Appleton City Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Appleton City, Missouri.
- Location
- 600 North Ohio, Appleton City, Missouri 64724
- CMS Provider Number
- 265843
- Inspections on file
- 25
- Latest survey
- February 27, 2026
- Citations (last 12 mo.)
- 2 (1 serious)
Citation history
Health deficiencies cited at Appleton City Manor during CMS and state inspections, most recent first.
A resident with schizophrenia, bipolar disorder, HTN, and type 2 DM was admitted with conflicting code status documentation: one page of the face sheet and the emergency book listed DNR, while another page of the face sheet, the physician’s orders, and a signed health care directive defaulted the resident to full code (CPR). One morning, a CNA found the resident unresponsive across the bed and summoned an RN, who noted no pulse, no respirations, and cyanosis but did not initiate CPR, relying on the DNR status shown in the emergency materials. Interviews with CNAs, LPNs, the MDS coordinator, SSD, DON, NP, Medical Director, and Administrator confirmed that, in the absence of a signed DNR or when documentation conflicted, the resident should have been treated as full code and CPR started, but this did not occur, leading to the cited deficiency.
A resident with significant mobility and cognitive impairments, who required staff assistance and a mechanical lift for transfers, was injured when a CNA hurriedly attempted to reposition the resident in a Broda chair without proper communication or technique. The CNA, who had not completed documented training or skills competency, pushed on a stuck lever, causing the resident to fall and sustain a mouth laceration and a hairline fracture. Staff and family interviews confirmed the CNA did not follow facility policy for safe repositioning.
A resident in a LTC facility made a threatening statement towards others during a smoke break, but the facility failed to report this potential abuse to the DHSS within the required two-hour timeframe. Staff intervened and documented the incident, but there was confusion about the reporting process, leading to a delay in notifying the appropriate authorities.
A resident with lung cancer and COPD was found with marijuana and unknown pills in their room, which were not documented in their care plan. The facility failed to follow its policies on incidents, smoking, and medication storage, leading to a deficiency. Staff were unaware of the resident's possession of these items, and there was a lack of communication and documentation regarding the incident.
A resident with a history of anxiety, depression, and insomnia exhibited distressing behaviors, including verbal aggression and refusal of care. The facility failed to implement non-pharmacological interventions, relying instead on medication adjustments. Despite policies emphasizing behavior understanding and minimizing psychoactive medication use, the facility did not provide consistent psychological services or behavior management, leading to a deficiency in care.
A resident with a history of depression and anxiety exhibited distressing behaviors, including yelling and refusing care, which were not adequately addressed by the Social Services Designee (SSD). The resident expressed unhappiness with the facility and a desire to move, but the SSD did not follow up or provide necessary interventions. The resident's behaviors were often related to smoking and dissatisfaction with staff response times, particularly during the evening shift. The SSD lacked training and was unaware of her responsibilities in monitoring and addressing residents' behaviors.
The facility failed to implement effective infection control practices, including Enhanced Barrier Precautions (EBP) and proper hand hygiene, during wound care for two residents. Staff did not follow standard practices, such as changing gloves or sanitizing hands between wound measurements, potentially contaminating wounds. Observations showed that staff lacked knowledge about EBP and did not consistently use personal protective equipment (PPE) during care.
A resident with multiple medical conditions and at risk for pressure ulcers did not receive consistent care and documentation for their wounds. The facility failed to perform weekly skin assessments and obtain treatment orders for all wounds. Observations showed multiple open areas on the resident's buttocks without corresponding treatment orders. Staff interviews revealed inconsistencies in wound care practices and communication, leading to inadequate care for the resident's pressure ulcers.
The facility failed to maintain adequate RN coverage and did not have a full-time Director of Nursing (DON) after the previous DON resigned without notice. Interviews and staffing sheets revealed inconsistent RN coverage, with the previous DON working various shifts before leaving. The facility was actively seeking to fill these positions through advertisements and potential contracts.
The facility failed to manage residents' personal funds according to regulations, particularly for those receiving Medicaid services. Funds exceeding $50 were not deposited into an interest-bearing account, and there was inadequate documentation and access to funds for several residents. The Business Office Manager acknowledged the funds were kept in a safe, not in an interest-bearing account, despite knowing the requirement.
A resident with a history of traumatic subdural hemorrhage and monoplegia was transferred without a Hoyer lift, contrary to physician orders and facility policy. The resident's care plan required Hoyer lift transfers due to non-ambulatory status, but a nurse aide manually transferred the resident, believing the order was PRN. Staff interviews confirmed the requirement to use the Hoyer lift, highlighting a deficiency in accident hazard prevention and supervision.
A resident with severe cognitive impairment and a history of intracerebral hemorrhage experienced increased edema and weight gain due to the facility's failure to administer medications as ordered, monitor the resident's condition, and notify the physician in a timely manner. Despite orders to decrease amlodipine and monitor blood pressure, staff inconsistently checked vital signs and failed to document or communicate the resident's worsening condition, leading to significant health issues.
The facility did not ensure RN coverage for at least eight consecutive hours daily, as required. Review of work schedules for several months showed multiple days without an RN scheduled. Interviews with staff revealed uncertainty about RN availability, and the administrator noted staffing limitations, with only two RNs employed, one part-time.
The facility failed to ensure that eight nurse aides completed CNA training within four months of employment, as required by policy. Observations showed aides providing direct care without certification, and interviews revealed repeated delays in certification due to facility issues. The administrator acknowledged the problem, but no corrective actions were mentioned.
The facility failed to ensure the Dietary Manager had the necessary certification or experience for the role. Despite being employed since 2005, the Dietary Manager had no training in food service management. The facility's policy lacked clarity on required qualifications, and the Administrator acknowledged the need for training but had not yet implemented corrective actions.
The facility failed to maintain sanitary conditions in the kitchen and food storage areas, with observations of debris, greasy residues, and improper food handling. The kitchen lacked structured cleaning protocols, and food preparation areas were not sanitized after handling trash. Flies were present, and food storage temperatures were not properly monitored, leading to spoiled and improperly stored food items. The Dietary Manager and Registered Dietician acknowledged these issues, but facility practices did not align with policies.
The facility did not submit the required PBJ Staffing Data Report to CMS for the second quarter of 2024. The new Administrator, who started in July, found that the report had not been completed for some time and was unable to enter data for the previous period. She was unaware of who was responsible for the submission prior to her tenure.
The facility did not maintain an effective QAPI plan, lacking documentation of Performance-Improvement-Plans (PIPs) and evidence of attempts to correct deficient practices. There was no infection preventionist or medical director input in the QAPI process. The Administrator could not find any QAPI policy or procedure, nor provide documentation of PIPs or weekly reviews for identified problems.
The facility failed to maintain documentation of a functioning QAA Committee that met quarterly with required members. The facility lacked a policy for the QAA Committee, and records showed no documentation of quarterly meetings. Additionally, there was no Infection Preventionist, and the medical director did not regularly attend meetings. The Administrator confirmed these issues during an interview.
The facility failed to implement a comprehensive infection control program, lacking processes for Legionella monitoring and proper respiratory hygiene. Staff did not cover clean linens during transport, and wound care supplies were placed on residents' tables without barriers. Enhanced Barrier Precautions were not understood or implemented, with inconsistent PPE use during resident care.
The facility failed to maintain an effective antibiotic stewardship program, lacking a comprehensive log for residents on antibiotics and failing to include antibiotic therapy in care plans for two residents. Staff interviews revealed confusion about responsibility for the program, resulting in inadequate tracking and documentation of antibiotic use.
The facility did not have a designated certified infection preventionist (IP) responsible for the infection prevention and control program. The Administrator was unsure who was monitoring infections, and an LPN confirmed they were not tracking infections. The previous DON and ADON had been responsible, but no current staff member was identified for infection prevention. Another LPN also confirmed they were not monitoring any infection program.
The facility failed to complete Criminal Background Checks (CBC) for four new hires, including Nurse Aides and a Certified Medication Technician, before allowing them to work with residents. Despite policy requirements, the facility did not document the completion of these checks, as revealed through personnel record reviews and staff interviews.
A facility failed to provide a bed hold policy for a resident with Alzheimer's and vascular dementia during two hospital transfers. The facility did not document or provide written bed hold information to the resident or their responsible party. Interviews revealed confusion among staff about responsibilities for bed holds, with the LPN unsure of procedures and the Administrator acknowledging lapses in maintaining a bed hold log.
The facility failed to manage code status accurately for residents, leading to discrepancies in documentation and lack of physician orders. A resident's care plan did not reflect their DNR status, while another's care plan incorrectly listed them as DNR. Two residents had conflicting code status information in their records. Staff interviews revealed inconsistencies in the process of documenting and verifying code status.
A facility failed to administer medications as ordered for a resident with severe cognitive impairment and cardiovascular conditions, resulting in a nine-day lapse in medication administration. Additionally, the facility lacked an effective system for timely medication destruction, with numerous medications awaiting disposal. Staff interviews revealed uncertainty about the destruction schedule, and the administrator confirmed that the process was not consistently implemented.
The facility failed to act on pharmacy recommendations for gradual dose reductions of psychoactive medications for a resident and did not complete monthly drug regimen reviews for three residents. Staff interviews revealed confusion about responsibility for these tasks, with the DON, ADON, and LPN providing conflicting information.
A facility failed to develop a baseline care plan for a resident within 48 hours of admission, despite the resident having complex medical conditions. Interviews with staff revealed that care plans should be completed within 24 hours and accessible in the resident's chart, but this was not done, resulting in a deficiency.
The facility failed to provide adequate pressure ulcer care for two residents, with staff not documenting full assessments, updating care plans, or notifying physicians of new or changing wounds. A resident with Alzheimer's and vascular dementia had wounds that were not consistently documented or treated according to orders. Interviews revealed staff's lack of understanding of proper wound care procedures.
A resident with a left-hand contracture did not receive consistent care to maintain or improve ROM due to the facility's failure to ensure the ordered hand splint was consistently used and monitored. The resident's care plan was not updated to include the splint order, and it was not documented in the MAR or TAR. Observations showed the splint was not consistently worn, and staff interviews revealed a lack of clear responsibility and communication regarding its application and monitoring.
The facility failed to provide proper incontinence care for two residents, as staff did not perform hand hygiene or change gloves during care. Observations showed improper cleaning techniques, such as using the same wipe multiple times and not cleansing the genital area. Interviews with staff confirmed that expected procedures were not followed, indicating a lack of adherence to protocols.
A resident with multiple health conditions experienced weight loss, and the facility failed to implement the RD's recommendations for larger meal servings and a dietary supplement. The RD's recommendations were not included in the care plan, and there was no physician order for the supplement. Interviews revealed confusion among staff about responsibilities for implementing dietary changes, leading to a deficiency in maintaining the resident's nutritional status.
A facility failed to obtain physician orders for a resident's CPAP machine, which was used for sleep apnea. The resident's care plan lacked information on CPAP use, and staff were unaware of the necessary care procedures. Interviews revealed that staff had not received training on the machine, and there were no documented orders for its use or settings.
A facility failed to limit PRN psychotropic medications to 14 days for a resident with dementia, who received clonazepam 27 times in a month without an end date. Another resident on quetiapine did not have documented attempts at gradual dose reduction (GDR), despite facility policy requiring such measures. Interviews revealed staff uncertainty about medication review responsibilities and expiration dates for PRN medications.
The facility failed to maintain accurate medical records for two residents, resulting in incomplete documentation of their conditions and hospital transfers. One resident's records lacked a care plan and progress notes for an emergency room visit, while another resident's records did not document the condition leading to a psychiatric unit admission. Staff interviews highlighted the expectation for documenting changes in condition and hospital transfers, but the facility lacked a policy on record accuracy.
The facility did not post the required daily nurse staffing information in a prominent place accessible to residents and visitors. The postings lacked the facility name, total and actual hours worked, and names of key nursing staff. Staff were unaware of posting responsibilities and requirements.
A staff member yelled and used inappropriate language towards another staff member in the presence of a resident with severe cognitive impairments. The incident occurred when the staff member was assisting the resident with a gait belt, despite being advised to use a wheelchair for the resident's safety. Multiple staff members corroborated the incident, noting the behavior was undignified.
The facility failed to ensure a resident's drug regimen was free from unnecessary drugs by not adequately monitoring blood pressure as ordered. The resident had orders for blood pressure medications and monitoring each shift, but staff did not consistently document the readings. Interviews revealed inconsistencies in following orders and a lack of policy for monitoring with medication administration.
The facility failed to ensure a resident's drug regimen was free from unnecessary drugs by not specifying a diagnosis for the use of Ativan for agitation. The resident, with Alzheimer's and dementia, was administered Ativan without a documented diagnosis justifying its use. Staff interviews revealed inconsistent documentation practices, and the facility lacked a policy on psychotropic medications.
The facility failed to ensure residents were treated with dignity and respect when a CNA yelled and used profanity towards another staff member in front of a resident with severe cognitive impairments. Multiple staff members corroborated the incident, noting the CNA's aggressive response when advised to use a wheelchair for the resident's safety.
The facility failed to report allegations of abuse involving a CNA cursing at two residents to the state within the required timeframe. Both residents had significant cognitive impairments and were fully dependent on staff for daily living activities. The incident was reported to the DON six days after it occurred, but the facility did not self-report the abuse to the DHSS.
The facility failed to ensure a resident's drug regimen was free from unnecessary drugs by not adequately monitoring blood pressure as ordered. Despite physician's orders to record blood pressure each shift, staff did not document monitoring on multiple occasions. Interviews revealed inconsistencies in understanding and executing the orders, and the facility lacked a policy and oversight in reviewing MARs and TARS.
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs by not specifying a diagnosis for the use of Ativan for agitation. The resident, diagnosed with Alzheimer's and dementia, was administered Ativan without a documented diagnosis justifying its use. Staff interviews revealed frequent administration of Ativan without proper documentation, and the facility lacked a policy on psychotropic medications.
Failure to Honor Full Code Status Due to Conflicting Documentation and Omission of CPR
Penalty
Summary
The deficiency involves the facility’s failure to provide care consistent with a resident’s advance directives and physician orders when staff did not initiate CPR for a resident who was a full code. The resident’s medical record contained conflicting documentation regarding code status: page one of the face sheet listed DNR, while page two listed CPR in the advance directive field. The resident’s current physician’s order sheet contained an order for CPR, and the health care directive form, signed by the resident’s guardian, indicated that the guardian did not wish to make a health care directive at that time, which staff stated defaulted to full code. The Social Services Director and nursing staff reported that, in the absence of a signed DNR, the resident’s status should be full code and CPR should be initiated if the resident was found unresponsive. On the day of the incident, a CNA checked on the resident around 6:00 A.M. and observed the resident sleeping. When the CNA returned around 7:45 A.M. to assist the roommate, the resident was found lying across the bed, appearing as if they had attempted to sit up and then slumped over, and did not respond. The CNA called for the nurse and then checked the emergency book, which indicated the resident was DNR. RN E responded, found the resident lying across the bed with no heartbeat or respirations, lips blue, and a gray appearance, and did not initiate CPR. RN E instead notified the Administrator, and together they pronounced the resident deceased at 7:55 A.M. without starting CPR. Nursing progress notes documented that the resident was found unresponsive at 7:50 A.M., with ashen face and purple lips, and that the resident was pronounced deceased at 7:55 A.M. Multiple staff interviews revealed inconsistent understanding and use of code status information. Staff reported that code status could be found in several locations, including the emergency binder, the electronic medical record, the resident’s door tag (red sticker for DNR), and the face sheet. LPNs, CNAs, the MDS Coordinator, and the SSD stated that if there was no signed DNR or if code status information conflicted, the resident should be treated as full code and CPR should be started and continued until EMS arrived. The DON, SSD, NP, Medical Director, and Administrator all confirmed that the resident’s health care directive and physician orders supported a full code status and that the resident’s code status should have been consistent throughout the record. Despite this, RN E and the Administrator relied on the DNR notation on the face sheet and the emergency book and did not question the discrepancy or initiate CPR when the resident was found unresponsive.
Resident Fall and Injury Due to Improper Repositioning by CNA
Penalty
Summary
A deficiency occurred when a Certified Nurse Aide (CNA) assisted a resident in a hurried manner, resulting in the resident falling from a wheelchair. The resident, who had diagnoses including contracture of muscle in the lower leg, dementia, and a recent intracapsular fracture of the right femur, was dependent on staff for mobility and required the use of a mechanical lift for all transfers. Despite these needs, the CNA attempted to reposition the resident in a Broda chair by pushing on a stuck lever, which caused the resident to tip forward and fall to the floor, sustaining a laceration to the mouth and a hairline fracture below the right knee. The facility's policies required staff to ask permission before repositioning residents and to ensure resident safety, dignity, and comfort during lifting and movement. Staff were also expected to be observed for competency in using equipment and to adhere to safe lifting techniques. However, the CNA involved had not completed documented skills competency reviews or new employee training, and there was no evidence of training or skills checks in the personnel file. Interviews with staff and family members confirmed that the CNA did not announce themselves or explain the repositioning process to the resident, contrary to facility policy and standard practice. Prior to the incident, concerns had been raised about the CNA moving too quickly with residents, and the CNA had been re-educated on the need to slow down and be gentle. Despite this, the CNA proceeded to reposition the resident without proper communication or technique, leading to the fall and injury. Multiple staff and family interviews corroborated that the CNA's actions were rushed and not in accordance with established procedures for resident safety.
Failure to Report Alleged Abuse in a Timely Manner
Penalty
Summary
The facility failed to report an allegation of possible abuse to the Department of Health and Senior Services (DHSS) within the required two-hour timeframe. The incident involved a resident who made a threatening statement towards other residents during a smoke break. Despite staff intervention and documentation of the incident, the facility did not report the threat to the DHSS as required by their policy. The incident occurred when a resident became verbally aggressive during a smoke break, claiming ownership of a spot and threatening to harm others with a hammer. Staff intervened by redirecting the resident and separating the involved parties. The resident was then assisted to their room and put to bed, with no harm reported to any parties involved. However, the facility's staff did not document the reporting of this potential abuse to the DHSS, as required by state regulations. Interviews with staff revealed a lack of clarity regarding the reporting process for abuse allegations. Some staff members believed that the Director of Nursing (DON) was responsible for reporting to the state agency, while others assumed the incident did not constitute abuse. The Social Services Director and other staff members were unaware of the incident until days later, indicating a breakdown in communication and reporting procedures within the facility.
Resident Found with Marijuana and Pills, Facility Policies Not Followed
Penalty
Summary
The facility failed to maintain an environment free from potential hazards when a resident was found with marijuana and unknown pills on their person and in their room. The resident, who was admitted with diagnoses including lung cancer and COPD, was not documented as a smoker in their care plan or admission records. Despite being cognitively intact, the resident admitted to smoking marijuana on facility grounds for pain relief due to cancer, and had brought the substances from home. The facility's policies on incidents, smoking, and medication storage were not adequately followed. Staff did not document the resident as a smoker in the care plan, and there was a lack of education and intervention to prevent future occurrences. The Social Service Director and Business Office Manager found contraband items during a search of the resident's person and room, which included marijuana vape pens, a bottle of marijuana concentrate, and unmarked pills. These items were confiscated and given to the Administrator, but the staff failed to document the discovery of medication pills on the resident's person. Interviews with staff revealed a lack of awareness and communication regarding the resident's possession of marijuana and pills. The Director of Nursing was not fully involved in the investigation and only identified the medication as Tylenol and Advil. Staff were not informed about the resident having these items, and there was no documentation of the pills found on the resident. The facility's failure to adhere to its policies and ensure proper supervision and documentation contributed to the deficiency.
Failure to Provide Behavioral Health Care
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident who exhibited signs and symptoms of psychosocial distress. The resident, who had a history of anxiety disorder, dysthymic disorder, depression, and insomnia, displayed behaviors such as yelling, verbal abuse, and refusal of care. Despite these behaviors, the facility did not develop and implement resident-specific non-pharmacological interventions to address the resident's psychosocial needs. The resident's care plan included the use of antidepressant and antianxiety medications, but there was no evidence of a comprehensive behavioral health plan or regular psychological consultations. The facility's policies emphasized the importance of understanding the meaning behind resident behaviors and minimizing the use of psychoactive medications. However, the facility primarily relied on medication adjustments, such as increasing lorazepam and adding Depakote, to manage the resident's behaviors without exploring non-pharmacological interventions. The resident's behaviors, including verbal aggression and threats towards staff and other residents, were documented in nurse progress notes. Despite these ongoing issues, there was a lack of consistent involvement from the social services department and no documented psychological services or behavior management interventions. The facility's failure to address the resident's behavioral health needs contributed to the deficiency in providing necessary care and services.
Failure to Provide Adequate Social Services for Resident with Depression
Penalty
Summary
The facility failed to provide appropriate medically related social services for a resident with a history of depression, anxiety disorder, and dysthymic disorder. The Social Services Designee (SSD) did not adequately address or assist in finding the root cause of the resident's yelling, cursing behaviors, refusal of care, and general unhappiness living at the facility. The resident had a history of verbal altercations and outbursts, which were documented in the nurse's progress notes, but there was a lack of follow-up or intervention from the SSD. The resident's care plan included the use of antidepressant and antianxiety medication, behavioral health consults as needed, and monitoring for signs and symptoms of depression and anxiety. Despite these measures, the resident continued to exhibit distressing behaviors, including yelling at staff, refusing care, and making threats towards staff and other residents. The SSD did not document any follow-up or interventions after the resident expressed unhappiness with the facility and a desire to move to another city. Additionally, the SSD did not review the resident's progress notes to identify problems or provide necessary interventions. Interviews with facility staff revealed that the resident's behaviors were often related to smoking and the timing of smoke breaks. The resident expressed dissatisfaction with the facility and the staff's response to his needs, particularly during the evening shift. The SSD admitted to not receiving any training for her role and was unaware of her responsibilities in monitoring residents' behaviors and providing necessary interventions. The lack of appropriate social services and interventions contributed to the resident's ongoing distress and dissatisfaction with the facility.
Inadequate Infection Control Practices in Wound Care
Penalty
Summary
The facility failed to establish and maintain an effective infection control program, as evidenced by the lack of implementation of Enhanced Barrier Precautions (EBP) and inadequate hand hygiene practices during wound care for two residents. The facility did not have a policy for EBP, which is an infection control intervention designed to reduce the transmission of multidrug-resistant organisms (MDROs) through targeted gown and glove use during high-contact resident care activities. Observations revealed that staff did not follow standard infection control practices, such as washing or sanitizing hands at appropriate times during wound care. Resident #1, who had multiple sclerosis, heart failure, and type two diabetes mellitus, was at risk for pressure ulcers and had three Stage 2 pressure ulcers. During wound care, a Licensed Practical Nurse (LPN) failed to change gloves or sanitize hands between measuring multiple wounds, potentially contaminating them with infectious materials. Additionally, the LPN did not perform hand hygiene upon completion of the task. Another observation showed that a corporate nurse and an LPN did not don gowns or change gloves between measuring wounds, further risking contamination. Resident #2, diagnosed with unspecified dementia, depression, hypertension, and type two diabetes mellitus with diabetic neuropathy, had a burn on the left thigh. During wound care, an LPN placed supplies on the bedside table without a barrier, did not change gloves or perform hand hygiene after removing a dressing, and potentially contaminated the treatment cart by placing used supplies back into it. Interviews with staff, including LPNs, a Registered Nurse (RN), and a Nurse Practitioner (NP), revealed a lack of knowledge about EBP and inconsistent practices regarding the use of personal protective equipment (PPE) and hand hygiene during wound care.
Inadequate Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for a resident with multiple medical conditions, including multiple sclerosis, heart failure, and type two diabetes mellitus. The resident was at risk for pressure ulcers and had three Stage 2 pressure ulcers. The facility's policies required weekly skin assessments and wound tracking, but these were not consistently performed. The resident's care plan indicated a need for pressure-reducing devices and specific treatments, but there were lapses in documentation and communication regarding the resident's wounds. The nursing staff did not consistently document the resident's wounds or obtain treatment orders for all wounds. There were gaps in the nursing progress notes, with no documentation of the wound or treatment for several days. When documentation was present, it often lacked complete information about the wounds, such as size, location, and treatment orders. Observations revealed that the resident had multiple open areas on the buttocks, but there were no corresponding treatment orders in the Physician Order Sheet for these areas. Interviews with staff revealed inconsistencies in wound care practices and communication. Some nurses applied dressings without orders, and there was a lack of notification to the physician about new or worsening wounds. The Nurse Practitioner was not informed of all skin concerns, and there was confusion among staff about the appropriate treatment for the resident's wounds. The corporate nurse emphasized the importance of complete documentation and physician notification, but these practices were not consistently followed, leading to inadequate care for the resident's pressure ulcers.
Facility Lacks RN and DON Coverage
Penalty
Summary
The facility failed to ensure adequate registered nurse (RN) coverage and did not have a Director of Nursing (DON) available to fulfill necessary duties on a full-time basis. The previous DON had been providing routine floor coverage before resigning without notice, leaving the facility without a DON or RN. The facility's policy mandates sufficient qualified nursing staff to meet residents' needs and requires a registered nurse to serve as the DON on a full-time basis, except when waived. However, the facility was unable to meet these requirements, as evidenced by the absence of a DON or RN on staff and the reliance on advertisements to fill these positions. Interviews with various staff members, including the Business Office Manager, Administrator, and several nursing staff, confirmed the lack of a DON and RN coverage. The facility's daily staffing sheets showed inconsistent RN coverage, with the previous DON listed as working various shifts, including as a charge nurse and certified nursing assistant (CNA), before resigning. The Administrator acknowledged the absence of a DON and RN, stating that the facility was actively seeking to fill these positions through advertisements and potential contracts. The deficiency was identified during a survey, with the facility census at 38 residents.
Failure to Properly Manage Residents' Personal Funds
Penalty
Summary
The facility failed to manage and account for residents' personal funds as required by regulations. Specifically, the facility did not deposit residents' personal funds exceeding $50 into an interest-bearing account for two residents receiving Medicaid services. Additionally, the facility did not maintain an ongoing balance or provide reasonable access to funds for seven residents. The Business Office Manager (BOM) admitted that resident funds were kept in a locked safe in the Administrator's office, with only the Administrator and BOM having access. The funds were not kept in an interest-bearing account, despite the BOM's awareness of the requirement. During an observation, it was found that several residents had cash amounts documented on paper, but these amounts were not accurately reflected in the interest-bearing account as required. For instance, one resident had $73 in cash, but the paper balance showed $100.74, and another resident had $200 in cash with no interest-bearing account documentation. The facility's policy mandates that residents' personal funds over $50 for Medicaid recipients should be deposited in an interest-bearing account, but this was not adhered to, leading to a deficiency in managing residents' financial affairs.
Failure to Follow Hoyer Lift Transfer Orders
Penalty
Summary
The facility failed to ensure that residents were as free from accident hazards as possible by not adhering to physician orders for the safe transfer of a resident using a Hoyer lift. The facility's policy mandates that the Hoyer lift is a two-person operation and that any staff transferring a resident alone would face immediate termination. Despite this, an observation revealed that a nurse aide transferred a resident without using the Hoyer lift, instead assisting the resident to stand and pivot to a wheelchair and recliner without a gait belt. The resident involved had a history of traumatic subdural hemorrhage, monoplegia of the upper limb, and was non-ambulatory, requiring total dependence on staff for transfers using a Hoyer lift. The resident's care plan and physician orders specified the use of a Hoyer lift for all transfers, which was reinforced by an in-service training and a care plan meeting. However, the nurse aide believed the Hoyer lift order was PRN and proceeded with a manual transfer, contrary to the established orders and policy. Interviews with various staff members, including nurse aides, restorative aides, and the administrator, confirmed that the resident was to be transferred using a Hoyer lift as per physician orders. The staff acknowledged the requirement to follow these orders, yet the incident demonstrated a failure to comply, resulting in a deficiency related to accident hazards and supervision in the facility.
Failure to Administer Medications and Monitor Edema
Penalty
Summary
The facility failed to provide care per standards of practice for a resident with edema, resulting in increased edema, weight gain, and an inability to wear shoes. The resident, who had severe cognitive impairment and was not taking a diuretic, had a history of intracerebral hemorrhage, hemiplegia, seizures, and muscle weakness. The facility did not have a policy related to monitoring changes in condition, and staff failed to administer medications as ordered, monitor the resident as ordered, and notify and follow-up with the physician in a timely manner. The resident's care plan required staff to monitor and document any edema and notify the physician. However, the staff did not consistently check the resident's blood pressure as ordered and failed to document further entries related to the resident's edema or notify the clinic. Despite new orders to decrease amlodipine due to edema and monitor blood pressure, the resident's condition worsened, with significant weight gain and increased edema noted in subsequent evaluations. Interviews with staff revealed a lack of communication and follow-up regarding the resident's condition. Nurse aides reported the resident's legs had been swollen for months, but this was not communicated to the nurse. The LPN and ADON indicated that they would expect a response to a fax regarding a resident by the end of the day or would follow-up with a call, but this did not occur. The DON confirmed that the physician should be notified for increased edema and that staff should follow physician orders.
Failure to Provide RN Coverage for Required Hours
Penalty
Summary
The facility failed to provide the services of a registered nurse (RN) for at least eight consecutive hours per day, seven days a week, as required. The facility's policy mandates the presence of an RN for this duration unless waived, and the Director of Nursing (DON) may serve as a charge nurse only when the facility has an average daily occupancy of 60 or fewer residents. However, a review of the monthly work schedules for July, August, and September 2024 revealed multiple days where no RN was scheduled, indicating a breach of this requirement. Interviews conducted during the survey further highlighted the deficiency. An LPN mentioned uncertainty about the daily presence of an RN, while a Certified Medication Tech confirmed that although there was always a nurse working, it was unclear if an RN was available for the required hours. The facility's administrator acknowledged that the previous DON did not clock in or out due to being salaried, and currently, only two RNs were employed, with one working part-time every other weekend. This staffing situation contributed to the failure to meet the regulatory requirement of having an RN on duty for the specified hours.
Failure to Ensure Timely CNA Certification for Nurse Aides
Penalty
Summary
The facility failed to ensure that eight nurse aides completed a certified nurse aide (CNA) training program within four months of employment, as required by their policy. The policy mandates that all nursing assistants must complete the basic course and be certified within four months of employment. However, the review of the facility's records and the state agency CNA registry website revealed that none of the eight sampled nurse aides were certified within the stipulated time frame, with some aides having been employed for several years without certification. Observations and interviews further highlighted the deficiency. Nurse aides were observed providing direct care to residents despite not being certified. Interviews with the nurse aides revealed that they had attended CNA classes multiple times, but due to various reasons, such as the facility not setting up certification dates or instructors becoming unavailable, they were unable to complete the certification process. This situation persisted for several years for some aides, indicating a systemic issue in the facility's training and certification process. The facility's administrator acknowledged the issue, stating that nurse aides should be certified in a timely manner. However, the report does not mention any corrective actions or follow-up measures taken to address the deficiency at the time of the survey. The lack of certified nurse aides potentially compromises the quality of care provided to residents, as these aides are performing duties without the necessary certification and training.
Deficiency in Dietary Manager Qualifications
Penalty
Summary
The facility failed to employ sufficiently qualified staff in the food and nutrition services department, specifically in the role of the Dietary Manager. The Dietary Manager, who was hired in May 2024, did not possess the required certification or experience for the position. Despite being employed at the facility since 2005, the Dietary Manager had previously worked as an Activities Director and a nursing assistant, with no training or certification in food service management. The facility's policy on dietary services did not specify the required qualifications for the Dietary Manager position, and there was no documentation provided to confirm that the Dietary Manager met the minimum qualifications. During interviews, the Dietary Manager acknowledged the lack of training or certification in food service management. The facility's Administrator also recognized the need for the Dietary Manager to have some training and was aware of the educational requirements needed for the role. The Administrator mentioned plans to enroll the Dietary Manager in educational classes to address the deficiency, but at the time of the survey, these actions had not yet been implemented.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by multiple observations of unsanitary conditions in the kitchen and food storage areas. The kitchen floor was found to have debris, and various surfaces, including stackable containers, the stove, and steam table handles, were covered with a yellow greasy residue. Additionally, the handles of the three-compartment refrigerator were noted to be brownish tinged and slick to the touch. The Dietary Manager admitted to cleaning the kitchen herself without a cleaning list or assignment sheet, indicating a lack of structured cleaning protocols. Further observations revealed that food preparation areas were not maintained in a sanitary condition. Debris was present on food preparation tables, and a box fan with brown, fuzzy debris was blowing towards these tables. A Dietary Aide was observed handling trash and then rolling out trash bags on a food prep area without immediate cleaning or sanitization. Flies were seen landing on kitchen serving items and the steam table, and doors to various areas, including the outside, were left open. Staff were observed handling diet cards with debris on them and then touching food contact areas without proper sanitation. The facility also failed to maintain proper food storage temperatures. The three-door refrigerator was observed with an exterior thermometer reading 50 degrees F and an interior thermometer reading 48 degrees F, with no temperature entries logged by staff. Food items such as ham, turkey breast, and mayonnaise were stored at temperatures above the recommended range. Additionally, spoiled and improperly stored food items were found in the refrigerator and freezer, including undated and cling-wrapped items with visible spoilage. The Dietary Manager and Registered Dietician acknowledged the issues with temperature monitoring and food storage, but the facility's practices did not align with their stated policies.
Failure to Submit Timely Payroll-Based Data to CMS
Penalty
Summary
The facility failed to submit payroll-based data to the Centers for Medicare and Medicaid Services (CMS) in a timely manner, as required. The facility, with a census of 38, did not submit the Payroll Based Journal (PBJ) Staffing Data Report for the fiscal year quarter two of 2024, covering the period from April 1 to June 30, 2024. During an interview, the Administrator, who assumed her position in July, stated that she had only recently started the PBJ for the months of July, August, and September. She discovered that the report had not been completed for some time and was unable to enter data for the previous period. The Administrator was unaware of who was previously responsible for submitting the report.
Failure to Implement Effective QAPI Plan
Penalty
Summary
The facility failed to implement and maintain an effective, comprehensive Quality Assurance and Performance Improvement (QAPI) plan. This deficiency was identified through interviews and record reviews, revealing that the facility did not have a policy or procedure related to a comprehensive QAPI Plan. The facility lacked documentation of Performance-Improvement-Plans (PIPs) or evidence of good-faith attempts to correct identified deficient practices. Additionally, there was no current identified infection preventionist participating in the QAPI process, nor was there documentation of medical director input. During an interview, the Administrator admitted the inability to find any policy or procedure for QAPI and was unable to provide documentation of PIPs for any items. The facility also failed to conduct weekly reviews, including documentation and measurements, for problems identified by QAPI. The facility census was 38 at the time of the survey.
Deficiency in QAA Committee Documentation and Participation
Penalty
Summary
The facility failed to maintain documentation of a functioning Quality Assessment and Assurance (QAA) Committee that met at least quarterly with the required members. The facility, with a census of 38, did not provide a policy regarding the QAA Committee. Records showed that staff lacked documentation to confirm that the QAA Committee met quarterly with the necessary members. Additionally, the facility did not have an Infection Preventionist to participate in the QAA Committee, and the medical director did not regularly attend the QAA Committee meetings. During an interview, the Administrator acknowledged the absence of an infection preventionist and was unable to determine the frequency of the medical director's participation in the QAA Committee.
Inadequate Infection Control Measures in LTC Facility
Penalty
Summary
The facility failed to implement a comprehensive infection prevention and control program, as evidenced by several deficiencies observed during the survey. The facility did not have a process in place to monitor for Legionella, a severe form of pneumonia, despite having a policy that outlined the necessary steps for prevention. The Maintenance Supervisor admitted to not conducting any monitoring for Legionella, and there was no documentation available to show compliance with the Legionella policy. Additionally, the facility's infection control measures were inadequate, as staff were observed not following proper respiratory hygiene and hand hygiene protocols. A Restorative Aide was seen coughing in the hallway without wearing a mask or covering their mouth, despite having pneumonia, and continued to work with residents without taking appropriate precautions. The facility also failed to adhere to its linen management policy, which required clean linens to be covered and protected from contamination. Observations revealed that clean resident clothing was transported on uncovered carts, and staff confirmed that this was the standard practice. Furthermore, the facility did not follow proper procedures for wound care, as supplies were placed directly on residents' bedside tables without a clean barrier, potentially contaminating the supplies and the residents' environment. This was observed in the care of two residents, both of whom had pressure ulcers and required wound care. The facility lacked a policy for Enhanced Barrier Precautions (EBP), an infection control intervention designed to reduce the transmission of multidrug-resistant organisms. Staff interviews indicated a lack of understanding and implementation of EBP, with inconsistent use of personal protective equipment (PPE) during high-contact resident care activities. Observations showed that staff did not don gowns during wound care for residents with pressure ulcers and Foley catheters, and there was no signage or PPE cart available to indicate the need for EBP. The Administrator acknowledged that staff were likely unaware of what EBP entailed, further highlighting the facility's failure to implement effective infection control measures.
Deficiency in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program, as evidenced by the lack of a comprehensive and current antibiotic log for residents with active infections. The facility's policy on antibiotic stewardship was not adhered to, as there was no ongoing tracking of antibiotic use, and the care plans for two residents on antibiotics were incomplete. The facility's infection control binder contained outdated and incomplete records, with missing information for several months, indicating a lack of proper monitoring and documentation. Resident #30, who was admitted with diagnoses including intraspinal abscess and osteomyelitis, was on an antibiotic regimen. However, the resident's care plan did not include details related to antibiotic therapy, and the resident was not listed in the facility's infection control logs for July and August 2024. Similarly, Resident #15, who had undergone major orthopedic surgery and was receiving multiple antibiotics for a foot infection, did not have antibiotic therapy included in their care plan. Despite being on active antibiotic orders, the resident's treatment was not adequately tracked or documented. Interviews with facility staff revealed a lack of clarity and responsibility regarding the antibiotic stewardship program. The Director of Nursing and other staff members were unaware of the deficiencies in tracking antibiotic use, and there was confusion about who was responsible for the program. The previous Director of Nursing had managed the program, but after their departure, the responsibility was not clearly assigned, leading to lapses in monitoring and documentation of antibiotic use and infection control.
Lack of Designated Infection Preventionist
Penalty
Summary
The facility failed to designate a certified infection preventionist (IP) responsible for the infection prevention and control program (ICPC). The facility, with a census of 38, did not have a policy related to the IP position. During interviews, the Administrator was unsure who was monitoring infections, despite having taken the infection preventionist course without completing the test. It was suggested that an LPN might be monitoring infections, but the LPN confirmed they did not have IP certification and were not tracking infections. The previous Director of Nursing (DON) and Assistant Director of Nursing (ADON) had been responsible for monitoring, but no current staff member was identified as in charge of infection prevention. Another LPN also confirmed they were not monitoring any infection program. The Administrator acknowledged the need for a staff member to monitor and track antibiotics, infections, and wounds.
Failure to Complete Criminal Background Checks for New Hires
Penalty
Summary
The facility failed to develop and implement effective abuse prevention policies, specifically in the area of staff screening through Criminal Background Checks (CBC). This deficiency was identified when the facility did not follow up on requested CBCs for four staff members, including two Nurse Aides, a Restorative Aide, and a Certified Medication Technician. The facility's policy, dated 09/09/13, mandates that all potential new hires must have a background check initiated before employment and that no new employee should have direct contact with residents until this step is completed. However, the personnel records for these staff members showed that while CBCs were requested, there was no documentation of their completion or findings. Interviews with the Business Office Manager and the Administrator revealed a lack of awareness and oversight regarding the completion of these checks. The Business Office Manager, who started in August 2024, acknowledged the absence of completed CBCs for the four staff members and had created a checklist to ensure compliance with hiring procedures. The Administrator expressed an expectation that all required documentation and CBCs be completed before new employees work with residents, indicating a gap between policy expectations and actual practice.
Failure to Provide Bed Hold Policy for Hospital Transfers
Penalty
Summary
The facility failed to provide a bed hold policy for a resident who was transferred to the hospital on two separate occasions. The resident, who had Alzheimer's disease and vascular dementia, was admitted to the hospital and discharged back to the facility twice. On both occasions, the facility did not document providing written bed hold information to the resident or their responsible party, nor did they have a copy of the bed hold policy provided to them. This lack of documentation and communication regarding the bed hold policy was identified during a review of the resident's medical records and hospital visit summaries. Interviews with facility staff revealed a lack of clarity and responsibility regarding the bed hold policy. The LPN indicated that social services were responsible for bed holds, but was unsure if a copy needed to be provided to residents upon discharge or transfer. The ADON stated that staff should have bed holds signed and a copy made for all transfers. The Administrator acknowledged that nurses should complete and send bed holds with residents when transferred, and that the social worker should follow up and maintain a log of bed holds, which had not been done. This lack of adherence to the bed hold policy resulted in the deficiency identified by the surveyors.
Deficiency in Code Status Management
Penalty
Summary
The facility failed to ensure the timely and accurate identification of code status for residents, which is crucial for determining whether a resident wishes to receive cardiopulmonary resuscitation (CPR). This deficiency was identified through observations, interviews, and record reviews, revealing that the facility did not have a process in place to manage code status effectively. Specifically, there were no physician orders related to code status for three residents, and conflicting code status information was found in the medical records of two other residents. For Resident #36, the face sheet indicated a do not resuscitate (DNR) status, but the care plan did not reflect this choice, and there were no physician orders confirming the code status. Similarly, Resident #30's face sheet showed a full code status, but the care plan incorrectly listed the resident as DNR, and there were no physician orders to confirm the code status. Resident #3's documentation was inconsistent, with a DNR sticker on the chart but no corresponding physician order. Additionally, Resident #11's records showed conflicting information, with a face sheet indicating full code status, but the physician order sheet listed DNR. Resident #26's documentation also had discrepancies, with a DNR sticker on the chart but a physician order for full code. Interviews with staff, including a Nursing Aide, LPN, DON, and the Administrator, highlighted inconsistencies in the process of documenting and verifying code status, indicating a lack of a standardized procedure for managing this critical information.
Failure in Medication Administration and Destruction
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident, as evidenced by the failure to obtain and administer medications as ordered for a newly admitted resident. This resident, who had severe cognitive impairment and multiple cardiovascular conditions, did not receive prescribed medications including amlodipine, magnesium oxide, and potassium chloride for nine consecutive days. The staff documented that the medications were not available but failed to notify the physician or document any progress notes regarding the unavailability of these medications. Additionally, the facility did not have an effective system for the timely destruction of medications that could not be returned to the pharmacy. Observations revealed a locked cabinet containing numerous medication cards waiting to be destroyed, and the facility lacked a policy regarding the disposal or destruction of medications. Interviews with staff indicated that the destruction of medications had not occurred for over a month, and there was no clear schedule for when this should be done. The facility's medication destruction log showed that medications for multiple residents were waiting to be destroyed for various reasons, including expiration and discontinuation by physicians. Despite the presence of a medication destruction log, the process was not being carried out in a timely manner, as confirmed by interviews with staff who were unsure of the destruction schedule. The administrator acknowledged that the destruction should occur weekly or monthly, but this had not been consistently implemented.
Failure to Act on Pharmacy Recommendations and Conduct Monthly Drug Reviews
Penalty
Summary
The facility failed to ensure that pharmacy consultant recommendations for gradual dose reductions (GDR) were acted upon for a resident who was prescribed psychoactive medications. Specifically, for one resident with diagnoses including anxiety disorder, depression, schizoaffective disorder, and Alzheimer's disease, the facility did not attempt a GDR for the antipsychotic medication risperidone, despite pharmacy recommendations to decrease the dosage. The physician did not respond to or sign the pharmacy recommendation sheets for GDRs dated July and August 2024. Additionally, the facility did not complete monthly drug regimen reviews (MMRs) for three residents. One resident with diagnoses of unspecified dementia, insomnia, and dizziness had no documentation of an MMR completed by a pharmacist for August and September 2024. Another resident with heart disease, heart failure, insomnia, unspecified dementia, and anxiety also had no record of MMRs. A third resident with arthritis, a history of depression, and seizures lacked an MMR for August 2024. Interviews with facility staff revealed confusion regarding responsibility for MMRs and GDRs. The Assistant Director of Nursing (ADON) and the Director of Nursing (DON) were unsure of who was responsible for these tasks, with the DON suggesting it could be the responsibility of the ADON or medical records. The Licensed Practical Nurse (LPN) indicated that the DON was responsible for MMRs and physician notification for GDRs. The facility administrator confirmed that medications should be reviewed by the pharmacist and physician monthly.
Failure to Develop Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to develop a baseline care plan for a resident within 48 hours of admission, as required by their policy. The resident, who was admitted with multiple complex medical conditions including congestive heart failure, chronic kidney disease, chronic respiratory failure, type 2 diabetes mellitus, lymphedema, atrial fibrillation, and chronic obstructive pulmonary disease, did not have a baseline or comprehensive care plan documented in their medical record. This omission was identified during a review of the resident's records, which showed that the resident arrived from the hospital via wheelchair with oxygen cannisters, but no care plan was completed. Interviews with facility staff, including two LPNs and the Administrator, revealed that baseline care plans should be completed within the first 24 hours of admission and be accessible in the resident's chart to assist with care needs. However, in this case, the staff did not document the completion of the required care plan, leading to a deficiency in meeting the resident's immediate needs upon admission.
Inadequate Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevent new ulcers from developing for two residents. The staff did not document full regular assessments of wounds, update care plans, notify physicians in a timely manner of new or changing wounds, or ensure that physician's orders were followed. For Resident #30, there were multiple instances where wounds were not fully assessed or documented, and new wounds were not reported to the physician promptly. The resident had several wounds, including on the coccyx, ankle, and scrotum, which were not consistently documented or treated according to physician orders. Resident #36 also experienced inadequate wound care. The resident had a history of Alzheimer's disease and vascular dementia and was at risk for pressure ulcers. The staff failed to document full assessments of the resident's wounds, including a blister on the right heel and an open area on the right buttock. The facility did not have complete documentation of wound assessments for the months of July and August 2024, and the care plan was not updated to reflect new skin areas. Interviews with facility staff, including the DON, ADON, and LPNs, revealed a lack of understanding and execution of proper wound care procedures. The DON admitted to being new and still learning about care plans, while the Administrator was unsure if skin assessments were completed for all residents. The facility's failure to adhere to its own policies and procedures for wound management and care planning contributed to the deficiencies observed by surveyors.
Failure to Ensure Consistent Use and Monitoring of Hand Splint
Penalty
Summary
The facility failed to ensure that a resident received appropriate care to maintain or improve range of motion (ROM) due to inconsistent use and monitoring of an ordered hand splint. The resident, who was admitted with diagnoses including intracerebral hemorrhage, hemiplegia, seizures, and muscle weakness, was noted to have developed a left-hand contracture. A Nurse Practitioner recommended and ordered a left-hand brace for the contracture, but the facility did not update the resident's care plan to include this order. Additionally, the brace was not documented in the Medication Administration Record (MAR) or Treatment Administration Record (TAR), and there were no further progress notes or updates in the resident's restorative notes since the initial assessment. Observations revealed that the resident did not consistently wear the brace, and it was often found off the resident's hand. Interviews with staff indicated a lack of clear responsibility and communication regarding the application and monitoring of the brace. The Restorative Aide mentioned that nurses were responsible for assistive device orders, while the Licensed Practical Nurse stated that the brace should be included in the orders and monitored by a nurse. The Assistant Director of Nursing and the Director of Nursing both emphasized the importance of including such orders in the care plan and monitoring them, but this was not done, leading to the deficiency.
Improper Incontinence Care and Hand Hygiene
Penalty
Summary
The facility failed to provide proper incontinence care for two residents, leading to potential infection risks. Observations revealed that nursing aides did not perform hand hygiene before donning gloves and failed to change gloves or wash hands during the care process. For Resident #12, aides did not cleanse the genital area and used the same wipe multiple times without changing gloves, which is against the facility's policy and nursing standards. For Resident #6, similar deficiencies were observed. The staff did not clean the urethral meatus and used the same wipe multiple times to clean the resident's gluteal area, again without changing gloves or performing hand hygiene. This improper technique was noted despite the resident's severe cognitive impairment and dependency on staff for personal hygiene. Interviews with staff, including a Nursing Assistant, LPN, and the Director of Nursing, confirmed that the expected procedure was not followed. They acknowledged that incontinence care should be performed every two hours, with proper hand hygiene and glove changes, and that residents should be cleansed from front to back using one wipe per swipe. However, the Director of Nursing was unsure of the facility's specific incontinence care procedure, indicating a lack of clarity and adherence to established protocols.
Failure to Implement Dietary Recommendations for Resident
Penalty
Summary
The facility failed to ensure that all residents received the recommended interventions to maintain acceptable nutritional status, specifically for one resident identified as experiencing weight loss. The resident, who had diagnoses including coronary artery disease, dementia, high blood pressure, and heart disease, was on hospice services and had a regular diet. The Registered Dietitian (RD) recommended larger meal servings and a daily dietary supplement, Carnation Instant Breakfast (CIB), for weight maintenance. However, these recommendations were not included in the resident's care plan, and there was no physician order for the CIB. Interviews with facility staff revealed a lack of clarity and communication regarding the implementation of the RD's recommendations. Nursing staff were responsible for notifying the physician and documenting orders in the Physician Order Sheet (POS), but this was not done. The dietary staff were unaware of the resident's need for CIB, as the resident was not listed on the CIB list used by the dietary department. The RD communicated her recommendations verbally and through progress notes, but there was confusion about whose responsibility it was to ensure these were implemented. The Director of Nursing (DON) and the Administrator were also unclear about the process for documenting and implementing new dietary recommendations. The DON expected nursing staff to obtain and document orders, while the Administrator emphasized the need for timely documentation and implementation of new orders. The lack of a clear policy and communication between departments led to the failure to provide the recommended dietary supplement to the resident, resulting in a deficiency in maintaining the resident's nutritional status.
Failure to Provide Physician Orders for CPAP Use
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident using a CPAP machine, as there were no physician orders obtained for its use and care. The resident, who was admitted with conditions including diabetes, high blood pressure, atrial fibrillation, obesity, and chronic kidney disease, was observed using a CPAP machine for sleep apnea. However, the facility did not have a policy related to CPAP use, and the resident's care plan did not include any information regarding the CPAP machine. Additionally, the September 2024 Physician's Order Sheet and Medical Administration Record lacked documentation of an order for the CPAP machine or its settings. Interviews with staff revealed a lack of awareness and training regarding the CPAP machine. A nursing assistant was unsure if a physician order was required and had not received any education on the machine. An LPN confirmed the absence of a physician's order and noted that such an order should include the diagnosis, settings, and care instructions for the CPAP machine. The Director of Nursing and the Administrator both acknowledged the need for physician orders and care planning for CPAP use, indicating a systemic oversight in ensuring proper respiratory care for the resident.
Failure to Limit PRN Psychotropic Medications and Attempt GDRs
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic PRN medications, which should be limited to fourteen days unless evaluated by a physician. One resident, diagnosed with Alzheimer's disease and vascular dementia, was prescribed clonazepam without an end date and received the medication 27 times in July, exceeding the 14-day limit. The order was eventually discontinued 29 days after it was written. Additionally, a new order for olanzapine was issued without a diagnosis or end date, although it was not administered. The facility also failed to attempt a gradual dose reduction (GDR) for another resident who was on psychotropic medications. This resident, diagnosed with unspecified dementia and other conditions, had been on quetiapine since July of the previous year and January of the current year, with no documented attempts at GDR. The facility's policy requires GDRs and non-pharmacological interventions before continuing psychotropic medications, but these were not documented for this resident. Interviews with facility staff revealed a lack of clarity and responsibility regarding medication reviews and GDRs. The Assistant Director of Nursing was unsure who was responsible for these reviews, and the Director of Nursing was uncertain about the need for expiration dates on PRN psychotropic medications. The Administrator acknowledged that PRN psychotropic medications should have a 14-day end date, but this was not consistently implemented.
Deficient Documentation of Resident Transfers
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, leading to deficiencies in documentation related to changes in their conditions and subsequent hospital transfers. For one resident, the facility did not document a care plan or nurses' progress notes regarding the transfer to and return from the emergency room. The resident was taken to the emergency room due to poor lab results and returned to the facility for compassionate care at the request of the resident and their Power of Attorney. Another resident, diagnosed with Alzheimer's disease and vascular dementia, was transferred to a hospital's inpatient psychiatric unit due to a major neurocognitive disorder. The facility's records lacked documentation of the resident's condition prior to the hospital admission, including assessment findings, the reason for the transfer, and notification to the physician. The nursing progress notes did not include any entries from the time leading up to the hospital admission. Interviews with facility staff, including LPNs, the Assistant Director of Nursing, the Director of Nursing, and the Administrator, revealed that there was an expectation for staff to document changes in residents' conditions, reasons for hospital transfers, and notifications to physicians and families. However, the facility did not have a policy related to the accuracy of or documentation in resident records, which contributed to the deficiencies observed.
Failure to Post Required Nurse Staffing Information
Penalty
Summary
The facility failed to post the required daily nurse staffing information in a prominent place that was readily accessible to residents and visitors. The posted information did not include the name of the facility, nor did it show the total and actual number of hours worked for each category of licensed and unlicensed staff directly responsible for resident care per shift. Observations on multiple days revealed that the postings were located on a bulletin board at the nurses' station, which was not easily accessible to residents. Additionally, the postings lacked the names of the registered nurse (RN), Director of Nursing (DON), and Assistant Director of Nursing (ADON), and only included first names of staff working in each position. Interviews conducted during the survey indicated a lack of awareness among staff regarding the responsibility for posting the daily schedule and the specific information required on the postings. An LPN interviewed was unaware of who was responsible for the postings and what information needed to be included. The facility administrator acknowledged that the facility should have a posting that included the total hours worked available for residents and visitors to view. The facility also did not provide a policy related to the posting of staffing hours.
Staff Yelling and Cursing in Presence of Resident
Penalty
Summary
The facility failed to ensure all residents were treated with dignity and respect when a staff member yelled and cursed in the presence of residents. Specifically, on the night of 04/09/24, CNA A was observed yelling and using inappropriate language towards another staff member, NA B, in the presence of Resident #1. Resident #1, who has severe cognitive impairments including Alzheimer's disease and dementia with behavioral disturbances, was being assisted by CNA A with a gait belt. NA B advised CNA A to be careful due to the resident's need for a wheelchair, to which CNA A responded with profanity, stating they had been doing the job for 13 years and did not need to be told how to do it. Multiple staff members, including NA D and LPN C, corroborated the incident, noting that CNA A's behavior was inappropriate and undignified in the presence of the resident. Resident #1's care plan indicated severe cognitive impairment and a need for staff assistance with emotional, intellectual, physical, and social needs. The resident also had a communication problem related to a hearing deficit and no longer used hearing aids. The incident occurred when CNA A, who appeared irritated upon arrival, was assisting the resident from the break room to their room. Despite being advised to use a wheelchair for the resident's safety, CNA A insisted on using a gait belt and responded aggressively to NA B's caution. The Director of Nursing and the Administrator acknowledged that such behavior was inappropriate and undignified around residents.
Failure to Monitor Blood Pressure as Ordered
Penalty
Summary
The facility failed to ensure that all residents' drug regimens were free from unnecessary drugs by not adequately monitoring blood pressure as ordered for one resident who received medications to help control blood pressure. The resident, who had diagnoses including atrial fibrillation, heart failure, and high blood pressure, had orders to administer metoprolol and amlodipine and to record blood pressure each shift. However, staff did not document monitoring the resident's blood pressure on the second shift on eight dates and did not document monitoring on the third shift at all in January 2024. Interviews with various staff members revealed inconsistencies in understanding and following the orders for blood pressure monitoring, and there was no policy in place regarding following physician's orders and monitoring with the administration of medications. The Director of Nursing and Administrator acknowledged that there were missed shifts where blood pressure was not taken as ordered. The facility did not have staff reviewing the Medication Administration Records (MARs) and Treatment Administration Records (TARs) to ensure that medications and orders were being followed correctly. This lack of oversight and adherence to physician's orders led to the deficiency in the resident's care, as the necessary blood pressure monitoring was not consistently performed and documented.
Failure to Specify Diagnosis for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that all residents' drug regimens were free from unnecessary drugs when staff did not specify a diagnosis for the use of a psychotropic medication for one resident. The resident, who had diagnoses of Alzheimer's disease and unspecified dementia with behavioral disturbances, was prescribed Ativan for agitation without a documented diagnosis justifying its use. The resident's care plan included administering medications as ordered and monitoring for side effects and effectiveness, but the specific diagnosis for Ativan was not documented in the resident's records or progress notes. Interviews with facility staff revealed that the Ativan was administered about twice or three times a day, and the family nurse practitioner had reinstated the medication for the resident's confusion and wandering behaviors. However, the Director of Nursing and Administrator acknowledged that the staff had not documented the diagnosis for Ativan administration and had only recently started asking staff to document what interventions were tried before administering the medication. The facility did not provide a policy regarding psychotropic medications, contributing to the deficiency.
Staff Yelling and Cursing in Presence of Resident
Penalty
Summary
The facility failed to ensure all residents were treated with dignity and respect when a staff member yelled and cursed in the presence of residents. Specifically, CNA A was reported to have yelled and used profanity towards NA B in front of Resident #1, who has severe cognitive impairments including Alzheimer's disease and dementia. The incident occurred when CNA A was assisting the resident with a gait belt, and NA B advised caution due to the resident's unsteady condition. CNA A responded aggressively, stating they had been doing the job for 13 years and used inappropriate language. Multiple staff members, including NA B, NA D, and LPN C, provided written statements and interviews corroborating the incident. They reported that CNA A appeared irritated and rushed, and despite being advised to use a wheelchair for the resident's safety, CNA A insisted on using the gait belt. The Director of Nursing and the Administrator acknowledged that such behavior was inappropriate and undignified. The resident's care plan indicated a need for staff to communicate respectfully and consider the resident's cognitive decline and communication problems, which was not adhered to during this incident.
Failure to Report Alleged Abuse in a Timely Manner
Penalty
Summary
The facility failed to ensure all allegations of possible abuse were reported immediately to management and within two hours to the State Survey Agency. Specifically, it was reported that a Certified Nurse Aide (CNA A) cursed at two residents, but the facility did not report this allegation to the state within the required timeframe. The incident was reported to the Director of Nursing (DON) six days after it occurred, and the facility did not self-report the allegation of abuse to the Department of Health and Senior Services (DHSS). Resident #1, who has diagnoses including unspecified dementia with behavioral disturbances, insomnia, pain, blindness in one eye, and atherosclerosis of the aorta, was one of the residents involved. The resident's care plan indicated total dependency on staff for daily living activities and a potential for physical aggression and verbal abuse towards staff. Despite these vulnerabilities, the facility did not report the alleged abuse in a timely manner. Resident #2, who has diagnoses including metabolic encephalopathy, unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, pneumonia, acute respiratory failure with hypoxia, major depressive disorder, seizures, hallucinations, contracture, and unspecified psychosis, was the other resident involved. The resident's care plan also indicated total dependency on staff for daily living activities and a potential for verbal aggression. Similar to Resident #1, the facility failed to report the alleged abuse within the required timeframe, and the investigation was delayed.
Failure to Monitor Blood Pressure as Ordered
Penalty
Summary
The facility failed to ensure that all residents' drug regimens were free from unnecessary drugs by not adequately monitoring blood pressure as ordered for one resident who received medications to help control blood pressure. The resident, who had diagnoses including atrial fibrillation, heart failure, and high blood pressure, had physician's orders to administer metoprolol and amlodipine and to record blood pressure each shift. However, staff did not document monitoring the resident's blood pressure on the second shift on eight dates and did not document monitoring on the third shift at all in January 2024. Additionally, the facility did not have a policy regarding following physician's orders and monitoring with the administration of medications. Interviews with various staff members, including LPNs and the Director of Nursing, revealed inconsistencies in the understanding and execution of the blood pressure monitoring orders. Some staff members believed that blood pressure should be checked each shift if ordered, while others were unsure if the orders were being followed. The Director of Nursing and Administrator acknowledged that there were missed shifts where blood pressure was not monitored as ordered. The lack of a policy and oversight in reviewing MARs and TARS contributed to the deficiency in ensuring the resident's drug regimen was free from unnecessary drugs.
Failure to Specify Diagnosis for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that all residents' drug regimens were free from unnecessary drugs when staff did not specify a diagnosis for the use of a psychotropic medication for one resident. The resident, who had diagnoses of Alzheimer's disease and unspecified dementia with behavioral disturbances, was prescribed Ativan for agitation without a documented diagnosis justifying its use. The resident's care plan included administering medications as ordered and monitoring for side effects and effectiveness, but it did not specify a diagnosis for the Ativan prescription. Interviews with staff revealed that the Ativan was administered about twice or three times a day, and there was no documentation of a diagnosis for its administration. The Family Nurse Practitioner reinstated the Ativan as needed for the resident, who exhibited confusion and wandered into other residents' rooms. The Director of Nursing and Administrator acknowledged that the Family Nurse Practitioner reviewed and made changes to the resident's medications and that they had been monitoring behaviors and completing medication changes. However, the facility did not provide a policy regarding psychotropic medications, and there was no documentation of non-pharmacological interventions being tried before administering the Ativan.
Latest citations in Missouri
The facility failed to honor residents’ rights to choose their attending physician when company leadership terminated an existing physician’s services and restricted residents to two company-selected physicians. Cognitively intact residents with multiple medical conditions, including hemiplegia, heart failure, anxiety, depression, and bipolar disorder, previously under the care of the terminated physician, were presented letters by social services instructing them to select one of the two new physicians, without the option to retain their current provider. Some residents refused to sign or later reported feeling anxious, upset, and forced into changing physicians, while one resident’s guardian stated they were told they had to choose a different physician after being informed the original physician would no longer be allowed to see residents. The Administrator, DON, and social services staff confirmed that the directive to remove the original physician and limit choices came from company management, despite facility policies stating residents have the right to choose their physician.
Surveyors found that nurse aides were being charged for CNA training and competency evaluation through a written assistance agreement requiring repayment of $720 in non‑refundable tuition via payroll deductions, and through direct payment for certification programs. Personnel file review and staff interviews showed that aides were hired into NA roles and then offered or required to participate in CNA programs funded upfront by the facility but repaid by the aides over time, or paid directly by the aides themselves, while the Administrator confirmed this reimbursement practice and the absence of an in‑house clinical training program.
A resident with epilepsy and quadriplegia, who was cognitively intact but had poor short-term memory, missed multiple doses of three prescribed anti-seizure medications (lamotrigine, levetiracetam, and lacosamide) over two days due to staff failures in medication ordering, administration, and communication. Lacosamide, a controlled drug requiring manual reorder 72 hours before the last dose, was allowed to run out and was not available for scheduled doses, and staff did not clearly document or notify the physician about its unavailability. On a day when the resident left on a leave of absence, morning and evening doses of all three anti-seizure medications were not given, medications were not sent with the family, and staff did not verify the resident’s return for the evening med pass. The following day, additional lacosamide doses were missed, there was no timely physician notification of missed doses, and the resident subsequently experienced prolonged seizure activity requiring EMS transport and hospitalization, where neurology attributed the breakthrough seizure to medication noncompliance related to missed antiepileptic doses.
Facility staff did not ensure that multiple nurse aides who had been employed for more than four months completed required CNA training and certification within the mandated timeframe, and personnel files lacked documentation of program completion. Several NAs reported working independently on the floor and performing resident care while either still in CNA classes, having recently finished classes but not yet tested, or awaiting authorization to test. The facility’s policies did not address required timeframes for CNA training completion, Human Resources acknowledged terminating and then rehiring some uncertified NAs, the administrator was aware that some NAs were beyond the four‑month limit without certification, and the DON stated they were unaware that NAs had exceeded the four‑month period and were not involved with HR decisions.
A resident with cognitive impairment and a history of sexually inappropriate behaviors, including exposing genitals and seeking sexual attention, had been placed on 1:1 supervision, but staff were not consistently informed or clearly assigned to provide continuous observation. On a locked unit, this resident left the room, went to the dining area for coffee, and stood near another cognitively impaired resident while a CMT, focused on med pass, called a CNA instead of intervening directly. Before the CNA could reach them, the sexually disinhibited resident grabbed the other resident’s breast. Multiple CNAs and the CMT reported they did not know the resident was on 1:1 or were not relieved of other duties, resulting in a lack of continuous supervision and failure to intervene in time to prevent the resident-to-resident sexual contact.
A resident with a history of stroke-related pain had an order entered by nursing for Tramadol 50 mg PO BID for moderate pain, but the medication was not administered for four consecutive days because the physician did not sign the controlled-substance order until several days after it was written. During this time, the resident reported ongoing, typical post-stroke pain and requested to resume Tramadol, which had previously been effective. The DON and NP confirmed that controlled medications require a physician’s signature before pharmacy dispensing, and the facility’s own medication administration policy called for safe, timely administration and appropriate handling of missed or delayed medications, which did not occur in this case.
A resident with heart failure and edema, but no cancer diagnosis, was intended to have a Torsemide dose reduced due to dry mouth; however, an RN entered the order incorrectly in the EMR, selecting Torpenz (Everolimus), a breast cancer medication, instead of Torsemide when both appeared together in the system’s search results. The erroneous Torpenz order, listed for edema, was not read back or verified before being saved and was transmitted to the pharmacy, which also failed to question the lack of a cancer diagnosis. As a result, the resident received 28 doses of Torpenz over several weeks, while nursing notes documented ongoing complaints of dry mouth, concerns about medication safety, and difficulty swallowing.
Multiple cognitively intact residents with psychiatric and brain disorder diagnoses were involved in separate resident‑to‑resident altercations in common areas that escalated to physical abuse, including choking, repeated blows to the head, and multiple punches to the face, resulting in bruising and scratches. In each case, disputes over a TV remote, food, coffee, or a thrown drink led one resident to physically assault another, while staff were present or nearby and either became aware only after yelling and fighting had begun or intervened only verbally despite hearing explicit threats and knowing a resident’s history of quick escalation. These events demonstrate that the facility did not effectively identify, monitor, and intervene in situations where abuse was likely to occur, as required by its own abuse and neglect policy.
The facility failed to ensure blood glucose monitoring and insulin administration were documented and carried out per physician orders and facility policy for three diabetic residents. Orders required blood sugar checks before meals and at bedtime and various insulin regimens, including long‑acting and rapid‑acting insulins, yet MAR/TAR reviews showed multiple missed opportunities for insulin doses and blood sugar checks, including one resident with no recorded blood sugar checks at all. One resident reported that staff sometimes forgot to check blood sugar or give insulin, and that the resident occasionally had to request these services. Leadership interviews revealed that the ADON had previously conducted daily medication administration audits but had been pulled to work the floor for several weeks, with no one else assigned to continue audits, and that staff were expected to chart in real time and document all administrations, refusals, and related notes, which was not consistently done.
A resident with schizophrenia, anxiety, and depression, who had a history of negative behaviors and identified triggers such as rude or "mouthy" people, became involved in a verbal argument with another cognitively intact resident in a dining area. Staff present were aware of this resident’s triggers and care-planned coping strategies but only reminded the other resident not to throw a drink and did not initiate the facility’s behavioral health response (Code [NAME]) or actively use non-pharmacological interventions at the start of the escalation. After repeated verbal warnings, the second resident threw a drink, prompting the first resident to get up and repeatedly strike the other in the face, causing visible bruising to the nose and forehead before staff separated them and called a Code [NAME].
Failure to Honor Residents’ Right to Choose Attending Physician
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to choose their attending physician when new company management terminated services of an existing physician (Physician A) and limited residents’ options to two company-selected physicians (Physician B and Physician C). The facility’s own Resident Rights policy and admission packet state that residents have the right to self-determination, to choose their physician, and to designate which health care professionals will be involved in their care. Despite this, company leadership issued a 30‑day termination of services notice to Physician A, and the Administrator acknowledged that residents were only given the choice of Physician B or Physician C, even though she could see no reason why Physician A could not continue to see residents. Resident #1, who had no cognitive impairment and required partial assistance with ADLs due to hemiplegia, had Physician A listed as the attending physician on the face sheet. A letter dated 04/20/26, addressed to this resident, informed them that Physician A’s services were being terminated and that they must choose either Physician B or Physician C; the resident refused to sign because Physician A was not offered as an option. Resident #1 reported feeling anxious and upset, stated that the new company was forcing a change in primary care physician, and said the facility gave no reason why Physician A could not remain their physician. Resident #1 also reported having to comfort another resident who was crying about losing access to Physician A. Resident #2, who also had no cognitive impairment, used a walker, and had diagnoses including anxiety, depression, and hypertension, likewise had Physician A listed as attending physician and received a similar 04/20/26 letter indicating Physician A would no longer be with the facility and requiring selection of a new physician from the two listed. The Social Services Clerk told this resident they needed to pick another physician, and the resident signed the letter with Physician B circled, later stating they felt forced into choosing another physician and were anxious because they did not recognize the new physician’s name or have contact information. Resident #3, with no cognitive impairment, heart failure, bipolar disorder, and a guardian, also had Physician A listed as physician and was told by the Social Services Clerk that Physician A could no longer be their physician; no letter documenting this change was found in the record. Resident #3 reported being upset, nervous, and depressed, and their guardian stated they were told by the Administrator that they had to choose a different physician, initially being told Physician A could still come, then later that Physician A had been sent a 30‑day notice and would not return. Physician A confirmed receiving the termination letter, stated he held an active license in good standing, and reported being told by the Administrator that the new company wanted to use its own doctors and that he would no longer be allowed to see residents, despite his willingness to continue under existing protocols. The Social Services Clerk and DON both acknowledged that residents should be able to choose their physician and that the directive to remove Physician A came from company management.
Nurse aides charged for CNA training and competency evaluation
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure that nurse aides were not charged for a competency evaluation program, as required. Review of the facility’s CNA Training Program Assistance Agreement, dated 2025, showed that the agreement required the student to pay CNA training program fees set at $720.00, payable in installments per pay period, with fees described as non‑refundable and no course completion granted until the cost to the facility was reimbursed. The agreement also stated that if the student did not complete the course, no refund would be issued. Review of the active employee list and personnel files showed three nurse aides employed by the facility, including one aide enrolled in a certification program outside the facility and another aide with a signed CNA Training Program Assistance Agreement. In interviews, one NA reported working in laundry for about a year before moving into an NA position and stated the facility offered to pay the CNA program cost upfront with a repayment plan deducted from his or her paycheck, although this aide was not yet enrolled and had not received funds. Another CNA reported being hired as an NA in 2024 and stated the facility required him or her to pay for the CNA certification program, and that he or she is now certified. The Administrator confirmed that the facility did not have its own clinical program for NAs in training and that the facility’s practice was to pay the certification program cost upfront and then have NAs sign an agreement to reimburse the facility over a 12‑week period. These interviews and document reviews demonstrated that NAs were being charged, directly or through repayment agreements, for CNA training and competency evaluation programs.
Missed Anti-Seizure Medications Lead to Breakthrough Seizure and Hospitalization
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident with a seizure disorder was free from significant medication errors when multiple doses of prescribed anti-seizure medications were missed. Facility policies required medications to be ordered from the pharmacy on a timely basis, with refills requested 72 hours prior to the last dose, and required that all physician orders be followed as prescribed, with reasons for any deviations documented in the medical record. The resident had a care plan identifying a seizure disorder related to spinal cord injury and epilepsy, with interventions including administering medications as ordered and monitoring for effectiveness and side effects. Despite these policies and care plan interventions, the resident’s anti-seizure medication lacosamide, a controlled drug, was not reordered in time, resulting in the medication running out. Record review showed that the resident had physician orders for lamotrigine, levetiracetam, and lacosamide, all scheduled twice daily at 8:00 A.M. and 8:00 P.M. The controlled drug receipt for lacosamide showed that on 4/4/26 one tablet was given and zero tablets remained, and the MAR documented that on 4/6/26 both the 8:00 A.M. and 8:00 P.M. doses of lacosamide were missed, with a reference to progress notes. Progress notes on 4/6/26 documented that a medication was on order and later noted as not available, but did not specify which medication. There was no documentation that the physician was notified of the missed anti-seizure medications on 4/5/26 or 4/6/26 prior to the resident’s seizure activity. Interviews indicated that staff believed lacosamide would be automatically reordered, even though it was a controlled medication requiring a manual reorder 72 hours before the last dose. Additional missed doses occurred when the resident left the facility on a leave of absence. The Leave of Absence sheet showed the resident was signed out by family in the morning with an anticipated return in the late afternoon. The MAR documented that on that day, the 8:00 A.M. and 8:00 P.M. doses of lamotrigine, levetiracetam, and lacosamide were missed due to the resident being absent from the facility without medication. The family was not provided with the resident’s medications to administer while out, and the family member later reported only learning from the hospital that doses had been missed. A CMT stated they were not aware the resident had left until attempting the 8:00 A.M. med pass, did not check the Leave of Absence sheet, and did not recall looking for the resident for the 8:00 P.M. med pass, assuming the resident was still gone. An LPN working that evening reported the resident returned around dinner time and that they were not informed the resident had missed seizure medications earlier in the day, and could not explain why the evening doses were not administered when the resident was back in the facility. On the following day, the resident experienced seizure activity characterized by twitching, drooling, unresponsiveness to verbal stimuli, and convulsions lasting several minutes, followed by a second episode. EMS was called, and the resident was transported to the hospital. The hospital discharge summary documented that the resident, who had a history of seizure disorder and other neurologic conditions, was admitted for a breakthrough seizure and that EMS reported the resident had not received antiepileptic medications for two to three days due to supply issues at the facility. Neurology concluded the breakthrough seizure was likely due to medication noncompliance. The resident’s physician later documented that the resident had uncontrolled seizure secondary to missed doses of medication, specifically noting missed lamotrigine, and stated that they had not been informed by the facility of the missed doses of lamotrigine, levetiracetam, and lacosamide prior to the hospitalization. The DON acknowledged that lacosamide had not been reordered in a timely manner and that the resident left the facility without receiving any of the day’s medications, with no explanation for why evening doses were not given after the resident’s return. The facility’s own policies required that if a medication was ordered but not present, staff should call the pharmacy or supervisor to obtain the medication, and that all physician orders be followed with reasons for any deviations documented in the medical record. Interviews with nursing staff and the DON confirmed that CMTs were responsible for notifying nurses when medications were unavailable, and nurses were expected to contact the pharmacy, notify the DON and/or physician, and obtain further instructions if medications could not be delivered. In this case, there was no documentation that the physician was notified of the missed anti-seizure medications before the resident’s seizure, and staff interviews revealed gaps in communication about the resident’s leave of absence, the lack of medication supply, and the missed doses. These actions and inactions resulted in the resident missing multiple doses of critical anti-seizure medications over two days, culminating in a breakthrough seizure and hospitalization, with neurology attributing the seizure to medication noncompliance and the physician documenting uncontrolled seizure secondary to missed doses.
Noncompliance With CNA Training and Certification Timeframes for Multiple Nurse Aides
Penalty
Summary
Facility staff failed to ensure that nurse aides who had worked more than four months completed a nurse aide training program within the required timeframe, and that appropriate documentation of completion was maintained. Review of personnel files for five nurse aides (NA A, NA B, NA C, NA D, and NA E) showed hire dates in late October and early November 2025, with no documentation that any of them had completed the nurse aide training program. The facility’s policies did not include guidance on the required timeframe for completion of nurse aide training. Human Resources reported that some nurse aides had been terminated in October 2025 because they were not certified and then rehired, and the administrator acknowledged awareness that a few nurse aides were beyond the four‑month timeframe without certification. Interviews with the involved nurse aides confirmed that they had been working independently on the floor and performing resident care despite not having completed certification. NA A stated they had worked as an NA since 2025, were supposed to be done with the CNA class, and were waiting on an email to take the test, while working the floor alone and providing resident care. NA C reported working as an NA since April 2025, having finished the CNA class a few weeks prior but still awaiting testing, and also working independently providing resident care. NA D stated they had worked the floor for two years as an NA, were currently in CNA classes that began in November, and still had one or two classes left due to cancellations. The DON stated awareness that several NAs were working but was not aware that some were past the four‑month limit, and reported having no involvement with Human Resources or knowledge of the terminations and rehires related to lack of certification.
Failure to Maintain Effective One-on-One Supervision Resulting in Resident-to-Resident Sexual Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from sexual abuse by another resident despite known sexually inappropriate behaviors and an order for one-on-one supervision. One resident had diagnoses including anoxic brain damage, paraphilia, and sexual dysfunction, with a care plan noting occasional sexually related behaviors such as exposing genitals and touching the hands of residents of the opposite gender. The care plan directed staff to monitor and redirect behaviors and report changes in behavior or cognitive status. The resident’s behaviors reportedly worsened over time, and staff were instructed by administration to keep this resident separated from residents of the opposite gender due to ongoing sexual behaviors. Another resident involved in the incident had dementia with severe cognitive impairment, wandered frequently, and required extensive assistance with most ADLs. This resident’s care plan noted increased behaviors and a tendency to wander into other residents’ rooms, with a stop sign posted on the door to deter others from entering and taking personal items. There is no indication in the report that this resident had any sexually inappropriate behaviors; rather, the resident was cognitively impaired and dependent on staff supervision and protection. The facility’s own investigation documented that the sexually disinhibited resident was placed on one-on-one supervision on a specific date due to seeking out sexual attention, and that an alert was entered to continue one-on-one. However, multiple CNAs and a CMT reported they were not informed that the resident was on one-on-one, and administration did not clearly assign a specific staff member to provide continuous one-on-one supervision. On the day of the incident, the resident left the room, went to the dining room for coffee, and stood near the cognitively impaired resident. The CMT, who was passing medications, saw this and called a CNA to check on the resident instead of personally intervening. Before the CNA could reach them, the sexually disinhibited resident grabbed the other resident’s breast. Staff interviews consistently indicated that if a resident was on one-on-one, a specific staff member should remain with that resident at all times, but on the day of the incident the CNA assigned to the hall still had other resident care duties and could not maintain constant visual supervision. The facility’s investigation verified that sexual abuse occurred and that staff failed to intervene and redirect the resident prior to the breast grabbing, despite the one-on-one order and known risk behaviors.
Failure to Provide Ordered Narcotic Pain Medication Due to Unsigned Physician Order
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received physician-ordered narcotic pain medication as prescribed. A resident admitted with diagnoses including muscle weakness had a physician order for Tramadol 50 mg by mouth twice daily for moderate pain, with an order date of 4/3/26 at 3:15 p.m. The Medication Administration Record for 4/1/26 through 4/30/26 showed that Tramadol was not documented as administered from the evening of 4/3/26 through 4/7/26. The facility’s Medication Administration Policy required safe, accurate, and timely medication administration, including assessment and documentation of missed or delayed medications and adherence to physician orders, but the ordered Tramadol was not provided during this period. Record review showed that the Tramadol order was entered by nursing on 4/3/26, and the resident later reported to the nurse practitioner on 4/7/26 that they were having pain all over due to a prior stroke, that this pain was typical, and that they had taken Tramadol in the past with good effect and wanted to resume it. The nurse practitioner documented a trial of Tramadol 50 mg twice daily if approved by the physician. The DON stated there was an order for Tramadol on 4/3/26 that was not signed by the physician until 4/7/26, and that the medication could not be sent from the pharmacy until after the physician signed the order. The nurse practitioner confirmed that prescriptions for controlled medications such as Tramadol must be signed by the physician and that the medication could not be dispensed until the physician’s signature was obtained. As a result, the resident did not receive the ordered Tramadol for four consecutive days.
Chemotherapy Medication Administered Due to Transcription Error in Electronic Order Entry
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe and effective medication system, resulting in a resident receiving a chemotherapy-related medication that was never ordered by the practitioner. The resident had no cognitive impairment and diagnoses including heart failure, edema, and a history of heart attack, with no diagnosis of cancer. The resident’s physician orders included Torsemide 20 mg daily for fluid retention, and later an order was entered on 03/18/26 for Torpenz (Everolimus) 10 mg daily for edema, despite Everolimus being a breast cancer medication and not ordered by the practitioner. On 03/18/26, an RN documented a new order from a nurse practitioner to decrease Torsemide to 10 mg daily due to the resident’s complaint of dry mouth, but there was no nursing note documenting any order for Torpenz. The March and April MARs showed that Torpenz 10 mg was administered daily from 03/19/26 through 04/15/26, for a total of 28 doses. During this period, nursing progress notes documented multiple resident complaints including dry mouth, concerns about whether medications were dangerous, fluctuating sensations of feeling hot and cold, and difficulty swallowing attributed to dry mouth. The error was traced to the RN’s entry of the medication order into the electronic system. The RN reported that when typing “TOR” into the electronic ordering system, Torpenz and Torsemide appeared side by side, and the wrong medication was selected. The RN did not read the order back before saving it in the electronic record, and the incorrect Torpenz order was transmitted to the pharmacy as a treatment for edema. The pharmacist later identified that the resident had no cancer diagnosis and contacted the facility, leading to confirmation with the physician that the intended order was a dose change of Torsemide to 10 mg daily, not a new order for Torpenz. The facility’s administrator and PCP both acknowledged that the error stemmed from a transcription mistake in the electronic medical record and that the pharmacy also did not initially catch the inappropriate medication and indication.
Failure to Prevent Resident-to-Resident Physical Abuse in Common Areas
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse during multiple resident‑to‑resident altercations. Facility policy defined abuse as the willful infliction of injury, including certain resident‑to‑resident altercations, and required the facility to identify, correct, and intervene in situations where abuse was more likely to occur through assessment, care planning, and monitoring. Despite this, three cognitively intact residents sustained injuries from peers in separate incidents involving disputes over a TV remote, food, and a drink thrown during an argument, all occurring in common areas where staff were present or nearby. In the first incident, a cognitively intact resident with paranoid schizophrenia and mood disorder symptoms was seated in a wheelchair watching TV when another resident with schizoaffective disorder stood over the resident and struck the resident several times in the chest and face during a dispute over a TV remote. Witness accounts and a police report indicated that the aggressor placed both hands around the victim’s neck and choked the resident, resulting in redness to the face, chest, and scratches on the neck. The ADON reported seeing the aggressor’s hands around the victim’s neck and hitting motions before staff intervened. The facility’s own investigation substantiated that physical contact occurred and classified the event as abuse, yet the altercation escalated to choking and hitting before effective intervention occurred. In the second incident, two cognitively intact residents with schizoaffective/bipolar diagnoses became involved in a hallway altercation after one resident became angry about not receiving noodles or coffee that the other resident had. The aggressor called the other resident names and then hit the resident near the left eye several times, causing a hematoma and visible bruising around the eye, eyebrow, and forehead. Staff heard loud yelling and, upon exiting the smoke room or looking up from charting, observed the residents already on the floor or actively fighting, with witnesses specifically seeing one resident hitting the other. The facility’s investigation concluded that a peer‑to‑peer physical altercation occurred, with one resident identified as the aggressor and the other as the victim, and the ADON and NP both characterized the event as abuse, but the conflict progressed to repeated blows to the head before staff separated the residents. In the third incident, two cognitively intact residents with psychiatric and brain disorder diagnoses were seated together in the dining room when a conversation about parenting and family escalated. One resident repeatedly told the other that if juice was thrown, the resident would “whoop” the other’s “ass,” and staff and another resident heard these verbal threats and told the potential aggressor not to throw the drink. Despite these warnings and staff awareness that the threatened resident escalated quickly, staff remained at a distance and only intervened verbally. The resident then threw juice on the peer, who immediately responded by punching the resident in the face multiple times with a closed fist until staff physically separated them. Multiple witnesses, including CNAs, a CMT, and other residents, confirmed that the drink was thrown and that one resident then repeatedly struck the other in the face, causing bruising to the nose and left eyebrow/forehead area. The facility’s initial investigation determined the incident was not abuse, but the ADON, NP, and DON later acknowledged that the altercation would be considered abuse and that it could have been prevented had staff intervened more directly when the threats and escalation were first observed.
Failure to Document and Administer Ordered Blood Glucose Checks and Insulin
Penalty
Summary
The deficiency involves the facility’s failure to ensure that services related to blood glucose monitoring and insulin administration were provided and documented in accordance with professional standards and physician orders for three residents with Type II Diabetes Mellitus. Facility policies required that all insulin be administered per physician orders, coordinated with mealtimes and bedtime snacks unless otherwise specified, and that staff document the insulin dose, site, time, and nurse signature after administration. Policies also required licensed nurses to routinely review electronic MARs/TARs, document any medications not given with an appropriate chart code and progress note, notify the DON/ADON/RN, Administrator, physician, and legal guardian as applicable, and document a plan/solution and any adverse reactions when medications were omitted. Staff were expected to review their MARs/TARs before the end of each shift to ensure all ordered medications and treatments were administered and properly documented. For one cognitively intact resident with a diagnosis of Type II Diabetes Mellitus, physician orders included Humalog (insulin lispro) per sliding scale, insulin glargine 25 units subcutaneously at bedtime (to be held for blood glucose less than 70 mg/dL), and blood sugar checks before meals and at bedtime. Review of this resident’s April MAR/TAR showed six missed out of 27 opportunities for insulin glargine administration, seven missed out of 81 opportunities for insulin lispro administration, and 11 missed out of 108 opportunities for blood sugar checks. During interview, the resident reported that staff sometimes forgot to check blood sugar and give insulin, and that the resident occasionally had to ask staff to perform blood sugar checks or insulin administration when it was not done as ordered. The resident also speculated that staff might be performing checks and administration outside scheduled times and not documenting them. For a second resident with Type II Diabetes Mellitus, orders included blood sugar checks before meals and at bedtime and Lantus (insulin glargine) 12 units subcutaneously twice daily, with subsequent changes to insulin lispro per sliding scale, Lantus 13 units twice daily, and then Lantus 10 units twice daily during April. Review of the April MAR/TAR showed nine missed out of 36 opportunities for insulin lispro administration, one missed out of seven opportunities for the Lantus 10-unit twice-daily order, seven missed out of 18 opportunities for the Lantus 13‑unit twice-daily order, and 10 missed out of 66 opportunities for blood sugar checks. For a third resident with Type II Diabetes Mellitus, orders included blood sugar checks before meals and at bedtime, insulin aspart per sliding scale, insulin aspart‑szjj 8 units subcutaneously before meals and at bedtime, and insulin degludec 4 units subcutaneously at bedtime. The April MAR/TAR for this resident showed nine missed out of 109 opportunities for insulin aspart, 10 missed out of 109 opportunities for insulin aspart‑szjj, four missed out of 27 opportunities for insulin degludec, and no documentation at all for ordered blood sugar checks. Interviews with facility leadership and clinical staff further described inactions related to monitoring and documentation. The ADON stated they had not noticed documentation issues with blood sugar checks and insulin administration but acknowledged residents had informed them at times that blood sugars were not checked. The ADON reported that CMTs could check blood sugars, some CMTs were certified to administer insulin, and that nurses were responsible for most blood sugar checks and insulin administration. The ADON felt staff were not good about documenting refusals and noted that they had previously conducted daily medication administration audits but had been assigned to work the floor for three to four weeks, preventing completion of these audits, and no one else had been assigned to perform them. The ADON also suggested documentation might be missed when staff responded to behavioral emergencies, while reiterating that staff were responsible for documenting all blood sugar checks, insulin administration, refusals, and related progress notes, and for communicating with nurse management when issues interfered with documentation. The NP stated an expectation that staff follow all physician orders, document refusals of blood sugar checks and insulin administration, follow facility policy for blood sugar checks and insulin administration, and notify the provider when required by order, and reported not having heard resident complaints about these issues. The DON and Regional Nurse Consultant stated that all staff were expected to chart in real time and that there was no excuse for failing to document blood sugar checks or insulin administration. They confirmed that the ADON had been performing medication administration audits but had been working on the floor more frequently and was unable to continue the audits, and that no other person had been assigned to perform them. They expressed the belief that staff were performing blood sugar checks and insulin administration but not documenting them, and reiterated that refusals of blood sugar checks and insulin administration also needed to be documented. These findings collectively show multiple missed and undocumented blood glucose checks and insulin administrations, contrary to physician orders and facility policy, for three residents during the review period.
Failure to Initiate Behavioral Health Response During Verbal Escalation Leading to Resident Assault
Penalty
Summary
The deficiency involves the facility’s failure to follow its behavioral health response procedures, specifically not initiating a Code [NAME] at the start of a verbal escalation involving a resident with known behavioral health diagnoses. Facility policy required that residents receive necessary behavioral health services, including person-centered, non-pharmacological interventions and staff education to recognize and respond to behavioral triggers and escalating behaviors. Resident #2 had documented diagnoses of schizophrenia, anxiety disorder, and major depressive disorder, with a care plan noting prior physical altercations, negative behaviors such as yelling, threatening to hurt people, and throwing objects, and triggers including rude people, yelling, cursing, and people not listening. Interventions in the care plan included closely monitoring for signs of anxiety, acting before the resident lost control, avoiding power struggles, respecting personal space, and using coping skills and meaningful activities to reduce anxiety and prevent escalation. On the day of the incident, Resident #1 and Resident #2 were seated at a table and became involved in a verbal argument. According to interviews and witness statements, the conversation included comments about Resident #1’s child and led to mutual name-calling. Resident #2 warned Resident #1 multiple times not to throw a drink and stated that he/she would “whoop” Resident #1’s “ass” if the drink was thrown. Staff present, including CNAs, were aware that Resident #2 had triggers related to “mouthy people” and boredom and that he/she escalated quickly to anger. One CNA reported checking in with Resident #2 when the argument started but did not actively intervene, instead only reminding Resident #1 not to throw the water. Another staff member was heard shouting for the residents to stop just before the altercation became physical. Staff interviews later indicated that they recognized there had been an opportunity to intervene earlier using Resident #2’s coping strategies, such as talking, walking, or engaging in activities, but these interventions were not implemented at the onset of the verbal escalation. The situation escalated when Resident #1 threw a cup of juice or water at Resident #2, after which Resident #2 got up and began hitting Resident #1 in the face. Witnesses observed Resident #2 punching Resident #1, and staff then called a Code [NAME] and physically separated the residents. Resident #1 sustained yellow and purple bruising to the nose and left eyebrow/forehead area and reported pain in those areas. Resident #2 was later observed in his/her room breathing heavily and appearing anxious, with superficial scratches to the upper chest, and reported that he/she had “blacked out” during the incident and continued punching until staff pulled him/her away. Multiple staff, including CNAs, a CMT, the ADON, the NP, and the DON, acknowledged that the altercation was triggered behavior and that earlier, more active behavioral intervention at the start of the verbal escalation could possibly have prevented the physical assault. The failure to utilize the facility’s behavioral health practices and procedures, including calling a Code [NAME] at the start of the verbal escalation and implementing care-planned non-pharmacological interventions, led to Resident #2 striking Resident #1 in the face and causing bruising. Resident #1, who was cognitively intact and had no documented behavioral symptoms in the MDS look-back period, was later care planned for involvement in a physical altercation with emotional distress and bruising to the nose. Resident #2, also cognitively intact with no behavioral symptoms noted in the most recent MDS look-back period, nonetheless had an existing care plan documenting significant behavioral risks, triggers, and required interventions. Staff interviews consistently reflected awareness of Resident #2’s behavioral history, triggers, and need for meaningful activities and coping support, yet during the incident they did not fully implement these interventions or initiate the behavioral health response at the onset of the verbal conflict. This sequence of inaction in the face of known risk factors and escalating verbal aggression directly preceded the physical altercation and resulting injury to Resident #1.
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