Westminster Village North
Inspection history, citations, penalties and survey trends for this long-term care facility in Indianapolis, Indiana.
- Location
- 11050 Presbyterian Dr, Indianapolis, Indiana 46236
- CMS Provider Number
- 155167
- Inspections on file
- 29
- Latest survey
- November 24, 2025
- Citations (last 12 mo.)
- 30
Citation history
Health deficiencies cited at Westminster Village North during CMS and state inspections, most recent first.
A deficiency was cited when a facility area was found to contain accident hazards and lacked adequate supervision to prevent accidents, resulting in unsafe conditions for residents.
A resident with severe cognitive impairment and congestive heart failure did not receive a newly ordered diuretic medication as prescribed due to delays in pharmacy delivery and lack of documented interim measures, resulting in missed doses over a two-day period.
A registered nurse did not perform hand hygiene after removing gloves and failed to wear a gown while providing wound care to a resident under Enhanced Barrier Precautions for MDRO risk. The nurse acknowledged that these steps were normally followed, and the facility's policy required both hand hygiene and appropriate PPE during such high-contact care activities.
A facility failed to ensure the accuracy of an MDS assessment for a resident with dementia and anxiety disorder. The assessment inaccurately reported no behaviors, despite progress notes indicating otherwise. Social Services was responsible for completing the MDS section on behaviors.
A resident with dementia and severe cognitive impairment exhibited frequent aggressive behaviors, but the facility failed to implement a specific care plan with effective interventions. Despite the facility's policy emphasizing person-centered care, staff relied on ineffective redirection techniques and pharmacological interventions without adequately documenting or evaluating non-pharmacological approaches.
A resident with dementia and anxiety disorder received an incorrect dosage of fentanyl patches due to a failure to follow updated physician orders. The resident was prescribed a 25 mcg fentanyl patch every three days, but on one occasion, both a 25 mcg and a 12 mcg patch were administered, resulting in a total dose of 37 mcg. This discrepancy was noted during an interview with the DON, who confirmed that staff should adhere to physician orders.
The facility failed to treat residents with dignity and respect, as evidenced by multiple complaints. A resident reported CNAs turning off call lights without returning, while another faced inappropriate comments from a nurse during personal care. Delays in toileting assistance and lack of tablecloths in the health center contributed to feelings of neglect. A CNA prioritized their break over providing incontinent care, further violating residents' rights.
The facility failed to address a grievance from the resident council regarding the removal of tablecloths in the health center dining rooms. Despite the council's repeated concerns and the facility's policy requiring prompt action and follow-up, no formal grievance documentation or response was provided. The council felt they were treated differently compared to other dining areas in the facility.
The facility failed to address resident grievances effectively, as evidenced by incomplete documentation and lack of follow-up on grievances filed by residents. A resident reported grievances about CNAs being rude, but the forms lacked confirmation and follow-up. Another resident filed grievances about a nurse's refusal to administer insulin correctly and a disagreement over medications, but did not receive follow-up or resolution. Additionally, the facility did not provide a means for residents to file grievances anonymously, as forms were not readily available without asking staff.
The facility failed to ensure proper documentation and follow-up after fall incidents for several residents, leading to deficiencies in care. Residents with dementia, Alzheimer's, and other conditions experienced multiple falls without adequate post-fall assessments or updated care plans. Despite repeated incidents, the facility did not consistently complete incident reports or implement new interventions to prevent further falls.
The facility failed to maintain proper kitchen sanitation and food storage practices. Staff did not wear beard restraints, leading to potential hair contamination. Expired food items were found in the refrigerator, and the dishwasher failed to reach the required temperature, resulting in dirty utensils. Soiled rolling carts were also observed in the food storage area, indicating a lack of adherence to sanitation policies.
The facility failed to maintain an effective pest control program, leading to the presence of flying insects in a food storage area in one of the kitchens. During a tour, tiny flying insects resembling gnats were observed in the air and on products, with a total of nine insects counted. The Kitchen Manager confirmed that there should not be any flying insects in the kitchen or storage area.
A resident, who is 6 foot 8 inches tall and dependent on a wheelchair, was not provided with a suitable wheelchair upon admission to the facility. The available wheelchair was too small, causing discomfort and improper positioning, which affected the resident's ability to sit upright and feed himself. Despite efforts to obtain a specialty wheelchair, delays persisted, leading to the deficiency noted in the report.
A resident with Alzheimer's disease experienced a fall in the facility, but the incident was not initially considered a fall by the nurse, leading to a failure to notify the resident's representative. The facility's policy requires immediate notification of such events, but the clinical record lacked documentation of this notification.
A resident reported a grievance involving a CNA discouraging water intake to avoid frequent changes, which the DON considered abusive. Despite this, the facility did not report the incident to the IDOH as required, and there was no documentation of an investigation. The resident was cognitively intact and had no history of false allegations.
The facility failed to obtain vital signs before administering medication to a resident with specific parameters, did not follow up on a urinalysis for a combative resident, and failed to ensure two residents attended their neurology appointments due to scheduling and transportation errors.
A facility failed to document a physician's order for a resident's continuous oxygen therapy in the EHR and did not change the humidification container as per policy. The resident, on hospice care with multiple diagnoses, had a humidification container with cloudy water that was not bubbling. The hospice provider's order was not entered into the EHR, and the care plan lacked details on continuous oxygen use. The ADON confirmed the facility's responsibility for oxygen-related care, which was not met according to the facility's policy.
A resident with low back pain did not receive a pain-relieving patch as ordered. The care plan required a lidocaine patch to be applied for 12 hours daily. However, the resident reported not receiving the patch at times, and on one occasion, the patch was not replaced as scheduled. An RN confirmed the delay in applying the patch due to time constraints.
A facility failed to conduct pre and post assessments for a resident receiving dialysis, as required by their policy. The resident, with chronic kidney disease and requiring hemodialysis, did not have documented assessments on two scheduled dialysis days. The DON confirmed that staff should have conducted these assessments, which are mandated by the facility's dialysis policy.
A facility failed to ensure medications in its medication carts were not expired, as a vial of Humalog insulin without an expiration date was found. An LPN acknowledged the requirement for dating opened vials and was unable to locate the vial used for a resident with type 2 diabetes. The facility's policy mandates discarding multi-dose vials within 28 days of opening.
Two residents reported receiving unappetizing grilled cheese sandwiches, with one describing it as cold toast with cheese and the other as a microwaved, hard sandwich. The facility's previous method involved using a toaster, but changes were made to use a pan or grill for preparation.
A facility failed to maintain infection control during medication administration. A QMA picked up dropped pills with bare hands, and an RN used a personal blood pressure device on multiple residents without cleaning it between uses. The facility's policy requires avoiding touching medications without gloves.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which resulted in the presence of accident hazards and insufficient oversight to protect residents from potential harm. No additional details regarding the specific hazards, the number of residents affected, or their medical conditions at the time of the deficiency are provided in the report.
Failure to Timely Administer Newly Ordered Medication
Penalty
Summary
The facility failed to ensure that a newly ordered medication, furosemide 20 mg, was received and administered in a timely manner as ordered by the physician for a resident with congestive heart failure and severe cognitive impairment. The resident was noted to have swelling, redness, and blistering on the left lower extremity, prompting a physician's order for furosemide to be given twice daily for four days. However, the medication was not documented as administered on the evening of the order date, nor the following morning and evening, with the first documented dose given two days after the order was placed. There was no documentation that the facility pharmacy had been contacted regarding the delay in delivery, nor evidence that the medication was accessed from the Emergency Drug Kit, despite its availability. The DON confirmed the pharmacy's delivery schedule and was unable to explain the delay in receiving the medication. The packing slip indicated the medication was delivered two days after the order, and facility records did not show any interim measures taken to provide the medication as ordered.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
A deficiency occurred when a registered nurse (RN) failed to follow proper infection prevention and control protocols during wound care for a resident with a diagnosis that included congestive heart failure and severe cognitive impairment. The resident was under Enhanced Barrier Precautions (EBP) due to being at high risk for acquiring or spreading multidrug-resistant organisms (MDROs), as indicated by the facility's policy. The physician's order required specific wound care procedures for the resident's right foot. During the observed wound care, the RN donned disposable gloves and removed the old dressing, but after removing the gloves in the bathroom, did not perform hand hygiene before applying a new pair of gloves. Additionally, the RN did not don a gown prior to beginning the wound treatment, despite gowns being available in the room and the facility's policy requiring both gloves and gowns for high-contact activities such as wound care under EBP. The RN acknowledged during an interview that she would normally wear a gown and perform hand hygiene after doffing gloves, but failed to do so during this instance. The facility's current EBP policy, provided by the Director of Nursing, clearly outlined the requirements for PPE use and hand hygiene during high-contact care activities for residents at high risk for MDROs.
Inaccurate MDS Assessment for Resident Behaviors
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for a resident's behaviors. Resident B, who has diagnoses including senile degeneration of the brain, dementia with agitation, dementia with psychotic disturbance, and anxiety disorder, was reported to have exhibited behaviors on multiple occasions. However, a Significant Change MDS assessment dated 9/30/24 inaccurately indicated that Resident B exhibited no behaviors. This discrepancy was identified through a review of progress notes that documented behaviors on several dates prior to the assessment. An interview with the MDS Coordinator revealed that Social Services was responsible for completing the MDS section regarding behaviors.
Inadequate Behavior Management for Resident with Dementia
Penalty
Summary
The facility failed to adequately care plan for a resident diagnosed with dementia and exhibiting behaviors. Resident B, who had severe cognitive impairment and a history of physical aggression, was not provided with a care plan that included specific interventions for managing her behaviors until several months after admission. Despite frequent occurrences of behaviors such as yelling, refusal of medications, and combative actions, the facility did not document resident-specific approaches or evaluate the effectiveness of interventions. Interviews with facility staff revealed that the behavior management program was insufficient, with no resident-specific interventions being implemented. The staff attempted various redirection techniques, but these were largely ineffective. The facility's policy on behavioral health services emphasized person-centered care and non-pharmacological interventions, but these were not adequately reflected in Resident B's care plan or the staff's approach. The facility's documentation was lacking in terms of recording the approaches taken to manage Resident B's behaviors and the outcomes of these interventions. The Director of Nursing acknowledged that the charting did not reflect the interventions and approaches used. Additionally, the former Social Services Director noted that the facility's behavior management program did not appropriately address the needs of residents with behaviors, relying instead on pharmacological interventions without exploring non-pharmacological options.
Failure to Administer Narcotic Pain Medication per Physician Orders
Penalty
Summary
The facility failed to administer a narcotic pain medication according to physician orders for one resident, identified as Resident B, who was under review for pain management. Resident B's clinical record indicated multiple diagnoses, including senile degeneration of the brain, dementia with agitation, dementia with psychotic disturbance, and anxiety disorder. A physician order dated October 20, 2024, prescribed a 12 mcg fentanyl patch to be applied every three days, which was later updated on November 6, 2024, by a hospice note to increase the dosage to 25 mcg. A subsequent physician order on November 7, 2024, confirmed the application of a 25 mcg fentanyl patch every three days. However, on November 10, 2024, the controlled drug use record showed that both a 25 mcg and a 12 mcg fentanyl patch were administered, resulting in an incorrect total dose of 37 mcg, contrary to the physician's order of 25 mcg. This error was identified during an interview with the Director of Nursing on December 16, 2024, who confirmed that nursing staff were expected to follow physician orders for medication administration. The facility's policy on medication administration, provided by the DON, emphasized adherence to prescriber orders, including any specified time frames.
Failure to Ensure Resident Dignity and Respect
Penalty
Summary
The facility failed to ensure residents were treated with dignity and respect, as evidenced by multiple incidents involving residents' complaints about staff behavior and care. Resident N reported that CNAs would turn off her call light, promising to return but failing to do so, leaving her feeling neglected. Resident P recounted an incident where a nurse made an inappropriate comment when asked for assistance with personal care, questioning what Resident P did at home and expressing discomfort with the task. Resident 52 expressed feeling like a second-class citizen due to the lack of tablecloths in the health center compared to other parts of the campus. Resident B experienced long delays in receiving toileting assistance, with staff turning off the call light and not returning as promised, leading to feelings of being treated poorly. Resident K reported waiting a long time for incontinent care, and when she voiced her concerns, a CNA responded by prioritizing their break over the resident's needs. These incidents highlight a pattern of neglect and disrespect towards residents, violating their rights to dignity and self-determination as outlined in the facility's resident rights policy.
Failure to Address Resident Council Grievance on Dining Room Tablecloths
Penalty
Summary
The facility failed to promptly address a grievance raised by the resident council regarding the removal of tablecloths in the health center dining rooms. This issue was first noted in the resident council minutes from April 2024, where a resident expressed dissatisfaction with the absence of tablecloths. Despite the administrator's encouragement to adapt to the changes, the concern persisted, and by July 2024, the resident council reiterated their grievance, noting that tablecloths were still used in the assisted living and independent living dining rooms, but not in the health center. The council felt they were being treated differently and had not received any follow-up on their grievance, other than being informed that the new company had decided to stop using tablecloths. Interviews with facility staff revealed a lack of formal grievance documentation and follow-up. The administrator claimed there were no grievances from the resident council for the months of April, May, or June 2024. The Activity Director, who assisted with the resident council meetings, acknowledged hearing the residents' concerns but admitted she had never filled out grievance forms for general concerns raised by the council. The facility's policy on resident and family grievances, updated in March 2020, mandates that complaints and concerns expressed by the resident council should be promptly addressed by the department manager, with a follow-up response provided to the council. This policy was not adhered to in this instance, leading to the deficiency.
Failure to Address Resident Grievances Timely and Effectively
Penalty
Summary
The facility failed to address resident grievances in a timely and comprehensive manner, as evidenced by the lack of documentation and follow-up on grievances filed by residents. Resident N, who was cognitively intact and had a care plan addressing mood alterations, reported grievances about CNAs being rude and disrespectful. However, the grievance forms lacked confirmation of the grievances, dates of follow-up, and written notifications regarding actions taken. Additionally, there was no documentation of whether the grievances were confirmed or not, and Resident N did not always receive follow-up about her concerns. Resident P, also cognitively intact, filed grievances regarding an evening shift nurse's refusal to administer insulin correctly and a disagreement over blood pressure medications. Despite filing grievances, Resident P did not receive follow-up or resolution, and the grievance forms lacked confirmation of the grievances and dates of follow-up. The forms also did not contain information on whether the grievances were confirmed or not. Resident P expressed a preference for a different nurse but was told no other nurse was available, leading to reluctance in filing further grievances due to fear of retaliation. Resident R's family filed grievances concerning communication issues related to the resident's care and requests for an x-ray due to back pain. The grievance forms did not include confirmation of the grievances or follow-up dates. Additionally, the facility did not provide a means for residents to file grievances anonymously, as grievance forms were not readily available on the units without asking staff. The facility's grievance policy required written decisions and follow-up information, but these were not consistently provided, leading to deficiencies in addressing resident grievances.
Inadequate Fall Management and Documentation in LTC Facility
Penalty
Summary
The facility failed to ensure proper documentation and follow-up after fall incidents for several residents, leading to deficiencies in care. Resident E, who had dementia and a history of falls, experienced multiple falls without adequate post-fall assessments or updated care plans. Despite several incidents, including falls due to environmental hazards and poor supervision, the facility did not consistently complete incident reports or implement new interventions to prevent further falls. Resident E's care plan was outdated, and post-fall assessments were not conducted every shift for the required 72 hours. Resident C, diagnosed with congestive heart failure and dementia, also experienced multiple falls without proper documentation or intervention. The facility failed to complete post-fall assessments every shift for three days, and there was a lack of new interventions to prevent future falls. Despite Resident C's cognitive decline and increased dependency, the facility did not adequately address her fall risk, leading to repeated incidents. Other residents, including Residents F, M, and D, also experienced falls without proper follow-up. Resident F, with Alzheimer's disease, had falls that were not properly assessed or documented, and post-fall assessments were incomplete. Resident M, who had a stroke, experienced a fall during a transfer, but the facility did not conduct post-fall assessments as required. Resident D, with left-sided hemiplegia, had multiple falls without incident reports or updated care plans, and necessary equipment like a reacher was missing from his room.
Deficiencies in Kitchen Sanitation and Food Storage
Penalty
Summary
The facility failed to maintain a clean, sanitized, and well-organized kitchen environment, which led to several deficiencies. Observations revealed that staff did not wear beard restraints, which could lead to hair contamination in food. Additionally, the facility did not properly manage food storage, as expired items such as Jello cups and hot dogs were found in the refrigerator. The facility's policy requires that foods past their expiration date be discarded and that all food be stored to prevent contamination. Further deficiencies were noted in the operation of kitchen equipment and cleanliness. The dishwasher in kitchen 2 failed to reach the minimum required wash temperature of 150 degrees Fahrenheit, resulting in dirty silverware and plates. Despite attempts to repair the dishwasher, it remained out of order. Additionally, soiled rolling carts were observed in the food storage area, indicating a failure to follow the facility's sanitation policy, which requires that kitchenware and food-contact surfaces be cleaned and sanitized after each use.
Pest Control Deficiency in Kitchen
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of flying insects in a food storage area within one of the two kitchens. This deficiency potentially affected 97 out of 123 residents. During a tour of kitchen 1, conducted with the Kitchen Manager and Dining Service Director, tiny flying insects resembling gnats were observed in the air and on products in the storage area. A total of nine insects were counted in the immediate area. An interview with the Kitchen Manager confirmed that there should not be any flying insects in the kitchen or storage area.
Failure to Provide Appropriate Wheelchair for Resident
Penalty
Summary
The facility failed to provide a wheelchair that accommodated the height of a resident, identified as Resident D, who was 6 foot 8 inches tall and dependent on a wheelchair for mobility. Upon admission, Resident D did not have his own wheelchair, and the facility provided him with the largest available wheelchair, which was still too small. This resulted in discomfort and improper positioning, as observed on multiple occasions where Resident D's hips did not touch the back of the wheelchair seat, and his feet were on the floor with his left ankle turning inward. Resident D expressed that the wheelchair was uncomfortable and caused him pain, impacting his ability to sit upright and feed himself properly. The facility's therapy department had contacted an outside vendor for a specialty wheelchair shortly after Resident D's admission, but there were delays in obtaining a suitable chair. Despite follow-ups and inquiries about a sturdier, long-term solution, the facility had not yet received a quote for a more appropriate wheelchair by the time of the survey. The lack of timely provision of an appropriate wheelchair for Resident D, who had a history of traumatic brain injury and left-sided hemiplegia, contributed to the deficiency noted in the report.
Failure to Notify Resident's Representative of Fall
Penalty
Summary
The facility failed to notify a resident's representative of a fall event involving Resident F, who was cognitively impaired and had a diagnosis including Alzheimer's disease. The resident had a care plan indicating a potential for falls due to deconditioning gait/balance problems and being unaware of safety needs. On a specific date, Resident F was found sitting on the floor in the Aspen activity room, having reportedly gotten up from her wheelchair to sit on the floor. The resident denied falling and reported no pain, and the incident was not initially considered a fall by the nurse who observed the situation. Despite the facility's policy requiring immediate notification of a resident's legal representative or an interested family member in the event of an accident with potential for injury, the clinical record did not include documentation of notification to Resident F's representative regarding the fall. The Director of Nursing confirmed that the nurse did not consider the incident a fall, which led to the lack of notification. This oversight was identified during a complaint investigation, highlighting a deficiency in the facility's adherence to its notification policy.
Failure to Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an alleged incident of abuse involving a resident, identified as Resident N, to the Indiana Department of Health (IDOH) as required. Resident N, who was cognitively intact and had diagnoses including an unspecified injury of the cervical spinal cord and diabetes, reported a grievance on a specific date. The grievance involved a CNA telling Resident N not to drink as much water to avoid needing frequent changes, which the Director of Nursing (DON) considered abusive. Despite this, there was no documentation or notes from an investigation into the grievance, and the nursing staff denied the allegation. The Social Service Assistant (SSA) who documented the grievance could not recall if Resident N provided names of the staff involved, and Resident N did not have a history of making false allegations. The Administrator confirmed that the grievance was not reported to IDOH, and there was no report or file for the incident. The facility's abuse policy, which mandates immediate or within 24-hour reporting of suspected or known abuse to IDOH, was not followed in this case.
Failure to Administer Medications and Schedule Appointments Appropriately
Penalty
Summary
The facility failed to ensure that vital signs were obtained prior to administering a medication with specific parameters for Resident 32. The resident, diagnosed with chronic kidney disease, congestive heart failure, and diabetes mellitus, was prescribed torsemide, a diuretic medication, with instructions to hold the medication if the systolic blood pressure was less than 100. However, the electronic medication administration record did not indicate that blood pressure was measured before administering the medication from July 2 to July 17, 2024. The facility's policy on measuring blood pressure was not adhered to, as the vital signs were recorded in the evening rather than before medication administration. For Resident 80, the facility did not follow up on a urinalysis ordered by a nurse practitioner due to the resident's dementia, depression, and anxiety disorder. Despite multiple physician orders for a urinalysis with culture and sensitivity, the urine specimen was not collected due to the resident's combative behavior. There were no laboratory results or progress notes indicating follow-up actions regarding the uncollected urinalysis, despite the nurse practitioner's note on November 30, 2023, ordering the test again. The facility also failed to ensure that Residents F and N attended their neurology appointments. Resident F, diagnosed with Alzheimer's disease, was supposed to have a neurology consultation, but due to a scheduling error, the appointment was not confirmed, and transportation was not arranged. Similarly, Resident N missed a neurology appointment due to transportation issues and staff not having the resident ready in time. The facility's transportation services policy was not followed, leading to missed appointments for both residents.
Failure to Document Oxygen Order and Maintain Equipment
Penalty
Summary
The facility failed to ensure that a resident on continuous oxygen therapy had a physician's order for the oxygen documented in the electronic health record (EHR) and did not provide the necessary care and services by neglecting to change the humidification container as per policy. During an observation, it was noted that the humidification container for the resident's oxygen therapy was dated over a month prior, and the water inside was cloudy and not bubbling, indicating improper function. The resident, who was on hospice care, had diagnoses including congestive heart failure, dementia, chronic bronchitis, and anxiety disorder. The facility's staff did not enter the hospice provider's handwritten order for continuous oxygen into the EHR, as confirmed by an LPN. Additionally, the resident's care plan did not include a plan for the use of continuous oxygen, nor was it noted in the Significant Change Minimum Data Set (MDS) assessment. The Assistant Director of Nursing (ADON) confirmed that the care plan should have included the use of continuous oxygen and that the facility's staff, not the hospice company, were responsible for the care services related to oxygen use. The facility's Oxygen Administration policy outlined the need for a physician's order and proper equipment maintenance, which was not adhered to in this case.
Failure to Administer Pain Patch as Ordered
Penalty
Summary
The facility failed to administer a pain-relieving patch as ordered for a resident, identified as Resident K, who was diagnosed with low back pain. The care plan for Resident K indicated that medications should be administered as ordered, including a physician's order for an Aspercreme lidocaine patch to be applied to the lower back for 12 hours daily. The Treatment Administration Record (TAR) documented that the patch was applied and removed as ordered from July 9 through July 17, except for the removal on July 17. During an interview on July 10, Resident K reported not receiving the pain patch as ordered at times, and at the time of the interview, she did not have a patch on her lower back. On July 17, Resident K indicated she had not received a new patch that day, and the patch from July 16 was still in place. Registered Nurse (RN) 6 confirmed that she had not applied the scheduled 8:00 a.m. patch on July 17 due to time constraints and subsequently applied a new patch after the interview.
Failure to Conduct Pre and Post Dialysis Assessments
Penalty
Summary
The facility failed to conduct pre and post assessments for a resident receiving dialysis, as required by their dialysis policy. Resident 176, who was admitted with a diagnosis of chronic kidney disease and required hemodialysis due to renal failure, did not have documented pre or post assessments on two dialysis days. The resident was scheduled to receive dialysis every Monday, Wednesday, and Friday, but the clinical record lacked assessments for the sessions on Friday, 7/12/24, and Monday, 7/15/24. During an interview, the Director of Nursing confirmed that staff should have been conducting these assessments. The facility's dialysis policy mandates providing necessary care and treatment consistent with professional standards, physician orders, and the resident's care plan, which was not adhered to in this case.
Expired Medication Found in Facility's Medication Cart
Penalty
Summary
The facility failed to ensure that medications stored in the medication carts were not expired, as observed during a review of the facility's medication storage rooms and carts. Specifically, a multi-dose vial of Humalog insulin was found in a medication cart without an expiration date, despite being opened on a previous date. The insulin was intended for Resident P, who has a diagnosis of type 2 diabetes mellitus and requires insulin administration based on a sliding scale for blood sugar readings. During an interview, an LPN acknowledged that all opened insulin vials should have an open date and an expiration date, and that they expire 28 days after opening. However, the LPN was unable to provide the vial from which the insulin was administered to Resident P at 7:00 a.m. on the day of the observation, despite searching the medication cart and room. The facility's policy requires that multi-dose vials be dated and discarded within 28 days of opening, and that outdated medications be returned or destroyed as instructed by the dispensing pharmacy.
Deficiency in Providing Palatable Grilled Cheese Sandwiches
Penalty
Summary
The facility failed to provide palatable grilled cheese sandwiches to two residents, both of whom were cognitively intact. Resident 62 reported receiving a sandwich that consisted of two pieces of toast with a cold slice of cheese in the middle, which was not appetizing as the cheese was not melted nor grilled. Similarly, Resident 93 described receiving a sandwich that was microwaved, resulting in a hard texture, akin to a hockey puck. These incidents were reported during interviews conducted with the residents. The issue was discussed in a Dining Committee Meeting, where feedback regarding the always available menu was addressed. The Director of Dietary Service confirmed that the previous procedure for making grilled cheese sandwiches involved using a toaster rather than grilling them. However, with changes implemented by a new dietary company, the procedure was altered to use a pan or grill instead of a toaster. This change was intended to improve the quality of the sandwiches served to residents.
Infection Control Breach During Medication Administration
Penalty
Summary
The facility failed to maintain proper infection control practices during medication administration, as observed in two separate instances. In the first instance, a Qualified Medication Aide (QMA) was observed preparing medications for a resident. During the process, the QMA dropped pills onto the medication cart and picked them up with bare hands before placing them into the medication cup. This occurred with multiple medications, including Senna, glycopyrrolate, and pyridostigmine, all of which were administered to the resident without following proper hygiene protocols. In the second instance, a Registered Nurse (RN) used a personal wrist blood pressure device on multiple residents without cleaning or disinfecting it between uses. The RN used the device on four different residents consecutively, admitting to usually cleaning it between every other resident. The RN was unsure of the cleaning instructions for the device, which had been in her possession for many years. The facility's policy on medication administration procedures, which was provided by the Administrator, clearly states that care should be taken to avoid touching tablets or capsules unless wearing gloves, indicating a breach in protocol.
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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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