Wesleyan Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Marion, Indiana.
- Location
- 729 West 35th St, Marion, Indiana 46953
- CMS Provider Number
- 155455
- Inspections on file
- 35
- Latest survey
- January 27, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Wesleyan Health Care Center during CMS and state inspections, most recent first.
Surveyors identified multiple failures in sanitary food handling and storage, including a CNA who adjusted two residents in wheelchairs and then unwrapped and handled a piece of bread with bare hands without performing hand hygiene. Dietary staff were observed touching their face and hair, biting fingernails, and then handling food-contact surfaces and food items, including touching the inside of bowls while plating food, using bare fingers to arrange chicken on plates, placing the food-contact side of plastic bowl covers against clothing, and using fingers to remove potato skin. In dry storage, several dented cans with damage on end seams remained in regular stock instead of being removed per policy. A resident reported observing staff touch their face and arms during meal service without subsequent handwashing, and facility policies required avoidance of bare-hand contact with food, proper handwashing, and removal of cans with dents over seams.
Surveyors found that the facility failed to provide necessary nail care for two residents who were dependent on staff for ADLs. One resident with dementia and epilepsy was repeatedly observed with long, dirty, chipped fingernails despite receiving multiple showers, and another resident with cerebral palsy and profound intellectual disabilities had dried debris under most fingernails while requiring total assistance for personal care. Staff interviews showed inconsistent practices and understanding about when and how CNAs and nurses should perform and document nail care, and facility policy only stated that nail care would be provided "as needed," leading to unaddressed nail hygiene needs.
A resident with hypertension and coronary artery disease had an order for losartan 50 mg daily with instructions to hold the dose if systolic blood pressure (SBP) was below 110, and a care plan that called for BP monitoring and administration of antihypertensives as ordered. Review of MARs over two months showed multiple instances where the resident’s SBP was documented below 110, yet losartan was still administered and not held. QMAs and an LPN reported that their practice was to check BP before giving antihypertensives and to hold medications with parameters when readings were outside the ordered range, and one QMA acknowledged she should have held the medication when SBP was below 110. The DON stated she expected staff to hold BP medications when parameters were not met, and the facility’s policy required licensed staff to consult and follow physician orders and parameters, which did not occur in this case.
A resident with dementia, depression, bradycardia, and AFib, who required partial to maximal assistance for transfers, ambulation, and toileting, experienced numerous falls over a short period, including falls with injury and a major injury. Despite being care planned as high risk for falls due to impaired judgment, memory loss, history of falls, narcotic analgesics, and psychotropic use, the resident was repeatedly found on the floor in her room, bathroom, and near doorways after attempting unassisted transfers or ambulation. Facility documentation consistently identified root causes such as self-transfers and ambulating without assistance in the context of severe cognitive impairment and poor safety awareness, while staff interviews acknowledged frequent falls and ongoing self-initiated mobility. Observations and records show that the resident continued to be in situations where she could move without effective supervision, leading to repeated accidents in violation of the facility’s obligation to prevent avoidable accidents.
A resident with cerebral palsy, dysphagia, and a PEG feeding tube had physician orders and care plans requiring Enhanced Barrier Precautions (EBP) due to the feeding tube. An EBP magnet and PPE were present at the room, but during observed PEG site care, a Unit Manager performed high-contact device care using gloves only and did not don a gown, despite scant tan drainage noted at the site. The DON and IP gave inconsistent interpretations of when gowns were required, and the IP stated she would not have used a gown in the same situation. The facility’s EBP policy, however, identified residents with feeding tubes as requiring EBP and specified gown and glove use for high-contact activities, including feeding tube care.
A resident with quadriplegia and contractures fell from bed and fractured her knee after a CNA attempted to provide care without the required two-person assistance. Despite the care plan indicating the need for two staff members for bed mobility, the CNA proceeded alone, leading to the resident's fall. Interviews revealed that staff were aware of the two-person requirement, but documentation inconsistencies showed the resident was often recorded as needing only one-person assistance.
A resident's call light was not within reach, violating the facility's policy to accommodate resident needs. The resident, with conditions like hemiplegia and dementia, was observed without access to the call light in both a wheelchair and bed. An LPN confirmed the oversight, noting it may have been misplaced during a bedsheet change.
A resident with multiple health conditions experienced a deficiency in their living environment due to a failure to repair a hole in the wall of their room. The hole, which allowed cold air to enter, was temporarily plugged with a blue glove by an x-ray technician. Despite the resident's requests for repair, no work orders were submitted, and the facility lacked a policy for room maintenance. The administrator and maintenance director were unaware of the issue, and the facility did not use blue gloves, indicating the glove was not from the facility.
A resident with severe cognitive impairment was observed multiple times without being shaved, despite requiring assistance with personal hygiene. Interviews with CNAs revealed inconsistencies in shaving routines, and the DON acknowledged the lack of documentation for refusals or behaviors. The facility's policy required personal hygiene twice daily, which was not followed for this resident.
A resident with dementia lost their lower denture and the facility failed to arrange timely dental appointments, resulting in a prolonged period without the necessary dental appliance. Despite initial efforts with Company A, the replacement denture was delayed and never arrived. The family obtained a new denture from Company C, but it went missing again, and by the following year, the resident still did not have a replacement. The facility's policy required timely referrals for lost dentures, but this was not followed, and staff interviews revealed a lack of awareness and documentation regarding the resident's dental needs.
The facility failed to follow proper infection prevention and control strategies for two residents in COVID-19 isolation. A resident's room lacked a sign indicating required precautions, and staff did not use face shields as required. Another resident's caregiver incorrectly placed an N95 mask over a surgical mask. Both residents were under strict isolation orders due to positive COVID-19 tests, and the facility's policy required specific PPE use.
The facility failed to ensure urinary catheter outputs were monitored and documented for three residents, resulting in one resident being hospitalized with a blocked catheter and urinary tract infection. Inconsistent documentation and lack of adherence to catheter care policies were observed.
The facility failed to administer insulin as ordered and scheduled for two residents. Insulin was administered late on multiple occasions, and the Director of Nursing indicated that while insulin was given on time, the nurses did not document it correctly. This deficiency relates to Complaint IN00432015.
The facility failed to supervise a resident during a nebulizer treatment as required by physician orders and facility policy. The resident, who had multiple severe respiratory conditions, was found unattended with the nebulizer machine in operation. Staff interviews confirmed the lack of supervision, and the facility's policy emphasized the need for observation during such treatments.
Unsanitary Food Handling and Improper Storage of Dented Cans
Penalty
Summary
The deficiency involves failure to ensure food was prepared and served under safe and sanitary conditions, including improper hand hygiene and food handling during meal service. During a lunch observation, a CNA moved two male residents in their wheelchairs and then immediately handled a resident’s wrapped bread, unwrapping it and touching the bread with bare hands without performing hand hygiene in between. The CNA later acknowledged she did not perform hand hygiene and should not have touched the bread with bare hands. Additional observations during the same lunch period showed dietary staff engaging in multiple unsanitary practices: one dietary employee pulled her hairnet down below her ears and touched her cheeks while waiting for a tray, another dietary employee repeatedly touched the inside food-contact surfaces of bowls with his fingers while plating food, and the Assistant Dietary Manager used his bare fingers to arrange chicken pieces on a plate and placed the food-contact side of plastic bowl covers against his shirt to separate them. Another dietary employee bit around her fingernail and then handled the food-contact portion of plastic bowl covers without hand hygiene, and used a fork and bare fingers to remove the skin from a baked potato. The Dietary Manager later confirmed these actions were inconsistent with facility policies prohibiting bare-hand contact with food and requiring proper handwashing. The deficiency also includes failure to properly manage dented canned goods in dry storage. During a kitchen observation, surveyors found a can of sliced apples with a dent on the top seal, a can of peas and diced carrots with a dented seal, and a can of cheddar cheese with a dented bottom seal, all with recent intake dates. The Dietary Manager stated these dented cans should have been removed from regular storage and placed on an upper shelf for supplier credit, and signage was posted instructing staff what to look for regarding canned food. Facility policies in effect at the time required staff not to touch food with bare hands, to follow approved handwashing procedures, and to treat cans with dents over side or end seams as unsafe. A resident interview corroborated concerns about hygiene practices during meal service, with the resident reporting having seen staff touch or rub their face and arms without washing their hands afterward.
Failure to Provide Necessary Nail Care During ADL Assistance
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary daily grooming assistance, specifically nail care, for residents who were unable to perform this activity of daily living themselves. For one resident with major depressive disorder, dementia, and epilepsy, surveyors repeatedly observed long, dirty, chipped, and jagged fingernails over multiple days, despite documentation that the resident had received several showers during the same period. The resident’s MDS showed moderate cognitive impairment and a need for partial/moderate assistance with personal hygiene, and the care plan indicated he required physical assistance with ADLs and bathing due to dementia and schizophrenia. Nonetheless, his nails remained untrimmed and uncleaned across several observations. Another resident with cerebral palsy, profound intellectual disabilities, aphasia, severe cognitive impairment, and functional limitations in both upper and lower extremities was observed with tan dried substance under seven of ten fingernails. Her care plans documented total assistance by two staff for a.m. and p.m. care and included interventions such as manicures during 1:1 programming. Staff interviews revealed inconsistent practices and understanding regarding nail care: CNAs and nursing staff variously stated that nail care was done on shower days, on an as-needed basis, or only when residents requested it, and that nail care was not documented. The DON and facility policy indicated nail care was to be provided as needed and checked on shower days, but the observed condition of the two residents’ fingernails and the lack of documentation showed that necessary nail care was not consistently provided.
Failure to Follow BP Medication Hold Parameters for Antihypertensive Therapy
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders for blood pressure medication parameters for one resident. The resident had diagnoses of essential hypertension and atherosclerotic heart disease of a native coronary artery without angina pectoris, and an order for losartan potassium 50 mg daily with instructions to hold the dose if the systolic blood pressure (SBP) was less than 110. The resident’s care plan for hypertension indicated goals for blood pressure management and interventions that included taking blood pressures as ordered, monitoring for pattern changes, and administering antihypertensive medications as ordered. Review of the medication administration record (MAR) for December showed multiple dates on which the resident’s SBP was below 110 (including readings such as 109/50, 101/52, 108/64, 109/79, and 103/68), yet the losartan was still administered and not held as ordered. Review of the MAR for January showed additional dates on which the resident’s SBP was below 110 (including readings such as 109/52, 108/73, 106/52, 108/66, 108/62, 105/46, and 107/55), and again the losartan was administered instead of being held per the physician’s parameters. Interviews with QMAs and an LPN indicated that staff were aware that blood pressure should be checked prior to administering antihypertensive medications and that medications with parameters should be held and the nurse notified if readings were outside the ordered range. One QMA, upon reviewing the MAR, acknowledged she should have held the medication when the SBP was below 110. The DON stated she expected staff to hold blood pressure medications when parameters were not met. The facility’s policy on following physician orders/parameters required licensed healthcare providers to consult and follow physician orders prior to administering medications or performing procedures, which was not followed in this case.
Failure to Provide Adequate Supervision for Cognitively Impaired Resident With Recurrent Falls
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and prevent repeated falls for a severely cognitively impaired resident. The resident had diagnoses including dementia, major depressive disorder, bradycardia, and atrial fibrillation, and required partial to maximal staff assistance with transfers, ambulation, toileting, and hygiene. MDS assessments documented severe cognitive impairment, disorganized thinking, inattention, poor safety awareness, frequent incontinence, and shortness of breath with exertion. Over time, the resident experienced multiple falls, including falls with injuries and a major injury, despite being identified as at risk for falls related to impaired judgment, memory loss, history of falls, narcotic analgesics, and psychotropic medications. From late December through mid-January, the resident had a series of falls in her room, bathroom, and common areas, often while attempting to transfer or ambulate without assistance. She was repeatedly found on the floor beside her bed, in the bathroom, near her recliner, or in doorways, frequently after attempting self-transfers or ambulating alone. Documentation consistently identified root causes such as transferring or ambulating without assistance, losing balance, and sliding from bed, with contributing factors of dementia, severe cognitive impairment, poor safety awareness, and a history of multiple recent falls. The record also notes that the resident sometimes removed her shoes, wore only socks, or manipulated and removed chair alarms, and that she frequently refused to use her wheelchair when going to the bathroom. Despite the resident’s ongoing pattern of falls and her severe cognitive impairment, the facility’s approach relied heavily on intermittent checks, signage, and environmental measures while the resident continued to self-transfer and ambulate unassisted. Staff and leadership interviews acknowledged that the resident had fallen many times in a short period, that some falls were attributed to maladaptive behaviors and possibly bradycardia, and that she continued to try to care for herself and get up on her own. Staff reported trying to keep her in common areas when awake and to keep her room door open to observe her, but observations showed that at times the resident was in bed with the door closed. The cumulative documentation shows repeated falls, including a minimally displaced radial head fracture of the right elbow, occurring in the context of severe cognitive impairment and ongoing self-initiated transfers and ambulation without consistent, effective supervision to prevent these accidents. The care plan identified the resident as at risk for falls and referenced her fracture from a fall, with interventions such as scheduled toileting, use of an anti-roll back device on the wheelchair, encouraging her to stay in common areas while up, non-slip footwear, and assisting her to areas of increased supervision when restless. However, the clinical record and narrative notes describe continued falls under similar circumstances—unassisted transfers, ambulation without help, and attempts to reach the bathroom or bed independently—indicating that the resident’s needs for supervision were not effectively met. Interviews with CNAs and nursing leadership further confirm that, despite awareness of her frequent falls and behaviors, the resident was still often in situations where she could and did attempt to move without assistance, leading to repeated accidents. Throughout this period, the resident’s pattern of behavior, cognitive status, and physical limitations remained consistent, and the facility’s own fall investigations repeatedly cited the same root causes and contributing factors. The facility’s policy states that it will provide an environment free from accident hazards and implement supervision and assistive devices consistent with residents’ needs to prevent avoidable accidents. In this case, the documented series of falls, including those resulting in injury and a major injury, occurred while the resident continued to self-transfer and ambulate without adequate, effective supervision, constituting the failure cited in the deficiency.
Failure to Follow Enhanced Barrier Precautions During PEG Tube Site Care
Penalty
Summary
The deficiency involves the facility’s failure to follow its infection prevention and control program, specifically its Enhanced Barrier Precautions (EBP) policy, for a resident with a gastrostomy tube. The resident had diagnoses including cerebral palsy, dysphagia, and gastrostomy status, and received continuous enteral feeding via a PEG tube, with orders for EBP in place. Care plans documented that the resident required EBP due to the gastrostomy tube and that staff were to follow EBP during care and minimize infection risk related to the tube site. During an observation, an EBP magnet was posted outside the resident’s room, and PPE (a yellow isolation gown and gloves) was available inside the room. The Unit Manager prepared to perform PEG site care, performed hand hygiene, and wore gloves, but did not don an isolation gown. She cleansed the PEG insertion site using soapy washcloths, working from the insertion site outward and using different edges of the washcloth, then rinsed and dried the area. A scant amount of tan drainage was observed on the washcloth during cleansing. Throughout this high-contact device care activity, the Unit Manager did not wear a gown despite the facility’s EBP policy identifying feeding tube care as a high-contact resident care activity requiring gown and glove use. In interviews, the Unit Manager stated she believed gowns were only needed when dealing with the tube feeding itself or if the PEG site was red, infected, inflamed, had drainage, or if splattering might occur, and that gloves alone were sufficient for personal care. The DON initially indicated that EBP, including gown use, was required for personal care such as PEG site care and that the PEG site was the reason for the resident’s EBP status, but later acknowledged conflicting information received from the Infection Preventionist and then confirmed that a gown should have been worn. The Infection Preventionist reported conducting EBP rounding and education but stated she did not believe a gown was needed for this PEG site care because the GI tract was not sterile, there was no chance of splash, no prolonged contact, and the PEG site was old with no drainage observed, and indicated she would have done the same as the Unit Manager. The facility’s written EBP policy, however, specified that residents with feeding tubes require EBP and that PPE (gown and gloves) is necessary when performing high-contact care activities, including device care such as feeding tubes, for the duration of the resident’s stay or until the device is discontinued.
Failure to Provide Adequate Assistance Leads to Resident Fall
Penalty
Summary
The facility failed to provide adequate supervision and assistance for a resident who required total assistance from two staff members for bed mobility. This deficiency resulted in the resident falling from the bed and sustaining a fracture to the left knee joint. The resident, who was quadriplegic and had multiple contractures, was being assisted by a CNA who attempted to change the resident's bed sheets and incontinence pad without the help of a second staff member, despite the care plan indicating the need for two-person assistance. The resident's care plan, which was current and had been revised multiple times, clearly stated that the resident required the assistance of two staff members for bed mobility due to her quadriplegia and contractures. However, the CNA proceeded to provide care alone, which led to the resident rolling off the bed and sustaining injuries. The resident had previously informed the CNA of the need for a second staff member, but the CNA assured her that he could manage alone. During the incident, the resident's leg went over the side of the bed, causing her to fall. Interviews with staff and the resident confirmed that the facility staff were aware of the requirement for two-person assistance, yet documentation showed that the resident was often recorded as needing only one-person assistance for bed mobility. This inconsistency in documentation and practice contributed to the incident. The resident's medical history, including quadriplegia, contractures, and other conditions, made her particularly vulnerable to falls, emphasizing the importance of adhering to the care plan requirements.
Resident's Call Light Not Within Reach
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, which is a deficiency in accommodating the needs and preferences of the resident. During a random observation, a resident was seen in a high-backed wheelchair facing the television without the call light within reach. The resident confirmed during an interview that the call light was not accessible, and he had been waiting for over an hour for assistance to be placed in bed. Later, the resident was observed lying in bed with the call light placed on his roommate's nightstand, again out of reach. The resident was unsure of the call light's location. The resident's clinical record indicated diagnoses of flaccid hemiplegia affecting the left side, vascular dementia, and other conditions requiring substantial assistance for daily activities. A care plan noted the resident's risk for falls and specified that the call light should be within reach. An LPN confirmed the call light was not within reach and suggested it was misplaced during a bedsheet change. The facility's policy mandates that call lights be accessible to residents, which was not adhered to in this instance.
Failure to Repair Damaged Wall in Resident's Room
Penalty
Summary
The facility failed to maintain a homelike environment for a resident by not repairing a damaged wall in the resident's room. The resident, who has multiple sclerosis, atherosclerosis, peripheral vascular disease, and major depressive disorder, was cognitively intact and required minimal assistance with daily activities. During an observation, a blue glove was found stuffed into a hole in the wall near the heating/cooling unit, which the resident reported was done by an x-ray technician to block cold air. The resident had requested repairs multiple times but could not recall specific dates. The administrator was unaware of the issue as no work orders had been submitted, and the facility did not use blue gloves, suggesting the glove was not from the facility. Interviews with the administrator and maintenance director revealed that the heating/cooling unit had been replaced, but no records or work orders documented this replacement. The maintenance director confirmed the unit was replaced before a deep clean of the room, but the hole was not addressed. Despite the administrator's claims of maintaining the facility in good condition, a hole was also noted in the Director of Nursing's office. The corporate nurse mentioned that the facility had a guardian angel program and regular nurse visits, implying someone should have noticed the hole. However, the facility lacked a policy for the maintenance or upkeep of physical property or resident rooms.
Failure to Provide Daily Grooming Assistance
Penalty
Summary
The facility failed to provide daily grooming assistance for a resident, identified as Resident 112, who was observed multiple times over several days without being shaved. Observations on different days showed that the resident participated in activities and meals without having been shaved, despite having facial hair growth noticeable enough to be described as the thickness of two quarters stacked. The resident's clinical record indicated severe cognitive impairment and a need for supervision or assistance with personal hygiene, yet there were no documented refusals or behaviors that would explain the lack of grooming. Interviews with Certified Nursing Assistants (CNAs) revealed inconsistencies in the shaving routine, with some indicating that shaving was done only on shower days, while others suggested it was done more frequently if needed. The Director of Nursing (DON) acknowledged that staff should attempt to shave male residents daily but could not find documentation of any refusals or behaviors from Resident 112 regarding ADL care. The facility's policy on personal hygiene, which was last revised in 2021, stated that personal hygiene, including shaving, should be performed twice daily, yet this was not adhered to in the case of Resident 112.
Failure to Provide Timely Dental Care for Resident
Penalty
Summary
The facility failed to arrange timely dental appointments for a resident who lost their lower denture, resulting in a prolonged period without the necessary dental appliance. Resident B, who was admitted in February 2023 with a full set of dentures, lost the lower plate within three months. Despite an initial appointment with Company A, the replacement denture was delayed and never arrived. The family eventually canceled the insurance with Company A and obtained a new lower denture from Company C within three weeks. However, the lower plate went missing again in December 2023, and by December 2024, the resident still did not have a replacement. The resident's clinical record indicated a history of dementia and severe cognitive impairment, but lacked documentation regarding the use of dentures. Despite a dental note from May 2023 suggesting the need for adhesive for a proper fit, the facility did not ensure the resident received a replacement lower denture. Interviews with staff revealed a lack of awareness and documentation regarding the resident's dental needs, and the Social Services Director admitted to not knowing how long the resident had been without the lower denture. The facility's policy required referrals for dental services within three days for lost or damaged dentures, but this was not adhered to in Resident B's case. The Administrator expressed reluctance to replace the denture due to the resident's refusal to wear it, but there was no documentation to support this claim. The facility's failure to address the resident's dental needs in a timely manner and lack of proper documentation contributed to the deficiency.
Inadequate COVID-19 Isolation Precautions
Penalty
Summary
The facility failed to ensure proper infection prevention and control strategies for transmission-based precautions for two residents in COVID-19 isolation. For Resident 35, multiple observations revealed the absence of a sign on the door indicating required precautions and a lack of face shields in the over-the-door organizer. RN 12 entered the resident's room wearing a gown, gloves, and an N95 mask but did not use a face shield, mistakenly believing that regular glasses sufficed. Interviews with staff confirmed the requirement for a face shield in addition to glasses unless goggles were used. The Infection Preventionist Nurse also confirmed that a sign indicating precautions should be present on the door. For Resident 67, CNA 15 incorrectly placed an N95 mask over a surgical mask before entering the resident's room, despite a sign indicating the need for contact and droplet isolation. LPN 3 informed CNA 15 of the error, but the CNA prioritized timely meal delivery over proper mask application. The Infection Preventionist Nurse confirmed that the N95 mask should not be worn over a surgical mask. Both residents had physician's orders for strict single isolation due to positive COVID-19 tests, and the facility's policy required adherence to standard precautions, including the use of a NIOSH-approved respirator, gown, gloves, and eye protection.
Failure to Monitor and Document Urinary Catheter Outputs
Penalty
Summary
The facility failed to ensure urinary catheter outputs were monitored and documented for three residents, resulting in one resident being transferred to the hospital with a large amount of urine retained from a blocked urinary catheter. Resident D, who had a history of neuromuscular dysfunction of the bladder and traumatic brain injury, was found to have inconsistent and missing documentation of urinary output. On multiple occasions, there was no recorded urine output, and Resident D was eventually transferred to the hospital with respiratory failure and a clogged catheter, leading to a urinary tract infection and significant discomfort upon catheter change. Resident H, diagnosed with quadriplegia and urinary retention, also had inconsistent documentation of urinary output. There were several days where no urine output was recorded, despite physician orders requiring documentation every shift. The lack of consistent monitoring and documentation raised concerns about the adequacy of care provided to Resident H. Resident J, with a suprapubic catheter and multiple urinary tract-related diagnoses, similarly had gaps in urinary output documentation. There were several days with no recorded urine output, despite physician orders for regular monitoring. Interviews with staff revealed that while CNAs were responsible for documenting outputs, there were lapses in ensuring this documentation was completed, and the nurses and unit manager did not consistently verify the documentation. The facility's policy on catheter care was not adhered to, leading to these deficiencies.
Failure to Administer Insulin as Ordered and Scheduled
Penalty
Summary
The facility failed to administer insulin as ordered and scheduled for two residents, Resident B and Resident C. Resident B's clinical record showed that insulin glargine, which was supposed to be administered at 8:00 p.m., was given late on multiple occasions, including at 11:44 p.m., 1:41 a.m., and 11:37 p.m. Additionally, insulin aspart was also administered late at 10:33 p.m. instead of the scheduled 5:30 p.m. Resident B had diagnoses of type 2 diabetes mellitus without complications and with diabetic neuropathy. Resident C's clinical record indicated similar issues, with insulin glargine scheduled for 8:00 p.m. being administered late at times such as 2:29 a.m., 11:20 p.m., 1:08 a.m., and 4:01 a.m. Resident C had diagnoses of type 2 diabetes mellitus with unspecified diabetic retinopathy, diabetic polyneuropathy, and hyperglycemia. During an interview, the Director of Nursing (DON) indicated that the residents were given insulin on time, but the nurses failed to document the administration correctly. The facility's policy on the timely administration of insulin mandates that insulin be administered according to physician's orders and documented accurately. The failure to adhere to this policy resulted in the cited deficiencies. This citation relates to Complaint IN00432015.
Failure to Supervise Resident During Nebulizer Treatment
Penalty
Summary
The facility failed to ensure a resident received supervision per physician order and facility policy during the administration of a nebulized medication. During a random observation, Resident G was found lying in bed with a nebulizer mask on her face and the nebulizer machine in operation, but no nurse was present in the room or hallway. Nurse Manager 9 later entered the room, turned off the nebulizer machine, and placed the nebulizer mask on top of the machine. Resident G's clinical record indicated that the nebulizer treatments were to be administered by a clinician, and the facility policy required observation of the resident during the procedure for any change in condition. Interviews with Nurse Manager 9 and LPN 13 confirmed that Resident G should have been supervised during the nebulizer treatment. LPN 13 admitted that she was supposed to supervise Resident G but was attending to another resident who needed help with his shoes. The facility's policy on Nebulizer Therapy, provided by the Director of Nursing, also indicated the necessity of observing the resident during the procedure. Resident G had multiple diagnoses, including morbid obesity with alveolar hypoventilation, obstructive sleep apnea, acute respiratory failure with hypoxia, and chronic obstructive pulmonary disease with acute exacerbation, which necessitated close supervision during nebulizer treatments.
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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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