Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Cardinal Care Strategies during CMS and state inspections, most recent first.
A facility failed to promptly separate two residents after a CNA witnessed one resident sexually assaulting another, and the alleged perpetrator was still in the room when the QMA arrived. The assaulted resident was cognitively intact and had multiple mental health diagnoses, while the other resident had dementia and a history of sexually inappropriate behaviors. The investigation was incomplete because the facility did not interview other residents or staff members, and the resident’s record lacked a post-incident physical assessment.
Failure to complete a physical assessment after an alleged resident-to-resident sexual abuse incident. A resident reported that another resident entered her room, removed her brief, and penetrated her vagina with his finger while she said no and stop; a CNA and QMA also observed the other resident with his pants down and his fingers in the resident’s vagina. The resident’s record included multiple psychiatric diagnoses and cognitive impairment-related diagnoses, but no post-incident physical assessment was documented, and the DON stated no other residents were assessed after the event.
Surveyors determined that two halls were functioning as locked, secured units requiring a keypad code for entry and exit, with no alternative unlocked access and no posted code. Facility leadership believed prior corporate actions and a dementia disclosure form were sufficient for secured-unit status and were unaware that state authorization was required; there was no policy, criteria, or program governing secured units. Record review for four residents on these halls showed physician orders allowing residence on a secured unit but no corresponding assessments or evaluations to identify the medical or behavioral symptoms being treated, and in several cases no care plans addressing the need for secured placement, despite MDS data showing little or no wandering or maladaptive behaviors.
A resident with bipolar disorder, borderline personality disorder, and anxiety, who was care planned for demanding behaviors and psychosocial vulnerability, was subjected to verbal abuse by a QMA. During an interaction in which the resident became upset and made threatening statements, the QMA responded by threatening to hit the resident if the resident hit her, stating they would both go to jail. The QMA admitted making this threatening statement, which met the facility’s definition of verbal abuse and violated the resident’s right to be free from abuse.
A dietary employee served 4 oz of beef and noodles on nine meal trays even though the menu and portion guide called for an 8 oz serving for all diet types. The Dietary Mgr confirmed the trays were short by 4 oz each, and the facility policy stated every effort would be made to serve the items on the posted menu.
Resident funds were not fully covered by the facility’s surety bond. The BOM and Administrator provided records showing the facility managed funds for 71 residents, while the bond covered only $80,000.00. Bank statements showed the resident funds account repeatedly exceeded that amount, including balances over $115,000 and as high as $195,004.68. The Administrator stated the facility reviewed balances daily but believed the excess amounts did not need to be ensured once the balance later dropped below $80,000.00.
Loose pills were found in 2 medication carts during observations, including multiple unidentified or marked tablets in the 100 East cart and several marked tablets in the 100 West cart. QMA 10 and an LPN both stated loose pills should not have been present, and the ADON stated no loose pills should have been found in the carts. The ADON also said unit managers completed weekly storage audits and the pharmacy completed monthly cart audits, but no medication cart audits had been performed since 12/18/25.
Two residents discharged from Medicare A skilled services did not receive the required SNF ABN; instead, staff completed only the SNF NONMC form and believed it was the same document. The BOM and Therapy Director said they used the NONMC after therapy discharge, and the Corporate Nurse Consultant stated the facility had no beneficiary notification policy and staff had not been trained on proper SNF ABN use.
Failure to prevent resident-to-resident abuse occurred when a resident with a history of aggression and anger outbursts was placed with a cognitively impaired roommate. Staff observed the resident push the roommate against a closet door while yelling about items in the closet, and the roommate was upset and confused during the incident. The record lacked a roommate-specific care plan for the aggressive resident, lacked evidence of prior notification about the room change, and the investigation file did not include staff interviews or the incident report.
Unnecessary psychotropic medication use without documented targeted behaviors. Three residents received antipsychotic medications, including Risperdal and Seroquel, but their records lacked resident-specific targeted behaviors, supporting documentation of delusions, hallucinations, or maladaptive behaviors, and care plans tied to the medication use. For one resident, the documented behaviors were mainly resistance to staff-initiated care or redirection; for the others, staff interviews and MDS/psychiatry notes described them as calm, stable, or easily redirected, with no observed psychotic behaviors.
Incomplete Investigation of Resident-to-Resident Abuse: The facility failed to thoroughly investigate and maintain records for a resident-to-resident altercation in which one resident accused a roommate of stealing clothing and was yelling at the roommate to leave his closet. Although staff separated the residents and documented no injury, the investigation file lacked staff witness statements, the incident report, and interviews with interviewable residents near the room where the event occurred. Interviews showed nearby CNAs had written statements, but an LPN later had to be asked to provide one and another LPN said she had not received any statements.
Failure to Provide Transfer/Discharge Notices and Bed Hold Policy: The facility did not document that required transfer/discharge notices and bed hold policy information were provided to residents or their representatives for multiple hospital transfers. Three residents with conditions including anxiety, epilepsy, COPD, neurofibromatosis, anemia, BPH, and borderline personality disorder were sent to the ER for changes such as mental status changes, UTI symptoms, being found unresponsive, a displaced nephrostomy tube, altered mental status, and bloody catheter drainage, but the records lacked proof that the notices were given or who received them.
Failure to complete a required PASARR Level 2 assessment for a resident with diagnoses including delusional disorders, anxiety, psychosis, and vascular dementia. The record showed a Level I screen outcome with referral for an onsite Level 2, but no completed Level 2 documentation was present. The SSD said the Level 2 was cancelled in the online system and believed the resident's LOC approval made further PASARR screening unnecessary, while the Corporate Nurse Consultant stated the facility had no PASARR policy.
Failure to Invite Resident Representative to Care Plan Meeting: A resident with schizophrenia, Parkinson's disease, AFib, PE, respiratory failure, and HF had an admission care conference where the resident attended, but the appointed guardian/representative did not. The record lacked documentation that the representative was invited or any reason for the absence, and the representative later stated they were never invited to any care plan meetings.
Inadequate Humidification for Oxygen Therapy: A resident with COPD receiving continuous oxygen via nasal cannula was observed multiple times with the concentrator set at 4 to 5 L/min, but the humidification bottle was empty and covered in a white film. The resident’s record included orders for continuous oxygen and weekly changes of the oxygen equipment, and staff interviews confirmed the oxygen setup and water level should be checked each shift.
QAPI program failed to address repeat medication labeling deficiencies. The facility had prior survey findings related to unlabeled medications, and the QAPI binder lacked audits for repeat deficiencies. During a later survey, unlabeled medications were again found on 2 of 4 med carts, including the 100 East and 100 West carts, despite the ADON stating the QAA committee met daily and monthly and weekly cart audits were in place.
A resident with a catheter was later identified as positive for C. Auris, but the room remained marked with an orange EBP sign and PPE setup instead of the correct contact isolation precautions. Staff interviews showed confusion about EBP versus contact isolation, and a laundry aide entered the room wearing only a surgical mask and no additional PPE. The IP later stated CDC guidance required contact isolation for the resident’s C. Auris infection.
Failure to offer and document pneumococcal vaccinations for 3 residents. One resident with COPD, neurofibromatosis, and epilepsy had a prior pneumococcal vaccine but no consent/declination form or documented offer. A second resident with schizophrenia, DM2, and HTN had historical pneumococcal vaccines but no consent/declination form and no additional offers since 2023. A third resident with anxiety, stroke, and delusional disorder had no vaccine history, no consent/declination form, and no documented offer. The IP stated admission paperwork often lacked vaccine history and that consent/declination forms were uploaded to the EMR.
Failure to Notify Resident Before Roommate Change: A cognitively intact resident with opioid abuse, alcohol use, chronic pain, MDD, and anxiety was given a new roommate without prior notice. The resident said he did not know he had a roommate until he returned to his room and found the new resident already there. The SSD said she typically gave verbal notice and documented it, but could not provide evidence that this resident was notified before the roommate change.
Two cognitively impaired residents experienced sexual abuse by another resident with intellectual disabilities, involving inappropriate touching and exposure. Staff observed concerning situations but did not immediately recognize or report them as abuse, instead attributing them to behavioral or hygiene issues. Documentation was incomplete, and required notifications and reporting procedures were not fully followed. The residents involved had significant cognitive and physical impairments, and there was no care plan addressing sexually inappropriate behaviors for the perpetrator.
Staff failed to promptly report and accurately document allegations of resident-to-resident sexual abuse to facility leadership and the State Agency. Two residents with cognitive impairments were involved in separate incidents with another resident, resulting in inappropriate sexual contact and physical evidence of abuse. Despite staff observations and internal discussions, the required notifications and documentation were delayed or incomplete, and clinical records did not reflect the events or relevant assessments.
Two residents with cognitive impairments were involved in separate incidents of alleged sexual abuse by another resident with intellectual disabilities. Staff observed inappropriate situations, including exposure and possible sexual contact, but did not follow proper investigative protocols or protective interventions. Documentation was incomplete, communication among staff and leadership was inconsistent, and the facility failed to report the incidents as sexual abuse to the state. Family members learned of the events through anonymous calls, raising concerns about transparency and adherence to abuse prevention policies.
A staff member failed to immediately report an incident where a QMA used inappropriate and disrespectful language toward a resident with multiple medical conditions, resulting in the resident becoming upset and crying. The delay in reporting the incident to facility administration and state authorities was not in accordance with the facility's abuse prevention policy.
A resident with multiple medical conditions was subjected to verbal abuse by a QMA, who used inappropriate and profane language when addressing the resident about the cleanliness of his room. The incident caused the resident to become upset and cry, and although an LPN and CNA provided support afterward, the LPN did not immediately report the abuse as required by facility policy.
Following a verbal abuse allegation by a staff member, the facility did not complete required psychosocial assessments for three cognitively impaired, non-interviewable residents with conditions such as dementia, anxiety, depression, and schizophrenia. The investigation included staff and resident interviews and skin checks, but lacked documentation of psychosocial evaluations for these vulnerable residents as mandated by facility policy.
Surveyors found that three residents receiving oxygen therapy did not have their oxygen tubing and cannulas stored in dated storage bags as required by facility policy. Instead, the equipment was left draped over wheelchairs, tucked into pockets, or anchored on devices without proper storage, and staff confirmed that storage bags were not consistently provided or maintained.
Surveyors observed a shower room with significant cleanliness issues, including soiled floors with standing water, open beverage containers, dirty sink, toilet with dark rings, uncovered trash, linens on the floor, and fecal smears. The Housekeeping Manager acknowledged the condition was unacceptable, despite a facility schedule requiring daily cleaning.
The facility failed to provide consistent bedtime snacks for a resident with specific dietary needs and several others, as reported by the resident council. A resident with dementia, diabetes, and malnutrition did not receive ordered snacks due to supply issues. The resident council reported frequent unavailability of snacks, with no documented resolution. Staff sometimes used personal funds to purchase snacks for diabetic residents. The facility's snack policy was not effectively implemented, and feedback from resident council meetings was not documented.
A facility failed to provide adequate dementia services for a resident with Alzheimer's and wandering behavior. Despite a care plan to ensure safety, the resident persistently wandered into other residents' rooms, causing disturbances. After being moved to a secured unit without a transition plan, the resident was injured in an altercation, leading to his return to the previous hall with increased monitoring.
The facility failed to label medications with resident identifiers in a medication cart and storage room. In the 100 East Unit cart, two medication cups with pills lacked labels, and in the 200 Unit Storage Room, two Trulicity pens were unlabeled. LPNs confirmed the lack of labeling made it impossible to identify the medications' ownership, violating the facility's policy.
A resident with a severe cognitive impairment and a documented dairy allergy was served sherbet containing dairy, despite clear instructions on their meal ticket. Dietary staff, including the Dietary Manager and Registered Dietitian, failed to recognize the presence of dairy in the sherbet, indicating a lack of understanding of food ingredients.
A cook in the facility failed to change gloves between tasks, leading to potential food contamination for 69 residents. The cook used the same gloves to handle a bread bag, bread slices, baked potatoes, and utensils, violating the facility's policy on glove use. She was unaware of the contamination risk her actions posed.
The facility failed to ensure timely documentation of physician and NP visits for several residents, with delays ranging from 39 to 126 days. Residents with various diagnoses, including anxiety, depression, diabetes, and schizoaffective disorder, experienced significant delays in having their care visit notes documented and signed. The facility acknowledged the issue but had not fully implemented corrective actions at the time of the report.
The facility failed to ensure timely physician and NP visits for six residents, resulting in significant gaps in required face-to-face visits. Residents reported only seeing the NP or not having seen a doctor at all, with some going over 100 days without a visit. The deficiency highlights a lack of adherence to regulatory requirements for alternating visits between physicians and NPs.
The facility failed to thoroughly investigate an allegation of physical abuse involving a cognitively impaired resident by a staff member. The investigation included interviews with staff who witnessed the incident but did not extend to other staff or residents. The resident involved had severe cognitive impairment and multiple diagnoses, including Alzheimer's Disease and dementia with behavioral disturbances.
The facility failed to ensure residents had privacy while using the facility telephone. Residents used the phone at the nurses' station, where conversations could be overheard, and there was no private place for them to talk. The facility did not have a policy related to residents' privacy while using the phone.
The facility failed to implement physician's orders for blood glucose monitoring for a resident with diabetes and did not adequately monitor bowel movements for four residents. The clinical records lacked necessary documentation, and staff interviews revealed inconsistencies in following the facility's bowel management policy.
A resident with dementia and agitation was administered lorazepam by an LPN without securing an order from a medical provider and without confirming with the pharmacy, violating the facility's protocol for emergency medication dispensing.
The facility failed to identify and address the behavioral health needs of three residents, leading to significant safety concerns. Resident D was found with syringes in his room, and the facility did not conduct a preadmission assessment or develop a care plan for his substance abuse history. Resident C, with a history of sexually inappropriate behaviors, was found in bed with Resident B, both undressed. The facility did not conduct a preadmission assessment or develop a care plan for Resident C's behaviors, and staff were not informed of her history.
Failure to Separate Residents and Thoroughly Investigate Alleged Sexual Abuse
Penalty
Summary
The facility failed to ensure immediate protective actions were taken after an alleged resident-to-resident sexual abuse incident involving two residents. According to the report, a CNA heard one resident saying “no” and “stop,” looked around the privacy curtain, and saw another resident standing over her with his pants down and forcing his fingers inside her vagina. The CNA ran to get the QMA and nurse, but the QMA later observed the alleged perpetrator still in the room with his fingers in the resident’s vagina and removed him only after entering the room. The report states the facility did not ensure the residents were separated promptly after the alleged abuse was witnessed. The resident who was allegedly assaulted was described as cognitively intact on admission, with diagnoses including major depressive disorder, unspecified psychosis not due to a substance or known physiological condition, unspecified disorder of adult personality and behavior, unspecified symptoms and signs involving cognitive functions and awareness, and other sexual disorders. Her record lacked a physical assessment completed after the incident. The other resident had diagnoses including unspecified dementia, moderate, with other behavioral disturbance, generalized anxiety disorder, and mood disorder due to known physiological condition with manic features. His care plan documented sexually inappropriate behaviors, including sexually inappropriate remarks, attempting to kiss staff, and attempting to touch staff. The facility’s investigation was also incomplete. The investigation file contained face sheets, care plans, orders, a trauma-informed care review, a social service note, and two witness statements, but it lacked interviews of residents and other staff members to determine whether there were additional witnesses or allegations. During interviews, the DON stated no other residents were assessed after the incident, and the Administrator stated they had not interviewed other residents related to the incident. The facility policy required all allegations to be thoroughly investigated, including review of documentation and evidence, review of the resident’s medical record, interviews of witnesses, staff members on all shifts, the resident’s roommate, family members, and visitors, and documentation of the investigation completely and thoroughly.
Failure to Complete Physical Assessment After Alleged Sexual Abuse
Penalty
Summary
The facility failed to ensure a physical assessment was completed for a resident after an allegation of resident-to-resident sexual abuse. Resident B was observed and interviewed after the incident and stated that Resident C came into her room, shut the door, removed her incontinence brief, and put his finger in her vagina while she told him to stop. A facility investigation file contained witness statements describing CNA 6 hearing Resident B say no and stop, then seeing Resident C standing over Resident B with his pants down and forcing his fingers inside her vagina, after which CNA 6 got the QMA and nurse. A social service note also documented that Resident B reported another resident took her pants and brief off and touched her while she said no, and that she was calm with no signs of psychosocial distress. Resident B’s record included diagnoses of major depressive disorder, unspecified psychosis not due to a substance or known physiological condition, unspecified disorder of adult personality and behavior, unspecified symptoms and signs involving cognitive functions and awareness, and other sexual disorders. Her admission MDS indicated she was cognitively intact and had no maladaptive behaviors, and she required a mechanical lift for transfers. The record lacked a physical assessment following the incident. Resident C’s record included diagnoses of unspecified dementia, moderate, with other behavioral disturbance, generalized anxiety disorder, and mood disorder due to known physiological condition with manic features; his admission MDS indicated he was cognitively intact and had no maladaptive behaviors. The DON stated no other residents were assessed after the incident, and the facility policy required the investigator to review the resident’s medical record to determine physical and cognitive status at the time of the incident and since the incident.
Locked Units Used as Secured Halls Without Authorization or Individual Justification
Penalty
Summary
Surveyors found that the facility failed to protect residents from involuntary seclusion by locking and securing two units (the 200 and 300 halls) without authorization from the Indiana Department of Health and without appropriate clinical justification for individual residents. During observations on two consecutive days, the double doors to the 200 hall were closed and locked, requiring an unposted keypad code for both entrance and exit, with no other unlocked access to the unit. The adjoining 300 hall (Swan unit) could only be accessed by passing through the locked 200 hall doors, also requiring a code, effectively making both halls secured units. Review of IDOH licensing records showed no authorization to occupy any secured unit within the facility. Interviews with the COO and Nursing Officer revealed that the facility leadership believed that submission of an FSSA dementia disclosure form met requirements for a secured unit and were unaware that IDOH did not license or authorize dementia units. They indicated that prior LSC and LTC survey teams had allowed the units to be secured, but they had no documentation of IDOH Division of Long Term Care approval or authorization for occupancy as secured units. The Administrator and DON further indicated there was no facility criteria, policy, or program related to the operation of secured units, and that they had assumed, based on prior ownership and corporate direction, that the 300 hall was an approved secured dementia unit and the 200 hall an approved secured behavioral unit. Record review for four residents residing on these locked units showed a lack of required assessments, evaluations, and care planning to justify placement on a secured unit. One cognitively intact resident with bipolar disorder and other psychiatric diagnoses had an order to reside on a secured unit but no assessment identifying the medical or behavioral symptoms being treated, and her MDS showed no wandering or maladaptive behaviors. Another resident with paranoid schizophrenia, bipolar disorder, and intellectual disabilities had an order to reside on a secured unit but no assessment or care plan for that need, with MDS data showing severe cognitive impairment but only limited rejected care and no documented wandering. A resident with dementia and PTSD had an order to reside on a secured unit and had been placed on the 300 hall due to a dementia diagnosis, but had no care plan for secured placement and no documented wandering or elopement attempts. A resident with Alzheimer’s disease and other psychiatric diagnoses had an order to reside on a secured unit and a significant change MDS showing memory loss and some wandering, but no assessment or evaluation identifying the medical or behavioral symptoms being treated by locked unit placement. Leadership confirmed that these residents were placed on the secured units based on diagnoses and perceived needs, without prior formal evaluation or care planning for secured placement.
Failure to Protect a Resident From Verbal Abuse and Threats of Physical Harm
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from verbal abuse in the form of threats of physical violence by a staff member. Resident C, who had diagnoses including bipolar disorder-depression-severe with psychotic features, borderline personality disorder, and anxiety, was care planned for demanding behaviors and for risk of decline in psychosocial well-being related to past sexual assaults. The care plans directed staff to address the resident’s wants and needs in a timely manner, provide support and reassurance, allow the resident to vent and validate feelings, and encourage use of healthy coping mechanisms. Despite these identified needs and interventions, an incident occurred in which a Qualified Medication Aide (QMA 5) made a threatening statement to the resident. According to the facility’s investigation and interviews, Resident C reported that QMA 5 played a recording of the resident while in psychosis and laughed at it, then pushed a baby gate toward the resident’s knee, leading the resident to threaten to hit the aide with the gate. Resident C stated that QMA 5 responded by saying she would slap the resident if the resident hit her. In a written statement and phone interview, QMA 5 acknowledged telling the resident that if the resident hit her, she would hit the resident and they would both go to jail. The facility’s abuse prevention policy defined verbal abuse to include threats of harm, and the resident rights policy stated residents have the right to be free from verbal abuse. The staff member’s admitted threat of physical retaliation toward the resident constituted verbal abuse under the facility’s policies and resident rights requirements.
Incorrect Meal Portion Sizes Served
Penalty
Summary
The facility failed to ensure menus were followed to provide accurate portion sizes for entrees served. During a lunch meal service observation, a dietary employee was observed scooping a 4-ounce portion of beef and noodles onto nine meal trays that were already prepared for service. When interviewed immediately afterward, the employee stated the nine resident trays were ready for meal service and no additional items were needed, and confirmed she had served 4 ounces on each tray. The Dietary Manager reviewed the menu and portion size guide and stated all residents should have received an 8-ounce serving of beef and noodles, meaning an additional 4 ounces would need to be added to the nine prepared plates before service. The facility menu for the meal indicated an 8-ounce portion for every diet type served, and the facility policy stated every effort would be made to serve the items on the posted menu.
Resident Funds Not Fully Covered by Surety Bond
Penalty
Summary
The facility failed to assure the security of resident personal funds deposited with the facility because it did not maintain a surety bond that covered the total amount of resident funds. During review with the BOM, the facility provided a list showing 71 residents whose funds were managed by the facility, along with the most recent bank statement and the surety bond. The surety bond policy indicated the resident funds account was insured for $80,000.00. Bank statements for the resident funds account showed the ledger balance exceeded $80,000.00 on multiple occasions. The balance was documented at $116,270.81, $115,892.81, and $115,657.81 in early December 2025; at $80,669.58 and $80,327.58 in early November 2025; and on fourteen occasions in October 2025, including balances as high as $195,004.68. During interview, the Administrator stated the facility had balances in excess of $80,000.00 and that the corporation reviewed balances each business day, but believed the excess amounts did not need to be ensured once resident liability was removed and the balance dropped below $80,000.00.
Loose Pills Found in Medication Carts
Penalty
Summary
The facility failed to ensure medications were stored securely without loose pills in 2 of 4 medication carts reviewed, including the 100 East and 100 West carts. During an observation of the 100 East medication cart with QMA 10, one yellow ovate pill inscribed with H125, one white ovate pill inscribed with L612, and one white circle pill with no visible marking were found in drawers of the cart. During a concurrent interview, QMA 10 stated that no loose pills should have been found in the medication cart. During an observation of the 100 West medication cart with LPN 9, one white circular pill inscribed with RE22 and two yellow circular pills inscribed with L20 were found in drawers of the cart. LPN 9 stated during the observation that no loose pills should have been found in the medication cart and that any loose pills found should have been discarded appropriately. The ADON later stated that no loose pills should have been found in the medication carts and that unit managers performed weekly storage audits and the pharmacy performed monthly medication cart audits, but also stated that no medication cart audits had been performed since 12/18/25. The facility policy titled Medication Labeling and Storage stated that medications are to be stored in the packaging or dispensing systems in which they are received and that medications are to be stored in an orderly manner in carts and drawers.
Failure to Provide Required SNF ABN for Medicare Skilled Service Discharges
Penalty
Summary
The facility failed to provide the appropriate Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN) for 2 of 2 residents reviewed for beneficiary notifications. Resident 3 was admitted to Medicare A skilled services on 12/3/25, had a last covered day of 12/17/25, and the SNF Notice of Medicare Non-Coverage (NONMC) was reviewed and signed on 12/15/25. The NONMC stated the resident was discharged from therapy, but the clinical record did not contain a SNF ABN. Resident 43 was admitted to Medicare A skilled services on 11/27/25, had a last covered day of 12/5/25, and the SNF NONMC was reviewed and signed on 12/3/25. That NONMC also indicated the resident was discharged from therapy, and the clinical record lacked a SNF ABN. During interview, the BOM and Therapy Director stated they completed the SNF NONMC paperwork together after a resident was discharged from Medicare A services and believed the SNF NONMC and SNF ABN were the same form. They stated Residents 3 and 43 only received the SNF NONMC form and that they had not received training on the proper use of the SNF ABN form. The Corporate Nurse Consultant stated the facility did not have a policy related to beneficiary notifications.
Failure to Prevent Resident-to-Resident Abuse During Roommate Conflict
Penalty
Summary
The facility failed to prevent resident-to-resident abuse involving a cognitively dependent resident and a resident with a documented history of resident-to-resident altercations and anger outbursts. Resident B’s record showed diagnoses including opioid abuse, alcohol use with intoxication, chronic pain, major depressive disorder, and anxiety disorder. His care plans addressed psychosocial distress, mental illness, and potential physical aggression, including interventions to intervene before agitation escalated, but the record lacked a care plan specific to his prior resident-to-resident physical altercation and lacked resident-specific interventions to prevent further altercations. Resident B had a documented history of aggressive behavior. Progress notes showed he had a behavior during a smoking break in which he said he let his anger get the best of him, and later he was involved in a resident-to-resident physical altercation in which he hit another resident. On the evening of the incident involving Resident 76, Resident B reported that his roommate was going through his closet. Staff observed Resident B holding Resident 76 pushed up against the closet door, and Resident B did not deny pushing him. Resident B stated he yelled for staff to remove Resident 76 from the room. The facility record did not show that Resident B had been notified before being assigned a new roommate. Resident 76 had severe vascular dementia with behavioral disturbances, depression, and anxiety disorder, and was moderately cognitively impaired with supervision needed for activities of daily living. He had been moved into Resident B’s room shortly before the incident after a prior room change. During the altercation, Resident 76 was described as confused in the evening and upset by the event. Staff interviews indicated Resident B shoved Resident 76 into the closet door while yelling at him, and the residents were separated after the commotion. The facility investigation file lacked staff interviews and the incident report for the altercation, and the record showed the roommate placement occurred despite Resident B’s known history of resident-to-resident aggression and Resident 76’s cognitive impairment and evening confusion.
Unnecessary psychotropic medication use without documented targeted behaviors
Penalty
Summary
The facility failed to ensure that three residents were free from unnecessary psychotropic medication use related to antipsychotic medications. For Residents 5, 6, and 7, the clinical records did not identify resident-specific targeted behaviors to support the use of Risperdal or Seroquel, did not contain documented behaviors that matched the medication use, and did not include care plans addressing targeted behavioral symptoms. The records also lacked documentation showing delusions, hallucinations, or maladaptive behaviors that negatively impacted quality of life or quality of care for these residents during the review period. Resident 5 had diagnoses including Alzheimer’s disease, generalized anxiety, insomnia, and depression, and was ordered Risperdal 0.5 mg twice daily for agitation. The record contained several behavior notes, but the documented events showed the resident resisting staff-initiated care or redirection, such as being startled during care, resisting shaving or personal care, or being redirected from interactions with other residents. The record did not show that the resident initiated aggression without provocation, and staff interviews stated he was usually calm, wandered, and became upset when staff startled him or attempted care. Interviews also indicated he did not display hallucinations or delusions. Resident 6 had diagnoses including major depressive disorder, bipolar disorder, and anxiety, and was ordered Risperdal 1 mg twice daily for bipolar disorder. The quarterly MDS indicated she was moderately cognitively impaired and had no hallucinations, delusions, or maladaptive behaviors during the assessment period. The psychiatry note described her as stable, calm, cooperative, and without current concerns, and staff interviews stated she did not display hallucinations or delusions and did not have behaviors that negatively impacted her quality of life or care. Resident 7 had diagnoses including delusional disorder, adjustment disorder, intellectual disability, anxiety, and dementia, and was ordered Seroquel 75 mg at bedtime. Her MDS showed severe cognitive impairment with no hallucinations, delusions, or maladaptive behaviors during the assessment period, and the only behavior note described her crying in the hallway, stating she was scared, then calming easily after reassurance and assistance. Staff interviews stated she cried at times but had not been observed with hallucinations or delusions, and the record still lacked a targeted behavior and care plan for the antipsychotic use.
Incomplete Investigation of Resident-to-Resident Abuse
Penalty
Summary
The facility failed to complete and maintain a thorough investigation of a resident-to-resident abuse incident involving two residents after an altercation in which one resident accused the other of stealing clothing from his closet and was yelling for the roommate to get out of his closet. The incident was documented as having no injury, and staff separated the residents, completed skin assessments, moved one resident to another room, and placed both residents on 15-minute safety checks. The facility investigation included a recapitulation of the event, immediate actions taken, preventative measures, interviews from the two involved residents, three resident interviews from another unit, and an inservice attendance record, but it did not include staff statements, the facility incident report, or interviews with interviewable residents located near the room where the altercation occurred. During interviews, a CNA stated that she and two other aides were nearby when the commotion occurred and that each wrote individual statements and gave them to the nurse that night. An LPN later stated he had not previously written a statement for the investigation until he was asked to do so by administration on the day of the interview. Another LPN stated she was the nurse on the unit after the incident and had not been given any written statements about the altercation. The corporate nurse consultant acknowledged that the investigation lacked staff statements and stated that a complete investigation should include face sheets and orders, pertinent progress notes, an incident report, skin assessments as needed, staff and resident witness statements, a statement from the nurse on duty, and interviews with interviewable residents in close proximity to the incident.
Failure to Provide Transfer/Discharge Notices and Bed Hold Policy
Penalty
Summary
The facility failed to provide residents and/or their representatives with written notice of transfer/discharge and the bed hold policy for 3 of 4 residents reviewed for hospitalizations. Resident 2 had diagnoses including generalized anxiety disorder, epilepsy, substance abuse, and complex regional pain syndrome, and was cognitively intact on the quarterly MDS. The record showed two transfers to the emergency room for mental status changes/UTI symptoms and later being found unresponsive, but there was no indication that the resident or representative received a transfer/discharge notice or bed hold policy. Although forms dated for both events were later provided, they did not document who received the paperwork. Resident 56 had diagnoses including COPD, neurofibromatosis, and epilepsy, and was cognitively intact on MDS assessments. The record showed emergency room transfers for a displaced nephrostomy tube and for altered mental status at the family’s request, but the clinical record lacked indication that the resident or representative was given the transfer/discharge form and bed hold policy. Resident 43 had diagnoses including unspecified anemia, BPH with lower urinary tract symptoms, and borderline personality disorder, and was cognitively intact on MDS assessments. The record showed hospital transfers for altered mental status and for bloody drainage in the catheter bag with increased temperature and clamminess, but the record lacked indication that the resident or representative received the required notices; the forms provided later also did not identify who received them.
Failure to Complete Required PASARR Level 2 Assessment
Penalty
Summary
The facility failed to ensure timely completion of a required Level 2 PASARR assessment for one resident reviewed for PASARR. The resident had diagnoses including delusional disorders, generalized anxiety disorder, unspecified psychosis not due to a substance or known physiological condition, unspecified visual disturbances, and unspecified vascular dementia. The clinical record showed a 3/13/25 Notice of Level I PASARR Screen Outcome indicating a referral for a Level 2 onsite evaluation for suspected mental health disability, but the record did not contain documentation of a completed Notice of Level 2 PASARR Screen Outcome. During interview, the SSD stated she began working at the facility in November and used the Maximus Assessment Pro online system, where the resident's Level 2 was cancelled. She said the resident's Level of Care determination letter showed approval for indefinite long-term nursing care and she believed that meant the Level I and/or Level 2 was not needed. She later spoke with a customer service representative and was told the facility should have either completed the onsite Level 2 or restarted with a new Level I screening process. The Corporate Nurse Consultant stated the facility did not have a policy related to PASARR screenings.
Failure to Invite Resident Representative to Care Plan Meeting
Penalty
Summary
The facility failed to invite the resident representative to the resident's care plan meeting and did not document an explanation for the representative's absence. Resident 11 was admitted with diagnoses including schizophrenia, atrial fibrillation, pulmonary embolism with acute cor pulmonale, Parkinson's Disease with dyskinesia, encephalopathy, and rhabdomyolysis. The admission MDS dated 11/19/25 indicated the resident was cognitively intact, and guardianship papers were in place. During an interview, Resident 11 stated he had not been included in a care plan meeting and did not know whether his guardian had been invited. The clinical record showed an admission care conference was held on 12/4/25 and indicated the resident was in attendance, but the resident representative was not in attendance and no reason was documented, despite the form directing staff to add a reason if the representative was absent. The record lacked documentation of an invitation for the resident's representative to attend the care plan meeting. The resident's representative later stated they had not been invited to attend any care plan meetings for the resident. The Social Services Director stated invitations were typically placed in a binder or progress notes but could not provide information showing an invitation for this resident's representative, and the Corporate Nurse Consultant stated both the resident and representative should have been invited to participate.
Inadequate Humidification for Oxygen Therapy
Penalty
Summary
The facility failed to provide necessary respiratory services for a resident receiving continuous oxygen for COPD. Resident 56, who also had diagnoses of neurofibromatosis and epilepsy, was observed on multiple occasions lying in bed with a nasal cannula in place while the oxygen concentrator was set between 4 and 5 liters per minute. Each time, the water humidification container at the bedside was empty, and the inside of the container was covered in a white film. The container was dated 11/25 in black marker during each observation. The resident’s record showed an order for continuous oxygen at 3 to 5 liters per minute via nasal cannula and an order to change and date the oxygen, tubing, water bottle, and bag every Sunday on night shift. The resident’s care plan included oxygen therapy and related respiratory interventions. During interview, the resident stated staff did not check the oxygen concentrator setup often. An LPN stated staff should check the oxygen level and water container level on each shift, and the Corporate Nurse Consultant stated nursing staff were expected to assess each resident using oxygen on each shift, including confirming the equipment was set appropriately and the water level was adequate.
QAPI Program Failed to Address Repeat Medication Labeling Deficiencies
Penalty
Summary
The facility failed to develop and implement approaches to maintain a QAPI program to prevent repeat deficiencies related to drug labeling and storage. Review of the Summary Statement of Deficiencies from the facility’s last annual recertification and licensure survey, completed on 12/17/24, showed deficiencies related to unlabeled medications. During interview, the ADON stated the QAA committee met each morning and monthly to discuss current facility concerns, with falls identified as the current nursing topic, and that weekly audits were in place for medication carts. On 1/9/26, review of the current QAPI binder showed it lacked any audits for repeat deficiencies. Repeat concerns regarding medication storage and labeling were cited again during the 1/5/26 survey, when the facility failed to store medications according to professional standards relating to unlabeled medications for 2 of 4 medication carts reviewed, specifically the 100 East and 100 West carts. An undated facility policy provided by the ADON stated the committee would identify opportunities for improvement, address breakdowns in systems or processes, develop and implement improvement or corrective action plans, and continuously monitor effectiveness of interventions at each monthly meeting.
Incorrect Transmission-Based Precautions for Resident with C. Auris
Penalty
Summary
The facility failed to implement the correct infection control precautions for a resident who had a catheter and was later identified as positive for Candida Auris (C. Auris). The resident’s record showed a current order for strict isolation/contact isolation, and the care plan described isolation for observation for signs and symptoms of C. Auris. The record also indicated that all therapies, meals, and activities were to be provided in the room every shift, and progress notes documented that the resident remained on isolation for C. Auris. During observation, the resident’s door had an orange Enhanced Barrier Precautions (EBP) sign and PPE hanging on the door. Staff interviews showed confusion about the meaning of the sign and the correct precautions. An LPN stated she wore a gown, gloves, and mask for all care and believed the resident’s isolation sign was not the correct precaution. A CNA, laundry aide, housekeeper, and other nursing staff described the orange EBP sign as indicating that gown, gloves, and a face mask should be worn, and several stated they were unsure of the difference between EBP and contact isolation. The laundry aide entered the resident’s room to deliver clean laundry while wearing only a surgical face mask and without donning additional PPE. The Infection Preventionist stated the resident had been in EBP due to the catheter, but after being contacted by the health department and corporate nurse consultant, she acknowledged that CDC recommendations required contact isolation for the resident’s C. Auris infection rather than EBP. The corporate nurse consultant also stated the resident should have been moved into contact isolation per CDC guidelines.
Failure to Offer and Document Pneumococcal Vaccinations
Penalty
Summary
The facility failed to offer and administer appropriate pneumococcal vaccinations for 3 of 5 residents reviewed for infection control. Resident 56 had diagnoses of COPD, neurofibromatosis, and epilepsy, and was cognitively intact on the 12/30/25 significant change MDS. The record showed a historical unspecified pneumococcal vaccination given before admission, but there was no Pneumococcal Vaccine Consent or Declination Form and no documentation that the vaccine had been offered. Resident 61 had diagnoses of schizophrenia, type 2 diabetes mellitus, and hypertension, and was cognitively intact on the 10/28/25 quarterly MDS. The record showed historical unspecified pneumococcal vaccinations on 5/19/16 and 12/21/23, but there was no Pneumococcal Vaccine Consent or Declination Form and no additional offerings of the vaccine since 2023. Resident 8 had diagnoses of generalized anxiety disorder, unspecified cerebral infarction, and delusional disorders, and was cognitively intact on the 12/19/25 quarterly MDS. The record contained no historical pneumococcal vaccination information, no Pneumococcal Vaccine Consent or Declination Form, and no documentation that the vaccine had been offered. During interview, the Infection Preventionist stated she reviewed admission paperwork for vaccination information, but it did not always contain vaccination history and residents or representatives were not always familiar with their history. She stated any information found was documented in the EMR immunizations tab and that consent and declination forms were uploaded to the chart. The facility policy stated residents are assessed for pneumococcal vaccine eligibility prior to or upon admission and, when indicated, are offered the vaccine series within 30 days of admission unless medically contraindicated or the resident has completed the current recommended series.
Failure to Notify Resident Before Roommate Change
Penalty
Summary
The facility failed to provide written notice to a cognitively intact resident before changing his roommate. Resident B’s record showed diagnoses of opioid abuse, alcohol use, chronic pain, major depressive disorder, and anxiety disorder, and a significant change MDS assessment indicated he was cognitively intact and required set-up assistance for all activities of daily living. During interview, Resident B stated that in December, while he was out of his room, the facility brought in a new roommate and he did not know he had a roommate until he returned and found the new resident already there. Record review showed no notification to Resident B before the roommate change on 12/17/25. The ADON stated the Social Service Director was responsible for notifying residents when they were going to receive a roommate, and the SSD said she usually notified residents verbally and documented it in a progress note, but she could not provide evidence that Resident B was notified before the roommate was placed in the room. The SSD also stated the roommate was changed because of previous roommate incompatibility, and the corporate nurse consultant confirmed residents had the right to be notified before receiving a new roommate.
Failure to Prevent and Report Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to prevent resident-to-resident sexual abuse involving two cognitively impaired residents and another resident who was cognitively intact but had intellectual disabilities. On the day of the incident, one resident was found in another resident's room with his pants down and an erect penis, while the cognitively impaired resident was sitting on the bed with saliva on his face and mouth. Later that same day, another cognitively impaired resident was found with feces and blood on his shirt and incontinence brief, which appeared to have been tampered with, while the same perpetrating resident was in the room with feces and blood on his hands, performing self-gratification of his rectum. The affected resident indicated to police that the perpetrator had manipulated both his own and the victim's penis in a sexual manner, despite the victim's attempts to resist and call for help. Staff observations and interviews revealed that the incidents were not immediately recognized or reported as sexual abuse. Staff initially believed the interactions may have been mutual or related to behavioral issues, and did not want to embarrass the residents. The events were reported up the chain of command as concerns about hygiene, infection prevention, or behavioral issues, rather than as potential sexual abuse. Documentation in the clinical records was incomplete, lacking details about the events and failing to address the condition of the residents' genitals or rectum. The facility's abuse prevention policy required immediate notification of the Administrator, DON, and Social Services Director, as well as appropriate documentation and reporting to state agencies, but these procedures were not fully followed at the time of the incidents. The residents involved had significant cognitive and physical impairments, with one being non-verbal and dependent for care, and the other having moderate cognitive impairment and requiring supervision for activities of daily living. The perpetrating resident was cognitively intact but had a history of intellectual disabilities and behavioral issues, including a tendency to insert objects into his rectum. Despite these known risks, there was no care plan addressing sexually inappropriate behaviors, and staff did not implement adequate interventions to prevent recurrence. The facility's failure to recognize, document, and report the incidents as abuse, as well as the lack of comprehensive behavioral interventions, led to the deficiency.
Failure to Timely Report and Document Resident-to-Resident Sexual Abuse Allegations
Penalty
Summary
The facility failed to immediately report allegations of resident-to-resident sexual abuse to the Administrator and the State Agency, as required by policy. On two separate occasions, a cognitively impaired resident was found in a compromising situation with another resident who was cognitively intact but had intellectual disabilities. In one incident, a resident was found on another resident's bed with the other resident exposing his erect penis, and the first resident had saliva on his face and mouth. In another incident later the same day, a resident was found with feces and blood on his shirt and brief, while his roommate was in the same room performing self-gratification of his rectum, with feces and blood on his hands. The affected resident indicated to police that his roommate had manipulated both his own and the affected resident's penis in a sexual manner, despite being told to stop. Staff members observed and reported these incidents to various supervisors and managers, but the information was not promptly or accurately relayed to the Administrator or the State Agency. The facility's own policy required immediate notification of the Administrator and/or DON, as well as reporting to the state/certification agency, Ombudsman, and Adult Protective Services as applicable. However, the Administrator was not made aware of the potential sexual nature of the incidents until the following day, after the resident's family had been anonymously informed and contacted the police. The initial self-reported incident submitted to the State Agency did not identify the allegation as sexual abuse, and there was no indication that the incident involving the other resident was reported at all. The clinical records for the involved residents lacked documentation of the events, and skin assessments performed did not address the genitals or rectal areas, despite the nature of the allegations. The facility's failure to follow its abuse reporting policy resulted in a delay in protecting residents from further abuse and in notifying the appropriate authorities. The deficiency was identified through interviews, record reviews, and review of staff statements, which revealed inconsistencies and gaps in the reporting and documentation of the incidents.
Failure to Investigate and Protect Residents Following Alleged Sexual Abuse
Penalty
Summary
The facility failed to initiate investigative protocols and protective interventions in response to allegations of resident-to-resident sexual abuse involving two cognitively impaired residents and another resident with intellectual disabilities. On the day in question, one resident was found in another resident's room with the latter exposing himself, while the first resident had saliva on his face and mouth. Later that same day, another resident was found with feces and blood on his shirt and brief, while the same alleged perpetrator was in the room performing self-gratification. Staff observed these incidents and reported them to a qualified medication aide (QMA), but there was confusion regarding the chain of command and the appropriate steps to take. The QMA and other staff were not trained in interviewing residents about abuse, and their actions did not follow established protocols for abuse investigation. The facility's documentation and communication regarding the incidents were incomplete and inconsistent. The clinical records for the involved residents lacked documentation of the events, and skin assessments performed did not address the genital or rectal areas as would be expected in cases of alleged sexual abuse. The facility's self-reported incident to the state did not indicate an allegation of sexual abuse, and the administrator did not include this information in the report. Family members of one resident were informed of the incident by anonymous staff calls rather than by the facility, leading to concerns about transparency and a possible cover-up. The facility's abuse prevention policy required immediate notification of leadership, documentation, and reporting to state agencies, but these steps were not fully followed. Interviews with staff revealed that several employees, including CNAs, QMAs, and nurses, were involved in responding to the incidents but did not consistently communicate the nature of the events or follow the facility's abuse protocols. Some staff attempted to interview residents without proper training, and there was a lack of clarity about who was responsible for initiating an investigation. The administrator and DON were not fully informed of the sexual nature of the incidents until after the family contacted the police. The facility did not complete a comprehensive review of their abuse policy and procedures, and the events were not properly documented or investigated according to regulatory requirements.
Failure to Immediately Report Staff-to-Resident Verbal Abuse
Penalty
Summary
Staff failed to implement the facility's abuse prevention policy when an incident of staff-to-resident verbal abuse was not immediately reported as required. On the morning of the incident, a Qualified Medication Aide (QMA) was overheard by a Licensed Practical Nurse (LPN) using inappropriate and disrespectful language toward a resident, who subsequently became upset and cried. The LPN did not report the incident immediately, instead spending time with the resident to calm him down. Another Certified Nursing Assistant (CNA) also stayed with the resident. The QMA left the area after the incident. The resident involved had diagnoses including schizophrenia, convulsions, morbid severe obesity with alveolar hypoventilation, and hypertension. The incident was not reported to facility administration until several hours later, delaying the initiation of an internal investigation and reporting to state authorities. The facility's policy required immediate reporting of any abuse or suspicion of abuse to the Administrator, which was not followed in this case.
Failure to Protect Resident from Verbal Abuse by Staff
Penalty
Summary
A resident with diagnoses including schizophrenia, convulsions, severe obesity with alveolar hypoventilation, and hypertension was subjected to verbal abuse by a Qualified Medication Aide (QMA). The QMA was overheard by an LPN using inappropriate and disrespectful language, specifically telling the resident to clean his room using profanity. The resident became visibly upset and was crying as a result of the incident. The QMA left the room immediately after the incident, and the LPN spent time with the resident to calm him down, with additional support provided by a CNA. The incident was not reported immediately by the LPN who witnessed it, as she believed the resident was safe after the QMA left. The resident later confirmed feeling hurt and upset by the QMA's actions. The facility's policy requires residents to be free from all forms of abuse, including verbal abuse, but this policy was not followed in this instance, as the staff member's actions directly resulted in emotional distress for the resident.
Failure to Assess Psychosocial Harm After Verbal Abuse Allegation
Penalty
Summary
The facility failed to follow its abuse investigation policy by not providing psychosocial assessments for vulnerable, cognitively impaired residents after an allegation of staff-to-resident verbal abuse. The incident involved a staff member using inappropriate language toward a resident, which was reported to the state. During the investigation, the facility conducted staff re-education, staff interviews, interviews of cognitively intact residents, and skin assessments, but did not include psychosocial evaluations for non-verbal or cognitively impaired residents as required by policy. Specifically, three residents with significant cognitive impairments and diagnoses such as dementia, anxiety, depression, and schizophrenia did not receive psychosocial assessments during the investigation period. These residents were not interviewable at the time of the survey, and their clinical records lacked documentation of any evaluation of their psychosocial status following the alleged abuse. The facility's policy required observation and documentation of behavior, affect, and response to interaction for such residents, but this was not completed.
Failure to Provide and Maintain Dated Storage Bags for Oxygen Equipment
Penalty
Summary
Surveyors observed that the facility failed to provide and maintain dated storage bags for oxygen administration equipment for three residents who required oxygen therapy. Specifically, one resident's nasal cannula was found draped over the back of a wheelchair and lying in the seat, with no storage bag present. Another resident's nasal cannula was tucked into a pocket on the back of a wheelchair, also without a storage bag. In a third case, a resident's oxygen concentrator had the tubing and nasal cannula rolled up and anchored under the handle, again with no dated storage bag provided. During interviews, it was confirmed that storage bags were not consistently available or used, and the facility's policy required oxygen tubing and bags to be changed and dated weekly.
Failure to Maintain Clean and Orderly Shower Room
Penalty
Summary
The facility failed to maintain a clean and orderly shower room for resident use in one of four shower rooms observed. On two separate occasions, surveyors observed the 100 East hall shower room with significant cleanliness issues, including a soiled floor with standing water, open beverage containers, plastic wrappers, a bottle of powder in a dirty sink, a toilet bowl with dark rings, an uncovered trash container, a bag of linens on the floor, and a sheet draped over a shower chair and onto the floor. On a subsequent observation, there were multiple smears of feces on the floor, a visibly dirty sink, dark rings in the toilet bowl, and light-colored smears on the toilet seat. The Housekeeping Manager confirmed during the observation that the condition of the shower room was unacceptable. The facility's cleaning schedule indicated that shower rooms were to be cleaned daily.
Failure to Provide Consistent Bedtime Snacks
Penalty
Summary
The facility failed to provide evening snacks for a resident with specific dietary needs and for several residents as reported by the resident council. Resident 35, who has dementia, type II diabetes, and moderate protein-calorie malnutrition, had a physician's order for a peanut butter and jelly sandwich at bedtime as a nutritional supplement. However, multiple nurse's notes indicated that the ordered snack was not provided on several occasions due to a lack of supplies. The Dietary Manager was unaware of the issue, and the Unit Manager suggested that staff did not adequately seek out the snacks when they were unavailable in the pantry. During a resident council group interview, all seven residents expressed that bedtime snacks were frequently unavailable, an issue that had been raised in multiple meetings without resolution. The residents reported being told by staff that snacks were unavailable on most days of the week. A grievance form indicated that dietary staff were working on a new snack menu, but there was no follow-up documented. An audit showed that a significant number of residents did not receive bedtime snacks consistently. Confidential interviews revealed that the lack of snacks was a known issue, with staff sometimes using personal funds to purchase snacks for diabetic residents. The facility's policy on snacks was not effectively implemented, as evidenced by the lack of available snacks and the absence of staff education on the matter. The Dietary Manager was unaware of any snack menu, and the Activity Director noted that feedback from resident council meetings was not documented as instructed by management. The pantry was unusually well-stocked during the survey, suggesting that the issue was not consistently addressed. The lack of access to the kitchen by night shift staff further compounded the problem, leading to frustration among residents, particularly those with diabetes.
Failure to Provide Adequate Dementia Services for Wandering Resident
Penalty
Summary
The facility failed to provide appropriate dementia services for a resident diagnosed with Alzheimer's disease, restlessness, agitation, and generalized anxiety disorder, who exhibited intrusive wandering behavior. The resident's care plan, initiated in September 2023, aimed to keep the resident safe from wandering. However, multiple behavior notes from November 2024 documented the resident's persistent wandering into other residents' rooms, causing disturbances and requiring frequent redirection. Despite attempts to redirect the resident with activities such as watching TV and providing snacks, these interventions were unsuccessful. On December 12, 2024, the resident was moved to a secured behavior unit due to ongoing wandering concerns, but the clinical record lacked documentation of a plan to mitigate risks or ensure a successful transition. Following the move, the resident was involved in an incident where he was injured after entering another resident's room, leading to his relocation back to his previous hall with 15-minute checks initiated. The facility's administrator acknowledged the absence of a plan to support the resident's transition and safety, despite the resident's known history of intrusive wandering.
Medication Labeling Deficiency
Penalty
Summary
The facility failed to properly label medications with resident identifying information in one of the medication carts and one of the medication storage rooms. During an observation of the 100 East Unit medication cart, it was found that two medication cups containing pills were not labeled with any resident identifiers. An LPN indicated that the medications were pre-set for a resident who was not yet out of bed, and although she knew who the medications belonged to, others would not be able to identify them due to the lack of labeling. In the 200 Unit Medication Storage Room, two unopened Trulicity single-dose pens were found in the medication refrigerator without any resident identifiers or instructions for administration. An LPN confirmed that without labels, it was impossible to determine the ownership of the medications, and they would need to be destroyed. The facility's policy, revised in April 2019, requires all medications to be properly labeled in accordance with state and federal guidelines, which was not adhered to in these instances.
Failure to Prevent Serving Dairy to Resident with Allergy
Penalty
Summary
The facility failed to ensure that a resident with a documented dairy allergy was not served food containing dairy. Resident 72, who has a severe cognitive impairment and multiple food allergies including dairy, was observed being served sherbet containing whey and skimmed milk. This occurred despite the resident's meal ticket clearly indicating no dairy products due to allergies. The incident was witnessed during a meal service observation, where Dietary Aide 13 placed the sherbet on the resident's meal plate. The dietary staff, including Cook 12, Dietary Aide 13, the Dietary Manager, and the Registered Dietitian, were present when the sherbet was placed on the tray. None of these staff members recognized that sherbet contained dairy products, indicating a lack of understanding of the ingredients. The facility's policy on food allergies and intolerances, dated 2017, states that residents with food allergies should be identified and offered appropriate substitutions, but this policy was not effectively implemented in this instance.
Food Handling Deficiency Due to Improper Glove Use
Penalty
Summary
The facility failed to ensure food was served in a manner that prevented possible contamination, affecting 69 residents who consumed meals prepared in the facility kitchen. During a lunch meal service, a cook was observed using her gloved hands to handle a bread bag, which contaminated the gloves. She then used the same gloves to pick up individual slices of bread, place them into plastic serving bags, and handle baked potatoes, utensils, plates, bowls, and trays. This process was repeated without changing gloves, leading to potential food contamination. The cook, when interviewed, indicated she was unaware that she had contaminated her gloves and subsequently the food. The facility's policy, dated April 2019, clearly stated that bare hand contact with food is prohibited, and gloves should be changed between tasks. Disposable gloves are intended for single use and should be discarded after each use. The cook's actions were in direct violation of this policy, as she failed to change gloves between handling different items, leading to the contamination of food served to residents.
Delayed Documentation of Physician and NP Visits
Penalty
Summary
The facility failed to ensure that physician and nurse practitioner notes were documented and signed at the time of the visit for six residents. Resident B, with diagnoses including anxiety, depression, and diabetes mellitus, had a care visit by a nurse practitioner that was not documented until 72 days later. Similarly, Resident C, diagnosed with schizoaffective disorder, hypertension, and chronic obstructive pulmonary disorder, had a care visit note documented 55 days after the visit. Resident D, with conditions such as diabetes mellitus, depression, dementia, and hypertension, experienced delays in documentation ranging from 44 to 51 days for multiple visits. Resident E, diagnosed with anxiety, depression, and obesity, had an admission progress visit documented 126 days after the visit, with other visits also experiencing significant delays. Resident F, with schizoaffective disorder, bipolar disorder, and diabetes mellitus, had care visit notes delayed between 39 and 61 days. Resident G, diagnosed with depression, anxiety, and bipolar disorder, had a care visit documented 41 days after the visit. The facility's administrator acknowledged the issue of untimely documentation and indicated that an action plan was in development, although it had not been fully implemented at the time of the report.
Failure to Ensure Timely Physician and NP Visits
Penalty
Summary
The facility failed to ensure that physician visits occurred at the regulatory required frequency and that nurse practitioner visits alternated with a physician for required visits for six residents. Residents B, C, D, E, F, and G were all affected by this deficiency. Each resident had a primary care physician designated as the facility's Medical Director, and Nurse Practitioner 3 was identified as one of their medical care providers. However, the records showed significant gaps in the required face-to-face visits by either the physician or the nurse practitioner. Resident B had not had a physician visit since July 6, 2024, and had not seen either a physician or nurse practitioner since July 9, 2024, totaling 128 days without a visit. Resident C had a nurse practitioner visit on September 5, 2024, but had not seen a physician within the next 70 days. Resident D, admitted to the facility, had a nurse practitioner visit on July 18, 2024, but had not had a physician's visit since admission, a period of 130 days. Similarly, Resident E had not had a physician or nurse practitioner visit since July 27, 2024, totaling 111 days. Resident F had not had a physician or nurse practitioner visit since August 29, 2024, totaling 121 days. Resident G had not had a visit since August 8, 2024, totaling 99 days. Confidential interviews with residents indicated a lack of awareness of having a doctor, with some residents only seeing the nurse practitioner and others not having seen a doctor at all.
Failure to Investigate Allegation of Abuse Thoroughly
Penalty
Summary
The facility failed to thoroughly investigate an allegation of physical abuse involving a cognitively impaired resident, identified as Resident F, by a staff member, CNA 1. The incident was reported on 8/6/24, where CNA 1 allegedly grabbed Resident F by the arm and attempted to pull the resident away while in the hallway. The facility's investigation, as noted in the self-reportable document, included interviews with staff who witnessed the incident but did not extend to other staff members or residents to determine if there were additional concerns regarding abuse. Resident F's clinical record indicated severe cognitive impairment, with diagnoses including Alzheimer's Disease, pulmonary fibrosis, rheumatoid arthritis, stage 3 chronic kidney disease, and dementia with behavioral disturbances. During an interview, Resident F was unable to answer screening questions accurately. The facility's current Abuse Prevention and Prohibition Policy, dated 2/1/23, requires that investigations include attempts to interview non-verbal or cognitively impaired residents, or at least observe and document their behavior and responses. However, the facility's investigation did not include interviews or assessments of other residents, as confirmed by the Administrator.
Lack of Privacy for Residents Using Facility Telephone
Penalty
Summary
The facility failed to ensure residents had privacy while using the facility telephone. Resident E indicated that she used the phone at the nurses' station, where everyone could hear her conversations. The Social Service Director was unaware that Resident E needed a phone and mentioned that there were no landlines in the residents' rooms. Instead, residents used an office phone at the nurses' station, which did not provide privacy. Resident K was observed squatting in front of the nurses' station to use the phone, and QMA 7 confirmed that Resident E could only move as far as the phone cord allowed for privacy. The Administrator acknowledged that some residents had cell phones and that there were government cell phones available, but they had not been activated. Multiple staff members, including QMA 7 and CNA 14, confirmed that residents regularly used the nurses' station phone without a private place to talk. The facility did not have a policy related to residents' privacy while using the phone. This deficiency was identified during a complaint investigation.
Failure to Implement Physician's Orders and Monitor Bowel Movements
Penalty
Summary
The facility failed to ensure that physician's orders for blood glucose monitoring were initiated and implemented for a resident receiving insulin. Resident H, who had multiple diagnoses including type 2 diabetes mellitus and severe dementia, had physician's orders to check blood sugar three times daily and to notify the physician if blood sugar levels were outside specified ranges. However, the clinical record lacked current orders for blood sugar checks and monitoring, and the facility staff missed the order for blood sugars in September. This oversight was confirmed during an interview with the DON and the Administrator, who acknowledged that the order did not flow over to the medication/treatment administration records and was missed during the review process. The facility also failed to monitor bowel movements for four residents reviewed for bowel management. Resident B, who had a diagnosis of ventral hernia and obesity, had physician's orders for medication to treat constipation but lacked bowel movement monitoring documentation for multiple dates in April and May 2024. Similarly, Resident E, who had a diagnosis of constipation, had physician's orders for various medications to treat constipation but also lacked bowel movement monitoring documentation for several dates. Resident F, who had a diagnosis of hemiplegia and hemiparesis following cerebral infarction, had physician's orders for medications to treat constipation but lacked bowel movement monitoring documentation for specific dates. Resident H, who had a diagnosis of moderate protein-calorie malnutrition, also lacked a care plan for bowel management or constipation. The facility's bowel movement documentation was incomplete, and interviews with facility staff revealed inconsistencies in how bowel movements were documented and monitored. The facility's policy on bowel management was not followed, leading to gaps in documentation and monitoring of residents' bowel movements.
Failure to Follow Protocol for Administering Psychoactive Medication
Penalty
Summary
The facility failed to ensure a psychoactive medication was not administered to manage behavioral expressions without an order from a medical provider. Resident B, who had diagnoses including hypertension, alcohol dependence with alcohol-induced persisting dementia, and vascular dementia with agitation, was administered lorazepam 2 mg by LPN 1 without securing an order from the medical provider and without calling the pharmacy for confirmation. The medication was taken from the emergency medication kit without following the proper protocol, which requires two nurses to obtain medication from the kit and confirmation from the pharmacy. During interviews, it was revealed that LPN 1 claimed to have received a one-time order for lorazepam from NP 2, but NP 2 indicated she instructed LPN 1 to call NP 3 and did not give an order for lorazepam. NP 3 also confirmed that she did not give an order for any medications for Resident B. The facility's policy requires obtaining an order for controlled substances and contacting the pharmacist for an authorization code when emergency dispensing is needed, which was not followed in this case.
Failure to Address Behavioral Health Needs and Ensure Resident Safety
Penalty
Summary
The facility failed to identify and address the behavioral health needs of three residents, leading to significant safety concerns. Resident D, who had a history of substance abuse, was found with syringes containing a dark sticky substance in his room. The facility did not conduct a preadmission assessment to identify his needs and failed to develop an individualized care plan to ensure his safety and the safety of others. Staff members were not formally informed of his substance abuse history, and there was no behavior monitoring or management plan in place for him. The resident had visitors, and one visitor was suspected of bringing the syringes into the facility. The facility's psychiatric services were also not informed of his substance abuse history, and no safety plan was developed following the discovery of the syringes. Resident C, who had a history of sexually inappropriate behaviors and dementia, was found in bed with Resident B, both undressed from the waist down. The facility did not conduct a preadmission assessment for Resident C and failed to develop an individualized care plan to address her sexually inappropriate behaviors and wandering. Staff members were not informed of her history, and there was no behavior monitoring or management plan in place. The facility had been working to find a female-only dementia unit for her but had not documented or planned for this need. Resident C's inappropriate behavior history was not communicated to the staff, leading to the incident with Resident B. Resident B, who also had dementia, was involved in the incident with Resident C. His clinical record did not indicate any history of wandering or sexually inappropriate behaviors. The facility lacked a formal system to manage resident behaviors, and staff had to rely on getting to know the residents and using general approaches. The facility's policy on behavior management was not effectively implemented, leading to the failure to address the behavioral health needs of the residents and ensure their safety.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Muncie
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Brookside Care Strategies | 1.7 mi | — | 49 | 0 |
| Envive Of Muncie | 1.7 mi | ★★★★★ | 12 | 0 |
| Waters Of Muncie, The | 3.2 mi | ★★★★★ | 0 | 0 |
| Signature Healthcare Of Muncie | 3.8 mi | ★★★★★ | 30 | 0 |
| Waters Edge Village | 4.2 mi | ★★★★★ | 5 | 0 |
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