Waters Of Muncie, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Muncie, Indiana.
- Location
- 2400 Chateau Dr, Muncie, Indiana 47303
- CMS Provider Number
- 155443
- Inspections on file
- 35
- Latest survey
- May 15, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Waters Of Muncie, The during CMS and state inspections, most recent first.
Staff failed to immediately report observed and suspected abuse involving three cognitively impaired residents, resulting in delayed investigation and notification to appropriate leadership. An LPN and a CNA delayed reporting incidents of inappropriate sexual behavior, and the DON also delayed informing the Administrator. The residents involved had dementia and behavioral health issues, and one lacked a care plan for sexual behaviors. The facility's policy required immediate reporting, but this was not followed.
Staff failed to promptly report two incidents of sexually-toned abusive behavior between cognitively impaired residents. An LPN and a CNA delayed notifying the DON and Administrator, resulting in the required report to the state health department being submitted more than a day after the Administrator became aware. Facility policy required immediate reporting of such incidents, but this was not followed.
A resident with moderate dementia and behavioral disturbances exhibited inappropriate sexual behaviors, including fondling and sitting on another resident's lap. Although staff intervened during the incident, there was no care plan or documentation addressing these specific behaviors, and the incident was not reported to the DON or Administrator. Facility policies required individualized care planning and documentation for behavioral issues, but these were not followed in this case.
The facility failed to prevent the misappropriation of controlled medications, resulting in missing narcotic pain relievers for several residents. Significant discrepancies were found in medication counts and documentation, with staff failing to properly account for, document, or witness the destruction of controlled substances. Some medications were left unsecured after residents were discharged, and an LPN admitted to destroying medication alone, in violation of policy.
The facility did not report the misappropriation of controlled medications involving four residents to the appropriate agencies within the required timeframe. An LPN was implicated in missing narcotic medications and failed to comply with a drug screening before resigning. The investigation found missing medication count sheets and unaccounted tablets, but there was no evidence that the LPN was reported to the Attorney General's Office as required.
Shift-to-shift narcotic count sheets for two medication carts were not consistently completed or signed by staff, with multiple instances of missing documentation and unexplained discrepancies. This failure affected residents receiving controlled medications, as required counts and signatures were not performed at shift changes or during medication cart exchanges, contrary to facility policy.
The facility did not consistently complete and sign shift-to-shift narcotic count sheets for two medication carts, despite previous citations for similar issues and a policy requiring systematic monitoring through QAPI. This repeat deficiency affected residents receiving controlled medications and was not promptly addressed by the QAA committee.
The facility did not provide proper Medicare and Medicaid beneficiary notifications to two residents who remained after their skilled services ended. One resident did not receive an SNF-ABN, and another received an ABN late and without estimated costs; neither received all required notices. Staff interviews revealed uncertainty about the process, and no relevant policy was found.
A resident with chronic respiratory conditions was observed receiving oxygen at a higher flow rate than ordered and without the required humidification, as the humidification bottle was repeatedly found empty and unchanged. Staff interviews confirmed no changes to the physician's orders, and facility policy required both correct flow rate and regular maintenance of humidification equipment.
A cognitively impaired resident with multiple diagnoses was not accurately assessed for the use of side rails or enabler bars. Despite initial assessments indicating no need, an enabler bar was later ordered and used without consistent documentation or reassessment. The resident was subsequently found with their head entrapped between the mattress and side rail, highlighting a failure to follow facility policy for evaluation and documentation.
The facility did not consistently update and post daily nurse staffing information as required, with observations showing outdated postings over several days. Staff responsible for updating the postings reported delays due to other duties, resulting in incomplete compliance with facility policy.
A resident with dementia and behavioral disturbances repeatedly entered other residents' rooms and exhibited aggressive and inappropriate behaviors. Despite ongoing incidents and ineffective redirection, individualized interventions were not implemented, resulting in multiple resident-to-resident altercations.
A resident admitted to hospice with a DNR directive was incorrectly listed as full code in the facility's records. When the resident was found unresponsive, an LPN initiated CPR based on the inaccurate code status in the electronic health record, despite hospice documentation indicating DNR. Lack of review and coordination of the hospice plan of care by facility staff led to the resident receiving resuscitation efforts contrary to their wishes.
The facility failed to allow residents the freedom to go outside for fresh air due to insufficient staff for supervision. Residents expressed feeling like prisoners, and grievances were filed without resolution. Limited patio time was scheduled, and access to the courtyard was restricted, conflicting with the facility's policy on resident rights.
The facility failed to provide meaningful activities and an engaging environment for residents in the dementia care unit. Observations showed residents often sat watching TV without participating in scheduled activities, and there was a lack of diversionary materials. Residents with dementia and other conditions were observed spending time in their rooms without engagement, despite care plans emphasizing the importance of activities. Staff interviews confirmed that activities were not consistently offered, particularly in the mornings.
The facility failed to ensure proper controlled medication counts and acknowledgments for two medication carts. A QMA did not sign the 300 Unit Narcotic Count Sheets, and there were incomplete counts for shifts on 5/9/24. Similarly, an LPN on the Hope Springs Unit signed the Narcotic Count Sheets without verifying the counts, with missing signatures noted on 5/11/24 and 5/14/24. The facility did not adhere to its policy on controlled substances.
A resident with multiple health conditions and a facility-acquired pressure injury did not receive wound care as ordered by the physician. The dressing change was not completed on a specific day, and there was inconsistency in the documentation of the dressing change. Interviews revealed that the dressing change was not appropriately documented, and there was a lack of communication regarding the completion of dressing changes by hospice staff.
A resident with diabetes and wounds experienced significant weight loss due to the facility's failure to implement dietary recommendations. Despite being on a general diet and receiving an appetite stimulant, the resident's clinical record lacked orders for weekly weights and fortified potatoes, as recommended by the Registered Dietitian. Interviews revealed a breakdown in communication and implementation of these recommendations, resulting in inadequate nutritional support.
A facility failed to maintain complete and accurate communication records with a hospice provider for a resident receiving hospice services. The resident, with conditions including hemiplegia and breast cancer, was admitted to hospice care, but the facility's communication binder lacked necessary documentation, such as a sign-in sheet and CNA notes for May. Staff interviews indicated verbal communication occurred, but the binder was only updated monthly, contrary to the contract requirements for maintaining medical records.
Failure to Immediately Report and Investigate Alleged Abuse
Penalty
Summary
The facility failed to implement its abuse prevention program policy when staff members did not immediately report suspicions or observations of abuse involving three cognitively impaired residents. Specifically, an LPN observed a resident inappropriately touch another resident but delayed reporting the incident for several days, waiting until after the weekend to notify the Director of Nursing (DON) via text. Additionally, a CNA witnessed another resident fondling a peer and engaging in further inappropriate behavior but only reported the incident to the LPNs on duty, not to the DON or Administrator until the following day. The DON, upon receiving the report, also delayed informing the Administrator until a scheduled managers' meeting the next morning. The residents involved had significant cognitive impairments and behavioral health diagnoses, including dementia, encephalopathy, and psychiatric disorders. One resident had a care plan addressing socially inappropriate behaviors, but another resident with a history of behavioral disturbances lacked documentation or a care plan regarding sexual behaviors. Staff reports about the incidents were inconsistent, making it difficult for psychiatric providers to determine the accuracy and extent of inappropriate sexual behaviors. The facility's abuse prevention policy required immediate reporting of any incident, allegation, or suspicion of abuse to the Administrator or person in charge, regardless of the time or day. However, staff failed to follow this policy, resulting in delayed initiation of investigations and reporting to appropriate agencies. The lack of timely reporting and inconsistent documentation contributed to the deficiency cited during the survey.
Failure to Timely Report Allegations of Sexual Abuse Between Residents
Penalty
Summary
The facility failed to report two separate allegations of sexually-toned abusive behavior between cognitively impaired residents to the appropriate agencies within the required timeframe. In one incident, an LPN observed a resident put his hands up another resident's shirt sleeve and touch her breast, but did not report the incident to the Administrator at the time due to it being a weekend. The LPN waited several days before notifying the DON via text, and the DON did not inform the Administrator until the following day. In a separate incident, a CNA intervened when a resident fondled another resident's groin through his clothing and then sat on his lap and bounced up and down. The CNA notified two LPNs on the day of the incident but did not escalate the report to the DON or Administrator until the following day. The Administrator became aware of the incidents only after delays in internal reporting, and the incident was not submitted to the Indiana State Department of Health until more than 28 hours after the Administrator was informed. The facility's policy required immediate notification of such incidents to the Department of Health and law enforcement, but this protocol was not followed. The residents involved were cognitively impaired, and staff were expected to report incidents of this nature immediately, but failed to do so in both cases.
Failure to Identify and Care Plan for Inappropriate Sexual Behaviors in a Resident with Dementia
Penalty
Summary
The facility failed to identify, monitor, and develop individualized interventions for a resident with dementia who exhibited inappropriate sexual behaviors. The resident, who had diagnoses including moderate unspecified dementia with behavioral disturbances, depression, anxiety, delusional disorder, and pseudobulbar affect, was noted to have daily behavioral symptoms that had worsened compared to previous assessments. Despite multiple care plans addressing general behavioral disturbances, agitation, and memory impairment, there was no care plan or documentation specifically addressing the resident's sexually inappropriate behaviors. An incident occurred in which the resident fondled another resident's groin and subsequently sat on his lap and bounced up and down. Staff intervened and redirected the resident, but the incident was not reported to the DON or Administrator at the time. The clinical record lacked documentation of the inappropriate sexual behaviors, and there was no behavior monitoring or care plan related to these specific behaviors. Interviews with staff and administration confirmed the absence of documentation and individualized interventions for the sexually inappropriate behaviors. Facility policies required comprehensive, person-centered care plans to address each resident's risks and needs, including behavioral issues, and mandated documentation of behavioral incidents and interventions. However, the facility did not follow these procedures in the case of this resident, as evidenced by the lack of a care plan and documentation for the sexual behavior expressions, despite staff awareness and intervention during the incident.
Failure to Prevent Misappropriation of Controlled Medications
Penalty
Summary
The facility failed to prevent the misappropriation of residents' controlled medications for four residents, resulting in significant discrepancies in the accounting and disposition of narcotic pain relievers. In multiple instances, large quantities of controlled substances such as oxycodone-acetaminophen and tramadol were unaccounted for, with missing or incomplete Controlled Drug Record/Disposition Forms and narcotic count sheets. The discrepancies were identified during a facility investigation following a reported incident involving the disappearance of a resident's medication card and subsequent review of medication records for other residents. For one resident, 28 tablets of oxycodone-acetaminophen were missing, with only two tablets documented as administered and no record of proper disposition or destruction. Another resident had 58 tablets of tramadol unaccounted for, with missing count sheets for a portion of the medication delivered. Additional residents were found to have six and 28 tablets of controlled medications unaccounted for, respectively, with staff interviews confirming that narcotics were left in medication carts after residents were discharged and that destruction of controlled medications was not properly witnessed or documented. In one case, a nurse admitted to destroying medication alone, contrary to facility policy, and subsequently resigned after being asked to submit to a drug test. The clinical records for the affected residents showed that they had diagnoses such as chronic pain syndrome, cancer, and osteoarthritis, and were prescribed controlled medications for pain management. Documentation revealed that the required shift-to-shift narcotic counts were not accurately maintained, and pharmacy delivery receipts were not retained. Staff interviews confirmed that controlled medications were not sent with discharged residents and that proper procedures for medication destruction, including the presence of a witness, were not followed.
Failure to Timely Report Misappropriation of Controlled Medications
Penalty
Summary
The facility failed to report the misappropriation of resident medications to the appropriate agencies within the required timeframe for four residents. An investigation was initiated after it was discovered that a resident's oxycodone-acetaminophen medication card was missing, and the order had been discontinued following a shift change between two LPNs. The DON contacted the LPN involved, who claimed to have destroyed the medication after receiving an order to resume a different pain medication, but there was no witness to the destruction and the resident denied the reported symptoms. Further investigation revealed additional discrepancies in controlled medication counts for three other residents, including missing tablets and absent narcotic count sheets. The LPN implicated in the medication discrepancies was suspended, requested to undergo drug screening, but failed to comply and subsequently resigned. The facility's investigation did not show evidence that the LPN was reported to the Attorney General's Office for professional licensing issues, as required. Interviews with facility leadership confirmed that there was no policy regarding timely reporting to state agencies, and the administrator was unable to provide documentation that the LPN had been reported to the Attorney General prior to the survey.
Failure to Complete and Document Shift-to-Shift Narcotic Counts
Penalty
Summary
The facility failed to ensure that shift-to-shift narcotic count sheets were properly completed and signed for two of three medication carts reviewed, specifically the 300 Unit and 400 Unit medication carts. Observations and interviews revealed that required narcotic counts and signatures were missing at various shift changes and during medication cart exchanges. For example, on one occasion, the 400 Unit medication cart's narcotic log lacked signatures and count documentation at the beginning of a day shift and during a cart exchange. Staff interviews confirmed that the required shift-to-shift narcotic counts were not performed as per facility policy, and review of narcotic count sheets over the course of the month showed multiple instances of missing counts, missing signatures, and unexplained discrepancies. The deficiency had the potential to affect 11 of 46 residents who received controlled medications from the affected medication carts. The facility's policy required that two licensed nurses conduct and document a physical inventory of controlled substances at each shift change and whenever there was an exchange of keys. Despite this, documentation was incomplete or missing for several shifts, and some discrepancies were not explained. The DON acknowledged awareness of the issue during an audit for misappropriation of medications, and staff confirmed that the required procedures were not consistently followed.
Repeat Deficiency in Controlled Medication Count Documentation
Penalty
Summary
The facility failed to develop and implement effective approaches to maintain its Quality Assurance and Performance Improvement (QAPI) program, resulting in repeat deficiencies related to the management of controlled medications. Specifically, during the most recent survey, it was found that shift-to-shift narcotic count sheets were not completed and signed for two of three medication carts reviewed. This issue had previously been cited in the facility's last annual recertification and state licensure survey, where similar failures in controlled medication counts and acknowledgements were identified. Despite the facility's policy outlining systematic monitoring and evaluation of resident care through QAPI, the required processes were not consistently followed. Interviews with facility staff revealed that while the QAA committee met monthly and used an online program to track trends and document meetings, there was a delay in implementing a Performance Improvement Plan (PIP) when a repeat concern was identified. The issue with narcotic counts was discovered shortly before a QAPI meeting and discussed, but a PIP was not immediately established. As a result, the deficiency persisted and was observed again during the subsequent survey, affecting residents who received controlled medications from the affected medication carts.
Failure to Provide Required Medicare/Medicaid Coverage Notices
Penalty
Summary
The facility failed to provide required Medicare and Medicaid beneficiary notifications to two residents who transitioned from Medicare-covered skilled services to non-covered services while remaining in the facility. For one resident, the last covered day of Medicare Part A service was documented, and a Notice of Medicare Non-coverage (NOMNC) was signed by the resident's guardian one day prior to the end of service, but no Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF-ABN) was provided. For the second resident, an ABN was signed by the resident one week after covered services ended, but it lacked information about estimated costs for non-covered services, and no NOMNC was provided. Both residents remained in the facility after their Medicare coverage ended. Interviews with the current administrator and the social services designee (SSD) revealed uncertainty regarding why the proper forms were not given to the residents. The administrator was not in her position at the time the forms were completed, and the SSD indicated that the previous administrator handled the beneficiary paperwork. No beneficiary notification policy or additional documentation was found or provided before the survey exit.
Failure to Provide Ordered Oxygen Flow Rate and Humidification
Penalty
Summary
The facility failed to provide oxygen and humidity as ordered for a resident with chronic obstructive pulmonary disease, a solitary pulmonary nodule, and weakness. Multiple observations revealed that the resident was receiving oxygen via nasal cannula at 5 liters per minute (lpm), while the physician's order specified 3 lpm. Additionally, the humidification bottle attached to the oxygen concentrator was consistently empty and had not been changed since the date marked several days prior, despite orders for weekly changes and as needed for humidity. The resident was noted to have moderate cognitive impairment and required staff assistance for oxygen management due to impaired vision. Interviews with staff confirmed that there had been no changes to the resident's oxygen orders and that the oxygen flow rate and humidification should have been provided as ordered. The facility's policy required checking orders for accurate oxygen flow and maintaining humidifier bottles at least weekly and as needed. Despite these requirements, the resident continued to receive oxygen at an incorrect flow rate and without the prescribed humidification, and staff were unaware of any authorized changes to the care plan.
Failure to Accurately Assess and Document Side Rail Use Leads to Resident Entrapment
Penalty
Summary
A cognitively impaired resident with diagnoses including unspecified dementia, delusional disorders, muscle wasting, and frontotemporal neurocognitive disorder was not accurately assessed for the use of side rails or enabler bars. Initial assessments indicated that the resident did not require side rails or enablers, but a physician's order was later obtained for an enabler bar to assist with transfers and bed mobility. The care plan was updated to reflect the use of enabler bars, and interventions included periodic assessments. However, the Minimum Data Set (MDS) assessment did not document the use of mobility devices, and there was inconsistency in the documentation regarding the need for and use of enabler bars. The deficiency was identified when the resident was found on their knees beside the bed with their head entrapped between the mattress and the side rail, resulting in redness to the face. The side rail was in the up position at the time of the incident. The facility's policy required thorough evaluation, documentation, and regular reassessment for the use of side rails or enabler bars, but the records reviewed did not demonstrate that these procedures were accurately or consistently followed prior to the incident. This failure to complete accurate assessments and documentation led to the resident's entrapment event.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post complete and up-to-date nurse staffing information daily, as required. Multiple observations over several days revealed that the Daily Report of Nursing Staff was not updated each day and often displayed outdated information. For example, on several consecutive days, the posted staffing report reflected dates from previous days rather than the current date. This issue was observed at various times throughout the day, indicating that the required daily updates were not consistently performed. Interviews with facility staff revealed that the responsibility for updating the staffing posting was assigned to the scheduler and a QMA. However, the QMA reported that due to being needed to cover shifts and provide resident care, updating the staffing posting was sometimes delayed. The facility's policy required that the staffing information be posted daily at the beginning of each shift, including details on the number and category of nursing staff and total hours worked, but this was not consistently followed.
Failure to Provide Individualized Interventions for Resident with Dementia Leading to Repeated Altercations
Penalty
Summary
The facility failed to provide individualized interventions to prevent resident-to-resident physical altercations for a cognitively impaired resident diagnosed with dementia. The resident, who had a history of dementia with moderate behavioral disturbances, mood disorder, delusional disorder, and agitation, was involved in multiple incidents where he entered other residents' rooms uninvited, resulting in physical altercations. Despite being placed on one-to-one staff supervision after the initial incident, this intervention was discontinued after a short period when no further incidents were observed, even though the resident continued to display wandering, agitation, and resistance to redirection. The resident's care plan included general interventions such as redirection, one-to-one supervision as needed, and removal from areas with other residents, but these measures were not consistently effective. Documentation showed ongoing behaviors including wandering into other residents' rooms, agitation, physical aggression towards staff, inappropriate disrobing, and ineffective redirection attempts. Staff noted that the resident was difficult to redirect, and interventions such as moving the resident to a new room and involving family and hospice staff did not prevent further incidents. Multiple progress notes and behavior charting entries indicated that the resident continued to exhibit behaviors that placed him and others at risk, including entering other residents' rooms, physical aggression, and inappropriate public behavior. Despite these ongoing issues, individualized interventions to address the resident's specific behavioral triggers and prevent further altercations were not implemented, leading to repeated incidents of resident-to-resident altercations.
Failure to Implement Hospice DNR Directive Results in Unwanted CPR
Penalty
Summary
The facility failed to review and implement the hospice provider's plan of care for a resident who had been admitted to hospice services and had a Do Not Resuscitate (DNR) directive. Despite the hospice plan of care and POST form indicating the resident's DNR status, the facility's electronic health record and care plan continued to list the resident as a full code. When the resident was found unresponsive, an LPN, unfamiliar with the resident, checked the electronic health record, saw the full code status, and initiated CPR. Other staff believed the resident was a DNR, but the documentation available to the LPN indicated otherwise, leading to continued resuscitation efforts until emergency personnel arrived. Interviews revealed that key facility staff, including the SSD and MDS Coordinator, had not reviewed the hospice admission paperwork or plan of care, resulting in a lack of coordination between the facility and hospice provider regarding the resident's code status. The hospice provider had previously sent the POST form and admission documentation to the facility, but this information was not integrated into the facility's records. The facility's policy required coordination with hospice and inclusion of the hospice plan of care in the resident's record, but this was not followed, directly contributing to the confusion and the resident receiving unwanted CPR.
Residents' Rights to Outdoor Access Restricted
Penalty
Summary
The facility failed to ensure that residents had the freedom and assistance to exercise their rights to go outside for fresh air. During a Resident Council group interview, residents expressed their desire to sit outside but were not permitted due to a lack of staff available to supervise them. This issue was previously discussed in Resident Council meetings, and grievances were filed, but no effective resolution was documented. The facility's activity calendar showed limited scheduled patio time, and the courtyard required access through a secured unit, which was not available to all residents. Observations and interviews revealed that residents felt restricted, with one resident comparing the situation to being a prisoner. Staff members, including a CNA and an LPN, indicated uncertainty about allowing residents from unsecured units to access the courtyard. The facility's policy on resident rights emphasized the right to a dignified existence and self-determination, yet the facility's actions did not align with these rights, as residents were unable to exercise their right to access outdoor areas freely.
Failure to Provide Structured Activities in Dementia Unit
Penalty
Summary
The facility failed to provide meaningful, structured activities and an environment with available diversionary materials for residents in the secured dementia care unit. Observations revealed that residents often sat and watched TV without engagement or participation in scheduled activities. The activity calendar was not followed, and activities were not consistently offered, particularly in the mornings. Staff did not always invite all residents to participate in activities, and there was a lack of diversionary materials such as books, games, or sensory devices in common areas. Resident 25, diagnosed with dementia, depression, anxiety, and delusional disorder, was observed spending most of their time in their room, often asleep in a recliner, without engaging in any activities. The resident's care plans emphasized the importance of participating in activities, yet records showed minimal participation in morning activities. Similarly, Resident 7, with diagnoses including schizoaffective disorder and dementia, was mostly observed in a dark room, not participating in activities despite care plans encouraging engagement. Resident 42, also diagnosed with dementia and depression, was frequently found in their room, not involved in any activities, despite care plans highlighting the importance of engagement. Interviews with staff, including activity aides and the Dementia Care Director, confirmed that activities were seldom offered as scheduled, particularly before lunch. The Dementia Care Director admitted to confusion regarding activity attendance records and acknowledged that CNAs were supposed to offer meaningful pursuits to residents, but no documentation of CNA training was provided. The facility's policy emphasized the importance of structured activities for residents, yet observations and interviews indicated a significant gap between policy and practice.
Failure to Complete Controlled Medication Counts and Acknowledgments
Penalty
Summary
The facility failed to ensure proper controlled medication counts and acknowledgments were completed for two of the three medication carts reviewed, specifically the 300 Unit and Hope Springs Unit medication carts. On 5/15/25, it was observed that a Qualified Medication Aide (QMA) had not signed the 300 Unit Narcotic Count Sheets at the beginning of her shift, and there were incomplete narcotic shift counts with missing acknowledgments for shifts on 5/9/24. The 300 Unit Shift to Shift Narcotic Count Verification Log from 5/8/24 to 5/15/24 showed missing signatures for the oncoming and offgoing shifts, indicating a lack of accountability for controlled medications. Similarly, on 5/15/24, an LPN on the Hope Springs Unit signed the Narcotic Count Sheets without ensuring the total sheet count and total card/medication count were accurately recorded. Missing signatures and incomplete counts were noted on the Hope Springs Unit Narcotic Count Sheets for 5/11/24 and 5/14/24. The facility's policy on controlled substances, as provided by the Administrator, requires detailed records of receipt and distribution of controlled drugs, with change of shift counts conducted by authorized personnel. However, the facility did not adhere to this policy, as evidenced by the missing signatures and incomplete counts.
Failure to Complete and Document Wound Care as Ordered
Penalty
Summary
The facility failed to ensure that a wound treatment was completed as ordered by the physician for a resident with multiple health conditions, including peripheral vascular disease, heart failure, atrial fibrillation, type 2 diabetes mellitus, and who was receiving palliative care. The resident was severely cognitively impaired and required supervision and maximal assistance for various activities. The resident had a facility-acquired unstageable pressure injury on the right back, which was supposed to be treated daily with specific wound care instructions. However, the dressing change was not completed on one of the days as per the physician's order, and there was a discrepancy in the documentation of the dressing change. During a wound observation, it was noted that the dressing on the resident's wound was dated two days prior, indicating it had not been changed daily as required. The Treatment Administration Record showed that the dressing change was not completed on a specific date, and there was inconsistency in the documentation of who performed the dressing change. Interviews with the nursing staff revealed that the dressing change was not appropriately documented, and there was a lack of communication regarding the completion of dressing changes by hospice staff. The facility's policy required that wound care be completed as ordered, with proper documentation, which was not adhered to in this case.
Failure to Implement Dietary Recommendations Leads to Resident's Weight Loss
Penalty
Summary
The facility failed to provide adequate nutritional services as recommended by the Registered Dietitian for a resident, leading to significant weight loss. The resident, who had type 2 diabetes mellitus, depression, and generalized weakness, was admitted with an unstageable pressure ulcer and a surgical wound. Despite being on a general diet with a nutritional juice supplement and an appetite stimulant, the resident experienced a 9.13% weight loss over a short period. The clinical record lacked additional weight measurements and did not reflect the implementation of recommended dietary interventions such as fortified potatoes for lunch and dinner. The facility's dietary progress notes indicated that the resident was on nutritionally at-risk monitoring due to admission and wounds, with recommendations for weekly weights and fortified potatoes. However, these recommendations were not implemented, as confirmed by interviews with the Dietary Manager and nursing staff. The Dietary Manager failed to update the resident's meal tickets with the fortified potato supplement, and the clinical record lacked orders for weekly weights and the recommended dietary changes. This oversight resulted in the resident not receiving the necessary nutritional support to address her weight loss and nutritional needs. Interviews with facility staff, including the Dietary Manager, CNA, LPN, and DON, revealed a breakdown in communication and implementation of the Registered Dietitian's recommendations. Although the facility had a policy for monitoring residents with significant weight changes or skin breakdown through the S.W.A.T. program, the recommendations were not effectively communicated or documented in the resident's clinical record. The failure to implement these dietary recommendations contributed to the resident's continued weight loss and inadequate nutritional support.
Incomplete Hospice Communication Records
Penalty
Summary
The facility failed to ensure complete and accurate communication records between the facility and a hospice provider for a resident receiving hospice services. The resident, who had diagnoses including hemiplegia, hemiparesis, neoplasm of the left breast, and vascular dementia, was admitted to hospice services with a physician's order dated December 22, 2023. The hospice care plan required the facility to keep hospice staff updated on care changes, transfers, discharges, new orders, and changes in condition. However, the facility's hospice communication binder lacked a sign-in sheet for services provided and was missing communication notes from the hospice CNA for May 2024. Interviews with facility staff revealed that hospice staff communicated verbally with facility staff during visits, but the hospice communication binder was only updated when documentation was received from the hospice provider, typically at the end of each month. The Director of Nursing acknowledged that the communication binder should be kept current to ensure clear communication between the facility and the hospice provider. The facility's contract with the hospice provider required the maintenance of medical records, including progress and clinical notes, in accordance with the patient's plan of care.
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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