Willows Of Greensburg
Inspection history, citations, penalties and survey trends for this long-term care facility in Greensburg, Indiana.
- Location
- 410 Park Rd, Greensburg, Indiana 47240
- CMS Provider Number
- 155210
- Inspections on file
- 27
- Latest survey
- August 14, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Willows Of Greensburg during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple medical conditions did not receive appropriate urinary catheter care when a nurse inserted a catheter but failed to document reassessment after no urine return was observed. Blood was later found in the catheter tubing and bag, and hospital imaging revealed the catheter balloon was inflated in the penile urethra rather than the bladder.
A resident with severe cognitive impairment and multiple diagnoses did not receive a prescribed cognition medication for several weeks after an RN accidentally discontinued the order. The error was discovered when the family notified the facility, revealing that the medication had not been administered as required by the physician's order and facility policy.
A resident with severe cognitive impairment and multiple medical conditions experienced an unwitnessed fall. Staff delayed both the documentation of the incident and the initiation of neurological assessments, contrary to facility policy requiring immediate post-fall evaluation and documentation. The required risk management form and neuro checks were not completed promptly after the event.
The facility did not consistently implement or develop required care plan interventions for several residents, including missing or improperly placed fall prevention measures such as call light signage, non-skid strips, clip alarms, and wheelchair safety features, as well as lacking care plans for residents with PTSD. These deficiencies were confirmed through observations, record reviews, and staff interviews.
A resident with severe cognitive impairment and multiple diagnoses had both a signed DNR and POST form indicating DNR status, but also had a current physician's order for CPR. Staff interviews confirmed that the facility's process should ensure consistency between advance directives and physician orders, but this was not followed, resulting in conflicting documentation of the resident's code status.
A resident with hypotension and other medical conditions received midodrine despite physician orders to hold the medication when systolic blood pressure was above 140. The medication was administered multiple times when the resident's blood pressure exceeded this threshold, contrary to both the physician's order and facility policy. An LPN confirmed that such medications should be held and documented appropriately.
A resident with severe cognitive impairment and multiple medical conditions had numerous undocumented meal consumption entries for breakfast and lunch over several days. A CNA confirmed that meal intake should be recorded daily, and facility policy requires this documentation in the medical record.
The facility did not have an RN on duty for eight consecutive hours on two days during the review period. The DON confirmed that only one RN worked night shifts on those days, and their hours did not fulfill the daily requirement. The facility lacked a specific policy for RN coverage, relying instead on State and Federal regulations.
A resident with multiple chronic conditions did not have their increased Fluoxetine dose correctly transcribed after returning from a hospital stay, resulting in the administration of a lower dose than prescribed for several months. Nursing staff and the DON confirmed the error occurred during the order transcription process, contrary to facility policy requiring accurate medication order transcription.
Surveyors found that the medication refrigerator contained opened vials of TB serum that were not labeled with the date they were first used. An LPN confirmed that the vials should have been dated upon opening, and facility policy requires this practice. The issue was identified during a review of the medication room and associated records.
A resident with an indwelling urinary catheter and multiple medical conditions experienced a significant delay in obtaining a urinalysis with culture and sensitivity after a physician's order was placed. Despite repeated attempts by the lab to collect the sample, it was not available on several visits, resulting in cancellation of the original order and a delay in both laboratory results and initiation of antibiotic treatment. Facility policy requires timely laboratory services, which was not met in this case.
Three residents were found to have lapses in infection control, including a resident whose PICC line dressing was not changed as ordered or per facility policy, and two residents with indwelling urinary catheters whose drainage bags or tubing were repeatedly observed touching the floor. Staff acknowledged these practices did not meet facility policy for catheter care and infection prevention.
Survey results were not made easily accessible for residents and visitors on multiple days, with no clear posting near the entrance and missing documents in the designated location. The Administrator acknowledged that survey results should be available without needing to ask staff, in accordance with facility policy.
A resident experienced an unwitnessed fall, and the facility failed to document or report the incident, leading to delayed medical intervention. The resident, who was severely cognitively impaired, was later found to have a fractured hip after being sent to the hospital. The LPN involved did not follow the facility's fall management policy, resulting in a deficiency.
A resident's fall was not documented or reported by an LPN, leading to a delay in treatment for a fractured hip. The resident, who was severely cognitively impaired, showed signs of distress but the incident was not recorded in medical records. The facility's policy on fall management was not followed, resulting in a lack of timely care.
A facility failed to report an abuse allegation within the required timeframe. A staff member was observed engaging in inappropriate behavior with a resident, who has a history of inappropriate touching and severely impaired cognition. Despite the facility's policy requiring immediate reporting, the incident was not reported to the state in a timely manner.
A facility failed to accurately complete MDS assessments for a resident with behavioral symptoms. Despite observations and staff notes indicating aggressive behaviors, such as grabbing and hitting, these were not documented in the MDS assessments. The resident's care plan noted manipulative behaviors but lacked updated interventions, and behavior logs were incomplete.
A facility failed to update the behavior plan for a resident with severe cognitive impairment and ongoing aggressive behaviors, including inappropriate touching and physical aggression. Despite existing care plans, interventions were not revised to address persistent issues, leading to multiple incidents requiring staff intervention. Facility policies on behavior management and care plans were not effectively implemented.
A facility failed to monitor and address a resident's aggressive and inappropriate behaviors, which included grabbing and hitting staff, particularly targeting female staff members. The behavior log and clinical records lacked consistent documentation of these incidents, and the care plans in place were ineffective in managing the resident's behaviors. Staff interviews revealed ongoing challenges in handling the resident's conduct, highlighting a deficiency in the facility's behavioral health care services.
The facility failed to follow guidelines for insulin pen usage and physician's orders for blood pressure medication. A nurse did not cleanse insulin pens before use, and another resident's blood pressure was not documented before administering lisinopril, contrary to orders.
The facility failed to provide adequate education to a resident regarding urinary catheter care and proper placement of the catheter bag. The resident consistently placed the catheter bag improperly, and there was no documentation of education or a care plan for the resident's self-care practices. This deficiency was identified during a survey, highlighting the facility's failure to ensure proper catheter care and education, potentially contributing to the resident's recurrent UTIs.
The facility failed to follow infection control guidelines for a resident with an indwelling urinary catheter. The catheter drainage bag was observed resting on the floor or in a plastic wash basin on multiple occasions. The DON acknowledged the lack of a specific policy on catheter bag placement, although staff were aware that the bags should not touch the floor.
Failure to Provide Appropriate Urinary Catheter Care
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple diagnoses, including end-stage renal disease and Alzheimer's disease, was not provided with appropriate urinary catheter care. After a nurse inserted a 16 French indwelling urinary catheter, there was no urine return observed. Despite this, the clinical record did not show that the catheter placement was reassessed prior to the discovery of blood in the catheter tubing and bag. The facility's policy required that the catheter be inserted until urine flow was observed and not to force entry if resistance was met. Later, a medical assistant reported the presence of bright red blood in the resident's catheter bag, prompting emergency transport to the hospital. Imaging at the hospital revealed that the catheter balloon had been inflated within the penile urethra, rather than the bladder. The lack of documentation regarding reassessment of catheter placement after the absence of urine return contributed to the deficiency in providing appropriate catheter care.
Failure to Administer Ordered Medication Due to Accidental Discontinuation
Penalty
Summary
A resident with severe cognitive impairment and diagnoses including non-Alzheimer's dementia, atrial fibrillation, and hypertension had a physician's order for Memantine 5 mg twice daily. The order was discontinued on 7/7/25 with a note referencing medications from home, but the resident did not receive the prescribed Memantine from 7/8/25 through 7/28/25. Documentation shows that the family notified the facility of the discontinuation, and the nurse confirmed the medication was stopped in error. The medication was not administered for approximately three weeks due to this accidental discontinuation, despite the physician's order requiring its administration. Facility policy requires that medications be provided in accordance with physician orders, which was not followed in this instance.
Failure to Timely Document Fall and Initiate Neurological Assessments
Penalty
Summary
The facility failed to document a fall and initiate neurological assessments in a timely manner for a resident who was severely cognitively impaired and had multiple diagnoses, including stroke, heart failure, hypertension, dementia, anxiety, and depression. The resident, who used a walker and required staff assistance for ADLs, experienced an unwitnessed fall during the night shift. After the fall, the CNA alerted the nurse, who checked the resident's vital signs and assisted her back to bed. The resident subsequently complained of pain multiple times, but the nurse only checked vital signs and provided medication, without immediate documentation or a thorough assessment. The nurse did not complete the required risk management form for the unwitnessed fall until the following day, and the neurological assessment was not started until over an hour after the incident. Facility policy required immediate assessment and documentation following any fall, including a head-to-toe assessment, pain assessment, and timely initiation of neurological checks. The delay in both documentation and neurological assessment constituted a failure to follow established protocols for post-fall management.
Failure to Implement and Develop Required Care Plan Interventions for Falls and PTSD
Penalty
Summary
The facility failed to ensure that care planned interventions were implemented and that comprehensive care plans were developed for residents with specific needs, including fall prevention and management of PTSD. Multiple residents with a history of falls did not have the required interventions in place as outlined in their care plans. For example, one resident with Parkinson's disease and dementia, who had experienced multiple falls, did not have the prescribed call light signage or properly placed non-skid strips in their room, despite these being documented interventions following previous falls. Observations confirmed the absence or incorrect placement of these items during several checks, and staff interviews acknowledged the deficiencies. Another resident with severe cognitive impairment and a history of falls was supposed to have a clip alarm in use as a fall intervention. However, during observation, the alarm was attached to the resident's wheelchair rather than being in use while the resident was in bed, as required. Staff interviews revealed that hospice staff had failed to move the alarm after assisting the resident, and education on this intervention had previously been provided. Similarly, a third resident with severe cognitive impairment and a recent fall was supposed to have non-skid strips in front of their recliner, but repeated observations showed these strips were not present, and staff confirmed the intervention was missing. Additionally, the facility did not develop care plans for residents diagnosed with PTSD, as required. Two residents with PTSD lacked any care plan or interventions addressing this diagnosis, despite facility policy and staff acknowledgment that such care plans should be in place. Other deficiencies included the absence of anti roll back tippers and bright colored tape on a resident's wheelchair, both of which were documented fall prevention interventions. These failures were identified through record review, direct observation, and staff interviews, demonstrating a pattern of not following or implementing care planned interventions for multiple residents.
Failure to Document and Implement Advance Directive Consistently
Penalty
Summary
The facility failed to properly document and implement an appropriate advance directive for one resident. The resident, who was severely cognitively impaired and had diagnoses including hypertension, diabetes, and non-Alzheimer's dementia, had both a signed Out of Hospital Do Not Resuscitate (DNR) Declaration and Order, as well as a Physician Orders for Scope of Treatment (POST) form indicating DNR status. Despite these documents, the resident's clinical record contained a current, open-ended physician's order for Cardiopulmonary Resuscitation (CPR). Interviews with staff revealed that the process for completing and transcribing POST forms and DNR orders involved both nursing and social services staff, with an expectation that the POST form and physician's orders would match. The Director of Nursing confirmed that if a resident had an Out of Hospital DNR, there should not be a physician's order for CPR. The facility's policy required adherence to residents' rights to formulate advance directives and procedures to communicate code status, but this was not followed in this instance.
Failure to Follow Hold Parameters for Cardiac Medication Administration
Penalty
Summary
The facility failed to follow physician orders regarding the administration of midodrine, a medication prescribed for hypotension, for one resident. The physician's order specified that the medication should be held if the resident's systolic blood pressure was greater than 140. Despite this, the resident's electronic medication administration record showed that the medication was administered multiple times when the systolic blood pressure exceeded the prescribed threshold, with readings ranging from 141 to 180. These administrations occurred on several dates over a two-month period. The resident involved was cognitively intact and had diagnoses including anemia, orthostatic hypotension, and disorders of the autonomic nervous system. During an interview, an LPN confirmed that medications with hold parameters should not be given if vital signs are outside the specified range and should be documented as held with a reason. The facility's medication administration policy also required staff to obtain and record vital signs and to hold medications when vital signs were outside physician-prescribed parameters.
Failure to Document Meal Consumption for Cognitively Impaired Resident
Penalty
Summary
The facility failed to document meal consumption for a resident who was severely cognitively impaired and had multiple diagnoses, including dementia, hypertension, diabetes, stroke, anxiety, and depression. Review of the resident's clinical record revealed numerous instances where meal consumption values were missing for both breakfast and lunch across several dates. During an interview, a CNA confirmed that meal consumption should be recorded daily in the computer at the end of each shift. The facility's current policy also requires staff to document meal consumption in the medical record.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide a Registered Nurse (RN) on duty for eight consecutive hours a day for two of the seven days reviewed. According to the as-worked nursing schedule, there was no RN present for the required eight consecutive hours on both Saturday and Sunday during the review period. The Director of Nursing (DON) confirmed that only one RN worked the night shift on those days, and their hours did not meet the eight consecutive hour requirement for each day. Additionally, the DON stated that the facility did not have a specific policy for RN coverage and instead followed State and Federal regulations.
Failure to Accurately Transcribe Medication Orders on Admission
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including diabetes, anemia, heart failure, hypertension, seizure disorder, non-Alzheimer's dementia, and depression, did not have their medication orders correctly transcribed upon return from a hospital stay. The resident's psychiatric provider had increased the dose of Fluoxetine to 80 mg daily due to increased behavioral symptoms, and the hospital discharge instructions also specified this dosage. However, upon readmission, the facility transcribed the order as 40 mg daily instead of the intended 80 mg. As a result, the resident received only 40 mg of Fluoxetine daily from the time of readmission through several months, as documented in the electronic medication administration records. Interviews with nursing staff and the DON confirmed that the error occurred during the transcription process when the resident returned from the hospital, and the facility's policy required accurate transcription and clarification of medication orders.
Failure to Date Opened TB Serum Vials in Medication Room
Penalty
Summary
Surveyors observed that the medication refrigerator in the Station 4 medication room contained multiple vials of TB (tuberculin) serum that were not labeled with the date they were opened. Specifically, an opened vial of TB serum was found in a box received from the pharmacy, and another opened vial was found in a clear plastic bag with two boxes of TB serum, both lacking an 'opened on' date. The LPN present confirmed that the TB serum should have been dated when first used and acknowledged that several residents had been admitted since the medication was delivered. Review of the TB serum package insert and facility policy confirmed that opened vials must be dated and discarded after 30 days, but this procedure was not followed.
Delay in Obtaining Urinalysis for Resident with Indwelling Catheter
Penalty
Summary
The facility failed to obtain a urinalysis (UA) in a timely manner for one resident with multiple diagnoses, including anemia, orthostatic hypotension, renal insufficiency, neurogenic bladder, and disorders of the autonomic nervous system. The resident, who had an indwelling urinary catheter and was cognitively intact, had a physician's order for a UA with culture and sensitivity. Despite this order, the urine sample was not collected until several days later. Health status notes indicated the order was placed, but the sample remained pending for several days before collection. Interviews revealed that the laboratory made multiple attempts to collect the sample, but it was not available on three separate visits, leading to the cancellation of the original order. A nurse from the facility signed off on the cancellation. A new sample was eventually collected and processed, but this resulted in a significant delay in obtaining laboratory results and initiating antibiotic treatment for a urinary tract infection. The facility's policy requires timely provision of laboratory services, but this was not followed in this instance.
Failure to Follow Infection Control Guidelines for PICC Lines and Urinary Catheters
Penalty
Summary
The facility failed to follow infection control guidelines for three residents with either a peripherally inserted central catheter (PICC) line or indwelling urinary catheters. One resident with a PICC line had a physician's order and facility policy requiring the dressing to be changed every seven days, but the dressing was not changed for at least 13 days after placement. The resident and an LPN confirmed that the dressing had not been changed since the initial placement, despite the policy and order. Two other residents with indwelling urinary catheters were repeatedly observed with their catheter drainage bags or tubing touching or resting on the floor, both while in bed and in a wheelchair. Staff interviews confirmed that catheter bags should not touch the floor, and one CNA noted that the dignity sleeves used were too large, causing the bags to slide out and touch the floor. Facility policy required appropriate catheter care and maintenance of dignity and privacy, but these standards were not met during multiple observations.
Survey Results Not Readily Accessible to Residents and Visitors
Penalty
Summary
The facility failed to ensure that State Survey Results were readily available for residents and visitors to view on three out of five days during the survey period. Observations revealed that there was no posting near the front entrance indicating the location of the survey results, and on one occasion, a sign in the hallway by the therapy department directed individuals to a wall pocket where the results were supposed to be, but the documents were not present. The Administrator confirmed that the survey results should be accessible without requiring visitors to ask staff. The facility's policy states that a readable copy of the most recent survey results should be maintained in a binder in the main lobby and be readily accessible without staff assistance.
Failure to Document and Respond to Resident Fall
Penalty
Summary
The facility failed to provide timely and appropriate care to a resident following an unwitnessed fall. On the morning of 12/11/24, a CNA observed the resident stand up from his recliner and subsequently found him on the floor. The CNA and an LPN assisted the resident back to bed, but the LPN did not document the fall or report it to other staff members. The resident, who was severely cognitively impaired and had multiple diagnoses including dementia and COPD, did not initially express pain but was later observed rubbing his thigh and not acting like himself. The resident's condition worsened over the next day, with swelling observed in his right leg and hip. The NP assessed the resident and ordered monitoring and elevation of the leg. However, the resident's condition continued to deteriorate, leading to a STAT X-ray order due to concerns about swelling and leg shortening. Before the X-ray could be performed, the resident's respiratory status worsened, and he was sent to the hospital, where a fracture was confirmed. The facility's policy required immediate assessment and documentation of falls, which was not followed in this case. The LPN involved denied knowledge of the fall, and the incident was not documented in the resident's record. The DON confirmed that the LPN was no longer employed at the facility. The lack of documentation and communication regarding the fall led to a delay in appropriate medical intervention for the resident.
Failure to Document and Report Resident Fall
Penalty
Summary
The facility failed to document and report a resident's fall, which resulted in a delay in appropriate care and treatment. A Certified Nurse Aide (CNA) witnessed the resident stand up and subsequently fall, but the incident was not documented or reported by the Licensed Practical Nurse (LPN) who assisted the resident afterward. The resident, who was severely cognitively impaired and had multiple diagnoses including dementia and heart failure, did not initially show signs of pain but later exhibited symptoms such as rubbing his thigh and not eating. The Director of Nursing (DON) discovered the fall only after the resident was sent to the hospital with a fractured right hip. The resident's leg was noted to be swollen by the night shift nurse, and a Nurse Practitioner (NP) assessed the resident the following day, advising monitoring and elevation of the leg. However, the resident's condition worsened, leading to a hospital transfer where the fracture was diagnosed. The LPN involved denied knowledge of the fall, and the incident was not recorded in the resident's medical records. The facility's policy required immediate assessment and documentation of falls, including notifying medical staff and family, and updating care plans. However, these procedures were not followed, as evidenced by the lack of documentation and communication regarding the fall. The failure to adhere to these protocols resulted in a delay in identifying and treating the resident's injury.
Failure to Report Abuse Allegation Timely
Penalty
Summary
The facility failed to report an allegation of abuse to the Indiana Department of Health within the required two-hour timeframe. The incident involved a staff member, identified as Staff Member 11, who was observed by multiple staff members engaging in inappropriate behavior with a resident, referred to as Resident F. Staff members reported witnessing Staff Member 11 lying in bed with Resident F, allowing the resident to fondle her breasts and grab her buttocks without redirection. Despite these observations, the facility administrator did not report the allegations to the state prior to an internal investigation conducted by a corporate staff member. Resident F, who has a history of inappropriate touching and sexual gestures towards female staff, was noted to have severely impaired cognition due to conditions such as aphasia, hypertension, depression, and stroke. The resident's care plan included interventions to address these behaviors, such as stopping care immediately if inappropriate behavior occurred and preserving the resident's dignity and safety. However, the staff member involved did not adhere to these interventions, as evidenced by the lack of redirection and inappropriate interactions with the resident. The facility's policy mandates immediate reporting of such incidents, but this protocol was not followed, resulting in a deficiency.
Inaccurate MDS Assessment for Resident's Behavioral Symptoms
Penalty
Summary
The facility failed to ensure accurate completion of the Minimum Data Set (MDS) assessments for a resident, identified as Resident F, particularly concerning behavioral symptoms. During an observation, Resident F was seen punching the side of his wheelchair, and interviews with the Director of Nursing revealed that the resident had a history of grabbing behaviors. However, the Quarterly MDS assessments dated 06/06/24 and 08/30/24 did not document any behaviors such as hitting, kicking, or grabbing, despite evidence from behavior logs and staff notes indicating otherwise. The behavior logs showed that Resident F exhibited grabbing behaviors on multiple occasions between May 30, 2024, and June 6, 2024, but these were not reflected in the MDS assessments. Additionally, incidents on 08/24/24 and 08/27/24, where the resident displayed aggressive behaviors, were not documented in the behavior log. The resident's care plan, initiated on 5/24/24, noted manipulative behaviors but lacked updated interventions for ongoing behaviors. The facility did not provide a policy but used the Resident Assessment Instrument (RAI) as a guide for MDS assessments.
Failure to Update Behavior Plan for Resident with Aggressive Behaviors
Penalty
Summary
The facility failed to revise the behavior plan of care for Resident F, who exhibited ongoing inappropriate and aggressive behaviors. Resident F, with severe cognitive impairment and diagnoses including aphasia, hypertension, depression, and stroke, had a care plan initiated in April 2024 addressing sexual gestures and inappropriate touching, and another in May 2024 for manipulative behaviors. Despite these plans, the interventions were not updated to address the resident's persistent behaviors, such as hitting the wheelchair, grabbing staff, and causing a skin tear during a shower. Multiple incidents were documented where Resident F displayed aggressive and inappropriate behaviors, including an event where the resident was uncooperative on a facility bus, leading to damage and requiring staff intervention. Other notes indicated increased agitation, restlessness, and physical aggression towards staff, with ineffective distraction methods. Staff interviews confirmed the resident's persistent inappropriate behavior, such as grabbing female staff, which was not mitigated by existing interventions. The facility's policies on behavior management and comprehensive care plans were not effectively implemented, as the care plans lacked updated interventions for the resident's ongoing behaviors.
Failure to Address Resident's Aggressive and Inappropriate Behaviors
Penalty
Summary
The facility failed to adequately monitor, document, and address the behavioral health needs of Resident F, who exhibited aggressive and inappropriate behaviors. During observations and interviews, it was noted that Resident F frequently engaged in grabbing and hitting behaviors, particularly targeting female staff members. These behaviors included grabbing at staff's breasts and other private areas, causing physical harm such as dislocated thumbs and ripped clothing. Despite these incidents, the facility's documentation and interventions were insufficient, as evidenced by the lack of effective strategies to manage the resident's behaviors. The clinical records and behavior logs for Resident F revealed a pattern of aggressive and sexually inappropriate behaviors that were not consistently documented or addressed. The behavior log failed to record several incidents of aggression and inappropriate conduct, indicating a gap in the facility's monitoring and documentation processes. Additionally, the care plans in place for Resident F included interventions that were not effective in managing his behaviors, such as redirecting or stopping care, which did not prevent further incidents. Interviews with staff members highlighted the challenges they faced in managing Resident F's behaviors, with reports of physical aggression and inappropriate touching being common. The facility's policy on behavior management required tracking and documentation of ongoing behaviors, but this was not consistently followed. The lack of social service follow-up and revised interventions further contributed to the deficiency, as the facility did not adequately address the resident's behavioral health needs, leading to repeated incidents of aggression and inappropriate conduct.
Failure to Follow Insulin Pen Guidelines and Physician's Orders for Blood Pressure Medication
Penalty
Summary
The facility failed to follow manufacturer's guidelines related to insulin pen usage and physician's orders for blood pressure medication administration. During an observation, a nurse administered insulin to a resident without cleansing the rubber seals of the insulin pens with an alcohol wipe before attaching the needles, contrary to the facility's policy. The resident, who was moderately cognitively impaired with diagnoses including diabetes and stroke, received insulin without proper priming and cleansing procedures as per the manufacturer's guidelines and facility policy. The nurse admitted to not following the correct procedure during an interview after the medication administration. Additionally, the facility did not adhere to physician's orders for another resident who was severely cognitively impaired with diagnoses including stroke, hypertension, and diabetes. The resident's physician had ordered that a blood pressure medication, lisinopril, be held if the resident's systolic blood pressure was less than 110. However, the resident's electronic medication administration records showed that the medication was administered daily without documenting the resident's blood pressure prior to administration for 52 out of 69 days reviewed. A Qualified Medication Aide confirmed that vital signs should be checked and documented before administering medications with hold parameters, as per the facility's policy.
Failure to Provide Adequate Urinary Catheter Care Education
Penalty
Summary
The facility failed to provide adequate education to a resident regarding urinary catheter care and the proper placement of the urinary catheter bag. Observations revealed that the resident consistently placed the catheter bag on the side of her wheelchair under the armrest, above her waist, which is not the recommended placement. Interviews with the resident and staff confirmed that the resident performed her own catheter care and preferred the bag's placement for easier access. However, there was no documentation of education provided to the resident about the risks associated with improper catheter bag placement. The Director of Nursing (DON) admitted that education was usually given verbally and not documented, and there was no care plan for the resident's self-catheter care and bag placement. The resident's clinical record indicated a history of urinary tract infections (UTIs) and issues with catheter leakage and sediment. Despite physician orders for staff to provide Foley catheter care every shift, the resident's preference for self-care and improper bag placement were not adequately addressed or documented. The facility's policy on catheter care was not followed, as there was no evidence of documented education or a care plan for the resident's self-care practices. This deficiency was identified during a survey, highlighting the facility's failure to ensure proper catheter care and education for the resident, potentially contributing to the resident's recurrent UTIs.
Failure to Follow Infection Control Guidelines for Urinary Catheters
Penalty
Summary
The facility failed to follow infection control guidelines related to the management of indwelling urinary catheters for Resident 51. On multiple occasions, the resident's catheter drainage bag was observed either resting directly on the floor or in a plastic wash basin on the floor. Specifically, on 05/23/24, the drainage bag was in a dignity pouch but was hanging from the wheelchair with the bottom of the pouch resting on the dining room floor. On 05/24/24, the drainage bag was not in a dignity pouch and was resting directly on the floor. On 05/28/24, the drainage bag and pouch were laying in a plastic wash basin on the floor. On 05/30/24, the drainage bag was observed hanging out of the dignity pouch and resting on the floor mat, which was corrected by CNA 2 upon observation. The resident's medical history included Parkinson's disease, dementia, diabetes, BPH, and a history of bladder cancer, and he had an open-ended order for an indwelling urinary catheter due to obstructive uropathy. During an interview, the DON indicated that the facility did not have a specific policy on catheter bag placement, but staff were aware that catheter bags should not touch the floor. Despite this knowledge, the observations indicated a failure to consistently follow infection control guidelines, leading to the deficiency noted in the report.
Latest citations in Indiana
Surveyors observed that dietary staff repeatedly worked in kitchen and meal service areas with uncovered facial hair, despite facility policy and state sanitation requirements mandating effective hair restraints. Two dietary aides with short beards or mustaches were seen walking through food preparation areas, taking food temperatures, handling food, and plating meals at steamtables in dining rooms without any facial hair coverings, while the current policy required all hair, including facial hair, to be restrained to prevent contamination.
The facility failed to consistently provide and document required bed-hold policy notices when several residents were transferred to the hospital. In multiple cases, residents with dementia, psychotic disorders, COPD, chronic respiratory failure, altered mental status, and cerebral infarction were sent out for acute changes in condition, and while transfer notes reflected physician and family notifications, they lacked documentation that the bed-hold policy was discussed with the resident or responsible party. Notices of Transfer or Discharge often indicated a copy of the bed-hold policy was sent with the resident, but the records did not show signed and dated acknowledgment by the resident or appropriate representative, including in situations where a resident had moderate cognitive impairment, short-term memory issues, or a documented need for a proxy and a financial POA authorizing an agent for health care decisions.
Surveyors found that the facility failed to provide trauma‑informed and culturally competent care by not incorporating two residents’ extensive trauma histories and specific behavioral triggers into their care plans. One resident with documented homelessness, polysubstance abuse, severe accidents with multiple fractures, viral encephalitis with coma, physical and sexual abuse, loss of family contact, and a past suicide attempt had multiple behavior‑focused care plans that referenced identifying triggers but listed none and did not mention their physical, sexual, medical, or psychosocial trauma. Another resident with TBI from being struck by a truck, an 11‑month coma, long‑term state hospital residence, alleged shooting of a parent, and diagnoses including intermittent explosive disorder and borderline personality disorder had a PASRR identifying a specific trigger and notes of inappropriate sexual behavior, yet their care plans omitted these traumatic events, the identified trigger, and the sexual behavior. Staff interviews confirmed that residents were screened for trauma, but the trauma histories and triggers were not reflected in the individualized plans of care.
A resident with schizophrenia, post‑stroke hemiparesis, and mild cognitive impairment expressed feeling down and wanting to kill himself, but staff did not document asking about a specific plan, did not notify the physician or psychiatric NP as expected, and did not develop or update a care plan addressing depression or suicidal ideation. The SSD documented offering support and initiating 15‑minute checks once, but there was no further follow‑up or documentation of interventions after subsequent suicidal statements made in a care plan meeting with the resident’s father. The DON and Administrator reported that facility policy requires immediate notification of key staff, assessment for a plan and means of self‑harm, and thorough documentation, which were not carried out or reflected in the medical record for this resident.
A resident with schizophrenia, post-stroke hemiparesis, and mild cognitive impairment verbalized suicidal ideation, but the care plan did not address depression or suicidal thoughts, and required assessments and services were not accurately or timely documented. An SSD note recorded the resident saying he wanted to kill himself and referenced 15‑minute checks and a care plan update, yet the active care plan lacked depression/suicidal ideation interventions. Multiple late-entry Social Services notes were later added, describing follow-up visits and the resident denying suicidal ideation, but the SSD later reported she did not typically ask about a suicide plan and did not personally provide individual follow-up visits as described. These practices conflicted with the facility’s policy requiring factual, first-hand, and timely documentation of assessments and services.
A resident was observed with an Albuterol inhaler on an overbed table and later reported keeping the inhaler in a nightstand drawer, with no staff present during these observations. Record review showed the resident had no cognitive impairment on the admission MDS but lacked any documented self-medication administration assessment. The DON acknowledged that the required assessment had not been completed, despite facility policy requiring staff and the practitioner to evaluate each resident’s mental and physical abilities before allowing self-administration of medications.
Surveyors found that the facility submitted inaccurate direct care staffing data to CMS through the PBJ system over multiple days in a quarter. CASPER reports showed apparent gaps in 24-hour licensed nurse coverage, low weekend staffing, and a 1-star staffing rating, while internal staffing sheets documented that licensed nurses were present and the facility was fully staffed on those days. The Administrator reported that the discrepancies were due to PBJ data entry errors, despite a facility policy requiring all PBJ entries to be accurate, auditable, and verifiable against payroll, invoices, or contracts.
Surveyors found that the facility did not provide or document required written transfer/discharge notices and bed-hold policy information for four residents who were sent to the hospital, including individuals with conditions such as dementia, CHF, chronic respiratory failure, and CKD. In each case, progress notes showed that the resident was transferred for acute issues, but the clinical records lacked evidence that written notices were given to the residents or their representatives, and in one case lacked documentation that required information was sent to the receiving provider. Facility leadership, including the ADON, DON, and Administrator, acknowledged that the records did not contain the required documentation, despite a written policy requiring such notices and information exchange.
A resident with Alzheimer’s disease and depression, previously on an antidepressant, exhibited intermittent refusals of medications and care, occasional yelling at staff, and reports of unusual perceptions, such as believing men were in or near her room. Nursing notes over several months documented these refusals and complaints but did not show that the behaviors were evaluated or recorded as dangerous, non-redirectable, or causing significant distress, nor did they document specific non-pharmacological interventions attempted or their outcomes. Despite this, a psychiatric NP later added new diagnoses of schizoaffective disorder, borderline personality disorder, and delusional disorder and ordered an antipsychotic (Seroquel) without a comprehensive evaluation in the record to support these diagnoses. The facility’s psychotropic medication policy, which requires identification and documentation of target behaviors, use of nonpharmacological interventions, and ongoing behavior monitoring, was not followed for this resident.
The facility failed to keep PASARR Level I screenings accurate and current for three residents when new mental health diagnoses and psychoactive medications were initiated. One resident’s PASARR omitted a PTSD diagnosis and an added antidepressant, despite documentation of PTSD on the MDS and care plan and a physician order for Pristiq. Another resident’s PASARR listed only depression and dementia, even after additional diagnoses such as borderline personality disorder, delusional disorder, and schizoaffective disorder were added and an antipsychotic (quetiapine) was ordered, with the MDS later reflecting psychotic disorder, schizophrenia, and depression with antipsychotic and antidepressant use. A third resident’s PASARR did not include a depression diagnosis or newly ordered escitalopram and lorazepam, although the admission MDS documented depression with antianxiety and antidepressant use. These omissions occurred despite facility policy requiring a new Level I review after significant mental status changes, including new mental health diagnoses or new psychotropic medications.
Uncovered Facial Hair During Food Preparation and Meal Service
Penalty
Summary
The deficiency involves the facility’s failure to ensure that food was served in a sanitary and safe manner in accordance with professional standards and facility policy during multiple kitchen and meal service observations. During an initial kitchen observation, two dietary aides were seen walking through the kitchen food preparation area with uncovered facial hair. One aide had facial hair above and below the lip and along the jaw line, approximately one-fourth inch in length, and the other had a mustache of similar length; neither used any facial hair covering. These observations occurred while staff were present in the kitchen area where food was stored and prepared. During subsequent observations on the same day, the same two dietary aides were again observed with uncovered facial hair while directly involved in meal preparation and service. One aide walked through the kitchen while the noon meal was being prepared and placed into a transport cart for service in the south dining room, and later was observed plating the noon meal at the steamtable in that dining room, still without a facial hair covering. The other aide walked through the kitchen while the noon meal was being prepared and placed into the steamtable for the north dining room, took food temperatures, assisted with plating meals at the steamtable, and retrieved food items and supplies from the kitchen, all while having an uncovered mustache approximately one-fourth inch in length. The Dietary Manager stated that staff hair was to be covered when in the kitchen and during meal service, and the facility’s written policy and the cited Indiana Food Establishment Sanitation Requirements both required effective hair restraints, including for facial hair, to prevent contamination of food, equipment, and utensils.
Failure to Provide and Document Bed-Hold Policy at Time of Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure that required bed-hold policy information was provided and documented for four residents transferred to the hospital. For a resident with dementia, psychotic disorder, and autistic disorder who had a BIMS score of 0 indicating severe cognitive impairment, progress notes documented physician notification and guardian notification when the resident was sent to the hospital, but there was no documentation that the bed-hold policy was provided to the responsible party. A Notice of Transfer or Discharge later indicated a copy of the bed-hold policy was sent with the resident. Another resident with COPD and chronic respiratory failure, cognitively intact with a BIMS score of 13, experienced a decline in condition and was transferred to the hospital by ambulance; progress notes documented family notification but did not document any discussion of the bed-hold policy, although a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident. A third resident with altered mental status and cerebral infarction, with a BIMS score of 10 indicating moderate cognitive impairment and documented short-term memory impairment, experienced changes in condition and was transferred to the hospital. Progress notes stated the resident was their own responsible party and that no other notification was completed, and transfer documentation did not include the bed-hold policy, although an untimed Notice of Transfer or Discharge indicated a copy of the bed-hold policy was signed by the resident. A financial power of attorney document in the record showed the resident had designated an agent to act in consent or refusal of health care. For a fourth resident with dementia and osteomyelitis, transfer documentation and a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident, and the transfer form noted the resident required a proxy for decision making. The facility’s policy required that at the time of transfer to a hospital, written notice specifying the duration of the bed-hold policy and information on return to the next available bed be provided, and that a signed and dated copy of the bed-hold notice given to the resident or representative be kept in the resident file, which was not consistently documented for these residents.
Failure to Integrate Trauma Histories and Behavioral Triggers Into Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to identify and incorporate residents’ trauma histories and specific behavioral triggers into their care plans, despite documented histories of significant trauma and behavioral health issues. For one resident, extensive social service and progress notes documented homelessness, polysubstance abuse, major depressive and anxiety disorders, chronic pain, a history of severe car accidents with multiple fractures, viral encephalitis resulting in a three‑month coma, loss of child custody, multiple divorces, physical abuse by a spouse, the death of a fiancé who was struck by a car while in a wheelchair, lack of family contact, and a past suicide attempt by Valium overdose. Additional documentation noted a history of rape by a brother at age eight and prior placement under direct supervision and 15‑minute checks related to suicidal ideation. Despite these documented traumatic events and behavioral health concerns, the resident’s care plans did not identify a history of physical trauma, sexual trauma, homelessness, substance abuse, medical trauma, or attempted suicide. For this same resident, the MDS showed no cognitive deficit and identified behaviors such as verbal aggression and rejection of care, along with diagnoses including seizure disorder, depression, chronic pain syndrome, homelessness, and anxiety disorder. Multiple care plans addressed behaviors such as drug‑seeking, pretending to have seizures for attention or medication, making false allegations, verbal aggression when unable to smoke, and a desire for intimate relationships with consenting male residents. These care plans referenced goals such as effective coping skills, seeking staff support, and compliance with the smoking policy, and they called for identification and reduction of behavioral triggers. However, none of these care plans actually listed any specific triggers. The care plan addressing the resident’s right to consensual intimate relationships focused on assessment and education regarding consent but did not integrate the resident’s extensive trauma history. Staff interviews indicated the resident had displayed sexual behaviors since admission, including an incident where the resident expressed anger at another resident for not buying a soda after engaging in sexual acts. A second resident with a documented history of traumatic brain injury (TBI), dementia, seizure disorder, borderline personality disorder, anxiety, intermittent explosive disorder, tobacco use, and other behavioral/emotional disorders was also affected by the same deficiency. Social history and progress notes documented that this resident sustained a TBI after being hit by a semi‑truck while riding a bicycle at age 18, resulting in an 11‑month coma, followed by 13 years in a state hospital and subsequent residence in a group home. Additional documentation indicated the resident allegedly shot their father at age 26 after being sworn at and had a PASRR identifying TBI, intermittent explosive disorder, and borderline personality disorder, with a specific trigger of hearing the name of the current U.S. President. Progress notes also described inappropriate sexual behavior toward staff, including touching themselves intimately during personal care and refusing to stop when redirected. Despite this, the resident’s care plans, which addressed explosive disorder and history of altercations, risk for decreased psychosocial well‑being, and refusal to bathe or shower, did not list any specific behavioral triggers, did not reference the traumatic events such as being hit by a truck or shooting their father, and did not document the inappropriate sexual behavior. The Administrator and Social Service Director acknowledged that residents were to be screened for trauma and that trauma responses and PTSD should be added to care plans, but the specific trauma histories and triggers for these two residents were not incorporated into their plans of care.
Failure to Assess and Care Plan for Resident Suicidal Ideation
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess, investigate, and care plan for a resident’s suicidal ideation in accordance with its own policy and staff expectations. The resident had diagnoses including schizophrenia, cerebral edema, and hemiparesis/hemiplegia following a cerebral infarction, and a current MDS showed mild cognitive impairment (BIMS score 12). A progress note documented that the resident told the Social Services Director (SSD) he was feeling down and wanted to kill himself; the SSD offered assistance, activities, and initiated 15‑minute checks, and the note stated the care plan was updated. However, the note did not indicate that the SSD asked whether the resident had a plan to kill himself, and there were no additional notes regarding suicidal ideation or follow‑up. Review of the current care plan showed no problem, goal, or interventions addressing depression or suicidal ideation, and progress notes over the following month contained no documentation of physician notification related to the suicidal statement. Further record and interview evidence showed that the care plan conference summary did not document interventions for suicidal ideation, and the SSD acknowledged she did not normally ask residents expressing suicidal ideation if they had a plan. The SSD reported that the resident had admission paperwork mentioning suicidal ideation related to depression after a stroke and that the resident again vocalized suicidal ideation during a care plan meeting with his father, after which emotional support was offered and the father took the resident out on a leave of absence; no further visits or follow‑up were done. The DON stated that, upon notification of suicidal verbalization, staff should assess the resident, ask if there is a plan, remove potential means of self‑harm, immediately notify the psychiatric NP, and document the occurrence, and that a detailed progress note and updated care plan were expected but not present for this resident. The Administrator similarly stated that staff should ask about a plan, document interventions, notify the physician and family, and update the care plan, and indicated the resident should have had a care plan addressing depression with suicidal ideation. The facility’s written policy required immediate notification of the DON, SSD, and physician, an interview including asking about a plan and assessing mood and means for self‑harm, and thorough documentation of mood, behavior, and all actions taken, which were not reflected in the resident’s record.
Incomplete and Inaccurate Documentation of Suicidal Ideation and Follow-Up
Penalty
Summary
The facility failed to ensure accurate, complete, and timely documentation of assessments and services for a resident who verbalized suicidal ideation. Resident 6, who had schizophrenia, cerebral edema, and right-sided hemiparesis/hemiplegia following a cerebral infarction, had a BIMS score of 12 indicating mild cognitive impairment. The resident’s admission paperwork mentioned suicidal ideation related to depression after a stroke, and a Social Services note on 3/11/2026 documented that the resident was feeling down and said he wanted to kill himself. The Social Services Director (SSD) documented that she talked with the resident, coordinated with Activities, advised the resident to contact SSD or nursing if he wanted to talk, and that the resident was scheduled for 15-minute checks and the care plan was updated. However, the current care plan initiated on 2/26/2026 did not address depression or suicidal ideation. Multiple Social Services progress notes were later entered as late entries in April, with effective dates in March, stating that the resident had no plan and no longer had suicidal ideation, that he felt much better after 1:1 time, and that he continued his daily routine and therapy. These late entries described follow-up visits and reassessments of suicidal ideation on several consecutive days, but in interviews the SSD stated she did not normally ask residents about having a plan when they verbalized suicidal ideation and did not recall any other occurrences beyond the initial event. She further indicated she did not personally provide individual follow-up visits with this resident regarding suicidal ideation, despite the late-entry notes describing such visits. The DON acknowledged that late entries had been added to address concern about suicidal verbalization, and the Administrator stated that upon suicidal statements staff should ask about a plan, notify the physician and family, and update the care plan, and that this resident should have had a care plan addressing depression with suicidal ideation. The facility’s documentation policy required factual, first-hand, timely documentation, which was not followed in this case.
Failure to Complete Required Self-Administration Assessment for Inhaler Kept at Bedside
Penalty
Summary
Surveyors identified that a resident was allowed to keep and access an Albuterol inhaler without the facility completing the required self-administration medication assessment. During an initial tour, the resident was observed sitting in a wheelchair with a handheld Albuterol inhaler on the overbed table and no staff present in the room or hallway. On a subsequent observation, the resident again was in a wheelchair and reported that the Albuterol inhaler was stored in the top drawer of the nightstand, where it was found. Review of the clinical record showed an admission MDS indicating no cognitive impairment, but there was no documentation of a self-medication administration assessment. In an interview, the DON confirmed that the resident did not have the required self-medication assessment, despite the facility’s policy stating that staff and the practitioner must assess each resident’s mental and physical abilities to determine whether self-administering medications is clinically appropriate. This failure to complete and document a self-administration medication assessment for a resident who had an Albuterol inhaler kept at bedside constituted noncompliance with the facility’s own policy and with 410 IAC 16.2-3.1-11(a).
Inaccurate PBJ Staffing Data Submission to CMS
Penalty
Summary
The deficiency involves the facility’s failure to electronically submit complete and accurate direct care staffing information to CMS through the Payroll-Based Journal (PBJ) system for 22 days in a fiscal quarter. A CASPER report review on 4/6/26 showed that, according to PBJ data, the facility did not have licensed nursing coverage 24 hours per day on multiple specific dates across three months, had low weekend staffing, and held a 1-star staffing rating. However, review of the facility’s internal staffing sheets for that quarter indicated the facility was fully staffed and had licensed nurse coverage on all of the dates in question. During an interview, the Administrator stated that the PBJ information must have contained data entry errors, as she had verified licensed staff coverage on the timesheets. The facility’s PBJ policy in effect stated that all staffing data entered into the PBJ system would be auditable and verifiable through payroll, invoices, or contracts, but the submitted PBJ data did not accurately reflect the facility’s actual licensed nurse staffing as documented on internal records. No specific residents or clinical conditions were mentioned in the report, and the deficiency centers solely on inaccurate staffing data submission rather than direct resident care events.
Failure to Provide and Document Required Transfer/Discharge and Bed-Hold Notices
Penalty
Summary
The deficiency involves the facility’s failure to provide and document required written notices of transfer/discharge and bed-hold policies, as well as required information to receiving providers, for four residents who were transferred or discharged to the hospital. For a resident with generalized anxiety disorder, major depressive disorder, and dementia, progress notes showed that the resident was sent to the hospital via 911 for chest pain, lower back pain, and shortness of breath and later returned to the facility, but the clinical record lacked documentation that a written Notice of Transfer/Discharge and the bed-hold policy were provided to the resident or representative, and lacked documentation that required information was conveyed to the receiving facility. The ADON and the Administrator both confirmed there was no documentation that these written notices were provided. For a resident with congestive heart failure and muscle weakness who was sent to the emergency room for painful urination and bloody urine, the clinical record lacked documentation that a Notice of Transfer/Discharge or bed-hold policy was given to the resident or representative, which the DON confirmed. Another resident with chronic respiratory failure and diabetes was discharged to the hospital for respiratory failure, and a resident with chronic kidney disease and dementia was discharged to the hospital, but in both cases there was no documentation that a written notice of transfer/discharge or bed-hold policy was provided to the residents or their representatives. Review of the facility’s Transfer and Discharge policy, dated 1/15/26, showed that the policy required the facility to provide written transfer/discharge notices and bed-hold information to residents and representatives and to provide specified information to receiving providers, but the records for these four residents did not contain the required documentation.
Failure to Document Target Behaviors and Non-Pharmacological Interventions Before Initiating Antipsychotic
Penalty
Summary
The deficiency involves the facility’s failure to document how a resident’s behaviors presented danger or distress to self or others, and failure to document non-pharmacological interventions attempted prior to initiating an antipsychotic medication. Resident 6 had documented diagnoses of Alzheimer’s disease, depression, and severe cognitive impairment, and was receiving sertraline for depression. A PASSAR identified only depression and dementia, and the admission MDS listed Alzheimer’s disease and depression as active diagnoses. Over several months, nursing progress notes documented that the resident intermittently reported unusual perceptions, such as believing there were men causing trouble, a man in her room, or a man wanting to marry her and yelling through the walls, but there was no documentation that these episodes caused danger to the resident or others or that they resulted in unmanageable distress. From late April through mid-July, nursing notes primarily described the resident’s frequent refusals of evening and morning medications, blood sugar checks, blood pressure checks, insulin administration, hygiene care, and showers. Staff documented that the resident sometimes yelled at staff, said “Get out!”, was visibly upset by a room move, was leery of staff and asked to see name badges, and became upset about a pillow under her head until it was removed, after which she calmed down. The notes also recorded instances where the resident believed housekeeping had not cleaned her room or that she had not received medications when she had. However, there were no progress notes or assessments indicating that these behaviors were evaluated as dangerous, non-redirectable, or causing significant distress or functional impairment, and no detailed behavior monitoring logs were present as required by facility policy. On a psychiatric NP visit for initial psychotropic medication management, new mental health diagnoses of schizoaffective disorder, borderline personality disorder, and delusional disorder were added, and Seroquel 25 mg, an antipsychotic, was ordered. The clinical record did not contain a comprehensive evaluation to support these new diagnoses, and there was no documentation of target behaviors meeting the facility’s policy criteria for psychotropic use, such as behaviors representing danger to self or others, causing distress and impairment in functional abilities, or clearly attributable to psychosis or mania. The resident’s representative reported that the resident had no prior history of mental health disorders or psychiatric hospitalization and was unaware of the new diagnoses. The facility’s own psychotropic medication policy required identification and documentation of specific target behaviors, use and documentation of nonpharmacological interventions, and ongoing monitoring of behaviors and interventions, which were not reflected in the record for this resident.
Failure to Update PASARR Screens for New Mental Health Diagnoses and Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that Preadmission Screening and Resident Review (PASARR) Level I screenings were accurate and updated when new mental health diagnoses and psychoactive medications were initiated for multiple residents. For one resident with dementia, anxiety, depression, and post-traumatic stress disorder (PTSD), the PASARR completed on admission listed anxiety, depression, and dementia with sertraline and quetiapine, but did not include the PTSD diagnosis or the antidepressant Pristiq, despite the admission MDS and care plan documenting PTSD and a subsequent physician’s order for Pristiq. For another resident with Alzheimer’s disease, borderline personality disorder, delusional disorder, schizoaffective disorder, and depression, the PASARR only reflected depression and dementia with sertraline, even though additional mental health diagnoses were added later and an antipsychotic (quetiapine) was ordered for borderline personality disorder, and the quarterly MDS documented psychotic disorder, schizophrenia, and depression with antipsychotic and antidepressant use. A third resident had diagnoses including Alzheimer’s disease, depression, anxiety disorder, irritability and anger, and nonrheumatic aortic valve stenosis. The PASARR for this resident listed dementia and anxiety with Risperdal but omitted the diagnosis of depression and the medications escitalopram and lorazepam, although physician’s orders were in place for escitalopram for depression and lorazepam for anxiety, and the admission MDS documented depression with antianxiety and antidepressant use. Interviews with the Assistant Director of Nursing confirmed that new Level I PASARR screens should have been completed when new mental health diagnoses and psychoactive medications were added, and that the PASARR for one resident, completed prior to arrival, should have included all mental health diagnoses and medications. The facility’s own policy required notification of the state mental health authority within 14 days after a significant change in mental condition and specified that a new Level I screen is required for new mental health diagnoses or newly prescribed psychotropic medications, which was not followed in these cases.
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