented. An SSD note recorded the resident saying he wanted to kill himself and referenced 15‑minute checks and a care plan update, yet the active care plan lacked depression/suicidal ideation interventions. Multiple late-entry Social Services notes were later added, describing follow-up visits and the resident denying suicidal ideation, but the SSD later reported she did not typically ask about a suicide plan and did not personally provide individual follow-up visits as described. These practices conflicted with the facility’s policy requiring factual, first-hand, and timely documentation of assessments and services.
A resident was observed with an Albuterol inhaler on an overbed table and later reported keeping the inhaler in a nightstand drawer, with no staff present during these observations. Record review showed the resident had no cognitive impairment on the admission MDS but lacked any documented self-medication administration assessment. The DON acknowledged that the required assessment had not been completed, despite facility policy requiring staff and the practitioner to evaluate each resident’s mental and physical abilities before allowing self-administration of medications.
Surveyors found that the facility submitted inaccurate direct care staffing data to CMS through the PBJ system over multiple days in a quarter. CASPER reports showed apparent gaps in 24-hour licensed nurse coverage, low weekend staffing, and a 1-star staffing rating, while internal staffing sheets documented that licensed nurses were present and the facility was fully staffed on those days. The Administrator reported that the discrepancies were due to PBJ data entry errors, despite a facility policy requiring all PBJ entries to be accurate, auditable, and verifiable against payroll, invoices, or contracts.
Surveyors found that the facility did not provide or document required written transfer/discharge notices and bed-hold policy information for four residents who were sent to the hospital, including individuals with conditions such as dementia, CHF, chronic respiratory failure, and CKD. In each case, progress notes showed that the resident was transferred for acute issues, but the clinical records lacked evidence that written notices were given to the residents or their representatives, and in one case lacked documentation that required information was sent to the receiving provider. Facility leadership, including the ADON, DON, and Administrator, acknowledged that the records did not contain the required documentation, despite a written policy requiring such notices and information exchange.
A resident with Alzheimer’s disease and depression, previously on an antidepressant, exhibited intermittent refusals of medications and care, occasional yelling at staff, and reports of unusual perceptions, such as believing men were in or near her room. Nursing notes over several months documented these refusals and complaints but did not show that the behaviors were evaluated or recorded as dangerous, non-redirectable, or causing significant distress, nor did they document specific non-pharmacological interventions attempted or their outcomes. Despite this, a psychiatric NP later added new diagnoses of schizoaffective disorder, borderline personality disorder, and delusional disorder and ordered an antipsychotic (Seroquel) without a comprehensive evaluation in the record to support these diagnoses. The facility’s psychotropic medication policy, which requires identification and documentation of target behaviors, use of nonpharmacological interventions, and ongoing behavior monitoring, was not followed for this resident.
The facility failed to keep PASARR Level I screenings accurate and current for three residents when new mental health diagnoses and psychoactive medications were initiated. One resident’s PASARR omitted a PTSD diagnosis and an added antidepressant, despite documentation of PTSD on the MDS and care plan and a physician order for Pristiq. Another resident’s PASARR listed only depression and dementia, even after additional diagnoses such as borderline personality disorder, delusional disorder, and schizoaffective disorder were added and an antipsychotic (quetiapine) was ordered, with the MDS later reflecting psychotic disorder, schizophrenia, and depression with antipsychotic and antidepressant use. A third resident’s PASARR did not include a depression diagnosis or newly ordered escitalopram and lorazepam, although the admission MDS documented depression with antianxiety and antidepressant use. These omissions occurred despite facility policy requiring a new Level I review after significant mental status changes, including new mental health diagnoses or new psychotropic medications.
Uncovered Facial Hair During Food Preparation and Meal Service
Penalty
Summary
The deficiency involves the facility’s failure to ensure that food was served in a sanitary and safe manner in accordance with professional standards and facility policy during multiple kitchen and meal service observations. During an initial kitchen observation, two dietary aides were seen walking through the kitchen food preparation area with uncovered facial hair. One aide had facial hair above and below the lip and along the jaw line, approximately one-fourth inch in length, and the other had a mustache of similar length; neither used any facial hair covering. These observations occurred while staff were present in the kitchen area where food was stored and prepared. During subsequent observations on the same day, the same two dietary aides were again observed with uncovered facial hair while directly involved in meal preparation and service. One aide walked through the kitchen while the noon meal was being prepared and placed into a transport cart for service in the south dining room, and later was observed plating the noon meal at the steamtable in that dining room, still without a facial hair covering. The other aide walked through the kitchen while the noon meal was being prepared and placed into the steamtable for the north dining room, took food temperatures, assisted with plating meals at the steamtable, and retrieved food items and supplies from the kitchen, all while having an uncovered mustache approximately one-fourth inch in length. The Dietary Manager stated that staff hair was to be covered when in the kitchen and during meal service, and the facility’s written policy and the cited Indiana Food Establishment Sanitation Requirements both required effective hair restraints, including for facial hair, to prevent contamination of food, equipment, and utensils.
Failure to Provide and Document Bed-Hold Policy at Time of Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure that required bed-hold policy information was provided and documented for four residents transferred to the hospital. For a resident with dementia, psychotic disorder, and autistic disorder who had a BIMS score of 0 indicating severe cognitive impairment, progress notes documented physician notification and guardian notification when the resident was sent to the hospital, but there was no documentation that the bed-hold policy was provided to the responsible party. A Notice of Transfer or Discharge later indicated a copy of the bed-hold policy was sent with the resident. Another resident with COPD and chronic respiratory failure, cognitively intact with a BIMS score of 13, experienced a decline in condition and was transferred to the hospital by ambulance; progress notes documented family notification but did not document any discussion of the bed-hold policy, although a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident. A third resident with altered mental status and cerebral infarction, with a BIMS score of 10 indicating moderate cognitive impairment and documented short-term memory impairment, experienced changes in condition and was transferred to the hospital. Progress notes stated the resident was their own responsible party and that no other notification was completed, and transfer documentation did not include the bed-hold policy, although an untimed Notice of Transfer or Discharge indicated a copy of the bed-hold policy was signed by the resident. A financial power of attorney document in the record showed the resident had designated an agent to act in consent or refusal of health care. For a fourth resident with dementia and osteomyelitis, transfer documentation and a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident, and the transfer form noted the resident required a proxy for decision making. The facility’s policy required that at the time of transfer to a hospital, written notice specifying the duration of the bed-hold policy and information on return to the next available bed be provided, and that a signed and dated copy of the bed-hold notice given to the resident or representative be kept in the resident file, which was not consistently documented for these residents.
Failure to Integrate Trauma Histories and Behavioral Triggers Into Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to identify and incorporate residents’ trauma histories and specific behavioral triggers into their care plans, despite documented histories of significant trauma and behavioral health issues. For one resident, extensive social service and progress notes documented homelessness, polysubstance abuse, major depressive and anxiety disorders, chronic pain, a history of severe car accidents with multiple fractures, viral encephalitis resulting in a three‑month coma, loss of child custody, multiple divorces, physical abuse by a spouse, the death of a fiancé who was struck by a car while in a wheelchair, lack of family contact, and a past suicide attempt by Valium overdose. Additional documentation noted a history of rape by a brother at age eight and prior placement under direct supervision and 15‑minute checks related to suicidal ideation. Despite these documented traumatic events and behavioral health concerns, the resident’s care plans did not identify a history of physical trauma, sexual trauma, homelessness, substance abuse, medical trauma, or attempted suicide. For this same resident, the MDS showed no cognitive deficit and identified behaviors such as verbal aggression and rejection of care, along with diagnoses including seizure disorder, depression, chronic pain syndrome, homelessness, and anxiety disorder. Multiple care plans addressed behaviors such as drug‑seeking, pretending to have seizures for attention or medication, making false allegations, verbal aggression when unable to smoke, and a desire for intimate relationships with consenting male residents. These care plans referenced goals such as effective coping skills, seeking staff support, and compliance with the smoking policy, and they called for identification and reduction of behavioral triggers. However, none of these care plans actually listed any specific triggers. The care plan addressing the resident’s right to consensual intimate relationships focused on assessment and education regarding consent but did not integrate the resident’s extensive trauma history. Staff interviews indicated the resident had displayed sexual behaviors since admission, including an incident where the resident expressed anger at another resident for not buying a soda after engaging in sexual acts. A second resident with a documented history of traumatic brain injury (TBI), dementia, seizure disorder, borderline personality disorder, anxiety, intermittent explosive disorder, tobacco use, and other behavioral/emotional disorders was also affected by the same deficiency. Social history and progress notes documented that this resident sustained a TBI after being hit by a semi‑truck while riding a bicycle at age 18, resulting in an 11‑month coma, followed by 13 years in a state hospital and subsequent residence in a group home. Additional documentation indicated the resident allegedly shot their father at age 26 after being sworn at and had a PASRR identifying TBI, intermittent explosive disorder, and borderline personality disorder, with a specific trigger of hearing the name of the current U.S. President. Progress notes also described inappropriate sexual behavior toward staff, including touching themselves intimately during personal care and refusing to stop when redirected. Despite this, the resident’s care plans, which addressed explosive disorder and history of altercations, risk for decreased psychosocial well‑being, and refusal to bathe or shower, did not list any specific behavioral triggers, did not reference the traumatic events such as being hit by a truck or shooting their father, and did not document the inappropriate sexual behavior. The Administrator and Social Service Director acknowledged that residents were to be screened for trauma and that trauma responses and PTSD should be added to care plans, but the specific trauma histories and triggers for these two residents were not incorporated into their plans of care.
Failure to Assess and Care Plan for Resident Suicidal Ideation
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess, investigate, and care plan for a resident’s suicidal ideation in accordance with its own policy and staff expectations. The resident had diagnoses including schizophrenia, cerebral edema, and hemiparesis/hemiplegia following a cerebral infarction, and a current MDS showed mild cognitive impairment (BIMS score 12). A progress note documented that the resident told the Social Services Director (SSD) he was feeling down and wanted to kill himself; the SSD offered assistance, activities, and initiated 15‑minute checks, and the note stated the care plan was updated. However, the note did not indicate that the SSD asked whether the resident had a plan to kill himself, and there were no additional notes regarding suicidal ideation or follow‑up. Review of the current care plan showed no problem, goal, or interventions addressing depression or suicidal ideation, and progress notes over the following month contained no documentation of physician notification related to the suicidal statement. Further record and interview evidence showed that the care plan conference summary did not document interventions for suicidal ideation, and the SSD acknowledged she did not normally ask residents expressing suicidal ideation if they had a plan. The SSD reported that the resident had admission paperwork mentioning suicidal ideation related to depression after a stroke and that the resident again vocalized suicidal ideation during a care plan meeting with his father, after which emotional support was offered and the father took the resident out on a leave of absence; no further visits or follow‑up were done. The DON stated that, upon notification of suicidal verbalization, staff should assess the resident, ask if there is a plan, remove potential means of self‑harm, immediately notify the psychiatric NP, and document the occurrence, and that a detailed progress note and updated care plan were expected but not present for this resident. The Administrator similarly stated that staff should ask about a plan, document interventions, notify the physician and family, and update the care plan, and indicated the resident should have had a care plan addressing depression with suicidal ideation. The facility’s written policy required immediate notification of the DON, SSD, and physician, an interview including asking about a plan and assessing mood and means for self‑harm, and thorough documentation of mood, behavior, and all actions taken, which were not reflected in the resident’s record.
Incomplete and Inaccurate Documentation of Suicidal Ideation and Follow-Up
Penalty
Summary
The facility failed to ensure accurate, complete, and timely documentation of assessments and services for a resident who verbalized suicidal ideation. Resident 6, who had schizophrenia, cerebral edema, and right-sided hemiparesis/hemiplegia following a cerebral infarction, had a BIMS score of 12 indicating mild cognitive impairment. The resident’s admission paperwork mentioned suicidal ideation related to depression after a stroke, and a Social Services note on 3/11/2026 documented that the resident was feeling down and said he wanted to kill himself. The Social Services Director (SSD) documented that she talked with the resident, coordinated with Activities, advised the resident to contact SSD or nursing if he wanted to talk, and that the resident was scheduled for 15-minute checks and the care plan was updated. However, the current care plan initiated on 2/26/2026 did not address depression or suicidal ideation. Multiple Social Services progress notes were later entered as late entries in April, with effective dates in March, stating that the resident had no plan and no longer had suicidal ideation, that he felt much better after 1:1 time, and that he continued his daily routine and therapy. These late entries described follow-up visits and reassessments of suicidal ideation on several consecutive days, but in interviews the SSD stated she did not normally ask residents about having a plan when they verbalized suicidal ideation and did not recall any other occurrences beyond the initial event. She further indicated she did not personally provide individual follow-up visits with this resident regarding suicidal ideation, despite the late-entry notes describing such visits. The DON acknowledged that late entries had been added to address concern about suicidal verbalization, and the Administrator stated that upon suicidal statements staff should ask about a plan, notify the physician and family, and update the care plan, and that this resident should have had a care plan addressing depression with suicidal ideation. The facility’s documentation policy required factual, first-hand, timely documentation, which was not followed in this case.
Failure to Complete Required Self-Administration Assessment for Inhaler Kept at Bedside
Penalty
Summary
Surveyors identified that a resident was allowed to keep and access an Albuterol inhaler without the facility completing the required self-administration medication assessment. During an initial tour, the resident was observed sitting in a wheelchair with a handheld Albuterol inhaler on the overbed table and no staff present in the room or hallway. On a subsequent observation, the resident again was in a wheelchair and reported that the Albuterol inhaler was stored in the top drawer of the nightstand, where it was found. Review of the clinical record showed an admission MDS indicating no cognitive impairment, but there was no documentation of a self-medication administration assessment. In an interview, the DON confirmed that the resident did not have the required self-medication assessment, despite the facility’s policy stating that staff and the practitioner must assess each resident’s mental and physical abilities to determine whether self-administering medications is clinically appropriate. This failure to complete and document a self-administration medication assessment for a resident who had an Albuterol inhaler kept at bedside constituted noncompliance with the facility’s own policy and with 410 IAC 16.2-3.1-11(a).
Inaccurate PBJ Staffing Data Submission to CMS
Penalty
Summary
The deficiency involves the facility’s failure to electronically submit complete and accurate direct care staffing information to CMS through the Payroll-Based Journal (PBJ) system for 22 days in a fiscal quarter. A CASPER report review on 4/6/26 showed that, according to PBJ data, the facility did not have licensed nursing coverage 24 hours per day on multiple specific dates across three months, had low weekend staffing, and held a 1-star staffing rating. However, review of the facility’s internal staffing sheets for that quarter indicated the facility was fully staffed and had licensed nurse coverage on all of the dates in question. During an interview, the Administrator stated that the PBJ information must have contained data entry errors, as she had verified licensed staff coverage on the timesheets. The facility’s PBJ policy in effect stated that all staffing data entered into the PBJ system would be auditable and verifiable through payroll, invoices, or contracts, but the submitted PBJ data did not accurately reflect the facility’s actual licensed nurse staffing as documented on internal records. No specific residents or clinical conditions were mentioned in the report, and the deficiency centers solely on inaccurate staffing data submission rather than direct resident care events.
Failure to Provide and Document Required Transfer/Discharge and Bed-Hold Notices
Penalty
Summary
The deficiency involves the facility’s failure to provide and document required written notices of transfer/discharge and bed-hold policies, as well as required information to receiving providers, for four residents who were transferred or discharged to the hospital. For a resident with generalized anxiety disorder, major depressive disorder, and dementia, progress notes showed that the resident was sent to the hospital via 911 for chest pain, lower back pain, and shortness of breath and later returned to the facility, but the clinical record lacked documentation that a written Notice of Transfer/Discharge and the bed-hold policy were provided to the resident or representative, and lacked documentation that required information was conveyed to the receiving facility. The ADON and the Administrator both confirmed there was no documentation that these written notices were provided. For a resident with congestive heart failure and muscle weakness who was sent to the emergency room for painful urination and bloody urine, the clinical record lacked documentation that a Notice of Transfer/Discharge or bed-hold policy was given to the resident or representative, which the DON confirmed. Another resident with chronic respiratory failure and diabetes was discharged to the hospital for respiratory failure, and a resident with chronic kidney disease and dementia was discharged to the hospital, but in both cases there was no documentation that a written notice of transfer/discharge or bed-hold policy was provided to the residents or their representatives. Review of the facility’s Transfer and Discharge policy, dated 1/15/26, showed that the policy required the facility to provide written transfer/discharge notices and bed-hold information to residents and representatives and to provide specified information to receiving providers, but the records for these four residents did not contain the required documentation.
Failure to Document Target Behaviors and Non-Pharmacological Interventions Before Initiating Antipsychotic
Penalty
Summary
The deficiency involves the facility’s failure to document how a resident’s behaviors presented danger or distress to self or others, and failure to document non-pharmacological interventions attempted prior to initiating an antipsychotic medication. Resident 6 had documented diagnoses of Alzheimer’s disease, depression, and severe cognitive impairment, and was receiving sertraline for depression. A PASSAR identified only depression and dementia, and the admission MDS listed Alzheimer’s disease and depression as active diagnoses. Over several months, nursing progress notes documented that the resident intermittently reported unusual perceptions, such as believing there were men causing trouble, a man in her room, or a man wanting to marry her and yelling through the walls, but there was no documentation that these episodes caused danger to the resident or others or that they resulted in unmanageable distress. From late April through mid-July, nursing notes primarily described the resident’s frequent refusals of evening and morning medications, blood sugar checks, blood pressure checks, insulin administration, hygiene care, and showers. Staff documented that the resident sometimes yelled at staff, said “Get out!”, was visibly upset by a room move, was leery of staff and asked to see name badges, and became upset about a pillow under her head until it was removed, after which she calmed down. The notes also recorded instances where the resident believed housekeeping had not cleaned her room or that she had not received medications when she had. However, there were no progress notes or assessments indicating that these behaviors were evaluated as dangerous, non-redirectable, or causing significant distress or functional impairment, and no detailed behavior monitoring logs were present as required by facility policy. On a psychiatric NP visit for initial psychotropic medication management, new mental health diagnoses of schizoaffective disorder, borderline personality disorder, and delusional disorder were added, and Seroquel 25 mg, an antipsychotic, was ordered. The clinical record did not contain a comprehensive evaluation to support these new diagnoses, and there was no documentation of target behaviors meeting the facility’s policy criteria for psychotropic use, such as behaviors representing danger to self or others, causing distress and impairment in functional abilities, or clearly attributable to psychosis or mania. The resident’s representative reported that the resident had no prior history of mental health disorders or psychiatric hospitalization and was unaware of the new diagnoses. The facility’s own psychotropic medication policy required identification and documentation of specific target behaviors, use and documentation of nonpharmacological interventions, and ongoing monitoring of behaviors and interventions, which were not reflected in the record for this resident.
Failure to Update PASARR Screens for New Mental Health Diagnoses and Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that Preadmission Screening and Resident Review (PASARR) Level I screenings were accurate and updated when new mental health diagnoses and psychoactive medications were initiated for multiple residents. For one resident with dementia, anxiety, depression, and post-traumatic stress disorder (PTSD), the PASARR completed on admission listed anxiety, depression, and dementia with sertraline and quetiapine, but did not include the PTSD diagnosis or the antidepressant Pristiq, despite the admission MDS and care plan documenting PTSD and a subsequent physician’s order for Pristiq. For another resident with Alzheimer’s disease, borderline personality disorder, delusional disorder, schizoaffective disorder, and depression, the PASARR only reflected depression and dementia with sertraline, even though additional mental health diagnoses were added later and an antipsychotic (quetiapine) was ordered for borderline personality disorder, and the quarterly MDS documented psychotic disorder, schizophrenia, and depression with antipsychotic and antidepressant use. A third resident had diagnoses including Alzheimer’s disease, depression, anxiety disorder, irritability and anger, and nonrheumatic aortic valve stenosis. The PASARR for this resident listed dementia and anxiety with Risperdal but omitted the diagnosis of depression and the medications escitalopram and lorazepam, although physician’s orders were in place for escitalopram for depression and lorazepam for anxiety, and the admission MDS documented depression with antianxiety and antidepressant use. Interviews with the Assistant Director of Nursing confirmed that new Level I PASARR screens should have been completed when new mental health diagnoses and psychoactive medications were added, and that the PASARR for one resident, completed prior to arrival, should have included all mental health diagnoses and medications. The facility’s own policy required notification of the state mental health authority within 14 days after a significant change in mental condition and specified that a new Level I screen is required for new mental health diagnoses or newly prescribed psychotropic medications, which was not followed in these cases.
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