Cardinal Care Strategies
Inspection history, citations, penalties and survey trends for this long-term care facility in Muncie, Indiana.
- Location
- 4600 E Jackson St, Muncie, Indiana 47303
- CMS Provider Number
- 155400
- Inspections on file
- 45
- Latest survey
- January 9, 2026
- Citations (last 12 mo.)
- 26 (3 serious)
Citation history
Health deficiencies cited at Cardinal Care Strategies during CMS and state inspections, most recent first.
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 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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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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