Increase in Long-Term Care Residents with Serious Mental Illnesses Presents Challenges for Facilities and Staff: Case Reports

Main Article Content

Alyssa Pischel Ruth M. Tappen Karen Southard


Background. The increase in the number of residents with severe mental illness and/or substance use disorder in long-term care facilities in the United States presents serious challenges to those seeking admission to these facilities, their staff, and facility administrators.

Aims. Our purpose is to illustrate the situations for which long-term care facilities have been cited for failure to meet standards of care related to their residents' psychosocial well-being and behavioral expressions.

Methods. Publicly available data was accessed from several U.S. Centers for Medicare and Medicaid Services (CMS) data centers. Data obtained included the percentage of facilities that received citations for seven F-tags (a federal coding system) most relevant to effectively addressing residents' psychosocial well-being and behavioral expression needs. Case reports related to each of the selected standards (F-tags) were identified and summarized, and data on the facility involved was obtained for each case report.

Results. In the first half of fiscal year 2024, 25% of the long-term care facilities surveyed were cited for deficiencies related to protecting residents from abuse or neglect, and 19% were cited for failing to keep residents as free as possible from unnecessary psychotropic medication. The case studies illustrate the wide range of behavioral expressions that need to be addressed, from severe withdrawal and attempts to self-harm to sexual approaches to other residents to purposeful soiling of bed linens and aggression toward staff or other residents. In many instances, it was clear that facility staff did not know the requirements for an adequate response to the situation or how to respond effectively.

Conclusions. The case studies and related data reveal multiple, often interacting, assessment and care challenges that many long-term care staff are not prepared to handle effectively. They demonstrate the adverse impacts of untreated negative behavioral expressions and consequently suggest that staff may be unprepared to manage these multifaceted conditions. Poorly resourced facilities need support to adequately respond to this ever-growing, complex mix of service needs, less than generous reimbursement structures, and resident demographics.

Keywords: psychosocial and behavioral expression, serious mental illness, substance use, long-term care, nursing homes, skilled nursing facility, star ratings, health inspection survey

Article Details

How to Cite
PISCHEL, Alyssa; TAPPEN, Ruth M.; SOUTHARD, Karen. Increase in Long-Term Care Residents with Serious Mental Illnesses Presents Challenges for Facilities and Staff: Case Reports. Medical Research Archives, [S.l.], v. 12, n. 6, june 2024. ISSN 2375-1924. Available at: <>. Date accessed: 22 july 2024. doi:
Research Articles


1. European Commission, Directorate-General for Employment, Social Affairs and Inclusion. (2021). Long-term care report – Trends, challenges, and opportunities in an aging society. Volume II, Country profiles. Publications Office, 2021. Retrieved from

2. Yon Y, Ramiro-Gonzalez M, Mikton CR, Huber M, Sethi D. The prevalence of elder abuse in institutional settings: a systematic review and meta-analysis. Eur J Public Health. 2019;29(1):58-67. doi:10.1093/eurpub/cky093

3. Roberts, A., Ogunwole, S., Blakeslee, L., Rabe, M. (2018). The population 65 years and older in the United States: 2016. American Community Survey Reports, US Census Bureau. October 2018 (ACS-38). Retrieved from

4. Suriaga, A., Tappen, R., & Newman, D. (2023). The associations of opioid use in gun-related fatalities among older decedents in Florida. Innovation in Aging, 7(IS1), p. 834.

5. Ryan, T., Pearsall, A., Hatfield, B., & Poole, R. (2004). Long term care for serious mental illness outside the NHS: A study of out of area placements. Journal of Mental Health, 13(4), 425–429.

6. Botngård A, Eide AH, Mosqueda L, Malmedal W. Elder abuse in Norwegian nursing homes: a cross-sectional exploratory study. BMC Health Serv Res. 2020;20(1):9. Published 2020 Jan 3. doi:10.1186/s12913-019-4861-z

7. Fashaw, S., Thomas, K, McCreedy, E., Mor, V. (2020). Thirty Year Trends in Nursing Home Composition and Quality Since the Passage of the Omnibus Reconciliation Act. Journal of American Medical Director Association. 20 (2020) 233–239. DOI: 10.1177/233372142211 01260

8. Krauss, N.A., & Altman, B.M. (2004). Research Findings #5: Characteristics of Nursing Home Residents, 1996. Agency for Healthcare Research and Quality, Rockville, MD.

9. Lind, L. (2021). Meeting the emotional and behavioral needs of younger residents in long-term care. Caring for the Ages, pp 9–10. Retrieved from

10. McGarry, B., Joyce, N., McGuire, T., Mitchell, S., Bartels, S., Grabowski, D. (2019). Association between high concentrations of seriously mentally ill nursing home residents and quality of resident care. Journal of American Geriatric Society. 67(11). 2346-2352. DOI: 10.1111/jgs.16080

11. US General Services Administration, Department of Information and Regulatory Affairs (2015). Federal Register, Department of Health & Human Services, Centers for Medicare & Medicaid, 42 CFR Parts 405, 431, 447, 482, 483, 485, and 488. 80(136); 42168- 42269. Retrieved from

12. Kalideen, L., Govender, P., Van Wyk, J. (2022). Standards and quality of care for older persons in long term care facilities: a scoping review. BMC Geriatrics. 22(1):226. DOI: 10.11 86/s12877-022-02892-0

13. US Department of Health & Human Services, Centers for Medicare & Medicaid Services. (2024) State Operations Manual PP. Centers for Medicare & Medicaid. Retrieved from

14. US Department of Health & Human Services, Centers for Medicare & Medicaid (2023). Design for Care Compare nursing home five-star quality rating system: technical users’ guide. September 2023. Retrieved from

15. US Department of Health & Human Services, Centers for Medicare & Medicaid Services. (2024) S & C QCOR - Quality, certification, and oversight reports. Retrieved from

16. US Department of Health & Human Services, Centers for Medicare & Medicaid Services (2024). State Operations Manual, Chapter 7 survey and enforcement processes for skilled nursing facilities. Retrieved from

17. Stake, R.E. (1994) Case Studies. In: Denzin, N.K. and Lincoln, Y.S., Eds., Handbook of Qualitative Research, Sage, Thousand Oaks, 236-247.

18. Miles, M., Huberman, M., & Saldaña, J. (2020). Qualitative data analysis: A methods sourcebook (4th ed.). SAGE Publications.

19. Fullerton, C. A., McGuire, T. G., Feng, Z., Mor, V., & Grabowski, D. C. (2009). Trends in mental health admissions to nursing homes, 1999–2005. Psychiatric Services, 60(7), 965–971.

20. Xu, H., Intrator, O., Culakova, E., Bowblis, J. (2022). Changing landscapes of nursing homes serving residents with dementia and mental illness. Health Services Research. 57(3). 505-514. DOI: 10.1111/1475-6773.13908

21. Hugunin, J., Chen, Q., Baek, J., Clark, R., Lapane, K., Ulbricht, C. (2022). Quality of Nursing Homes Admitting Working-Age Adults with Serious Mental Illness. Psychiatric Services. 73(7) 745-751. DOI: 10.1176/ .202100356

22. Sanvisens A, Hernández-Rubio A, Zuluaga P, et al. Long-Term Outcomes of Patients With Cocaine Use Disorder: A 18-years Addiction Cohort Study. Front Pharmacol. 2021;12:625610. Published 2021 Feb 18. doi:10.3389/fphar.2021.625610

23. Bartels, S. (2004). Caring for the whole person: Integrated health care for older adults with severe mental illness and medical comorbidity. Journal of the American Geriatrics Society. 52(12).S249-S257. DOI: 10.1111/j.1532-5415.2004.52601.x

24. Bucy, T. Moeller, K. Shippee, T. (2022). Serious Mental Illness in the Nursing Home Literature: A Scoping Review. Sage Journals. DOI: 10.1177/23337214221101260

25. Jester, D. J., Hyer, K., Bowblis, J. R. (2020). Quality concerns in nursing homes that serve large proportions of residents with serious mental illness. The Gerontologist, 60(7), 1312–1321.

26. Ryan, T. Pearsall, A., Hatfield, B., Poole, R. (2004). Long term care for serious mental illness outside the NHS: A study of out of area placements. Journal of Mental Health. 13:4, pp. 425–429. DOI: 10.1080/09638230410001 729861

27. Depla MF, Pols J, de Lange J, Smits CH, de Graaf R, Heeren TJ. Integrating mental health care into residential homes for the elderly: an analysis of six Dutch programs for older people with severe and persistent mental illness. J Am Geriatr Soc. 2003;51(9):1 275-1279. doi:10.1046/j.1532-5415.2003.51413.x