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
- 46
- Latest survey
- April 22, 2026
- Citations (last 12 mo.)
- 28 (3 serious)
Citation history
Health deficiencies cited at Cardinal Care Strategies during CMS and state inspections, most recent first.
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.
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.
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.
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 found that staff failed to follow physician orders for several residents, including not documenting required physician notification and new insulin orders after a critically high blood glucose, not consistently obtaining or recording ordered daily weights, and administering antihypertensive and midodrine medications despite blood pressure readings outside ordered hold parameters. Documentation on the MAR and related records included unexplained "NA," "X," and blank entries for required weights, and cardiac and BP-related medications were given when systolic blood pressure was below or above specified thresholds, contrary to written orders and facility policy.
Informed consent was not documented before a psychotropic med was started for one resident with dementia and anxiety, and it was not documented before another resident's Vraylar dose was increased for aggression. The DON stated the consent form should be completed before initiation or dose increase, and the facility policy required informed consent before starting or increasing a psychotropic med.
A resident with alcohol abuse, anxiety, and major depressive disorder was transferred to the ER and later planned for transfer to another LTC facility, but no Discharge MDS was completed. The MDS coordinator stated the discharge MDS was not done at discharge and should have been completed within the required timeframe; the facility did not have a resident assessment policy and used RAI criteria for timing.
An MDS assessment failed to accurately reflect a resident's status when an antidepressant prescribed for insomnia was not documented on the admission MDS. The resident had Alzheimer's disease and major depressive disorder, and the MDS coordinator later confirmed the assessment was incorrect.
A resident was observed receiving O2 via nasal cannula on multiple occasions, but the chart had no current physician order for O2. The resident said she had been told after a recent hospitalization to use O2 for 30 days, but that time had passed and she was still using it because staff told her she needed it. The DON confirmed there was no current O2 order; the last order had already been discontinued.
A resident with documented diagnoses of CHF, atherosclerotic heart disease, and pacemaker dependence was admitted with clear record entries noting the presence and use of a cardiac pacemaker, including in the admission evaluation, skin assessment, and a physician note. However, the resident’s care plan did not address the pacemaker at all. The MDS Coordinator acknowledged that the pacemaker should have been care planned, noting that while there is no specific MDS item for pacemakers, diagnosis codes or nursing assessments should trigger care plan development. The Unit Manager confirmed that nursing, social services, and the MDS Coordinator can add items to care plans, and the facility’s care plan policy—emphasizing resident-focused, safety-oriented care—was in place but not applied to this resident’s pacemaker.
A resident with acute respiratory failure with hypoxia, pulmonary hypertension, and type 2 diabetes was observed receiving oxygen at 4.5 L/min via nasal cannula without a corresponding physician order in the clinical record. The DON acknowledged that an order should have been in place before oxygen was initiated. Facility policy on supplemental oxygen via nasal cannula requires administration only under a physician or provider order, in alignment with 410 IAC 16.2-3.1-47(a)(6).
A resident was discharged to an acute care hospital, but review of MDS listings showed that no discharge MDS assessment was completed for that resident. The MDS Coordinator acknowledged that a discharge assessment is required whenever a resident leaves the facility and could not explain why it was missed. The Executive Director reported there was no specific facility policy for MDS assessments and that staff relied on the RAI manual for guidance.
A resident with a fractured wrist returned from an orthopedic visit wearing a new black wrist splint after the cast was removed, but the clinical record lacked an updated physician order and instructions for splint use and care. Staff also did not document follow-up with the physician, and the care plan was not revised when the splint began being used; the DON acknowledged the missing order and lack of a policy for obtaining updated physician information.
The facility failed to document assessment and monitoring of a resident’s bruising and post-procedure condition, and failed to follow ordered medication hold parameters for two residents. One resident returned from an outpatient spinal injection with no nursing note or assessment, another had persistent bruising with no documentation, and two residents received Metoprolol and midodrine despite pulse or BP values outside ordered limits. A separate resident was observed with purple discolorations and a black scab, but the skin record did not reflect assessment or monitoring.
Failure to Follow Physician Orders for Insulin, Daily Weights, and BP-Related Medications
Penalty
Summary
The deficiency involves multiple failures to follow physician orders for medication administration and monitoring. For one resident with type 2 diabetes, peripheral vascular disease, and failure to thrive, a physician’s order directed use of Humalog insulin per a specific sliding scale and required physician notification if blood glucose exceeded 400. A blood sugar of 470 was recorded on one date, and the Medication Administration Record (MAR) showed that 5 units of Humalog were given, but there was no documentation in the MAR, assessment tab, or progress notes that the physician was contacted or that new insulin orders were obtained, despite the DON later stating that an additional 5 units had been ordered. Two residents with orders for daily weights did not have those weights consistently obtained or documented as ordered. One resident with heart failure, hypertension, and chronic kidney disease had a physician’s order for daily weights on dayshift, but on multiple dates in February, March, and April, the MAR/TAR and related documentation showed entries marked as “NA,” “X,” or left blank, with no recorded weights, no physician notification, and no explanation for the missing data. Another resident with hypertension, anxiety disorder, and severe protein-calorie malnutrition also had a daily weight order, yet on numerous dates in April and May, weights were marked “NA” without corresponding weights, physician notification, or explanatory documentation; one weight entry was crossed out and the re-weight was not obtained until the following day. LPNs provided differing explanations for “NA” and “X,” indicating inconsistent understanding of documentation practices. Additional deficiencies occurred in the administration of cardiac and blood pressure–related medications contrary to ordered hold parameters. One resident with hypertension had orders for amlodipine, hydralazine, and losartan potassium, each with instructions to hold the medication if systolic blood pressure (SBP) was less than 110, yet the MAR showed these medications were administered on specific dates when the SBP was below the ordered hold threshold. Another resident with hypertension and systolic and diastolic congestive heart failure had been hospitalized for severe hypotension and returned on midodrine with an order to hold the medication if SBP was greater than 110; however, the MAR showed multiple doses were given on various dates when SBP was outside the ordered hold parameter. These actions were inconsistent with the facility’s own policies requiring medications to be administered only as prescribed and weights to be accurately obtained and documented, and they formed the basis of the cited quality of care deficiency.
Informed Consent Not Documented Before Psychotropic Medication Start or Increase
Penalty
Summary
The facility failed to ensure informed consent was obtained and documented before starting or increasing psychotropic medications for 2 residents reviewed for unnecessary medications. One resident with diagnoses including dementia with psychotic behaviors and anxiety had Rexulti 1 mg initiated for dementia with agitation, with the medication started the next day, but the Psychoactive Medication Consent and Management Agreement dated after the start lacked documentation from the resident's representative giving consent for the new psychotropic medication. Another resident with diagnoses including Alzheimer's disease, major depressive disorder, psychotic disorder, and anxiety had Vraylar increased from 1.5 mg to 3 mg for aggression, with the higher dose started the next day. The Psychoactive Medication Consent and Management Agreement was dated after the increase and documented telephone consent on that later date. The DON stated the consent form should be completed prior to initiation or increase of a new psychotropic medication, and the facility policy required informed consent to be obtained and documented before initiation or an increase in dosage, including discussion of risks, benefits, and alternatives.
Discharge MDS Not Completed Timely
Penalty
Summary
The facility failed to ensure the Discharge MDS assessment was completed within the required timeframe for Resident 108. The resident’s record showed diagnoses of alcohol abuse, anxiety, and major depressive disorder. A progress note dated 12/18/25 at 12:50 a.m. documented that the resident was transferred to the emergency room, and another note dated 12/18/25 at 11:38 a.m. stated the resident would be transferred to another LTC facility upon discharge from the hospital. Review of the resident’s MDS assessments showed that no Discharge MDS assessment had been completed. The RAI 3.0 User’s Manual indicated the Discharge MDS must be completed within 14 calendar days after the discharge date and submitted within 14 days after completion. During interview, the MDS coordinator stated the discharge MDS was not completed at discharge and should have been completed within 14 calendar days of the discharge date; she also stated the facility did not have a resident assessment policy and used the RAI tool criteria for completion timeframes.
Inaccurate MDS Assessment Failed to Document Antidepressant Medication
Penalty
Summary
The facility failed to ensure an MDS assessment accurately reflected a resident's status for 1 of 32 residents reviewed for MDS accuracy. Resident 23 had diagnoses including Alzheimer's disease and major depressive disorder. Review of the April 2026 MAR showed the resident was prescribed mirtazapine at bedtime on 4/2/26 for insomnia, but the 4/9/26 admission MDS assessment did not document an antidepressant prescription. During interview, the MDS coordinator stated the 4/9/26 MDS assessment was incorrect and should have included the antidepressant medication.
Missing Current Physician Order for Oxygen
Penalty
Summary
The facility failed to ensure a current physician's order was in place for a resident receiving oxygen via nasal cannula. Resident 3 was observed in her room on multiple occasions using oxygen from a humidifying oxygen delivery machine via nasal cannula. During interview, the resident stated she had been told after her last hospitalization to use oxygen for another 30 days, but that time had passed and she was still wearing the nasal cannula and receiving oxygen because staff told her she needed it; she also stated the nasal cannula bothered her and she did not want to wear it if it was not necessary. Review of the clinical record showed diagnoses including atrial fibrillation and anxiety, but no current oxygen order. The last oxygen order had a start date of 2/2/26 and a discontinued date of 2/23/26. The DON confirmed there was no current physician's order for oxygen for the resident.
Failure to Include Cardiac Pacemaker in Comprehensive Care Plan
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and implement a comprehensive care plan addressing a resident’s cardiac pacemaker. The resident was admitted with diagnoses including presence of a cardiac pacemaker, congestive heart failure, atherosclerotic heart disease, and heart failure with reduced ejection fraction, with documentation indicating pacemaker dependence. An admission skin assessment noted no skin issues other than the pacemaker, and an admission evaluation documented that the resident utilized a cardiac pacemaker device. A physician’s note further confirmed the resident’s pacemaker dependence as part of her medical history. Despite this documented history and device use, the resident’s care plans did not include any interventions or problem statements related to the pacemaker. During interviews, the MDS Coordinator acknowledged that the pacemaker was not included in the care plan and stated it should have been, explaining that although there is no specific MDS item for pacemakers, a diagnosis code or nursing assessment documentation should trigger care plan development. The Unit Manager reported that nursing, social services, and the MDS Coordinator all have the ability to add items to a resident’s care plan. The facility’s Plan of Care policy, provided by the DON, stated that the care plan is to be resident-focused, provide optimal personalized care, and prioritize resident safety, but this was not followed for the resident’s pacemaker.
Oxygen Administered Without Required Physician Order
Penalty
Summary
The facility failed to ensure physician orders were in place for oxygen administration for one resident receiving respiratory care. During an observation on 5/8/26 at 9:45 a.m., Resident 101 was noted to be receiving oxygen at 4.5 liters per minute via nasal cannula. Review of the resident’s clinical record later that day showed diagnoses including acute respiratory failure with hypoxia, pulmonary hypertension, and type 2 diabetes, but no physician’s order for the use of oxygen could be located at the time of review. In a subsequent interview on 5/12/26 at 8:14 a.m., the Director of Nursing stated that physician orders for oxygen should have been present in the record before oxygen was initiated. The facility’s undated policy titled “Supplemental Oxygen Using Nasal Cannula,” provided on 5/13/26, specified that supplemental oxygen may be administered via nasal cannula only at the order of a physician or provider, consistent with 410 IAC 16.2-3.1-47(a)(6). These observations, interviews, and record reviews demonstrate that oxygen was administered to Resident 101 without the required physician order, contrary to both facility policy and state regulatory requirements.
Failure to Complete Required Discharge MDS Assessment
Penalty
Summary
The deficiency involves the facility’s failure to complete a required discharge Minimum Data Set (MDS) assessment for one resident. Record review showed that Resident 90 was admitted on an unspecified date and discharged on 2/10/26 to an acute care hospital, but the MDS listings contained no completed discharge assessment for this resident. During interview, the MDS Coordinator confirmed that a discharge assessment should be completed whenever a resident is discharged and could provide no reason why this assessment was missed for Resident 90. In a separate interview, the Executive Director stated there was no facility policy regarding MDS assessments and that assessments were completed using the Resident Assessment Instrument (RAI) manual. These findings were cited under 410 IAC 3.1-31(d).
Missing Physician Order and Care Plan Update for New Wrist Splint
Penalty
Summary
The facility failed to ensure follow-up was obtained for physician orders and instructions after a resident returned from an orthopedic follow-up appointment with a new left wrist splint. The resident had a fractured carpal bone from a fall that occurred while in the facility and was severely cognitively impaired on the admission MDS. After the resident’s cast was removed at the orthopedic visit, the resident returned wearing a black splint with tie string and was to wear it at all times except for bathing, but the clinical record did not contain an updated physician order or associated instructions for the splint. The record also lacked documentation that facility staff contacted the physician to obtain the updated order and instructions, and the care plan was not revised when the splint was first used. During interviews, the Unit Manager and DON acknowledged that the care plan had not been updated until later and that the record lacked a physician order showing the cast had been discontinued and the splint ordered. The DON also stated the facility lacked a policy for obtaining updated physician orders, progress notes, and specific instructions for the facility.
Failure to document assessments and follow medication parameters
Penalty
Summary
The facility failed to provide care according to orders and documented parameters for multiple residents. One resident with diagnoses including stroke, dementia, and osteoarthritis had an outpatient medial branch block at a surgery center, but there were no nursing progress notes documenting the procedure, the time the resident left the facility, the time the resident returned, or any assessment of the bandage or the resident’s condition on return. The Director of Nursing stated there was no documentation or assessment when the resident came back from the outpatient procedure. Another resident was observed with a dark purple bruise to the left antecubital area on multiple observations, but the record contained no documentation of that bruising. The resident’s diagnoses included anxiety disorder, major depressive disorder, diabetes, heart failure, high blood pressure, and acute kidney failure. The resident had care plan entries related to bruising and bleeding risk from anticoagulant use and bruising from needle sticks, and weekly skin observations documented no bruises. The DON stated the resident had a blood draw, but there was no documentation regarding the bruise to the left arm. Two residents had medications administered outside ordered parameters. One resident received Metoprolol Tartrate 50 mg twice daily for high blood pressure with instructions to hold if pulse was less than 60, but the MAR showed doses given when the pulse was below 60 on several occasions. Another resident on hospice care received midodrine 5 mg three times daily with instructions to hold if systolic blood pressure was greater than 110, but the MAR showed the medication was administered multiple times when systolic blood pressure exceeded that limit. In addition, a resident was observed with purple discolorations and a black scab on the left forearm, wrist, and hand, but the weekly skin assessment documented no bruising and there was no documentation that the discolorations were assessed or monitored.
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