Waters Of Rushville Skilled Nursing Facility, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Rushville, Indiana.
- Location
- 612 E 11th St, Rushville, Indiana 46173
- CMS Provider Number
- 155053
- Inspections on file
- 27
- Latest survey
- August 22, 2025
- Citations (last 12 mo.)
- 42
Citation history
Health deficiencies cited at Waters Of Rushville Skilled Nursing Facility, The during CMS and state inspections, most recent first.
A resident's medical administration record, containing personal and medical information, was left open and visible on a facility laptop atop the medication cart near the nurses' station while unattended. An LPN had left the area without securing the computer, allowing the information to be seen by anyone passing by, despite recent staff education on privacy protocols.
A QMA administered a discontinued PRN pain medication to a resident with lung cancer without checking the MAR or notifying a licensed nurse, resulting in a medication error. Required documentation and authorization procedures were not followed, and the incident involved a recently hired staff member.
A resident with lung cancer was given a discontinued dose of oxycodone by a QMA who failed to check the MAR, resulting in a medication error. The discontinued order was reflected in the MAR, but the medication remained in the med cart and was administered after discontinuation, with no documentation in the MAR or progress notes.
A packet of phenazopyridine 100 mg, prescribed for a resident with neuromuscular bladder dysfunction, was left unsecured on top of a medication cart near the nurses' station while no staff were present. An LPN reported being called away for another resident and did not secure the medication before leaving the area.
The facility did not have RN coverage for at least 8 hours on multiple days, as confirmed by schedule review and staff interviews. This affected all residents in the facility, and there was no policy in place to ensure sufficient nurse staffing.
Two residents experienced a lack of dignity and respect: one resident was left waiting up to 30 minutes for call light response, resulting in incontinence and embarrassment, while another was spoken to in a dismissive and hurtful manner by a QMA when requesting pain medication. Both residents were cognitively intact and required significant assistance, and these incidents demonstrate failures in timely response and respectful communication.
Two residents did not receive care as ordered: one did not have a timely endocrinology appointment scheduled despite physician orders and ongoing diabetes management needs, and another did not consistently receive prescribed wound dressings for skin damage, with multiple missed treatments documented. These deficiencies were confirmed through record review and staff interviews.
A QMA was observed handling oral medications, including hydroxyurea, with bare hands despite label instructions and facility policy requiring gloves and no direct contact. Additionally, a resident's CPAP mask was left uncovered on a bedside table and their urinary catheter drainage bag and tubing were in contact with the floor, contrary to facility infection control policies requiring proper storage and positioning.
A resident with multiple health conditions was admitted with a pressure ulcer, but the facility failed to provide a thorough assessment and timely treatment. The nursing assessment lacked detailed descriptions of the wounds, and treatment was delayed despite a Wound Assessment Report identifying a stage 3 pressure ulcer. The Director of Nursing acknowledged the oversight, which was exacerbated by staff departures and inadequate management during her absence.
The facility failed to conduct and document the required 72-hour post-fall assessments, including neurological checks, for three residents following falls. One resident was found deceased after incomplete monitoring, another had multiple falls with incomplete documentation, and a third had a fall resulting in a rib fracture with inadequate follow-up checks.
A medication transcription error occurred when a resident admitted with Parkinson's disease had their Sinemet dosage incorrectly entered into the EHR, leading to administration of an incorrect dosage. The hospital discharge instructions specified two tablets four times a day, but the EHR order was for one tablet four times a day. This error was identified during a review by the DON and NP.
The facility failed to ensure eight hours of consecutive RN coverage for 9 out of 91 days reviewed, potentially affecting 34 residents. Despite efforts to utilize both their own staff and agency nurses, the facility was unable to consistently fill the RN coverage. The facility did not have a specific policy for RN coverage but followed the Center for Medicare and Medicaid regulations.
The facility failed to accurately code falls in the MDS assessments for two residents with dementia. One resident had a fall with a bruise, and another had a fall resulting in a head laceration and another incident of sliding off the bed, but these were not accurately reflected in their MDS assessments.
The facility failed to accurately monitor two residents for bruising per physician orders. One resident with dementia had a bruise that was not documented until the day after it was observed, and another resident with atrial fibrillation had a bruise that was also not documented until the following day, despite physician orders for regular monitoring.
The facility failed to implement a pressure-relieving intervention as ordered by the podiatrist for a resident with an unstageable pressure ulcer on the right heel. The resident was observed multiple times with her right heel directly on the floor, despite the podiatrist's order to keep the heel off the ground. The resident indicated that she had not been offered an off-loading boot for the current pressure ulcer and expressed willingness to wear one. The Director of Nursing confirmed that the nurse who received the order should have implemented an intervention to keep the resident's heel off the floor.
The facility failed to provide a left-hand protector for a resident with contractures, despite a physician's order. The resident reported worsening pain and contracture, and no hand brace or palm protector was found in her room. The order was placed on hold, and alternatives like a rolled washcloth were suggested.
The facility failed to ensure that a fall mat was in place for a resident with dementia and a high risk for falls, as required by a physician's order. The fall mat was observed folded and stored away from the bed on multiple occasions, contrary to the facility's policy on fall interventions.
The facility failed to timely enter a resident with significant weight loss into the SWAT program. The resident experienced a 7.72% weight reduction over a month, but no SWAT notes were found for a 20-day period. Interventions were only documented after this delay.
A resident with abnormal weight loss experienced a significant weight decrease over a month, but the attending physician was not notified. The Regional Nurse Consultant confirmed the lack of documentation indicating physician notification.
The facility failed to ensure a timely response to a pharmacy recommendation for a resident with heart failure and moderate cognitive impairment. A recommendation for a gradual dose reduction of the resident's antidepressant was delayed by nearly two months, contrary to the facility's policy requiring a response within seven days.
A resident received two Tramadol tablets without an appropriate prescription, leading to a medication error discovered the next day. The error was due to the resident receiving her roommate's medication, and the family was notified over 14 hours later. The facility's medication administration policy was not followed.
The facility failed to maintain a medication administration error rate under five percent. Errors included administering omeprazole outside the accepted time window and improper administration of Humalog insulin via a Kwikpen. These issues resulted in a 7.4 percent error rate.
The facility failed to ensure proper infection control measures during a medication pass observation. An RN used a single alcohol pad to wipe her palms after removing gloves instead of using alcohol hand-sanitizer or washing her hands, as required by facility policy and CDC guidelines. The Administrator indicated that personal-sized bottles of hand-sanitizer were available, but the RN did not use them.
Resident Medical Information Left Unsecured and Visible
Penalty
Summary
During a medication administration observation, a facility computer laptop displaying a resident's medication administration record, including the resident's name and medical information, was left open and unattended on top of the medication cart near the nurses' station. The information was visible to anyone passing by, and no staff were present in the area for several minutes. The LPN responsible for the cart indicated she had been called away to assist another resident and did not secure the computer before leaving. A review of the resident's medical record confirmed the presence of multiple medical diagnoses and ongoing medication treatments. Despite recent staff education on the importance of securing medications and maintaining the confidentiality of resident information, the incident demonstrated a failure to protect the privacy of personal and clinical records as required by facility policy.
Failure to Ensure Proper Medication Administration and Documentation
Penalty
Summary
A medication error occurred when a Qualified Medication Aide (QMA) administered a dose of oxycodone 5 mg to a resident with a diagnosis that included lung cancer, after the medication order had been discontinued earlier that day. The QMA did not check the Medication Administration Record (MAR), which would have shown that the pain medication had been discontinued. There was no documentation in the progress notes or on the MAR indicating that the resident received the PRN pain medication on the evening in question, nor was there evidence that the QMA notified a licensed nurse prior to administration, as required by facility policy. The facility's policy and the QMA scope of practice require that a QMA obtain authorization from a licensed nurse before administering PRN medication, document the symptoms and the nurse's authorization, and ensure the record is cosigned by the nurse. In this incident, these steps were not followed. The medication had not yet been removed from the medication cart because only the DON or ADON could oversee its disposal, but the order had been updated in the computer system and reflected on the MAR. The QMA involved had been employed for about a month at the time of the incident.
Discontinued Medication Administered Due to MAR Verification Failure
Penalty
Summary
A medication error occurred when a qualified medication aide (QMA) administered a dose of oxycodone to a resident after the medication had been discontinued. The resident, who had diagnoses including lung cancer, was prescribed oxycodone 5 mg every four hours as needed for pain, with the order starting on 7-9-25 and discontinued on 7-16-25 at 11:45 a.m. Despite the discontinuation being reflected in the medication administration record (MAR), the QMA did not check the MAR before administering the medication on the evening of 7-16-25. There was no documentation in the MAR or progress notes of the medication being given at that time, but the Controlled Drug Receipt Record/Disposition Form confirmed the administration. The error was identified the following day, and it was noted that the medication had not yet been removed from the medication cart because only the DON or ADON are authorized to dispose of medications. The QMA involved had been employed for about a month at the time of the incident. The facility's director of nursing confirmed that this was the only medication error since the most recent annual survey and attributed the error to the staff member's failure to verify the MAR, which would have shown the medication had been discontinued.
Unsecured Medication Left Unattended on Medication Cart
Penalty
Summary
During a medication administration observation, a packet of phenazopyridine 100 mg, labeled for a resident with neuromuscular bladder dysfunction and prescribed for bladder spasms, was found lying unsecured on top of a medication cart near the nurses' station. The medication was left unattended for several minutes while no staff were present in the area. The LPN responsible for the medication stated in an interview that she had been called away to assist another resident and did not secure the medication in the cart before leaving. The medication cart itself was locked during this period, but the medication packet remained outside and accessible.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide Registered Nurse (RN) coverage for at least 8 hours per day on 5 out of 30 days reviewed, specifically on 1/7/25, 1/21/25, 1/22/25, 1/25/25, and 1/26/25. This lack of RN coverage was confirmed through both schedule review and interviews with the Director of Nursing (DON) and the Administrator. The DON acknowledged that there was no RN present in the building on those dates, and the Administrator stated that the facility did not have a policy on sufficient nurse staffing, although the expectation was to have RN coverage for 8 consecutive hours each day. All 43 residents in the facility were potentially affected by this deficiency.
Failure to Promote Resident Dignity and Timely Response to Care Needs
Penalty
Summary
Resident B, who had diagnoses including weakness, lack of coordination, osteoarthritis, congestive heart failure, and repeated falls, reported having to wait up to 30 minutes for staff to respond to their call light, particularly on weekends. The resident, who was cognitively intact and required substantial to maximal assistance with toileting and transfers, indicated that the delay resulted in incontinence of bowel and bladder, causing embarrassment when CNAs had to clean them. The resident was unable to get out of bed independently due to frequent falls and had reported the incident to staff at the time it occurred. Resident G, who had a history of left artificial knee joint, pain in the left knee, and muscle weakness, described an incident where a Qualified Medication Aide (QMA) responded in a dismissive and disrespectful manner when the resident requested pain medication after returning from the hospital. The QMA questioned the need for pain medication and made hurtful remarks, which negatively affected the resident's feelings. Both incidents reflect failures to promote dignity and respect for residents during care interactions.
Failure to Provide Timely Specialist Appointment and Consistent Wound Care
Penalty
Summary
A deficiency occurred when a resident with type 1 diabetes mellitus did not have a timely endocrinology appointment scheduled as ordered by the physician. The order to set up an appointment with the endocrinologist was first made and later revised to specify the provider, but documentation showed only a single progress note indicating a message was left with the endocrinology office. There were no further notes confirming that an appointment was scheduled until much later, and the resident reported not being informed about any appointment. The nurse practitioner stated the need for the appointment was due to the resident's complex diabetes management, and the DON confirmed the appointment was only recently scheduled, despite the earlier order. Another deficiency was identified for a resident with moisture-associated skin damage and a diagnosis of diabetes and incontinence, who did not consistently receive wound dressings as ordered. The treatment administration record showed multiple missed dressing changes over several days, despite a physician's order for twice-daily wound care. The plan of care included providing treatment as per the physician's order, but interviews revealed that missed treatments were attributed to either lack of notification from a QMA to a nurse or lack of documentation by the nurse if the resident was not on their scheduled assignment. Both deficiencies were supported by facility policies that require following physician orders and ensuring residents receive appropriate care and treatment. The survey findings were based on record reviews, resident and staff interviews, and facility policy review, confirming that the facility failed to provide timely specialist appointments and consistent wound care as ordered for the residents involved.
Failure to Adhere to Infection Control Standards in Medication Handling and Equipment Storage
Penalty
Summary
A Qualified Medication Aide (QMA) was observed preparing oral medications for a resident and touched each medication with bare hands, including hydroxyurea, which had specific instructions to wear gloves when handling. The QMA admitted to not noticing the label instructions and acknowledged that medications should not be touched with bare hands, as per facility policy. Facility documentation provided by the Administrator confirmed that infection control practices require medications to be dispensed without direct hand contact and to follow all label instructions. Additionally, a resident with a history of urinary tract infection and chronic obstructive pulmonary disease was observed with a CPAP mask left uncovered on the bedside table and an indwelling urinary catheter drainage bag and tubing in contact with the floor. The resident reported not having a storage bag for the CPAP mask and that staff had not assisted with cleaning the device. Facility policy requires CPAP masks to be stored in a plastic bag when not in use and catheter drainage bags to be kept off the floor. Staff confirmed these expectations during interviews.
Failure to Provide Timely Pressure Ulcer Care
Penalty
Summary
The facility failed to provide thorough assessment and timely treatment for a resident admitted with a pressure ulcer. Resident C, who had multiple diagnoses including peripheral vascular disease, diabetes mellitus, congestive heart failure, and hypertension, was admitted with an unstageable pressure ulcer. The admission nursing assessment noted a pressure ulcer on the left heel and redness and excoriation on the buttocks, but lacked detailed descriptions, measurements, or characteristics of the wounds. A subsequent Wound Assessment Report identified a stage 3 pressure ulcer on the right buttock, but the treatment was not initiated until several days later, as indicated by the medication administration record. The facility's Director of Nursing (DON) acknowledged the lack of wound assessments and follow-up on the wound care provider's recommendations. During the DON's absence, the Assistant Director of Nursing (ADON) was responsible for overseeing duties but did not seek assistance, leading to a lapse in wound care management. The abrupt departure of the ADON and other staff members further contributed to the oversight, as the DON was occupied with covering staffing needs and unable to address the wound report. The facility's policy required immediate steps to ensure treatment and interventions for pressure ulcers, which were not followed in this case.
Failure to Conduct 72-Hour Post-Fall Assessments
Penalty
Summary
The facility failed to ensure that three residents received the required 72-hour post-fall assessments, including neurological checks, following falls. Resident B, who had a history of alcohol dependency, weakness, and repeated falls, experienced an unwitnessed fall and was found disoriented. Although initial neurological checks were conducted, they were not continued as required, and no further documentation was made until the resident was found deceased the following morning. Resident F, who was severely cognitively impaired and had a history of multiple falls, experienced several falls during the review period. Documentation for the 72-hour post-fall monitoring was incomplete for three of these incidents. In one instance, the resident sustained injuries that were not immediately documented, and the physician was not notified of the changes in the resident's condition until later. Another fall was witnessed, but the corresponding post-fall monitoring report was not provided. Resident G, who had coronary artery disease and other health issues, sustained an unwitnessed fall and was sent to the emergency room, where a rib fracture was discovered. Upon her return to the facility, the required neurological checks were not consistently documented, and the 72-hour post-fall monitoring report was incomplete. The facility's policy required neurological checks for unwitnessed falls, but these were not adequately performed or documented for the residents involved.
Medication Transcription Error for Newly Admitted Resident
Penalty
Summary
The facility failed to ensure that medication orders for newly admitted residents were accurately transcribed into the electronic health record (EHR), resulting in a medication error for one resident. Resident D, who was admitted with diagnoses including weakness, cognitive communication deficit, and Parkinson's disease, had a discrepancy between the hospital discharge instructions and the physician order entered into the EHR. The hospital discharge instructions specified that Resident D should receive Sinemet 25 mg - 100 mg, two tablets, four times a day. However, the physician order entered into the EHR indicated only one tablet, four times a day. This transcription error led to Resident D receiving an incorrect dosage of Sinemet on multiple occasions. The medication administration record (MAR) showed that the incorrect dosage was administered on two consecutive days. Interviews with the Director of Nursing (DON) and the Nurse Practitioner (NP) revealed that there was a known issue with transcribing orders from hospital discharge instructions into the EHR, and the error was identified during a review process. The NP specifically noted the concern with Resident D's Sinemet order, highlighting the discrepancy between the hospital's discharge instructions and the EHR entry.
Failure to Ensure RN Coverage
Penalty
Summary
The facility failed to ensure eight hours of consecutive RN coverage for 9 out of 91 days reviewed, potentially affecting 34 residents. The PBJ Staffing Data Report for Fiscal Year Quarter 1 2024 indicated that there were nine days without the required RN coverage. Interviews with Corporate Payroll and the Regional Nurse Consultant revealed that the facility did not report any RN coverage for those days due to the absence of an RN on the skilled nursing facility. Despite efforts to utilize both their own staff and agency nurses, the facility was unable to consistently fill the RN coverage. Additionally, the facility did not have a specific policy for RN coverage but followed the Center for Medicare and Medicaid regulations.
Inaccurate Coding of Falls in MDS Assessments
Penalty
Summary
The facility failed to accurately code Section J regarding falls for two residents during their Minimum Data Set (MDS) assessments. Resident 14, who has a medical diagnosis of dementia, had an Annual MDS Assessment indicating one fall without injury, but a nursing progress note revealed a fall with a bruise to the right elbow. Similarly, Resident 16, also diagnosed with dementia, had an Annual MDS Assessment indicating one fall without injury, but intradisciplinary notes documented a fall resulting in a head laceration requiring staples and another incident of sliding off the bed without injury. These discrepancies were identified during a review of the clinical records and confirmed in an interview with the MDS Nurse.
Failure to Accurately Monitor Residents for Bruising
Penalty
Summary
The facility failed to accurately monitor residents for bruising per physician orders for two residents. Resident 14, who has dementia and is at risk for skin impairments, had a physician order to monitor for chronic bruising three times a day. However, a bruise with a scabbed area on her left forearm was not documented in the nursing progress notes until the day after it was observed. The treatment administration record indicated that the bruising had been monitored, but the nursing notes did not reflect this until later, showing a delay in documentation and monitoring as per the physician's order. Similarly, Resident 21, who has atrial fibrillation and is on blood-thinning medication, had a physician order to observe for signs and symptoms of bleeding or bruising every shift. A small bruise on her left posterior hand was observed but not documented in the nursing progress notes until the following day. The treatment administration record indicated monitoring, but the nursing notes did not reflect the bruise until later, indicating a failure to follow the physician's order for timely documentation and monitoring of bruising.
Failure to Implement Pressure-Relieving Intervention for Resident with Pressure Ulcer
Penalty
Summary
The facility failed to implement a pressure-relieving intervention as ordered by the podiatrist for a resident with an unstageable pressure ulcer on the right heel. The resident was observed multiple times with her right heel directly on the floor, despite the podiatrist's order to keep the heel off the ground. The resident indicated that she had not been offered an off-loading boot for the current pressure ulcer and expressed willingness to wear one. The Director of Nursing confirmed that the nurse who received the order should have implemented an intervention to keep the resident's heel off the floor. The resident's medical history includes generalized osteoarthritis, soft tissue disorder, muscle weakness, venous insufficiency, and congestive heart failure. The resident was cognitively intact and at risk of developing pressure ulcers. The podiatrist observed the pressure ulcer during a visit and ordered the resident to keep her heel off the ground. The care plan included interventions to encourage the resident to keep her heel off the ground and to wear a heel boot when her heel was not elevated. However, these interventions were not implemented, leading to the deficiency.
Failure to Provide Hand Protector for Resident with Contractures
Penalty
Summary
The facility failed to ensure that a left-hand protector or brace was available for a resident with contractures. The resident, who had a medical diagnosis of heart failure and moderate cognitive impairment, reported that her left hand hurt sometimes and that the contracture had worsened. She mentioned that padding was used about a year ago but was discontinued after it was lost. During observations, no hand brace or palm protector was found in her room, and the resident confirmed that nothing had been placed in her hand recently. A physician's order dated over a year ago indicated that the resident should use a left-hand protector at night to improve range of motion. However, the order was placed on hold after the Regional Nurse Consultant could not find the protector in the resident's room. Instead, a rolled washcloth or therapy carrot was suggested as an alternative. The facility's policy mandates following physician orders, but this was not adhered to in this case, leading to the deficiency.
Failure to Ensure Fall Mat in Place for High-Risk Resident
Penalty
Summary
The facility failed to ensure that a fall mat was in place for a resident while in bed, as required by a physician's order. Resident 7, who has dementia and is at high risk for falls, was observed on multiple occasions without the fall mat in place. Specifically, on two separate observations, the fall mat was found folded and stored between the foot of the bed and the closet while the resident was in bed. A CNA confirmed that the fall mat should have been in place. The facility's policy on incidents, accidents, and falls indicates that care plans should include appropriate interventions, but this was not adhered to in this case.
Failure to Timely Address Significant Weight Loss
Penalty
Summary
The facility failed to timely enter a resident with significant weight loss into the Skin and Weight Assessment Team (SWAT) program. Resident 14, who had a medical diagnosis of abnormal weight loss, experienced a weight reduction from 99.8 lbs on 2/1/2024 to 92.1 lbs by 3/2/2024, representing a 7.72% decrease. Despite the facility's policy requiring SWAT monitoring for residents with a 5% or more weight change in 30 days, no SWAT notes were found for Resident 14 between 3/1/2024 and 3/21/2024. It was only on 3/21/2024 that new interventions, such as adding power pudding to the lunch tray, were documented. This delay in addressing the resident's significant weight loss was confirmed through interviews and record reviews.
Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to timely inform Resident 14's provider of a significant weight change. Resident 14, who had a medical diagnosis of abnormal weight loss, experienced a weight decrease from 99.8 lbs on 2/1/2024 to 94.3 lbs on 3/1/2024, and further to 92.1 lbs on 3/2/2024. This represented a weight loss of 7.72% from 2/1/2024. An intradisciplinary note from 3/21/2024 addressed the weight loss but did not indicate that the attending physician was notified. During an interview on 3/27/2024, the Regional Nurse Consultant confirmed that there was no documentation in the medical record showing that the physician was informed of the significant weight loss.
Delayed Response to Pharmacy Recommendation
Penalty
Summary
The facility failed to ensure that a pharmacy recommendation was completed in a timely manner for one resident. The clinical record for a resident with a medical diagnosis of heart failure and moderate cognitive impairment was reviewed. A pharmacy recommendation for a gradual dose reduction of the resident's antidepressant was printed on October 15, 2023, but was not signed by a practitioner until December 14, 2023. The corresponding physician order to reflect the reduction was entered into the medical record on December 19, 2023. The facility's policy requires a response to pharmacy recommendations within seven days, which was not adhered to in this case.
Medication Administration Error
Penalty
Summary
The facility failed to ensure a prescription narcotic was not administered to a resident without an appropriate prescription. Resident C received two Tramadol tablets at bedtime, despite not having an order for this medication. The error was discovered the next day when Resident C mentioned to the nurse practitioner that she had slept well due to the medication. The Assistant Director of Nursing confirmed the administration of the medication, and the resident was monitored for adverse reactions. The family was notified over 14 hours after the error was discovered, causing distress to the family member. The root cause analysis revealed that Resident C was given her roommate's medication in error. The nurse responsible for the error was counseled, and the resident was monitored for any adverse effects. The facility's policy on medication administration, which includes verifying the resident's Medication Administration Record and identifying the resident before administering medication, was not followed. The Corporate Nurse confirmed that the Tramadol likely belonged to Resident C's roommate, as indicated by the Controlled Drug Receipt Record/Disposition Form, which showed discrepancies in the documentation of the medication's administration and destruction.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to ensure their medication administration error rate remained under five percent during three observations involving four staff members and eleven residents. Specifically, during a medication pass observation, a nurse administered omeprazole 20 mg to a resident at 4:50 p.m., which was outside the accepted practice of administering medications within one hour before or after the scheduled time of 3:00 p.m. This was confirmed by another nurse who indicated that it was facility policy to administer medications within a one-hour window of the scheduled time. Additionally, another nurse administered 4 units of Humalog insulin via a Humalog Kwikpen device subcutaneously into a resident's right deltoid but removed the needle immediately after the injection, contrary to the manufacturer's instructions to hold the needle in place for several seconds. The facility's guidelines for insulin pens did not address the length of time the needle should remain in the skin upon administration. These errors resulted in a medication administration error rate of 7.4 percent, exceeding the acceptable threshold.
Inadequate Hand Hygiene During Medication Pass
Penalty
Summary
The facility failed to ensure proper infection control measures during a medication pass observation involving four staff members and eleven residents. Specifically, RN 4 was observed to remove and discard her gloves after administering medications to three residents and then used a single alcohol pad to wipe only the palms of her hands instead of using alcohol hand-sanitizer or washing her hands. RN 4 explained that she did not have alcohol hand-sanitizer on her medication cart and the only available bottle was located at the nurse's station. This practice was not in accordance with the facility's policy or CDC guidelines, which require hand hygiene to be performed immediately after glove removal and before touching a patient or performing an aseptic task. The Administrator was informed of the concerns related to RN 4's hand hygiene practices and indicated that personal-sized bottles of alcohol hand-sanitizer were readily available for use. The facility's policy on medication administration, dated February 2017, required handwashing before beginning, whenever hands are contaminated, and if contact is made with the medication, but did not address the use of alcohol-based hand-sanitizer during a medication pass. The CDC's guidelines, retrieved from their website, emphasize the importance of hand hygiene and the need for supplies to be readily accessible in all patient care areas.
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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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